Josh Cutler, MSW, LICSW
I am always eager to learn new skills and modalities to use with clients. Earlier this year I was working with a client on gaining an increased sense of direction in their life, when a colleague recommended that I use some values clarification exercises from Acceptance and Commitment Therapy (ACT). It wasn’t long before I found myself using ACT values exercises with most of my clients - with great success. I started exploring more of what was available in the ACT model, and was impressed with the approach to cognitive distortions. Rather than disputing and trying to change thoughts, clients are taught to unhook from them in a process called defusion. I tried these techniques with my clients, who were very responsive. People started to feel better, faster. I have since read up extensively on ACT and taken several courses--it has been transformational, both personally and professionally.
So what is ACT? It is one of the third-wave Cognitive Behavioral Therapies (along with Dialectical Behavioral Therapy, Mindfulness Based Cognitive Therapy, and Behavioral Activation Therapy). According to co-founder Steven Hayes, PhD: “ACT uses acceptance and mindfulness processes, and commitment and behavior change processes, to produce greater psychological flexibility.”
Over one hundred randomized controlled studies have found ACT to be efficacious for a broad range of physical and mental health issues. Its application ranges from chronic pain to depression, anxiety to addiction, trauma to eating disorders - the list goes on and on. ACT’s premise is that human suffering is not pathological. It is normal. The problems come when our mind tries to fix psychological pain with the same processes that we use to solve other problems in our environment. When this happens, people lose contact with the present moment and get lost in their minds. We become preoccupied with avoiding those painful feelings and fall into patterns of behavior (including rumination) that pull us off course or distract from engaging in activities or relationships that give life purpose and meaning. Too often people are disabled by the notion that pain must be avoided or neutralized if they are to move forward. ACT uses a number of processes to help people to recognize that they have no control over their thoughts or feelings, but they can interact with them in healthier ways, and move forward with what matters in their life.
Russ Harris, MD explains that ACT is about “learning skills to handle difficult thoughts and feelings more effectively so they have less impact and influence over your life.” A = Accept your thoughts and feelings, and be present.
C = Choose a valued direction
T = Take action
The six core processes of ACT (Cognitive Defusion, Acceptance, Observer Self, Present Moment, Values, and Committed Action) are used in concert with the goal of developing greater psychological flexibility. We know that psychologically flexible people are more resilient and better able to handle the inevitable life challenges that come their way. Therapists are encouraged to call out what they notice happening emotionally in the room, including disclosing feelings that come up for them in session (if it serves the client). For example, if a client changes the subject when they touch on a painful emotion, the therapist might point that out and gently guide them back to experiencing and noticing that feeling. As part of this practice, metaphor is used frequently to highlight the way the mind works. One I often refer to is imagining your mind like a stage show: pain or distressing thoughts might show up on one part of the stage, but instead of focusing attention on battling the distress, you can instead learn to shift the spotlight to more valued activities on other parts of the stage, even while those uncomfortable thoughts and feelings are still present. I have found that ACT’s close attention to context fits well with social work’s person in environment perspective. Unlike more manualized evidence-based approaches, ACT invites therapists to bring other clinical wisdom, skills, and tools into the model. As long as you are consciously working in one of the processes and your intervention is ACT congruent (i.e. not disputing thoughts or trying to eliminate feelings) then you are doing evidence based ACT, even if the specific example or intervention is not described in a research study or textbook.
Finally, mindfulness is a key part of the ACT approach. Its application in ACT is different than other traditional religious and “new age” meditation approaches that I have encountered. Inner peace, higher consciousness, relaxation, and/or a quiet mind are not the goal - though these are welcome side-effects. The goal of mindfulness in ACT is to get present so that you can get going with doing the things that matter to you, even in the presence of pain. Dropping the inner peace agenda has been very freeing for me as I have reengaged with mindfulness practice through ACT. I sit with my eyes open, noticing what I see, hear and feel; I notice my thoughts and let them go, catch and release. I don’t worry if they keep coming. I breathe into my belly and bring my attention into the room. It isn’t about relaxation. It is about being present. I find that clients respond very well to this approach, especially those that have been unsuccessful with meditation in the past.
I am just at the beginning of an intense immersion in this approach. I would highly recommend it to anyone looking to develop their clinical skills with a concrete set of tools and strategies that can readily be tailored to your own unique approach - I believe that ACT has made me a better therapist and a better human.
These are some books and resources that I’d recommend:
- The Happiness Trap and ACT Made Simple by Russ Harris, MD (his online course is also excellent)
- The ACT Approach by Timothy Gordon, MSW
- Learning ACT by Jason Luoma, PhD
- Get Out of Your Mind and Into Your Life by Steven Hayes, PhD
- Things Might Go Terribly Horribly Wrong by Kelly Wilson, PhD
- Association for Contextual Behavioral Science https://contextualscience.org/
- YouTube has many lectures and clips of ACT in practice; check out the Praxis channel to start.
- Praxis offers expert live training: https://www.praxiscet.com/events