Article by Frances Coleman-Williams of The Metro
Having been ill for many years, I’ve tried a number of different treatments, including DBT and CBT.
I also had hospital stays, and tried to take my life multiple times. Not only was I struggling with many distressing symptoms of depression and Dissociative Identity Disorder and Complex PTSD but I was self-harming regularly. I was too unwell to work and struggling to find my way in the world.
When I found myself in hospital again, my psychiatrist referred me to a new psychotherapist and he suggested we try Acceptance and Commitment Therapy (ACT).
What is ACT?
It is about initially accepting that pain and suffering are normal and that deliberately trying to get rid of them will add to the distress.
This therapy is not a quick fix for mental illness but it is about coping with the distress while living a more fulfilled life.
They liken a mental illness to fighting a war – the theory suggests that if you remove yourself from the war and watch it, rather than taking part in it, you can start living your life (and the war may also subside).
The workbook guides you through the concepts, with explanations and exercises. Some of the exercises are related to your life and the difficulties you face, others are a little abstract to enable you to understand a concept fully.
The techniques underlying this therapy are:
Mindfulness – a way of being in the present moment, seeing our thoughts for what they are, without judgement. This enables us to look at our pain from a different perspective.
Acceptance – a way of accepting that pain is part of the life, not in a self-defeating or having to put up with it way, but in an active way that’s about embracing the moment. Also accepting that we are unlikely to be able to solve our problems in the ways we’ve been doing so far (by avoiding or fighting).
Commitment and values-based living – thinking about the dreams we have and what we value most in the world, also looking at what traps and barriers we put up in a form of self-sabotage.
This therapy is usually delivered in individual sessions with a trained therapist and varies from long-term therapy of 40, 2-hour sessions to ultra-short two to three half-hour sessions.
It uses a workbook, which is used both in sessions and for homework.
Alternatively, it is possible to work through the workbook on your own, provided you have a good support network for you to discuss anything that is brought up by the exercises and explanations.
Pros and cons of ACT:
It has a scientific basis and has research backing its concepts and techniques. The practical workbook makes it easy to understand and implement. The concepts can be applied to a range of mental and physical illnesses.
There is no space to address the underlying issues. It is highly structured and (depending on the therapist) therefore not individualised. It calls for a radical acceptance of the concepts and ideas in order to put them into action. You can’t wait until you’re ready, you just have to give it a go.
What was my experience of ACT?
Initially, I went through the predictable self-blame and criticism as I felt I was now being told my fight for survival was a) futile and b) causing me more pain. As usual, though, I was willing to put a lot of effort into the therapy.
It had slightly different concepts to anything I’d tried before so I desperately hoped it would help.
I found it counterintuitive that it wasn’t focused on the distressing symptoms I was having, but my therapist had faith in the therapy so I kept up the hard work. I was already practicing mindfulness so I appreciated doing some more work to hone the skill.
It was really interesting to work through the exercises and have a greater understanding of what I thought about my difficulties and move to a place where I could view them differently.
The concept and idea behind the therapy make a lot of sense, I can see they are logical and could be really helpful for a lot of people. But for me, not addressing the underlying problems became too much of a barrier for me to gain full effect from it.
The six guiding Principles of ACT are:
Principle 1: Cognitive defusion
This skill is about learning to perceive thoughts, images, memories and other cognitions for what they are – nothing more than bits of language and images – rather than what they often appear to be: threatening events, rules that must be obeyed, or objective truths and facts.
The opposite psychological process – cognitive fusion – refers to a blending of cognitions (products of the mind, such as thoughts, images, or memories) with the things that they refer to. In cognitive fusion, for example, our mind might have the same reaction to the phrase “chocolate cake” as if we were presented with a slice of it. That is, the mere presentation of the stimulus – the words “chocolate cake” – might be enough to start us drooling, imagining the sweet taste, and feeling the heavy, creamy texture in our mouths of the frosting. In a state of cognitive fusion, it seems as if:
- Thoughts are reality: as if what we are thinking is actually happening
- Thoughts are the truth: we totally believe them
- Thoughts are important: we treat them seriously, giving them our full attention
- Thoughts are orders: we automatically obey them
- Thoughts are wise: we assume they know best and we follow their advice
- Thoughts are threats: we let them frighten or disturb us (Harris, 2007)
But, as any dieter can tell you, the word or image of chocolate cake is not the same (at least in terms of both pleasure and caloric intake!) as the real thing. The process of cognitive defusion aims to separate unpleasant, unwelcome thoughts, feelings, urges, memories, or other products of the mind from ourselves. It is the stepping-back from them (a process called disidentification in traditions such as Psychosynthesis – Assagioli, 1973/1984) to get a perspective and see them for what they are: just bits of language passing through. Successful employment of cognitive defusion leads to a more spacious psyche, as we see from the second principle.
Principle 2: Expansion/acceptance
Called “acceptance” by some other ACT practitioners and theorists, this skill is termed “expansion” by Harris because “acceptance” is loaded with other meanings. It refers to the practice of making room for unpleasant feelings, sensations, and urges, instead of trying to suppress them or push them away. By opening up and allowing them to come and go without struggling with them, running from them, or giving them undue attention, we find that they bother us much less. They also move on more quickly, instead of hanging around and bothering us (Harris, 2006; Harris, 2007).
Imagine the situation for the client who says, “I feel so anxious about going out on a date. I’m so afraid that I won’t have anything to say, or that I’ll say something really dumb.” Through the use of CBT techniques we, as counsellors, could help the client dispute the negative beliefs that she is a poor conversationalist or a boring date, replacing her anxious thoughts with positive, affirming ones, such as that she is interesting, good at conversation, or a worthy social companion. Through longer, psychotherapeutic processes, we could help her to discover the experiences in her past (probably early childhood) which created the sense of her as socially inept. Psychotherapy takes a long time, however, and even when the effect of past history on present experience becomes known, there is still the “war of words” as the various voices within her – the critical ones and the affirming ones – clamour for attention. Being in such a war is a major drain on resources!
The ACT principle of expansion/acceptance works differently. It would ask the client to imagine that she is about to go out on a date. She would then be instructed to scan her body, observing where she felt the anxiety most intensely. Let’s say that she reports that she experiences a huge lump in her throat. She might be then asked to observe the sensation of the lump as if she were a scientist who had never seen anything like it before: to notice the shape, weight, vibration, temperature, pulsation, and other aspects of it. She would be invited to breathe into the lump, making room for it, allowing it to be there (even though we would be highly empathetic in understanding that she did not like it or want it there!). She might be given the “homework” between sessions to practice observing her lump of anxiety: not trying to get rid of it, but just letting the sensation of the lump, and possibly other sensations associated with anxiety, come and go as they pleased: acknowledging them, not resisting them, but also not engaging with them.
Principle 3: Contact (connection) with the present moment
To allow ourselves to experience sensations, feelings, and thoughts which have arisen is to follow the third ACT principle, that of making contact with the present moment, which Harris prefers to call “connection” (Harris, 2007, p 47). It means living in the present, focusing on whatever we are doing, and bringing full awareness to the here-and-now experience: with openness, interest, and receptiveness. Instead of dwelling on the past or worrying about the future, we are deeply connected with what is happening right here, right now. With the connection, we are fully engaged in whatever we are doing (Harris, 2006).
In practicing connection, we might ask: why bother pulling ourselves out of the past or the future to come back to the present moment? Why is doing so considered so beneficial for us? Harris points to three primary reasons:
This is the only life we’ve got (even for many who believe in such concepts as reincarnation, this is the only life we are aware of living right now or tend to have information about), so why not make the most of it? To be only half-present is to miss half of it. Lack of present-moment contact is akin to listening to a favourite piece of music with ear plugs in the ears, or eating a favourite food when the mouth is still numb from a visit to the dentist; we miss the richness there could be.
Right now is the only time when we have any power. Given that a foundation of ACT is being committed to appropriate, values-guided action, we can remind clients that, to create a meaningful life, we must take action, and the power to act exists only in the present moment. As the Arab saying goes, “One cannot mount a camel which has not yet arrived (the future), nor one which has already departed (the past)”.
“Taking action” means effective action, not just any old action. Effective action in ACT is defined as that which helps us to move in a valued direction. To find out in which way lies that direction, we must be psychologically present to be aware of what is happening, how we are reacting, and therefore how it is right for us to respond. Harris advocates recalling a mnemonic for ACT: “Accept your internal experience and be present; Choose a valued direction, and Take action”: ACT (Harris, 2007, p. 152).
Even those who tend to live their lives through the mediating influence of their thoughts generally have some experience of present-moment-contact: times when it arose spontaneously and unexpectedly. The client fearing social ineptness, for example, could be asked to reflect on anytime when she might have been totally engrossed in being with someone else (date or otherwise): the experience of, say, hanging on every word the person uttered, noticing the movements their mouth made as they were speaking, recalling the scent of the person, and how their hair was combed (or not). Full engagement with other person is likely to have ejected (however temporarily) thoughts of social inadequacy from her mind.
To practice this skill it is not necessary to go on an actual date (in the case of the person fearing social ineptitude), or even have another person around. We can ground ourselves in the present moment whenever or wherever we like, simply by tuning in. An ACT therapist, for example, might ask a client to notice every little aspect of their experience of taking a shower: the feel of the water as it hits the skin and runs down, the sight of the rising steam in the bathroom, or the scent of any soaps or other products applied to the body in the process of showering or after-shower care. Or a person could practice the present-moment-connection principle by observing minute details of the dishwashing experience after dinner: the clinking sound of the plates against the bench top, the feel of the soapy water washing over them, the sensation and sound of squeaking as the items become truly clean, and the visual experience of placing them on the drain board.
Even easier: an ACT-oriented counsellor could give a client a single piece of food – say, a dried fig – and ask the person to focus on nothing else but the eating of it. The client can be instructed that distracting thoughts and feelings may arise; these can be allowed to come and go as they will; the client’s attention should remain focused on the fruit. Upon “graduating” to an interpersonal situation, a client such as we have been discussing would be encouraged to have a conversation with another person focusing totally on that person rather than on her own thoughts and feelings. However the connection/contact with the present moment happens, it occurs through the Observing Self.
Principle 4: The Observing Self
The Observing Self is a powerful aspect of human consciousness, one largely ignored by Western psychology. To connect with it is to access a transcendent sense of self: a continuity of consciousness that is unchanging, ever-present, and unable to be harmed. From this most inclusive perspective of oneself, it is possible to experience directly such statements as found in some body-feelings-mind relaxations that, “I am my body, and I am more than my body; I am my feelings and I am more than my feelings; I am my mind and yet I am more than my mind” (Palmer, 1997). From this place, we are able to experience that our thoughts, feelings, memories, urges, sensations, images, roles, and physical body are peripheral aspects of ourselves, but as they are constantly changing, they are not the essence of who we are.
To understand the principle of the Observing Self is to comprehend that when we become aware of our thoughts, there are actually two processes occurring: that of thinking, and that of observing the thinking. We can draw the client’s attention – again and again if necessary – to the distinction between the thoughts that arise and the self that is observing them. From the perspective of the Observing Self, no internal experience (that is: thought, feeling, image, or urge) is dangerous or controlling (Harris, 2007).
We stated earlier that the six principles work together with one another to help us create a meaningful life. We can state now that present-moment-connection happens with the Observing Self. It involves bringing our full attention to what is happening here and now, without getting distracted or influenced by the thinking self. The Observing Self is said to be non-judgmental by nature, because judgments are thoughts, and therefore a product of the thinking self. The Observing Self doesn’t get into struggles with reality; it sees things as they are without resisting them. It is only when we judge things – such as “bad”, “unfair”, or “mean” – that we resist them. It is, then, the thinking self which tells us that “life shouldn’t be as it (reality) is”, that we would be happier if we were somewhere else, someone else, or somehow different. It is thus our thinking self that puts a veil of illusion between ourselves and life, disconnecting us from reality through boredom, distraction, or resistance.
The Observing Self, conversely, is incapable of boredom or resistance. It greets each stimulus, each experience, with openness, curiosity, and interest. Boredom and resistance are thought processes: stories that life would be more interesting or better if… (fill in the blank). The Observing Self, always present and available, is able to cut through that, waking us up and connecting us to the infinite possibilities of human experience that we may encounter, regardless of whether the experience is novel or familiar. Paradoxically, by engaging the Observing Self as we encounter unpleasant experience, we often find that the aspects we were dreading become much less bothersome than they were before. Things are seen in a new light (Harris, 2007).
To connect with the Observing Self is to have the ready capacity to disidentify from pain and unhappiness. As we stand in the shoes of the (disidentified) Observing Self, we can still feel pain and unhappiness (our thinking self may still be giving us thoughts that we hurt or are unhappy), but not all our consciousness is tied up in that, because some of it is involved with the Observing Self in watching ourselves feel the pain. Thus, the experience becomes more bearable as we experience – through the choice of two positions in which to be – a more spacious psyche.
Within the context of any given experience, we can choose – consciously or unconsciously, by default – where we stand. Our choice is determined by the values that we hold, so a key component of effective living is to be clear on what those values are.
Principle 5: Values clarification
This ACT principle is about clarifying what is most important in the deepest part of ourselves that we can access. It involves asking what sort of person we want to be, what is meaningful to us, and what we want to stand for in this life. Our values provide direction for our lives and motivate us to make significant changes. Guided by values, not only do we experience a greater sense of purpose and joyfulness, but also, we see that life can be rich and meaningful even when “bad” things are happening to us.
Thus, ACT-oriented counselling might ask the client to complete a “life values” questionnaire, which asks respondents to reflect on their values in ten domains, from family and marriage relationships through education and spirituality to community life and relationship with nature. Some clients would prefer to skip values clarification exercises, and there may be several reasons why this is so.
Values versus goals. Some people may not be clear on the difference between values and goals. Harris explains that goals are a one-shot deal where values are so because they are consistently in our lives as something we hold dear. He uses the analogy of someone going on a journey, saying that he will keep heading west. That consistent direction is analogous to a value because no matter how far the person may travel there is always more westerly direction in which he can proceed. Saying that he intends to ascend to the peak of a particular mountain along the way, however, is a goal, because once he climbs to the top of the mountain, he has achieved the goal, and it is a done deal (Harris, 2007). Once we know what we value, we can derive meaningful goals in order to live by our values. But therein may lie another obstacle to enacting this principle.
But are they my real values? Some individuals may resist enacting Principle 5, or even completing any questionnaires around it because they are uncertain whether the answers that they provide will reflect their “real” values. Of course, simply because someone says that they value a particular thing – say, being compassionate – it can be counted as their value because by definition, a value is something we hold dear. Merely to answer that we value a certain thing above others is to cherish it, to have it as a value. This is a similar objection to the person who says…
I don’t know what I want. Again, whatever we might choose is already our value, simply because we have valued it by naming it. But it does bring up the issue of…
What if my values conflict? Presumably if you are working to help clients using ACT methodologies, you will encounter this one; it is valid. To not have values pulling one in different directions is difficult to impossible, especially in hectic modern life. A client may, for example, dearly value the importance of quality time with family, and just as dearly want to rise through the ranks at work, thus giving primary attention to that; the two values are likely to conflict at some stage, if not regularly.
The reality is that we sometimes must prioritise one domain over another, asking ourselves: “What’s most important at this moment in my life, given the conflicting values I’m experiencing?” The person then needs to act on the chosen value, without worrying about what he or she is missing out on, knowing that, if necessary, the balance can be “corrected” at some later stage. Still, some will object to clarifying their values on grounds of past failure or frustration.
I don’t want to think about it; I’m just setting myself up for disappointment. Those who have experienced a lot of frustration or failure to live chosen values may be afraid to acknowledge what they really want, for fear that – yet again – they will fail to achieve it. These twin objections to choosing clear values speak to the “I can’t change”, “I’ll only fail”, or “I don’t deserve any better” fears that reside in many hearts. The past is the past and it cannot be changed, but the future begins right now. Clients expressing this sort of resistance can be encouraged to breathe into their discomfort and acknowledge that these statements are only thoughts; they can come and go as the client refocuses on the valuing exercise.
I’ll do it later. Yeah, right. As a counsellor or other mental health helper, you certainly will have heard this one before! Principle 5 of values clarification will go nowhere when the procrastination beast is roaming. Tell the client that it’s “later” now, and time to do what is enshrined in the very name of ACT therapy: act (Harris, 2007).
Principle 6: Committed action
At this last principle, the person sets goals and takes action: but not just any action. Here the person understands that the rich and meaningful life s/he desires is created by taking effective action, which is that guided by the chosen values. Will followers have a perfect record in pursuing the goals they have set? No, of course not, but no matter how many times someone may go “off the rails” – or not even get going down the track – the values are there to provide inspiration and motivation for re-engaging action. The goals are there to remind the person of the actions that will help him or her to arrive at the visualised life (Harris, 2006; 2007). In the final analysis, it is up to each person to supply the will and energy to take the action.
We can find analogy in the would-be traveller who really, really wants to go to Africa. The person buys informational and tour guide books on Africa, contacts travel agents and plans out the itinerary for the particular spots he wants to visit. He is sure his life will be fabulous if he can just get to Africa! But at the end of the day, he won’t actually be present for any of his planned safaris – and nothing at all will change in his life – unless he gets out of the armchair, packs his bag, and fronts up on the appointed day to board the plane. No amount of reading about Africa will give him the actual experience of Africa that he desires. He must, ultimately, supply the will and energy to go there in order to be changed by the rich and meaningful experience of Africa.