Tag Archives: Acceptance and Commitment Therapy

Treating depression by focusing on solutions and acceptance

Compiled by Lisa R. Rhodes November 21, 2022

Tanongsak Panwan/Shutterstock.com

Depression is a common mental health disorder and affects people from every walk of life, regardless of their age, race, ethnicity or socioeconomic background. According to the National Alliance on Mental Illness, approximately “21 million adults in the United States — 8.4% of the population — had at least one major depressive episode in 2020.” 

Common treatments for depression often include cognitive behavioral therapy (CBT) and psychotherapies that focus primarily on a client’s past. However, they are not the only approaches counselors can use. Solution-focused brief therapy (SFBT) and acceptance and commitment therapy (ACT) are evidence-based counseling approaches that have also been found to be effective in treating depression. Counseling Today asked six counselors to discuss the effectiveness of these two clinical approaches for treating clients with depressive symptoms. 

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Fostering hope through SFBT

By Foley L. Nash 

For me, one factor in the effectiveness of SFBT is the set of themes that runs through its basic tenets. The main themes are building exceptions to the presenting problem and making rapid transitions to identify and develop solutions intrinsic to the client or problem. These themes resonate well with clients, particularly those experiencing depression, as well as with a subset of depressed clients who experience comorbid anxiety, which can occur in as much as 70% of depression cases.

In treating depression, the emphasis of a solution-focused approach is to counter hopelessness, which is an important and common factor related to the frequently present risk of suicide. SFBT benefits depressed clients by engendering hope for the possibility of finding solutions in ways that are tied to the following basic tenets:

  1. A focus on competence, not pathology (emphasizing the client’s power and hope)
  2. The goal of finding a unique solution for the individual client (not a cookie-cutter approach)
  3. The use of exceptions to the problem to foster optimism (hope)
  4. The use of past successes to support/increase client confidence (hope)
  5. The view of the client as the expert (acknowledging the client’s power)
  6. The use of goal setting in charting a path to change (scaling questions are important in goal setting)
  7. A shared responsibility for change between client and therapist (supportive partnership)

In SFBT, the emphasis shifts from problems to solutions, which empowers clients by allowing them to access their own internal resources, strengths and prior successes.

The following are the aspects of SFBT that appeal to me:

  • It’s an evidence-based practice (EBP) and its proven effectiveness has been documented. As a managed care clinical director, I see increased emphasis on EBP providers by large payers. In my private work, employee assistance programs also like the use of EBPs for the greater likelihood of faster change in their shorter treatment episodes.
  • It’s largely focused on the skillful use of language for therapeutic purposes. As the Greek philosopher Epictetus said, “People are disturbed not by things, but by the views they take of them.” Helping clients to see things differently is one of the useful functions of SFBT, which allows clinicians to ask questions such as, “How did you make that improvement happen during that time?” or “What would your best friend say you did differently when things were better?” 
  • As a former language teacher/linguist who now conducts therapy in English and Spanish, I ascribe to the outlook that language is the tool of thought. SFBT can be immediately helpful in guiding clients to think differently about potential solutions. Instead of accepting that clients are as helpless as they may feel, counselors can try asking about how they have managed to achieve and sustain some of the times when the problem was absent or less severe. It’s helpful for the therapist to have some affinity for fluency in language and in the SFBT tools. As counselors study some of the SFBT principles, strategies and techniques, they will encounter many examples of questions that use language in helpful ways to change a client’s perspective, and they can become more skilled, thoughtful and proactive about how to use language to bring about a shift in a client’s perspective. 
  • I’ve found over time that SFBT and its tools are also very helpful in helping clients become “unstuck” and breaking an impasse.

SFBT focuses on helping the client to reframe the situation, develop second-order change that supports solutions, and see the situation as something they can manage and change by using their own strengths and abilities. While first-order change is behavioral, as in doing things differently (sometimes described as matter over mind), second-order change is conceptual (often described as mind over matter) and involves helping a client to see things differently. This type of change can help a client with depressive symptoms to be more readily able to make the desired behavioral change to move toward a modified or new solution.

I have also found that SFBT is effective in treating depression along with comorbid anxiety. In my practice, clients frequently present with both depression and anxiety. It’s useful to focus initially on whichever condition is creating the most significant impairment in functioning for the client. This can provide a quick initial improvement and encourages the client to continue to address the less problematic condition, which, in my experience, is usually the anxiety.

Comorbid anxiety and its occasional panic attacks often engender fear in clients, especially the fear of the next panic attack after an initial one, as well as the corresponding sense of fear about the loss of control. By providing hope to clients, SFBT has treatment application for both depression and anxiety.

Foley L. Nash is a licensed professional counselor supervisor with a private practice in Baton Rouge, Louisiana. He works mostly with adults and often provides short-term employee assistance program services. Contact him at foley1@foleynash.com.

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Working toward a solution-focused goal

By Marc Coulter 

Jeremy (a hypothetical client) was hopeful and enthusiastic early in life, but after a cross-country move and a long-term relationship ended just before the pandemic, he had difficulty coping. 

Some days, Jeremy couldn’t get out of bed to work. Other days, he showed up, but he felt dark and hopeless and didn’t care whether he lived. Jeremy’s depression continued through the pandemic and medication didn’t help.

When working with severely depressed clients such as Jeremy, SFBT practitioners maintain a stance of optimism and hope, knowing that a client’s past experiences and feelings of depression do not determine future outcomes. 

A solution-focused perspective directs the course of therapy toward solutions, rather than focusing on problems, and guides the questions we ask. With empathy, compassion, respect, curiosity and hopefulness, we acknowledge and honor whatever agonizing feelings, or perhaps the lack of feelings, clients such as Jeremy experience while co-creating a preferred future.

Hope

SFBT counselors often explore what gives depressed clients hope. In Jeremy’s case, what gave him hope was knowing that change was possible. Sometimes clients live their lives and show up to counseling sessions despite not feeling hopeful. SFBT counselors explore how clients show up and participate in their lives despite the lack of hope. In session, we reaffirm what they’ve said is meaningful in their lives and why it may be important to keep moving forward despite the lack of hope.

Solution building

In the book Tales of Solutions: A Collection of Hope-Inspiring Stories, Insoo Kim Berg, who along with Steve de Shazer co-founded SFBT, and Yvonne Dolan wrote that SFBT counselors begin therapy with a detailed description of a client’s desires. Clinicians can then explore possible times when these desired outcomes may have been present, even in small ways, to find solutions to their problems. The solution-building process for Jeremy might include questions such as “How might you want to cope given your circumstances? How have you been able to manage up until now? What helps even a little? What helps you make it through the day?” 

If Jeremy couldn’t imagine even one small movement toward feeling better, the counselor might ask, “What helps prevent it from getting worse?”

Focusing on Jeremy’s best hopes for therapy, the counselor might also say, “Suppose you’re walking away from our last session together and you’re thinking to yourself, ‘That was a really good use of my time, energy and money.’ What would you be walking away with that would make a difference?” Jeremy might respond, “Maybe I would feel less depressed.” The counselor could then ask, “Yes, of course, and if you felt less depressed, what might you feel instead?” Jeremy might say, “I guess lighter, more hopeful.”

The miracle question

When working with a client who is overwhelmed, depressed and suicidal, solution-focused counselors often ask the “miracle question,” a concept co-developed by Berg and de Shazer. The miracle question includes components of what the client has determined is a meaningful and important solution to their problem. In Jeremy’s case, that was “feeling lighter, more hopeful.” 

Using this technique, the counselor could ask Jeremy if it would be a miracle to feel this way, and Jeremy would agree. The counselor could ask him to imagine that while he was asleep the night before, a miracle happened. He would feel lighter and more hopeful, but because he was sleeping, he would have no idea the miracle happened.

The counselor could then ask Jeremy, “What might be the first thing you notice upon waking that would let you know that something was different?” After a pause, he might reply, “I would get up and not stay in bed.” The counselor and Jeremy could then explore how this would make a difference to him and the important people (and even pets) in his life. They could continue to slowly explore Jeremy’s miracle morning and the differences he and others had noticed.

Scaling questions 

The counselor could also use scaling questions, an SFBT tool, which can help to ground the miracle day for Jeremy in the reality of his life. For example, a scaling question might be, “On a scale of 1 to 10, with 10 being that miracle day and 1 being life prior to beginning counseling, where are you right now?” Jeremy may reply and say a 2. The counselor could then ask why he was that high (why he didn’t choose 1 or even -12) and explore what he was doing in his life that put him at that level rather than a lower one. Jeremy might name things like engaging with colleagues and taking care of his dog. Next, the counselor could ask him to imagine what he could do that would put him just a little higher on that scale, maybe even a half a point, and what difference that might make?

Marc Coulter is a licensed professional counselor in Lakewood, Colorado. He is a member of the American Counseling Association and past president of the Colorado Counseling Association. Contact him at marcjcoulter@liveyoursolution.com.

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The benefits and limitations of SFBT and CBT

By Nicole Poynter

SFBT and CBT are both effective in treating depression, but in different ways. Here are some of the benefits and limitations of both. 

If a client’s purpose for coming to therapy is to find a solution to a problem, then SFBT may be the right therapeutic approach. SFBT usually lasts for six to 10 weeks and focuses on a client’s strengths and capabilities. SFBT pays attention to the client’s problems in the present. In counseling, we believe that individuals have the inner resources, strengths and skills that are needed to help them to achieve their goals and overcome difficult life situations. The purpose of SFBT is for therapists to focus on a clients’ capabilities. This therapeutic technique focuses on problem-solving, generating solutions and moving toward a goal. 

The benefits of using SFBT for treating depression include the fact that it is short term and that is more cost effective than long-term therapy. Another benefit is that the counselor uses compliments in therapy, such as “That is amazing to hear,” when a client talks about a goal that has been met or a strength that was used, which can help to motivate clients to work toward their therapeutic goals. SFBT is also future-oriented, so clients do not get stuck in the past. The therapist focuses on what the client thinks their life will be like once the concern is resolved.

However, there are some limitations for choosing SFBT as a therapeutic model of choice. Some clients take more time to open up in therapy, so having only a few weeks for treatment does not make it easy to solve problems. This modality also focuses on the present, and it does not investigate the past and past traumas, which often contribute to unhealthy behaviors in the present. In addition, the counselor must trust the client and accept what the client desires for treatment, even if their goals are not beneficial. SFBT relies heavily on the therapist and client working together and works on the assumption that the client is willing to do the work to achieve their goal. 

CBT helps clients look at problems differently and encourages them to think in healthier ways. This approach focuses on thoughts, feelings and behaviors and how they are all connected. If a client has a negative thought, it can lead to a negative emotion, which can lead to unhealthy behaviors. In a CBT session, the counselor focuses on the client’s negative thinking, or cognitive distortions. Counselors help clients look for evidence to support a thought and evidence to support their thought distortions. After clients determine that they have more evidence against a negative thought, then they can work with the counselor to turn it into a more positive thought. 

There are some also some disadvantages to using CBT to treat depression. This approach is not intensive, so it is better for people with mild depressive symptoms. CBT has a high client dropout rate, which can be due to the hard work that is required in therapy or because it is not a quick fix. Although CBT is the strongest evidence-based treatment for depression, it takes a commitment to make it work. Clients must continue to use the skills they have learned to help prevent relapses. 

Neither one of these modalities is easy for clients. Homework is vital for both approaches, so clients can practice what they have learned in session. Change is gradual and takes time to manifest. There is no one-size-fits-all treatment for improving mental and emotional well-being. 

Both therapeutic treatments are effective in treating depression, so how does one know which one to use in practice? Talk to clients to understand their goals and preferences. Clarifying goals for therapy with a client will help determine what treatment modality is most appropriate. Being a therapist who is empathetic, client-centered and supportive is what is most important, regardless whether they use SFBT or CBT. 

Nicole Poynter is a licensed professional clinical counselor at Avenues of Counseling and Mediation LLC in Medina, Ohio. She works with children, adolescents, adults, and families and specializes in anxiety, depression, LGTBQIA+ issues, attention-deficit/hyperactivity disorder, parenting concerns, relationship distress, anger management and adjustment issues. Contact her at npoynter@avenuesofcounseling.org.

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Rekindling connection to self and others through ACT

By Lottena Wolters and Caitrin McKee

Since I (Lottena) began my D.C.-based private practice in 2016, new clients have increasingly presented with a profound loss of faith, but not in the religious sense. 

Theirs is a loss of faith in personal safety, which is included in the second level of Maslow’s hierarchy of needs, along with law and order, physical security and economic stability. Some of my clients have also lost faith in themselves and their fellow human beings and feel acutely disconnected from the communities outside their inner circles. This loss of faith is the primary and most persistent symptom of their depression. 

How do we help our clients feel connected and experience joy when they are bombarded with stressors such as news of political division, the ongoing COVID-19 pandemic and the worsening impacts of climate change? It can be deeply distressing to realize we lack the power to change the turmoil in the world, especially for our clients who are experiencing depression.

But what if the goal of therapy is not to change our clients’ emotions or reduce their depressive symptoms, but instead enable them to compassionately accept their feelings while engaging less with self-bullying thoughts? ACT is an evidence-based mental health approach that helps clients learn to accept what is out of their personal control and commit to actions that improve satisfaction with their quality of life.

Some of the most meaningful outcomes of ACT for depressed clients are increased resilience, a measure of one’s overall wellness that can reduce the risk of depression, and greater self-compassion. Self-compassion allows us to experience negative events and emotions with acceptance, which leads to a reduction of suffering. 

 At the onset of treatment, I (Lottena) have clients complete a resiliency questionnaire, a stress inventory and the Valued Living Questionnaire (VLQ). The VLQ is an ACT self-directed tool used to help clients assess their values across 10 domains of living (family, marriage/couples/intimate relations, parenting, friendship, work, education, recreation, spirituality, citizenship and physical self-care) and evaluate how successfully they have lived in accordance with those values in the past two weeks. Clients are asked to rate the 10 domains on a scale of 1 to 10, with 1 being “not at all important” and 10 being “very important.”  

I (Lottena) find that clients who are experiencing depression often rank themselves at a 2 or 3 in the domains that are most valuable to them. These clients will also score low on resiliency and high on external stressors. This was the case for one of my former clients, who I will refer to as “Mr. A.” 

Soon after rapport was established in therapy, Mr. A completed the resiliency questionnaire, stress inventory and VLQ. He scored high on stress and low on resiliency. The VLQ illustrated that Mr. A felt he was unable to prioritize his life, primarily his marriage, work and family. He ranked himself between a zero and a 2 for how successful he had been at living in accordance with his values during the previous two weeks. This client could not fathom how to get above a 5, and he felt that he should be a 10 in each domain.

Mr. A’s hopelessness was so intense that he would either disconnect from his feelings to function professionally and socially or drown himself in his sadness. Mr. A woke up with feelings of dread and felt hopelessly unmotivated about work, often arriving at least an hour late for his job. He socialized only when he was intoxicated, and he avoided conversations with his family. Mr. A reported that his wife complained he was only present in body but not in spirit. His depression impacted all areas of his life.

After using ACT therapeutic interventions (such as the willingness and action plan and exercises that incorporate mindfulness practices) in session, this client began to rank his success in these domains at a minimum of a 6, and usually higher, for most two-week periods. His faith in himself and his loved ones was seldom below a 5, even when he experienced an episode of depression. And he could connect to his feelings of optimism, pride and joy. 

Mr. A’s depression now has significant periods of remission, and when he experiences depressive symptoms, they rarely cause major problems for him at work, home or socially. The acceptance of both his depressed symptoms and new positive emotions allows him to treasure and protect his joyful experiences. He has undergone a profound transformation through his dedication to the ACT process. 

Thus, counselors should be open to trying ACT, which is sometimes overlooked as a therapeutic approach. I (Lottena) have utilized ACT for over 14 years as a clinician, and I often recommend it during supervision sessions with newly licensed therapists and graduate students. I find that ACT is flexible enough for both younger clinicians and more experienced clinicians who treat clients reporting increased feelings of hopelessness and persistent depression. And I can say that both the research and my own personal experience demonstrate its effectiveness with depressed clients.

Lottena Wolters is a licensed professional counselor and founder of the F.L. Wolters Group in Washington, D.C. She works with young adults and adults struggling with anxiety, mood disorders and attention-deficit/hyperactivity disorder. Contact her at lottena@flwoltersgroup.com.

Caitrin McKee is a registered yoga teacher and the patient care coordinator at the F.L. Wolters Group in Washington, D.C.

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Helping clients become unstuck with ACT

By Jared Torbet

In the initial assessment, Camie (pseudonym) presented as depressed, unmotivated and indecisive, and she ruminated on her insecurities, which are all common symptoms of depression. She also used humor and a noticeable dismissal or minimizing of her feelings. Once I noticed these avoidant strategies, I felt ACT would be a good fit for this client. 

At our next session, I helped Camie notice and name her internal experiences, including her thoughts, feelings and sensations; this is a basic mindfulness skill that Steven Hayes, the psychologist who founded ACT, believes is the most important mindfulness skill one can master. Camie’s internal world came into view as she began to notice and name that world in the present moment with ease.

We progressed to working with those internal experiences in a more helpful and workable way than she was accustomed to. Before I go further, let me share a warning label that comes with ACT. As therapists, we must do ACT, not explain ACT. It was vital that I guide Camie through an experiential journey, not a psychology lesson. Camie had a hard time differentiating herself from her depression, insecurities and fears. She was stuck.

I asked her to hold her depression, insecurities and the reality of being stuck in her hands and imagine it as an object. She described it to me as a big, heavy, lava-red, smokey, hot, smooth, oval-shaped sphere that was about 2 feet wide and 1 foot tall. “Where do you feel this object?” I asked. She replied, “Right here on my chest.” 

Together, we playfully engaged with the object. We handed it back and forth. I had her set it on the coffee table between us and walk to the other side of the room. I said, “If this stuff is sitting here on this table, and you’re standing over there, what does that tell us?” She replied, “I’m not that stuff.” 

She noticed a feeling of freedom and motivation from this exercise. This led us to discuss the range of her values, including relationships and career goals, as well as her fears and doubts. I guided her through an expansion exercise. We both breathed deeply while widening our arms and imagining making room for values, goals, fears and doubts. I asked how much of her energy is spent on these important things. She said, “Pretty much none.” 

“You spend so much time and energy trying to figure out, or get rid of, this heavy, red sphere,” I told her. “What would happen if you spent that time and energy on the things that matter the most to you?” She replied, “I would probably be a lot further in my life.” I asked, “Where would you be?” Without hesitation, she told me, “I would be teaching English as a second language (ESL) overseas.”

I said, “Wow, that sounds amazing! What is stopping you from going?” She smiled and replied “this” while she simulated holding the heavy, red sphere. So I asked, “What if you packed it in your suitcase, and just took it with you?” 

I could see the wheels turning. This was our segue into her accepting and allowing fear and doubt to be there. I taught her that her fear, which shows up as anxiety, is just trying to protect her. When she imagined her fear/anxiety, it took the form of her child-self.

I used the analogy of her being the captain of her own ship, with her thoughts, feelings and sensations being her deck mates. It felt right to offer the choice of inviting her child-self on board as co-captain. This helped her to organically embrace self-compassion and self-love. I told her that she cannot control all her deck mates, but she can guide the ship and build tolerance for those on board. And as long as she’s traveling in the direction of her values, her deck mates won’t cause as much ruckus, and some will even help her, especially her co-captain.

Camie, through her dedication to therapy and her hard work in session, was able to notice her thoughts, feelings and sensations. She was able to see the difference between her internal experiences and herself. She was able to defuse, or unhook, from unproductive thoughts, while bravely accepting her emotions and sensations. She learned to align her choices and actions with what mattered most to her, such as teaching ESL overseas, which she eventually did.

ACT is not for everyone. In my experience, ACT requires a client to be able to practice mindfulness and engage in mental imagery. Clients with aphantasia (the inability to voluntarily create mental images in one’s mind), for example, would most likely benefit from a different modality. Also, in cases where the client is at risk of suicide, homicide, child/elder abuse, domestic abuse, trafficking and other high-risk behaviors, including self-harm, more immediate and tangible interventions should be considered with safety as top priority. These are situations that should not be accepted but avoided and reported.

Jared Torbet is a licensed professional counselor and owner of Anxiety & Depression Clinic of Columbia in Missouri. He specializes in adults and teens who struggle with anxiety, depression or attention-deficit/hyperactivity disorder. Contact him at hello@comoclinic.com. 

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ACT: The mindful approach 

By Katy Rothfelder

ACT is an empirically supported and evidence-based treatment for individuals experiencing depression, yet it is an approach many clinicians are not trained or fully comfortable exploring. For clients experiencing depression and the clinicians who use ACT to treat them, we must first come in contact with the totality of human suffering. From this place, we can bear witness to the suffering within our clients in the here and now. It is from this willingness to let suffering come close, to see it as one of the many thousands of threads forming one cloth of the client, that we as clinicians can form a workable framework for the way in which internal and external experiences are woven to diminish valued living, as noted by Kelly Wilson and Troy DuFrene in their book Mindfulness for Two: An Acceptance and Commitment Therapy Approach to Mindfulness in Psychotherapy.

ACT moves beyond the language composed in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. This approach, which includes self as context as one of its core processes, defies labels such as “depressed client,” and instead appreciates the unique, narrow and broad experiences of the client. It takes the language and behaviors the client exhibits, such as “there’s no point,” and looks to transform those overt and covert behaviors into valued, flexible ways of being.

Mindfulness practice is a critical part of ACT. It can be argued that mindfulness, as it is understood in contemplative practices, is the totality of many of ACT’s six core processes — acceptance, defusion, self as context, values, committed action and contact with the present moment. And ACT’s core process of contact with the present moment is what we might contextualize as modern-day mindfulness. According to Jon Kabat-Zinn in his book Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life, mindfulness is “paying attention in a particular way: on purpose, in the present moment, nonjudgmentally.”

Unique to ACT is the way in which the six core processes interact, merge and flow with one another. They are not mechanistic in form, but rather are existent within a particular context and in service of creating psychological flexibility. 

Lindsay Fletcher and Steven Hayes, in their 2005 article “Relational frame theory, acceptance and commitment therapy, and a functional analytic definition of mindfulness” published in the Journal of Rational-Emotive and Cognitive-Behavior Therapy, defined psychological flexibility as “contacting the present moment fully as a conscious human being, and based on what the situation affords, changing or persisting in behavior in the service of chosen values,” which can also be considered a workable definition of mindfulness. 

Psychological flexibility is a practice and the outcome we continuously return to in ACT. Rather than seeking to get rid of unwanted, unpleasant thoughts or experiences, ACT aims to support individuals in living full, rich and meaningful lives without defense, while also engaging in the moment with what is most important to them. With many clients experiencing depression, as well as other experiences such as anxiety or trauma, contacting the present moment in a particular way can be helpful in reconnecting with valued living.

Contacting the present moment involves commitment and deliberate action, drawn from one’s values, with an awareness of the self as containing thoughts, emotions, roles, bodily states and memories. In essence, ACT supports individuals in experiencing their “wholeness,” with flexibility and persistence in valued living. 

ACT is not done to a client, but rather is experienced with and between the client and clinician, moment to moment, in a flexible, processed-based practice. 

Katy Rothfelder is a licensed professional counselor associate who is supervised by John Hart at the Anxiety Treatment Center of Austin in Texas. She specializes in obsessive-compulsive disorder and related disorders, anxiety, depression, trauma and neurodiversity. Contact her at katy@anxietyaustin.com.

 

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Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at lrhodes@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.

More than simply shy

By Bethany Bray July 29, 2019

Social anxiety is different from — and much more than — simply being shy or introverted or having poor social skills. Even so, people who live with social anxiety often find the disorder trivialized or minimized by others, including some mental health professionals, according to Robin Miller, a licensed professional counselor (LPC) and a member of the American Counseling Association.

“Shyness doesn’t necessarily have a negative impact on someone’s life. That’s an important thing to remember from a clinical point of view,” explains Miller, who specializes in working with adults with anxiety disorders at an outpatient practice just outside of Milwaukee. “Many of my clients get a pat on the head from people and [comments such as], ‘You’re just shy. You have nothing to worry about.’ But you wouldn’t get that for [symptoms of] posttraumatic stress disorder or other mental health issues. You wouldn’t say there’s nothing to worry about.”

Most of all, clients with social anxiety need support and reassurance as they try to discontinue old patterns and behaviors that they have adopted to cope with the paralyzing fear that often accompanies the disorder, says Brad Imhoff, an LPC who was diagnosed with social anxiety disorder in 2012 as he was working on his doctorate.

One characteristic of social anxiety is a constant feeling of apprehension regarding social situations. It is difficult to express just how oppressive and pervasive that feeling can be, says Imhoff, an assistant professor of counseling at Liberty University who lives in central Ohio and teaches in the university’s online program. “You carry this feeling of ‘I just can’t do this’ all the time,” he says. “As human beings, we’re social. And apprehension in every one of [those social situations] can be overwhelming.”

Imhoff, a member of ACA, says he recognizes the irony of his career choice: a person with social anxiety who speaks regularly to rooms full of people, both as a counselor educator and as a frequent presenter at conferences, including giving a session on social anxiety at the ACA 2019 Conference & Expo in New Orleans.

Imhoff has learned to navigate the challenges of social anxiety since his diagnosis, but he acknowledges still feeling anxious before speaking engagements. “The question is, how do I manage it and not let it get in the way of life?” he says. “I will have to manage this, to some extent, for my entire life and not let it get to the extremes it has in the past.”

Navigating life through avoidance

Social anxiety is one of a number of related issues — including specific phobia, panic disorder, separation anxiety disorder, generalized anxiety disorder and others — that fall under the anxiety heading in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

Called social phobia in decades past, social anxiety disorder is characterized by persistent fear over social or performance-related situations, according to the National Institute of Mental Health, which cites diagnostic interview data to estimate that 12.1% of U.S. adults will experience social anxiety disorder during their lifetime. Among adolescents ages 13-18, the lifetime prevalence is 9.1%. For all ages, social anxiety disorder is more prevalent in females than in males.

Researchers have not singled out a specific cause for social anxiety disorder, pointing instead to a combination of biological and environmental factors as contributors. Genetics appears to play a large role in many cases, as can negative childhood experiences such as family conflict or being bullied, teased or rejected by peers. It is also believed that individuals who have an overactive amygdala may experience more anxiety in social situations.

According to the Center for the Treatment and Study of Anxiety at the University of Pennsylvania, “Social anxiety disorder can affect people of any age. However, the disorder typically emerges during adolescence in teens with a history of social inhibition or shyness. The onset is usually accompanied by a stressful or humiliating experience, and the severity varies by individual. … There is a higher incidence of social anxiety disorder in individuals with first-degree relatives affected by other panic and anxiety disorders. However, there is no one gene that explains this biological trend. General findings indicate that personal experiences, social environment and biology all play a role in the development of the disorder.”

People often experience symptoms of social anxiety disorder to varying degrees across the life span, according to the center. Symptoms may lessen for stretches of time and then worsen during periods of change or stress, such as a job transition or when dealing with feelings of grief and loss.

What sets social anxiety apart from general anxiety is not only the social component but also an intense fear of judgment by others, explains Holly Scott, an LPC whose Dallas private practice is a regional clinic of the National Social Anxiety Center. People with social anxiety often harbor strong and pervasive feelings that others will notice their anxiety and judge them, which triggers avoidance behaviors, she says.

At the same time, there are nuances to the diagnosis, and social anxiety can look different in each client, Scott adds. For example, someone may be fine with public speaking and yet not be able to walk into a room in which they don’t know anyone.

“People think it’s not treatable,” Scott says. “Clients label it as ‘this is just the way I am, and I can’t change the way I am.’ It can be difficult to treat or to find a qualified practitioner, but it is treatable.”

Imhoff says he has read that on average, people go 15 years before seeking treatment for social anxiety. Counseling itself is a social interaction, he notes, and people with social anxiety may avoid treatment out of a fear of the close interaction or of being scrutinized by a practitioner.

Because people with social anxiety typically adopt avoidance as one of their coping mechanisms, and perhaps because of the way that social anxiety tends to get minimized or passed off as simply being introverted or shy, these clients often live life without seeking treatment until they reach a breaking point. As Imhoff points out, people can self-manage their social anxiety for an extended period of time by maintaining the same small circle of friends and following certain behavioral patterns such as always using the self-service checkout line at the grocery store.

Living with social anxiety is their reality, Imhoff explains, and they “forge ahead until something causes [them] to realize it’s more significant.” For Imhoff, that “something” was the impending scrutiny involved in defending his doctoral thesis.

“For social anxiety, it’s possible to navigate life with avoidance and survive for a long time. Then something comes up — a life change, such as entering the workforce — that causes them to need help,” he says. “A lot of these safety behaviors aren’t being done consciously. They are things we’ve done throughout our lives to find safety.”

Assessment and core beliefs

Avoidance behaviors are one of the biggest red flags that a client might be dealing with social anxiety, Miller says. These behaviors can extend to staying in situations in which the person is unhappy yet comfortable, such as a bad romantic relationship, a toxic friendship or a job that the person doesn’t enjoy or isn’t advancing in.

Other indicators include rumination and overthinking social experiences. This can include asking oneself over and over again, “What did that person think of me?” Miller explains, whether it’s an interaction with a neighbor while walking the dog or a yearly performance evaluation with one’s supervisor.

Counselors should be aware that social anxiety often co-occurs with other mental health issues such as depression and substance abuse (which often becomes a coping mechanism) that may need to be treated first or in tandem with the disorder, Miller adds. In addition, other issues such as grief may be complicating a client’s social anxiety. “They’re not always struggling with one thing. Make sure you’re working on what they’re struggling with the most,” Miller says.

Scott suggests asking clients at intake about how they deal with social situations and how often they go to gatherings or parties. Are they uncomfortable introducing themselves to new people, making a phone call or using the restroom in public places? If Scott hears symptoms that might indicate the presence of social anxiety, she uses a questionnaire (she recommends the Liebowitz Social Anxiety Scale, available at nationalsocialanxietycenter.com) to pinpoint the client’s fear level and to identify goals to focus on in therapy.

It can also be helpful to identify a client’s core beliefs and values and how those are affecting the person’s choices and behaviors, Imhoff says. People with social anxiety often carry a core belief that they’re inadequate or inferior, which spurs a fear of being judged, he explains. These clients frequently place weight and focus on situations that seemingly confirm their core belief and discount those that might disprove it. They might ruminate over a conversation with a colleague that didn’t go well, for example, without giving any consideration to all of the past conversations that did go well, Imhoff notes.

“They move through life paying very close attention to and taking to heart scenarios that confirm their core belief,” he says. “It’s important to help the client take off the blinders. Talk through ways they are competent, and get to the root of their concerns. Be aware of the multitude of their experiences and not just those they struggle with.”

To identify core beliefs, counselors can listen for themes in the way that clients talk about themselves, other people and the world. These themes can suggest deeply held beliefs to challenge or to explore further in therapy. Having clients work on thought journals can also be helpful in finding patterns, Imhoff says. He also suggests using a prediction log, in which clients name upcoming social scenarios that make them anxious and describe what they assume will happen. After the scenario occurs, clients can look back at their predictions with the counselor to talk through how accurate these foresights were.

After core beliefs and values have been identified, the counselor can work with clients to reframe their perspective around new core beliefs. For example, clients who place value on providing for their family could focus on that value to help them overcome their anxiety and discomfort over applying for a new job.

“Look for evidence that supports their new core belief,” Imhoff says. “If their belief is ‘I am capable,’ have them write down even the most minor piece of evidence [in a journal]. It makes it concrete and documented so they can refer back to it and talk it through with a counselor.”

From there, the counselor can work with clients on challenging cognitive distortions and black-and-white thinking, Imhoff suggests. Acceptance and commitment therapy (ACT) can be helpful, as can guiding clients to adopt a growth-focused orientation. With that mindset, every social interaction becomes an opportunity to learn rather than a pass-fail situation, Imhoff explains.

Clients with social anxiety may also feel that they’re failing because they can’t assume an extroverted, life-of-the-party façade. Counselors can help these clients learn that there is a continuum of social skills, Imhoff says. For example, perhaps they got through a work meeting and contributed their thoughts despite having a shaky voice and sweaty palms. “Work on [helping them realize] that it’s not black and white, it’s not all success or failure. There’s an in between for almost all scenarios,” he says. “Help them to recognize that in all social interaction, there is ebb and flow. It’s not a pass-fail exercise but an opportunity to connect with someone and learn moving forward.”

Additionally, ACT techniques can help clients learn to accept their anxiety rather than trying to get rid of it or avoiding triggering situations. Imhoff uses the imagery of “keeping anxiety in the passenger seat because I know it’s coming along but not letting it take control of the wheel.” Clients can learn to say, “There you are anxiety; I knew you were coming,” even as they move on with life and navigate situations they previously would have avoided.

Scott regularly uses cognitive restructuring and cognitive behavior therapy (CBT) with her clients who have social anxiety. She also uses a mindfulness technique called curiosity training that helps clients label their anxious thoughts as “background noise.” With this technique, users try to adopt an approach of curiosity about and interest in what is being said by others rather than assuming that others are judging them.

“In any situation,” Scott says, “whether they’re having a conversation, public speaking or sitting somewhere having lunch, they’ve usually got a constant dialogue going in their head. [It’s] self-criticism about how people must be thinking of them: ‘They don’t like my clothes’ or ‘I just stuttered while speaking.’ Curiosity training helps keep your mind on the present and learn how to pull your mind back when it starts wandering.”

Elizabeth Shuler, an LPC who has been working as an international school counselor in Amman, Jordan, for four years, recommends mindfulness techniques. She has often used Kristin Neff’s self-compassion practices in addition to dialectical behavior therapy, meditation and yoga for clients with social anxiety, both when she was in private practice in Colorado and Wyoming and currently in her work with adolescents and adults at her school.

“When we dig into their fears, most clients with social anxiety are really afraid that other people will agree with their own negative judgments of themselves. They’re worried that they will be proved right,” says Shuler, an ACA member. “I had a client who walked through the office the same way every day to avoid the people he was afraid of interacting with and had panic attacks when his route had to change or people he was avoiding crossed his path. These types of behaviors are meant to stave off panic but end up reinforcing it. My role as a counselor is to help clients see how these behaviors are actually making their panic worse and help them to slowly replace them with more helpful behaviors.”

Exposure

Exposure techniques are often central to treating social anxiety because they gradually reintroduce clients to anxiety-provoking situations in a healthy way.

Miller is trained in exposure and response prevention and finds it a powerful tool for working with clients with social anxiety. The behavioral technique requires clients to put in a lot of work themselves outside of sessions. The counselor collaborates with the client to develop a hierarchy of exposure based on the client’s needs and treatment goals and supports the client throughout the process.

As Miller explains, exposure assignments start small and build over time as clients become comfortable with each homework task. She describes this as a “Goldilocks situation” — not too much challenge and not too little, but just the right amount, tailored to each individual client. Miller says she emphasizes to clients that the treatment is in their hands — they have to do their part to experience a successful outcome.

“A lot of people have anticipatory anxiety, but once they do it [complete the exposure assignment], they’re OK,” Miller says. “A lot of people get over that hill of worry. They do it for a week or two and realize they can do it. Trust between a client and clinician is huge because we’re asking them to do really scary things.”

Miller often gives clients who are early in treatment the assignment of calling multiple businesses to ask what their hours are. Clients might have to overcome feeling a little foolish because that information is readily available on the internet, she notes. However, the goal is for clients to complete the task without falling back on habits they formed to avoid social situations, such as relying on technology in lieu of having personal interactions. Clients repeat the task over and over until they no longer feel anxious about picking up the phone and making a call, she explains.

Once they’ve mastered that task, clients might move on to going inside a store and asking a question in person. Or they might switch to walking their dog in their neighborhood during a busy time of day and saying hello to at least one other person during each walk.

As clients complete each task and return to their next counseling session, they process these interactions with Miller, discussing how the interactions felt to them and what went right or wrong. “Sometimes the client will come in and say, ‘I’m so bored with this.’ I say, ‘Great! That means it’s time to move on to something bigger,’” Miller says. “You need repetition with assignments. You need to do [tasks] over and over for your brain to get used to it. … The more you do it, [the more] it overwrites [old] patterns and anxious feelings.”

As a practitioner who specializes in treating social anxiety, Scott has a laundry list of exposure assignments that she uses with clients, ranging from making eye contact during a shopping trip to asking for directions from a stranger to calling into a radio talk show to singing karaoke. As clients progress, it can be helpful to assign them tasks that are certain to create some level of discomfort or awkwardness, such as going into Starbucks and ordering a hamburger, she says. This can be especially hard for clients who have a strong fear of being judged by others, but dealing with the responses they receive desensitizes these clients over time as they repeat the tasks.

Miller acknowledges that counselors may need to provide their clients with some ongoing motivation during exposure work. If clients come to session without completing their assigned tasks, she suggests asking leading questions to find out if they are avoiding the work or genuinely struggling to make it a priority among their other challenges.

“Who wants to go home and do anxiety-provoking things?” Miller says. “[We] have to find a way to motivate them. We want them to feel empowered to go out and do [an assignment]. Remind them that they’re in pain because something is not changing. … You can’t snap your fingers and make this go away. It’s going to be hard work and take time.”

It can be useful to circle back and remind clients of their core beliefs and the goals they want to achieve. For example, consider clients who say they ultimately want to start a family but whose social anxiety prevents them from entering the dating scene and potentially meeting a partner.

“They may not see how calling a drugstore [as an exposure assignment] is getting them to be able to date. But remind them that they’re building a foundation to be able to do that,” Miller says. “It may not have an immediate payoff, but the easier these things become for you, everything builds.”

Miller often uses the metaphor of training for a marathon to keep clients motivated. You don’t run 26.2 miles right away, she tells them. You start with one or two miles and then keep adding more distance, mile by mile.

Social skills

In addition to exposure work and cognitive restructuring, the counselors interviewed for this article recommend social skills training for clients with social anxiety. Avoidance behaviors may have kept these clients from learning and practicing social skills that are commonplace among their peers who do not deal with social anxiety.

“If you’ve been avoidant for years, you miss out on learning from all of the social interaction that others have had,” Miller says. “Sometimes they’ve built a life to minimize their pain, their anxiety.”

Goal setting and planning ahead, with support from a counselor, can help these clients navigate situations that are foreign to them and that naturally provoke anxiety. Miller suggests troubleshooting with clients. For instance, if their office holiday party is coming up, a counselor can talk through expected behaviors with clients and work on small talk and other exercises to help them get through the evening.

Setting realistic goals can also be comforting, Miller adds. “[They] don’t have to go in and work the room, [but] if they haven’t had a lot of social experience, they may not realize what’s expected,” Miller says. Instead, clients might set a goal of talking to three people whom they already know. Maybe at next year’s party, they can increase that goal from three people to five people.

Miller also reminds clients that a certain measure of social anxiety is simply part of being human. Even she, a therapist who makes a living talking to people, acknowledges sometimes being uncomfortable in social situations.

Kevin Hull is a licensed mental health counselor with a private practice in Lakeland, Florida, who specializes in counseling children, adolescents and young adults on the autism spectrum. Social skills training, along with group therapy, plays a large role in the work Hull does with clients around social anxiety, which he says often goes hand in hand with autism.

In individual counseling sessions, Hull uses puppets with clients to role-play social situations and work through what is expected. For example, Hull might instruct clients to verbalize a food order to his puppet without the usual help from mom or dad or ask his puppet for help finding a certain building on a school campus. Afterward, they process the experience together and talk about the emotions clients felt as their puppet had to interact and ask questions.

Humor can also be a great tool for overcoming the fear associated with social anxiety, says Hull, a member of ACA. He often shows clips of TV shows or movies (via YouTube) in client sessions as a lighthearted way of starting conversations about what is and isn’t appropriate when it comes to social skills. Particularly popular with clients are scenes with The Big Bang Theory’s Sheldon Cooper wrapping himself in bubble wrap to stay safe or wearing a second set of “bus pants” over his work outfit when taking public transportation. Another favorite is the title character in How the Grinch Stole Christmas, who initially can’t stand being around the Whos but ends up transforming over the course of the story.

“Using humor is a great thing to counter the fear,” Hull says. “When you can laugh at something, that gets people opening up and listening.”

Group work

Group therapy — a format in which clients are expected to interact with others and contribute to a discussion — would seem to be a nightmare for individuals who are socially anxious. But that’s not necessarily the case, according to Hull.

Although it can take clients some time to warm up to the idea, group therapy can play a powerful role in imparting the skills needed to navigate social anxiety, says Hull, an assistant professor and faculty adviser in Liberty University’s online master’s counseling program. In addition to helping participants sharpen their social skills, group counseling can instill perspective — something with which Hull’s clients who are autistic sometimes need extra help.

“With autism, clients have a hard time putting themselves in others’ shoes, so group is a great way for them to hear from the mouths of peers [and] hear them talk about what they’re going through,” Hull says. “Maybe someone [in group] had to ride a different bus than usual. It was terrifying at first, but they were OK and actually ended up talking to the person they sat next to.”

The group format, in which participants take turns offering comments, can model and teach the back-and-forth “tennis match” that is the basis of healthy conversation, Hull adds. It can also help clients learn to tolerate and listen when someone is talking about a subject that doesn’t interest them — a circumstance that previously would have triggered their fight-or-flight response and caused them to exit the situation.

Hull often has group participants speak for five minutes each on something they are passionate about. Afterward, he urges all of the group members to ask questions or make a comment about what was said.

“This is really hard with autism. If they don’t like something, it’s utterly meaningless to them,” Hull says. “This has them put themselves in others’ shoes and imagine how it’s like [something that they] like. This can transfer to social situations outside of group, such as a dinner party where other people are talking about whatever. Can you listen and learn something? It’s teaching their brain to overcome fear and learn a new normal. Everyone is scary when you first meet them, but you can do it. If you can do it in group, it’s the same as at school or a new job.”

Hull also uses video games in sessions as a way for participants to learn about group dynamics, leader/contributor roles and overcoming frustration (see sidebar, below).

It is important to prepare individuals with social anxiety for the group setting as much as possible ahead of time. Hull often shows clients the group room at his office (or emails them photos of it) and explains the format and what sessions will entail before they join group counseling.

“I walk back to the [group] room with the client and their caregiver before a group session so they can see it,” Hull says. “I explain, ‘Everyone who is coming here feels what you feel, and they’re all struggling with this.’”

When new clients join a group, he never makes them introduce themselves or speak right off the bat. He also allows them to bring anything that might boost their courage, such as a favorite stuffed animal or even a parent in the cases of younger clients. With social anxiety, it is important to allow clients to warm up and contribute at their own pace, he says.

“I can see group members five or six sessions in and they haven’t talked yet. I never stop trying to get them to engage or open up, even if all they can do is a head nod or fist bump,” Hull says. “[I emphasize that] I’m just happy they can be in the room.”

Hull acknowledges that group counseling isn’t a fit for every client who struggles with social anxiety. Social anxiety falls on a spectrum, and for some clients, the disorder is so severe that a group setting would be too much, he says. It is important to continue individual sessions with these clients, with group counseling becoming a possible long-term goal for some of them, he says.

When it comes to group counseling and social anxiety, it is crucial to take things step by step and to celebrate little victories, Hull emphasizes. With clients on the autism spectrum “the victories are fewer and far between,” he acknowledges, “but when they happen … you feel like you’ve won the Super Bowl.”

The long haul

Hull says that counselors should view social anxiety as a process rather than something to “fix.” Neuroscience tells us that the brain responds better to slow and steady change rather than forced or rushed adaptation. This is especially true for clients who struggle with social anxiety in addition to neurodevelopmental issues, past trauma or other mental health diagnoses, Hull notes.

Something else that counselors should avoid is projecting their assumptions onto clients with social anxiety. Just because the counselor went to prom as a teenager doesn’t mean that should automatically become a goal for every teenage client or, for that matter, even be considered the rite of passage that it once was, Hull says.

Counselors should really get to know their client’s world first before doing anything else, Hull says. “Avoid putting your agenda or perceptions on a client. We often see the potential in our clients, and it’s hard not to say, ‘Just do it!’ It can be discouraging and slow going at times, [but] be patient.”

 

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Technology and social anxiety: A double-edged sword

We live in a world where a person can text a happy birthday message to a friend, order a week’s worth of groceries for delivery and apply for a loan with the click of a button — all without having to speak to another human.

So, when it comes to social anxiety, technology can be a double-edged sword. Clients can certainly use it as an easy escape route to avoid social situations. At the same time, mental health practitioners can use it as a teaching tool with clients and as a bridge to overcoming long-held behavioral patterns.

“As great as it can be, technology can be part of avoidance,” says Robin Miller, a licensed professional counselor (LPC) who specializes in treating adults with anxiety. “Learn how to have conversations [about technology]. Make sure a client isn’t too reliant on it and unable to do things in a more social, direct way.”

Miller suggests that professional clinical counselors ask clients about their technology use at intake along with other questions about avoidance behaviors. Counselors can prompt clients to provide examples of situations where they feel most anxious and then listen for overreliance on technology, such as texting to ask someone out on a date or habitually using the self-service checkout line when shopping.

Social media can also exacerbate the assumption of judgment that often accompanies social anxiety, Miller adds. Clients who see photos and posts about friends’ and peers’ vacations, children or happy life events may come to believe that their lives pale in comparison.

Elizabeth Shuler, an LPC and an international school counselor, agrees. She says social media has created a new layer of social anxiety “centered around likes, comments and followers” in many of the adolescents with whom she works.

“I see students every day who are upset — to the point of panic attacks — that they’ve lost followers or that no one is liking their Instagram pictures. Instead of being afraid of being seen as stupid, these kids are afraid of not getting likes. It is a whole new world of judgment that has been unleashed on our teens, and it is taking a toll,” Shuler says. “However, many people who find face-to-face interaction intimidating can benefit from starting with digital interactions. Using texting, video and other digital means of conversation can help people with social anxiety learn social skills and give them a chance to practice new skills in a safer, lower stakes environment.”

Kevin Hull, a licensed mental health counselor in private practice, finds technology — specifically, video games — a natural tool for working with his young clients, many of whom are on the autism spectrum. In group counseling, Hull uses multiplayer games such as Minecraft to introduce clients to interacting and working together in a way that provokes less anxiety than face-to-face conversation might. Group members take turns being a “foreman” and leader in Minecraft sessions. The group learns to communicate and work together while dealing with frustrations and the nuances of the leader/contributor roles. “If technology wasn’t there, these kids would be even more regressed,” Hull says.

Conversations about technology use can also be an important part of social skills training in counseling, Hull adds. For example, young clients might claim that they are “dating” someone when they are actually just texting or playing video games together over the internet.

Hull often talks with clients about how texting is a good place to start communication but that it should not become their be-all, end-all. He’ll say to the client, “It’s great you’ve made a connection through texting, but what about the next level? Your brain’s process to communicate in text is the same as in speech. It’s just a different route.”

— Bethany Bray

 

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Social anxiety and college

The transition to college — leaving home, living with a roommate and establishing a new social circle, all while navigating academic responsibilities — doesn’t have to be paralyzing for students with social anxiety. Read more in our online exclusive, “Heading to college with social anxiety.”

 

 

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Contact the counselors interviewed for this article:

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@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.

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

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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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.