Tag Archives: Acceptance and Commitment Therapy

Counseling people who stutter

By Chad M. Yates, Karissa Colbrunn and Dan Hudock April 11, 2018

Kyle hears the drone of the elevator music playing behind the bland voice that states, “All calls are important to us. Thank you for your patience. A customer service representative will be with you in just a moment.” Kyle knows the message well because he has been on hold for nearly 15 minutes. While waiting, Kyle practices in his head the message he needs to state: “Hello, my name is Kyle, and I need to schedule a shuttle ride to and from the airport.”

Suddenly, a crackling voice replaces the music. “Hello, thank you for calling OK Shuttle. How can I assist you?”

Kyle feels his throat tighten and his chest begin to seize. “Hello, my name is Kyyyyyy, my name is Kyyyyyyy, Kyyyy.”

“Sir, are you there? Sir, are you there?” insists the customer service rep.

Kyle continues: “Hello, my name is Kyyyyle. I need to schedddddd … I need to schedddddd, scheddddd.”

“Sorry, sir,” the voice on the other line says. “We have a poor connection. Please call back again when your service is more reliable.”

The sound of the click thunders in Kyle’s ear as a tight-pitched squeal replaces the silence. Kyle looks down at his feet, too afraid to pick them up and move. He feels frozen in anger, disgust and helplessness. Fear precludes the idea of calling back again.

This experience is all too common for people who stutter (PWS). For these individuals, the experience of communication, which many of us take for granted, becomes a blockade that stands between connection, understanding and the navigation of one’s world.

Experts in the field of speech-language pathology define stuttering as a communication disorder involving disruptions, or disfluencies, in an individual’s speech. The cause of stuttering is typically thought to be a neurological condition that interferes with the production of speech. Although many children spontaneously recover from stuttering, for approximately 3 million U.S. adults (about 1 percent of the population), stuttering is chronic and has no cure. Despite this, there are ways to manage stuttering in both the behavioral sense (how much the person stutters) and the psychological sense (how much stuttering impacts the person’s life).

Situations such as the one that Kyle experienced can happen almost daily for PWS. The pain of these experiences often leads these individuals to isolate themselves from the things they love to do because the risk of communicating can feel as if it outweighs the benefits of living the life they want to live. Peer reactions to unusual speaking patterns can begin as early as age 4. These reactions persist and increase throughout adolescence, which can negatively affect many facets of life, including social relationships, emotional well-being and academic performance, for PWS. Adults who stutter have scored significantly lower in questionnaires regarding quality of life, specifically in regard to vitality, social functioning, emotional role functioning and mental health. Although various studies show that counseling is indicated with this population, many speech-language pathologists are not trained in counseling or do not feel comfortable with their counseling skills and abilities.

Interprofessional collaborations between speech-language pathologists and counselors can be considered best practice for helping PWS and other individuals with common communication disorders. Idaho State University’s counseling and speech-language pathology departments are involved in a unique relationship in which they are training both speech-pathology interns and counseling interns to work side by side to treat PWS. This treatment is provided through the university’s Northwest Center for Fluency Disorders Interprofessional Intensive Stuttering Clinic (NWCFD-IISC), which offers a two-week clinic for adolescents and adults who stutter.

The clinic is the first of its kind in which speech-language pathologists and counseling interns work together to treat the holistic needs of clients who stutter through acceptance and commitment therapy (ACT), a mindfulness-based mental health approach. We (the authors of this article) have conducted the clinic over four consecutive years. Through this experience, we feel that we can share recommendations for counselors working with PWS and with other clients who present with communication disorders. Additionally, we have observed key ingredients for interprofessional collaboration and can speak to strategies to build effective interprofessional teams.

Recommendations for counselors

To be effective working with PWS, counselors need to address the misconceptions they have about stuttering. Consulting resources, such as the National Stuttering Association and the Stuttering Foundation, that are supported by PWS can help counselors to debunk common myths associated with this population.

One common myth is that stress causes a person to stutter. Another myth is that taking deep breaths before one speaks can eliminate stuttering. We have heard countless “cures” for stuttering from the general public. These include placing spices under one’s tongue, receiving acupuncture and sitting or standing with the correct posture. These erroneous cures can be insulting and demeaning to PWS. At best, it is frustrating for PWS to hear these ideas repeated over and over again. Counselors should be knowledgeable about the lack of support for these types of cures while being able to point out to clients resources on effective treatments.

For PWS, reactions from listeners often can be painful. As PWS become more aware of their stuttering and encounter negative listener reactions to their disfluencies, they may develop negative emotions toward communication situations and begin to avoid speaking. The shame and guilt that PWS often feel for stuttering can lead to fear, anxiety and tension in relation to communication, as well as decreased self-confidence. PWS may develop secondary behaviors that they employ in hopes of alleviating their stuttering. These secondary behaviors might include avoiding eye contact, avoiding speaking to people in positions of authority and avoiding certain words that they anticipate stuttering. Being aware of this, it is important for counselors to understand the role that positive regard, expressed behaviorally through continuous eye contact or not averting their glance when PWS speak, can have on these individuals.

Working effectively with PWS also involves using positive and respectful communication practices. During conversations, time pressure can be present when PWS take longer to communicate. This can sometimes lead to one party attempting to finish the other’s sentences. To PWS, this behavior can suggest that their communication of ideas may not be as important as the other speaker’s time.

Finishing a person’s sentences is often done in reaction to uncomfortable feelings associated with the time pressure of communication. Counselors should be aware of when they are experiencing these feelings. They should continue to allow their clients who stutter to finish what they wish to say regardless of time pressure and regardless of whether these clients are having blocks (when sound or air is stopped in the lungs, throat or mouth/lips/tongue), breaking off speech or having repetitions (repeating a sound, syllable or word more than once or twice).

The final recommendation involves the use of person-first language. Often, PWS call themselves “stutterers.” Reframing the language to say a “person who stutters” can reduce the stigma that surrounds the word “stutterer.” This action also treats the person as an individual. During the NWCFD-IISC, we empower PWS and work to mitigate stigma by reinforcing the idea that what a person says is more valuable and important than the way he or she says it. We also affirm that all individuals deserve to communicate their thoughts and ideas.

Recommendations for interprofessional teams

Interprofessional teams can be difficult to start and maintain in practice. Professional training often maintains solo practice as its modality, adding topics related to interprofessional collaboration as elective practice. We have used the stuttering clinic as a way to train counseling and speech-language interns in interprofessional practice and application.

We have observed that to effectively build these teams, it is essential to train our interns on the respective scopes of clinical practice, professional roles and clinical responsibilities of each other’s professions. We also train our students on how to work in teams, how to build relationships based on open communication and respect, and how to understand and use team dynamics that occur during practice. Finally, we reinforce the shared values of both professions — that the well-being of the client is paramount to the purpose of the team.

We have observed that interns typically begin collaborations with thicker boundaries of professional practice and rigid time sharing when interacting with clients. However, after the pair begin to find comfort and understanding of each other’s professional roles, these boundaries begin to wane. Time sharing becomes much more dynamic and less rigid. When intern pairings are working effectively, we see the pair begin to assist each other in their roles and to plan out how they can work together to assist the client during the next session.

To facilitate the interns working together, we teach them specific strategies that are unique to each profession. For example, the speech-language interns learn how to use basic listening skills and practice these skills with the help of their counseling partners. Speech-language interns also learn the foundations of counseling interventions. Specific to the NWCFD-IISC, the interns learn the foundations of ACT. All interns are also taught the practice of meditation and mindful practice, and the principles of acceptance, thought defusion and emotional expansion. Counseling interns learn the foundations of speech-language pathology interventions. Specific to the NWCFD-IISC, they learn about how stuttering occurs, how to assess for stuttering and the social and emotional impacts of stuttering.

All interns in the clinic engage in pseudo-stuttering (fake stuttering) in public and use speech-modification techniques with all clinic participants and the public. Pseudo-stuttering can be used as a therapeutic strategy for PWS to increase acceptance and openness with their stuttering and to increase self-confidence. When the clinic interns pseudo-stuttered and used speech-modification techniques with NWCFD-IISC clients in public, the clients reported that these experiences strengthened the client-clinician relationship.

Our recommendation to counselors and speech-language pathologists who desire to develop collaborative teams is to be intentional about building a professional relationship on the grounds of respect and open communication. The team members should take time to learn about one another’s professions, roles and clinical responsibilities. We have observed during the training of our interns that speech-language pathologists are often focused on outcomes and data collection, whereas counselors are often more focused on process elements and the clinical relationship. It is essential to see both sides of the team as contributing to the overall impact in a unique way. The team members will work to support one another’s strengths and weaknesses.

Counseling interventions

The NWCFD-IISC uses an ACT framework. ACT was chosen because it provides a strengths- and skills-based approach grounded in mindfulness and psychological flexibility. ACT explores human suffering as it relates to psychological inflexibility. Using this framework, PWS learn to more fully focus on the present moment, become more accepting of their thoughts and feelings, and take steps toward acting in alliance with their personal values.

Several studies have supported positive results regarding the efficacy of ACT when applied to stuttering. In addition to this supported efficacy, we think that ACT closely aligns with the philosophy of the NWCFD-IISC. Our philosophy of treatment involves clients and students taking a team approach to understand, accept and effectively manage thoughts, emotions and behaviors related to stuttering. This is accomplished through generalized experiential activities, group education and discussion, and individual and group counseling.

ACT can be understood through the six guiding principles on the ACT hexaflex. These six principles are acceptance, thought defusion, mindfulness, self as context, values and committed action. Investigating how each principle applies, we can begin to understand the process of counseling PWS through an ACT lens.

1) Mindfulness: Clients who stutter often avoid the present moment by judgmentally reviewing the past or worrying about the future. Clinicians can help PWS to connect with the present moment through the use of meditation and mindfulness activities. Encouraging mindful practices can be a goal to incorporate in counseling.

2) Acceptance: PWS often feel like they have no control over their stuttering. Regardless of what they do, a stuttering moment may or may not arise. In these moments, PWS can choose to talk, choose to stutter openly and choose to acknowledge all the thoughts and emotions related to stuttering. Clinicians can help PWS explore acceptance of their thoughts and feelings. PWS do not need to like the thoughts or emotions they experience or enjoy stuttering. However, they can experience their thoughts or emotions as they surface without judgment.

3) Thought defusion: PWS have a tendency to overidentify with their thoughts or feelings, enabling these thoughts and feelings to become mental truths that cause inflexibility within the thought process. PWS may attempt to mentally avoid stuttering or become overwhelmed trying to control their speech. Additionally, PWS may feel certain that other people will reject or harshly criticize them, thus causing them to avoid social contact.

Clinicians can help PWS to explore and express all thoughts — helpful and unhelpful — about their stuttering. By unhooking from the thought or emotion, PWS can experience more psychological flexibility in relation to the context that the thought or emotion is occurring within.

4) Self as context: Individuals often associate with expressions in the form of labels, such as “I am smart” or “I am dumb.” These labels relate to content, not context. Individuals may define themselves in terms of content instead of context to fuse with thoughts and emotions that may be either known or unknown. PWS use self-as-content behaviors to avoid facing the reality of stuttering. PWS may think, “I stutter. That’s all I do. Because of my stuttering, I do poorly in school and never meet new people.”

Clinicians should explore with PWS how these thoughts about self are related either to content or context. Reinforcing flexibility in self-identity is key because it allows PWS to adapt more flexibly to novel situations.

5) Defining values: As described by Jason Luoma, Steven Hayes and Robyn Walser, in ACT, values are defined as “constructed, global, desired and chosen life directions” that can be expressed as adverbs or verbs. When exploring values with PWS, the notion of choice is important to discuss. Choice connotes the flexibility and autonomy they possess in defining what guides their behaviors or life direction.

A common values activity involves the “eulogy exercise.” During this activity, PWS visualize what a close friend would say at their funeral. Clinicians might even direct PWS to write down the values that were expressed during the eulogy: “He was a kind person” or “She was a caring friend” or “He was a compassionate individual.” Clinicians can then discuss these values with PWS and explore how these values are currently manifested and how they can become lost. Building awareness of what values are important in a person’s life can encourage these clients to persist through the difficult times they face.

6) Committed actions: ACT explores the concept of choice in alignment with values-based goals. When clients feel ready to initiate steps either within or outside of counseling, exploration of these committed actions in the counseling session is warranted. For PWS, committed actions could be used by encouraging challenging stuttering situations. For example, PWS may choose to take action directed at speaking situations during dating, during novel social interactions or within work settings. Committed action is the stage of counseling that encourages the synthesis of the tools within the complete hexaflex. PWS learn to engage in a way that is adaptive and flexible to their external and internal worlds.

Summary

Counseling PWS can be a rich and rewarding experience. Through our work in the NWCFD-IISC, we have built lasting connections with individuals in the stuttering community and learned how to form strong interprofessional teams that enhanced our understanding of two professions. In working with PWS, understanding the specific population concerns is key to effective treatment. Additionally, collaboration with professionals in the speech-pathology discipline can further enhance treatment experiences for PWS and for all professionals engaged in the collaboration.

 

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Chad M. Yates is a licensed professional counselor and an assistant professor in the Idaho State University (ISU) Department of Counseling. He has served as the mental health coordinator for the Northwest Center for Fluency Disorders at ISU for several years. He helped to develop the acceptance and commitment therapy (ACT) manuals and procedures for clients and clinicians at the clinic and supervises the counselors providing ACT. Contact him at yatechad@isu.edu.

Karissa Colbrunn is a school-based speech-language pathologist in Pocatello, Idaho. She is passionate about merging the values of the stuttering community with the field of speech-language pathology.

Dan Hudock is an associate professor at ISU. As a person who stutters, he is passionate about helping those with fluency disorders. One aspect of his research involves exploring effective collaborations between speech-language pathologists and mental health professionals for the treatment of people who stutter. He is the director of the Northwest Center for Fluency Disorders. For information about research, clinical or support opportunities, visit northwestfluency.org.

Letters to the editor: ct@counseling.org

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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.

Talking through the pain

By Laurie Meyers January 30, 2018

By the time the 43-year-old man, a victim of an industrial accident, limped into American Counseling Association member David Engstrom’s office, he’d been experiencing lower back pain for 10 years and taking OxyContin for six. The client, whose pain was written in the grimace on his face as he sat down, was a referral from a local orthopedic surgeon, who was concerned about the man’s rapidly increasing tolerance to the drug.

“He often took twice the prescribed dose, and the effect on his pain was diminishing,” says Engstrom, a health psychologist who works in integrated care centers.

The man’s story is, unfortunately, not unusual. According to the National Institutes of Health, 8 out of 10 adults will experience lower back pain at some point in their lives. As the more than 76 million baby boomers continue to age, many of them will increasingly face the aches and pains that come with chronic health issues. And as professional counselors are aware, mental health issues such as depression, anxiety and addiction can also cause or heighten physical pain.

Those who suffer from chronic pain are often in desperate need of some succor, but in many cases, prescription drug treatments or surgery may be ineffective or undesirable. Fortunately, professional counselors can often help provide some relief.

Treating chronic pain

At first, the client had only one question for Engstrom: “I’m not crazy, so why am I here?”

Although the man’s physician did not think that the pain was all in the man’s head, it is not uncommon for sufferers of chronic pain to encounter skepticism about what they are experiencing. “It was important … to defuse the idea that I might think he was imagining his pain,” Engstrom says. “So I [told him] that I accepted that his pain was real and that all pain is experienced from both body and mind. I told him that we would be a team and work on this together.”

Engstrom and the client worked together for five months. As they followed the treatment plan, the man’s physician slowly eased him off of the OxyContin.

Engstrom began by teaching the client relaxation exercises such as progressive muscle relaxation. “When in pain, the natural inclination of the body is to contract muscles,” Engstrom explains. “In the long term, this reduces blood flow to the painful area and slows the healing process. Contracted muscles can be a direct source of pain.”

Engstrom also began using biofeedback to promote further relaxation. In biofeedback sessions, sensors are attached to the body and connected to a monitoring device that measures bodily functions such as breathing, perspiration, skin temperature, blood pressure, muscle tension and heartbeat.

“When you relax, clear your mind and breathe deeply, your breathing slows and your heart rate dips correspondingly,” Engstrom explains. “As the signals change on the monitors, you begin to learn how to consciously control body functions that are normally unconscious. For many clients, this sense of control can be a powerful, liberating experience.”

As Engstrom’s client learned to control his responses, he began reporting a decrease in pain following the relaxation exercises.

Engstrom also used cognitive behavior therapy (CBT) methods, including asking the man to keep a daily journal recording his pain level at different times of the day, along with his activity and mood. Through the journal, the man started recognizing that his pain level wasn’t constant. Instead, it varied and was influenced by what he was doing and thinking at the time.

Engstrom highly recommends CBT for pain treatment because it helps provide pain relief in several ways. “First, it changes the way people view their pain,” he says. “CBT can change the thoughts, emotions and behaviors related to pain, improve coping strategies and put the discomfort in a better context. You recognize that the pain interferes less with your quality of life and, therefore, you can function better.”

In this case, the client was trapped by thoughts that “the pain will never go away” and “I’ll end up a cripple,” Engstrom says. He and the client worked on CBT exercises for several months, keeping track of and questioning the validity of such negative future thoughts. They also practiced substituting more helpful thoughts, including “I will take each day as it comes” and “I will focus on doing the best I can today.”

Chronic pain often engenders a sense of helplessness among those who experience it, Engstrom says, so CBT also helps by producing a problem-solving mindset. When clients take action, they typically feel more in control of their pain, he says.

CBT also fosters new coping skills, giving clients tools that they can use in other parts of their lives. “The tactics a client learns for pain control can help with other problems they may encounter in the future, such as depression, anxiety or stress,” Engstrom says.

Because clients can engage in CBT exercises on their own, it also fosters a sense of autonomy. Engstrom often gives clients worksheets or book chapters to review at home, allowing them to practice controlling their pain independently.

Engstrom notes that CBT can also change the physical response in the brain that makes pain worse. “Pain causes stress, and stress affects pain-control chemicals in the brain, such as norepinephrine and serotonin,” he explains. “By reducing arousal that impacts these chemicals, the body’s natural pain-relief responses may become more powerful.”

Although Engstrom acknowledges that he could not completely banish the discomfort his client felt, he was able to lessen both the sensation and perception of the man’s pain and give him tools to better manage it.

Taking away pain’s power

Mindfulness is another powerful tool for lessening the perception of pain, says licensed professional counselor (LPC) Russ Curtis, co-leader of ACA’s Interest Network for Integrated Care.

Mindfulness teaches the art of awareness without judgment, meaning that we are aware of our thoughts and feelings but can choose the ones we focus on, Curtis continues. He gives an example of how a client might learn to regard pain: “This is pain. Pain is a sensation. And sensations tend to ebb and flow and may eventually subside, even if just for a little while. I’ll breathe and get back to doing what is meaningful to me.”

Engstrom agrees. Unlike traditional painkillers, mindfulness is not intended to dull or eliminate the pain. Instead, when managing pain through the use of mindfulness-based practices, the goal is to change clients’ perception of the pain so that they suffer less, he explains.

“Suffering is not always related to pain,” Engstrom continues. “A big unsolved puzzle is how some clients can tolerate a great deal of pain without suffering, while others suffer with relatively smaller degrees of pain.”

According to Engstrom, the way that people experience pain is related not just to its intensity but also to other variables. Some of these variable include:

  • Emotional state: “I am angry that I am feeling this way.”
  • Beliefs about pain: “This pain means there’s something seriously wrong with me.”
  • Expectations: “These painkillers aren’t going to work.”
  • Environment: “I don’t have anyone to talk to about how I feel.”

By helping people separate the physical sensation of pain from its other less tangible factors, mindfulness can reduce the suffering associated with pain, even if it is not possible to lessen its severity, Engstrom says.

According to Engstrom, mindfulness may also improve the psychological experience of pain by:

  • Decreasing repetitive thinking and reactivity
  • Increasing a sense of acceptance of unpleasant sensations
  • Improving emotional flexibility
  • Reducing rumination and avoidant behaviors
  • Increasing a sense of acceptance of the present moment
  • Increasing the relaxation response and decreasing stress

Curtis, an associate professor of counseling at Western Carolina University in North Carolina, suggests acceptance and commitment therapy (ACT) as another technique to help guide clients’ focus away from their pain.

“ACT can help people revisit what their true values are, whether it’s being of service, having a great family life or creating art,” he notes. Encouraging clients to identify and pursue what is most important to them helps ensure that despite the pain they feel, they are still engaging in the things that give their lives meaning and not waiting for a cure before moving forward, Curtis explains.

Teamwork and support

In helping clients confront chronic pain, Curtis says, counselors should not forget their most effective weapon — the therapeutic relationship. Because living with chronic pain can be very isolating, simply sitting with clients and listening to their stories with empathy is very powerful, he says.

Counselors have the opportunity to provide the validation and support that clients with chronic pain may not be getting from the other people in their lives, says Christopher Yadron, an LPC and former private practitioner who specialized in pain management and substance abuse treatment. The sense of shame that often accompanies the experience of chronic pain can add to clients’ isolation, he says. According to Yadron, who is currently an administrator at the Betty Ford Center in Rancho Mirage, California, clients with chronic pain often fear that others will question the legitimacy of their pain — for instance, whether it is truly “bad enough” for them to need extended time off from work or to miss social occasions.

Curtis says it is important for counselors to ensure that these clients understand that the therapeutic relationship is collaborative and equal. That means that rather than simply throwing out solutions, counselors need to truly listen to these clients. This includes asking them what other methods of pain relief they have tried — such as supplements, over-the-counter painkillers, physical therapy, yoga or swimming — and what worked best for them, Curtis says.

The U.S. health care system has led many people to believe that there is a pill or surgery for every ailment, Curtis observes. This makes the provision of psychoeducation essential for clients with chronic pain. “Let them know there’s no magic bullet,” he says. Instead, he advises that counselors help clients see that relief will be incremental and that it will be delivered via multiple techniques, usually in conjunction with a team of other health professionals such as physicians and physical therapists.

Curtis, Yadron and Engstrom all agree that counselors should work in conjunction with clients’ other health care providers when trying to address the issue of chronic pain. Ultimately, however, it may be up to the counselor to put the “whole picture” together.

A 60-something female client with severe depression was referred to Engstrom from a pain clinic, where she had been diagnosed and treated for fibromyalgia. After an assessment, Engstrom could see that the woman’s depression was related to continuing pain, combined with social isolation and poor sleep patterns. The woman was unemployed, lived alone and spent most of her day worrying about whether her pain would get any better. Some of her previous doctors had not believed that fibromyalgia was a real medical concern and thus simply had dismissed her as being lonely and depressed. Despite finally receiving treatment for her fibromyalgia, the woman was still in a lot of pain when she was referred to Engstrom.

Engstrom treated the woman’s depression with CBT and taught her to practice mindfulness through breathing exercises and being present. Addressing her mood and sleep problems played a crucial role in improving her pain (insomnia is common in fibromyalgia). By dismissing the woman’s fibromyalgia diagnosis, discounting the importance of mood and not even considering the quality of her sleep, multiple doctors had failed to treat her pain.

Engstrom points out that in this case and the case of his client with lower back pain, successful treatment hinged on cognitive and behavioral factors — manifestations of pain that medical professionals often overlook.

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

 

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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.

 

‘I’m not broken, just stuck’

By Timothy A. Sisemore December 27, 2016

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.

Central points

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.

Conclusion

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

 

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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 tsisemore@richmont.edu.

Letters to the editor: ct@counseling.org

 

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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.

The Counseling Connoisseur: Zen and the Art of Home Improvement: Learning to ACT

By Cheryl Fisher July 24, 2016

“When you catch yourself slipping into a pool of negativity, notice how it derives from nothing other than resistance to the current situation.”

Donna Quesada, Buddha in the Classroom: Zen Wisdom to Inspire Teachers

 

I recently took on several home improvement projects. With a contractor hired, my home became a construction site for two weeks. I had pined over the built-in bookshelves, cabinets and window seat for so long that the books I had selected to place on the shelves were now in their second editions. Sawdust, spackle, paint and trips to the local hardware store became my new normal, but the inconvenience and chaos would all be worth it in the end. I had even thrown in a bathroom update project for my guest bathroom that had lain dormant since the 1980s. A new sink, faucet set, medicine cabinet and light fixture updated the look, especially after the dated tile backsplash was removed, spackled and painted. What a tremendous difference a light facelift can provide to the appearance and feel of a room. The final day arrived when I paid my contractor and began the arduous cleanup from two weeks’ worth of construction.

With everything clean, I stood back and admired my new built-ins. I imagined what the custom pillow that was being sewn would look like when put in the window seat. I longed to place the books on the shelves and board games in the cabinets. However, the paint needed to cure (according to our contractor), photo-1418754356805-b89082b6965eso there would be no decorating for at least two weeks lest we put dents in the freshly painted built-ins.

With a sigh (both of satisfaction and impatience), I took my admiration to the guest bathroom. It was so crisp with its new white marble sink and designer brushed nickel faucet against the blue walls. The large framed mirror (also brushed nickel) boasted ample storage in the cabinet. The three-sconce light tilted upward, shining new LED lights against the clean white ceiling. So classic and fresh: Blue and white, brushed nickel … and chrome? The glare from the chrome towel bars was blinding. I adjusted the towels a bit to cover the shiny finish. Unsuccessful, I turned the lights off, and then on again, to see if it had been just a momentary glare. Much to my frustration, however, the brash incongruence from all of the chrome accessories now looked painfully hideous.

OK, no worries. I would simply buy new towel bars and a toilet paper holder in a brushed nickel finish. My contractor was already on to a project for another client, but how hard could it be to replace these items myself? I would buy the same exact sizes, remove the old bars and slap the shiny new brushed nickel bars over top. Simple!

Those of you who have engaged in home improvements of any type know there are fundamental rules that govern this process:

1) Rarely are things as simple as they look.

2) It usually takes longer than planned.

3) It typically costs more than planned.

My simple project was no exception. As I removed the surface mounts, I noted huge holes left in the wall from previously removed toggle anchors. No worries. I would just put the new mounts over top and cover up the blemishes. No such luck. The positioning of the new towel rods exceeded the length of the previous mounts. Therefore, the mounts needed to be moved roughly 1.5 inches out from the original point. This resulted in the need to spackle the old sites and sand, measure, level and drill new holes for the new mounts.

Really? All I wanted to do was craft a quick little facelift for my guest bathroom. Now I was going to have to set aside time to plan the project, identify and collect the needed tools, and actually do the work! Furthermore, I would need to find the leftover paint or attempt to match the color. Frustrated, I went down to the basement where the tools hibernate. I collected my power drill, level, Allen wrench set, Phillips and straight-head screwdrivers, spackle paste and applicator, sandpaper and (low and behold) a can of matching blue paint for the touch-ups.

Armed with the tools, I went back up to the bathroom, laid out my tools and unfolded the instructions. Taking a deep breath, I accepted the situation, committed to the project and started the work.

Acceptance and commitment

Acceptance and commitment therapy (ACT), developed largely by Steven Hayes in the 1980s, is a mindfulness-based behavior therapy that assumes the normal human experience includes destructive patterns that results in psychological suffering. ACT, based on empirical study, emphasizes values, forgiveness, acceptance, compassion, living in the present moment and accessing a transcendent sense of self.

According to Russell Harris in his article “Embracing Your Demons: An Overview of Acceptance and Commitment Therapy,” the goal of ACT is to “create a rich and meaningful life while accepting the pain that inevitably goes with it.” Suffering and symptoms are not labeled and targeted for reduction. Often, it is our pathologizing of thoughts, behaviors and experiences that leads to attempts at symptom reduction or elimination. This pattern often results in disordered behavior — and the cycle continues.

The aim of ACT is to transform our relationship with our difficult thoughts, feelings and experiences in a way that normalizes the experience. The byproduct of acceptance appears to be — wait for it — symptom reduction.

For example, I recall working with a young client who had been experiencing some discontent in her relatively new marriage. She described her husband as “immature and a hermit.” She then went on to discuss how excited she was about a new work project that was challenging, social … and attached to a handsome, charismatic project leader who “commanded the attention of everyone in the room.”

The client initially denied her attraction to this co-worker and the role it played when viewing her less-than-perfect spouse. Once she was able to lean in to her feelings for the co-worker and assess the deeper meaning around her attraction, she recognized that she resented her younger husband who had always relinquished his power to her. He liked being taken care of, and she resented not having an equal partner. Armed with this revelation, the client was able to focus on her marital dissatisfaction in couples counseling rather than avoid it with the studly distraction at work.

Do the work

ACT interventions emphasize two main processes. The first is to develop acceptance of situations that are out of our control. Devoting energy and time to that which we have no control over is futile. The second is to commit to engaging in activities that cultivate living a valued and meaningful life. Again, there is emphasis on identifying that which is worthy of our efforts and energy.

Furthermore, there are six core principles that guide the processes.

  1. Cognitive defusion: The ability to view thoughts, images and memories as simply bits of language, words and pictures. This is different than perceiving them as threatening events, rules that must be obeyed or objective truths and facts. For example, my thoughts around the bathroom project rested in the “I don’t have time” category. I have struggled often with this myth that there is never enough time. When I stopped obsessing over these thoughts, I was able to actually take action.
  1. Acceptance: The process of making room for uncomfortable feelings, sensations, urges and experiences, and allowing those things to come and go without struggling with them, avoiding them or giving them undue attention. Once I accepted the feelings of inconvenience and discomfort that originally paralyzed me, I was better able to begin the steps toward completing the bathroom project.
  1. Contact with the present moment: Focus on and engage fully in whatever you are doing. Being able to watch my progress from holes in the bathroom wall to finished product was satisfying. Each step provided me with a new sense of accomplishment.
  1. The Observing self: From this perspective, it is possible to note that you are not your thoughts, feelings, memories, urges, sensations, images, roles or physical body. Although these are aspects of you, they are not the essence of you. I knew this was a project that would stretch me out of my professor-clinician-author comfort zone, and it was possible I would not succeed. However, the project (regardless of the end result) would not define me or my worth. I realized that I am part of something bigger that transcends my spackling abilities.
  1. Values: Clarify what is most important, significant and meaningful to you. I like to think of myself as open and always ready for a new challenge. My “can do” attitude has taken me to (and through) some amazing and challenging experiences. Completing this project would validate my belief that I am capable of any endeavor with a little effort.
  1. Committed action: Set goals that are guided by your values, and take effective action to achieve them. Breaking down my bathroom project into smaller, more manageable steps proved effective. Step by step, I completed each task and experienced success in a way that propelled me to the next step. Ultimately, I experienced the sense of accomplishment in tackling this small but meaningful project.

Conclusion

Clients often present an earnest desire to be pain free. We can assist them in reframing their understanding that the discomfort they are experiencing (which may be paralyzing) is a participant in their journey. It is the fear of this discomfort (anger, sadness and depression) and the desire to avoid it that creates greater angst. When we lean in to the situation, accept that it may be difficult and, during some parts, even unpleasant, we allow emotional space to engage in getting the work done! In other words, one can feel uncomfortable and still survive — even thrive and accomplish goals.

Therefore, taking a bit of my own advice, I rolled up my sleeves, grabbed a drill and proceeded to hang my new towel bars. Once I was able to accept the temporary discomfort of engaging in this project, I was able to commit the effort required to complete it. The mess, previously underneath the shiny new mounts, had been carefully and completely tended to, allowing my new towel racks to hang solidly and sturdily, ready to take on their purpose: to hang my new bath towels.

 

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Cheryl Fisher

Cheryl Fisher

Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland, and a visiting full-time faculty member in the Pastoral Counseling Department at Loyola University Maryland. Her current research examines sexuality and spirituality in young women with advanced breast cancer. She is currently working on a book titled Homegrown Psychotherapy: Scientifically-Based Organic Practices, of which this article is an excerpt. Contact her at cy.fisher@verizon.net.