Yet another model of counseling? I would have asked the same question before my introduction some years ago to acceptance and commitment therapy (ACT, and pronounced as the word, act). It is a model that stands on the shoulders of long-endorsed approaches to counseling, yet it takes these ideas into new and, I believe, more fruitful directions. So, if you’ll share with me a few minutes of your time, I’d love to introduce this intriguing model for clinical work. Maybe, like me, you’ll find this worth a closer look.
ACT actually evolved from behaviorism, although it is far from the old stereotypes of behavioral therapy. It draws largely on insights from a branch of behavioral research into language called relational frame theory (RFT). This fascinating approach concerns how our “languaging” about things can cause and perpetuate emotional distress. RFT is a bit difficult to understand, but ACT is like operating a car: You can drive it without understanding all that is going on “under the hood.” (By the way, my use of metaphors is deliberate. Part of RFT shows how metaphors are very beneficial in helping us understand and change how we see things.) One can be a competent ACT therapist without being an expert in RFT.
ACT also draws from cognitive behavior therapy (CBT) but pursues goals that are quite distinct. Although thoughts and language play a role in ACT, ACT does not share CBT’s focus on disputing the thoughts rationally. Rather, the goal is to form a different relationship with one’s thoughts. I’ll share more on that a bit later.
In keeping with its heritage, ACT is built on empirical research and boasts a bevy of studies showing its effectiveness across a wide spectrum of problems. More than 120 randomized trials have shown it to be as effective, if not more effective, than traditional therapies. Counselors can utilize ACT with confidence that it can help. One encouraging note is that studies show that counselors starting out in ACT generally feel less confident than they do with CBT but see better results.
One of the attractions of ACT is that it is transdiagnostic. That is, it works across diagnoses and does not make much of traditional diagnostic categories. In the counseling world, the idea of diagnosis is being increasingly questioned, particularly because of the overlap of symptoms and the lack of discrete categories. Earlier efforts to find empirical support for counseling models focused on identifying specific therapies for each diagnosis. That is a challenge given that comorbidity is more the rule than the exception in diagnosis.
The search is now on for the core processes that account for emotional suffering rather than just naming more and more diagnostic categories. ACT enters this debate by suggesting a core concept that produces suffering across many diagnoses: psychological inflexibility.
ACT argues that some pain, including emotional pain, is natural and inevitable in life. ACT authors somewhat mischievously refer to counseling that tries to help clients never to feel any anxiety or sadness as pursuing “dead person’s goals.” These clients become intent on avoiding all suffering and discomfort, and in so doing become “stuck” in their thinking, feeling and behavior. They thus spend their days trying to avoid discomfort that is inevitable in life. This paradoxically results in more suffering and a tightening of the pattern’s grip — much like trying to escape from a Chinese finger trap. The more effort that is spent on trying to avoid pain, the more pain it causes. This “control” agenda is in reality hopeless. Only a dead person experiences no unpleasant emotions, so a different approach is needed.
An example might illustrate further. Juanita is depressed and feels ignored in all social situations. To avoid the resultant pain, she begins staying home and watching television by herself. Although this allows her to avoid the anxiety of being in social situations, Juanita is stuck because she lacks the social relationships that she needs. Her anxiety of being “out there” is replaced with the more intense loneliness and depression of avoiding people.
In contrast, psychological flexibility involves a person’s skill in adapting cognitive processes and behavior to the specific context that he or she is facing and to contact the positive consequences of present actions as part of pursuing a valued path (adapted from Steven C. Hayes, Kirk D. Strosahl and Kelly G. Wilson, 2012). It requires flexible attention to the present moment and acceptance of some suffering, combined with a commitment to pursue values and the behavioral activation processes to do so.
For Juanita, psychological flexibility would mean examining her thought process, accepting the apprehension that comes with stepping into social situations and moving toward, rather than away from, those situations. She would learn skills for defusing her thoughts from those social situations, accepting the inevitable anxiety and stepping into occasions so that she can build the relationships she values.
The six skills of psychological flexibility
ACT focuses on six core processes that yield the goal of psychological flexibility. These processes are often diagrammed in a hexagon pattern, cleverly called the “hexaflex,” to show how each impacts the others (see figure below). We’ll look at each point on the diagram in the pairs they naturally come in, but only after a brief note on another important concept: namely, that ACT is not a preplanned, fixed approach. Rather, the counselor takes cues from what the counselee brings into session to determine which aspect might need work on a given day. (ACT texts also provide helpful assessment strategies.)
Open response style
This style is marked by looking at things as they are and not reflexively making unhelpful associations. The skills that constitute this style are defusion and experiential acceptance.
The first component, defusion, is one of the most difficult constructs in ACT and the most dependent on RFT. Skipping the technical explanations for our purposes, ACT sees comprehension of how we become fused to certain understandings of things and how we react to those understandings as being vital to change. People with obsessive-compulsive disorder might fuse the idea that anything they think must be true with a thought that they might kill someone. As a result, the mere thought that they might hurt someone else is tantamount to actually having evil intent in their core being and makes them a murderer. Obviously, this causes distress.
CBT might address this through a logical disputation of the irrational thought. In contrast, ACT teaches an awareness of this process and defuses the thought from the interpretation. One can look at one’s thoughts rather than from them.
A simple first intervention might be to have the counselee replace “I must be a murderer at heart” with “I had the thought that I might hurt someone.” In so doing, the person moves “from” the thought and seeing it as a statement of fact to seeing it merely as a passing idea in the mind. The popular “leaves on a stream” mindfulness exercise is helpful here too, with the person viewing thoughts as leaves to be observed and then released. The counselee thus learns to defuse rather than to debate. A phrase I often offer to counselees at this point is “You don’t have to believe everything you think” or, even simpler, “Thoughts aren’t facts.” The same approach also can be used with emotions.
The second component of the open response style is acceptance. In general, this term refers to an openness to accept things such as unpleasant thoughts or feelings. But in ACT, a more precise term would be willingness — the individual is willing to accept some thoughts and feelings in pursuit of a greater good.
A familiar illustration of this idea is the fitness mantra of “no pain, no gain.” Counselees often chuckle when I suggest that I want to lose weight without sweating or working out. They are aware that getting in better shape requires some discomfort. This allows me to ask a question: Why wouldn’t the same be true of mental health?
Numerous ACT metaphors illustrate this idea, but one of the simplest is the ball in the pool. Imagine that you have a beach ball in the pool with you. It annoys you, and you want it out of sight. You hold it underwater so that you don’t see it. That solves the problem in a way, but you also lose the mobility to do most of the fun things you normally do in a pool. Controlling the ball is so “expensive” that it costs you the pleasures of swimming. But if you are willing to accept the annoyance of the ball, you can reengage with the delights of life in the pool. An internet search of “ACT metaphor videos” will yield some short, clever resources that are very helpful in communicating these points to clients.
Now consider this as it relates to Juanita. You work with her to realize that her control agenda of avoiding all pain won’t work, so she is open to ACT. She is fused to the thought that whenever she goes to a social setting, she is shunned. Rather than argue with her about the objective truth of the thought, you guide her to realize that this is simply a thought. She need not hold on to it so tightly. It is much like the beach ball metaphor. If Juanita can accept this thought in the background, she is freer to move toward people and relationships.
Centered response style
In the center of the hexaflex (conveniently enough) are the two skills that constitute this vital part of psychological flexibility. The two skills that keep one centered in responding to one’s immediate context are contact with the present moment (being present) and self-as-context.
Present moment awareness, the third element of the hexaflex, likely strikes you as being related to mindfulness, and you are correct. However, mindfulness serves a different purpose in ACT than in other therapies. Whereas mindfulness often is considered a way to decrease stress and induce calm, it plays a different role in ACT. In fact, relaxation may even run counter to ACT’s goal. ACT counselors use mindfulness as a skill to help clients keep in contact with the present moment, even if there is discomfort in it. Much of our thinking gets us lost in the past or anxious about the future, but the only time we can act is in the present. We use many strategies to avoid the present, such as constantly doing something, shifting topics, living in the future through worrying and thinking about everyone else’s business except our own.
This shifting of attention away from the here and now serves to avoid discomfort and unwanted emotions even as it perpetuates problems. We need a moment-by-moment awareness of our internal states and external contexts to respond appropriately in the present. Simple examples of activities for this in ACT include having the counselee relax, close his or her eyes and keep one thought in mind, raising his or her hand whenever the thought slips away. Alternatively, one of my favorites is helping the person become centered, then placing an ice cube in his or her hand (a paper towel is also needed for the inevitable dripping). I then guide the counselee to observe the changing feelings from holding the ice cube — wetness, coolness, maybe a slight burning sensation and so on. This exercise keeps the counselee aware of the present situation and teaches him or her to accept the sensations that accompany it rather than using avoidance strategies.
Perhaps the most conceptually challenging dimension of psychological flexibility is self-as-context, the fourth element of the hexaflex. ACT distinguishes several aspects of self. Self as concept is the way we say, “I am …” So I can say, “I am a counselor” or “I am an art enthusiast” and so forth. This can be destructive, however, when it includes statements such as “I am a loser.” We can become fused to such notions of the concept of the self.
The self is more than this. It is also the place from which we observe life. Consider yourself in a counseling session. If you are like me, you are largely caught up in the flow of what is happening, but a part of you is simultaneously monitoring progress — observing it rather than participating in it. I catch myself noticing that I’m talking too much, or that my mind is drifting when the counselee talks, or even that the counselee is making poor eye contact or struggling to maintain a stream of thought. So, I simultaneously participate in the interaction and observe it.
Once we are aware of this as counselors, we can help our clients develop this vital skill. As we have seen, often clients are fused to their thoughts, and defusion may require the ability to step back and take perspective. People are also often fused to their interpretations of their thoughts (such as Juanita’s fusion to the sense that if people don’t line up to talk to her, it means they are ignoring her).
You can learn to listen to how much interpretation people bring to their stories and descriptions. I illustrate this with the example of two broadcasters at a basketball game. One broadcaster, typically designated the play-by-play commentator, describes the action so that listeners have a sense of objective presence at the game. The other broadcaster is a color commentator charged with analyzing and interpreting events. Many of our counseling clients are all color commentator and very little play-by-play. Much of mindfulness in ACT involves learning to be the observer rather than the participant or analyst.
A popular metaphor for this is the chessboard (it may be beneficial to have one in your office as you share this with clients). Explain how the black and white chess pieces can represent thoughts in the counselee’s mind. They are battling with each other in different ways and causing distress, much like the little angel and demon that appear on the shoulders of old cartoon characters when they are contemplating an action. Clients identify with this struggle and feel caught up in it. Invite the counselee to consider if there is another participant in this debate/game of chess. The answer is the chessboard itself. Every move affects the chessboard, but the thoughts are not the chessboard. This is the self-as-context.
Returning to Juanita, consider what the centered response style would look like for her. As her counselor, you would guide her to greater skill in observing her thoughts (and, yes, this overlaps with defusion). You might begin with exercises to help her monitor her thoughts and feelings in the counseling office to develop better contact with the present moment (this is also helpful should a client wander “out of the office” into other topics, times or places). Then ask Juanita to imagine going to a party. Have her track her thoughts as a play-by-play commentator without attempting to escape or interpret the feelings, developing a better sense of self as the person experiencing the anxiety rather than being hopelessly wrapped up in the anxiety.
Engaged response style
We have considered the “acceptance” part of ACT, but what of the “commitment” piece? This is the aspect of the psychologically flexible person that pursues valued directions through commitment.
One of the costs of avoidance is the loss of pursuing valued things in life. For Juanita, this is obvious. She avoids anxiety, but in the process she does nothing to move toward the relationships that she values. To borrow from our fitness metaphor again, the “gain” of working out is the reason one accepts the associated “pain.” One values fitness and health and understands those things cannot be achieved without doing difficult things to promote and maintain them.
The fifth element of the hexaflex is defining valued directions. Clients often are lost in escape and avoidance activities that cost them opportunities to have the things they value. Thus, a child who is afraid at night misses the opportunity for sleepovers with friends, even though he or she would value the fun of being at the friend’s house or, more precisely, the richness of a deeper relationship with the friend.
Values are life directions that are global, desired and chosen. They are “bigger” than goals. To illustrate, one may enter a counseling program with the goal of becoming a counselor, but the value behind it is investing one’s life in helping others. ACT offers a number of suggestions for helping clients clarify their values and how their inflexibility is keeping them from pursuing those values.
For example, you might ask clients to complete a “heroes worksheet” of people who inspire them or people they would like to emulate. Discuss what about the person speaks to the client. Another helpful technique is to have counselees imagine their 80th birthday party, attended by all the people they love most. Three of the people stand and state words of affirmation about what the counselee has meant to them. Who would those people be? What adjectives, descriptions or accomplishments would they speak about?
Values can lead to frustration if not pursued, so the sixth point of the hexaflex is committed action. The counselor helps the client translate values into committed action steps to take. Traditional behavioral activation or motivational interviewing strategies come into play here, with a focus on enduring any suffering the values might entail.
Think back to the Olympic Games that took place this past summer. So many of the stories of the successful athletes included conquering hardships, persevering through challenging contexts and overcoming various obstacles. We are well aware that sacrifice is necessary to achieve things in any area. ACT deliberately helps counselees make action plans based on their values and build patterns of action over time. Strategies might include encouraging clients to share their values with others and preparing them to stick to their plans in the midst of the barriers they will encounter along the way.
Values and committed action provide a natural home to the personal resources of counselees who value spirituality or religion in their lives. Properly understood, spiritual values are some of the more profound aspects of many people’s lives and a focal point to their getting out of bed in the morning. Furthermore, faith and spirituality can be helpful in moving reticent clients to action (Jason A. Nieuwsma, Robyn D. Walser and Steven C. Hayes, 2016).
Juanita just knows that she is anxious around people. She may not be aware that this is the flipside of desiring to have close relationships. As her counselor, you walk with her to help her recognize that intimacy is one of her core values and being around potential friends or lovers is a necessary step. She now realizes how her avoidance works against what she really wants, and she grasps that she wants intimacy more than freedom from anxiety. She develops a plan with you for attending a social event at work. Together, you and Juanita develop strategies to increase her motivation, including visualizing a friendship that comes out of the party. You troubleshoot how she will feel along the way and how to use the other skills as she willingly walks through the anxiety that awaits her. Together, you plan a celebration of her success at the next session.
The ACT model is a learning process. Clinicians will grow to use the six skills of psychological flexibility not only in counseling, but also in their personal lives. The growth I have personally experienced in learning ACT is one of my favorite things about it. My present moment awareness tells me how superficial this survey of ACT is, but I hope that this brief article activates your values of learning and trying new things, and that you will read up on ACT (a few resources are listed below), attend a workshop and test some of the techniques discussed here.
Additional suggested readings:
- Get Out of Your Mind & Into Your Life: The New Acceptance & Commitment Therapy by Steven C. Hayes with Spencer Smith, 2005
- Acceptance and Commitment Therapy: The Process and Practice of Mindful Change, second edition, by Steven C. Hayes, Kirk D. Strosahl and Kelly G. Wilson, 2012
- Learning ACT: An Acceptance and Commitment Therapy Skills-Training Manual for Therapists by Jason B. Luoma, Steven C. Hayes and Robyn D. Walser, 2007
- Mindfulness and Acceptance in Multicultural Competency: A Contextual Approach to Sociocultural Diversity in Theory and Practice by Akihiko Masuda, 2014
- ACT for Clergy and Pastoral Counselors: Using Acceptance and Commitment Therapy to Bridge Psychological and Spiritual Care by Jason A. Nieuwsma, Robyn D. Walser and Steven C. Hayes, 2016
Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.
Timothy A. Sisemore is director of research and professor of counseling at Richmont Graduate University. Contact him at firstname.lastname@example.org.
Letters to the editor: email@example.com
Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.