Overview of Treatment Approach Acceptance Theory and Intervention

Seven Minute Mindfulness

Five Steps to Mindfulness

Get Instant Access

The following section provides detailed information about how to use ACT in a clinical setting. There are several main goals that are generally presented in order when using ACT. This is not to say, however, that the ACT goals cannot be presented in a different order, or that the ACT therapist cannot choose to emphasize one goal over another, depending on the client's specific issues. ACT is diverse and flexible and allows for a range of concepts to be presented depending on client needs. Here we focus on main goals, using clinical examples of issues related to PTSD and trauma. For a more comprehensive presentation of ACT interventions, see Hayes et al., 1999; Hayes and Strosahl, 2005.

The acronym "ACT," while standing for the name of the therapy, also represents key issues in the approach: Accept, Choose, and Take Action. The premise involves a conscious abandonment of the mental and emotional change agenda when change efforts have not worked, replacing it with emotional and social acceptance—openness to one's own emotions and the experience of others (Hayes, 1994). This form if acceptance is applied to the domain of private subjective events and experiences, not to overt behavior or changeable situations (Greenberg, 1994). For instance, when speaking directly of trauma, the therapist using ACT would not encourage a client to stay engaged and "just accept" an abusive situation. Rather, the client would be encouraged to experience emotional processing while engaging in practical, safe, and valued behavior that may include getting out of the situation. Thus, as the very name suggests, ACT involves a focus on both acceptance and change.

The element of choosing or choice relates specifically to the client's ability to recognize a valued direction and engage in the required action. Although in tremendous pain, clients usually have a sense of what is important or what matters in their lives. Frequently, however, these valued goals have been lost or given up due to thoughts, feelings, or states of experience that tell the client that he or she cannot have those valued things until certain thoughts, feelings, or memories change or go away. For instance, the sexual abuse survivor may have the thought that she was damaged by the abuse and therefore is unable to engage in romantic relationships until the "damagedness" goes away. Sometimes the client will be in such pain that the idea of a meaningful, intimate relationship will rarely be contacted. Inside the pain there is a strand that leads back to values and choice; however, because the very pain of "damagedness" implies a desire for intimacy.

There are six essential components of ACT (Hayes, 2004), which are shown graphically in Figure 7.2: (1) acceptance, (2) defusion, (3) self as context, (4) committed action, (5) values, and (6) contact with the present moment. The figure helps note the relationship between these six processes. Defusion and acceptance both involve a release of excessive literalness, or "letting go"; self as context and contact with the present moment both involve verbal and nonverbal aspects of contacting the "here and now" as a conscious human being; values and committed action both involve positive uses of language to choose and complete courses of action ("getting moving in life"). The hexagram in Figure 7.2 can be sliced into two larger sections that define ACT more broadly. The first section (see Figure 7.3) describes

Hexaflex Case Monitoring Tool Act
FIGURE 7.2. The ACT model: hexaflex.

the acceptance and mindfulness processes included in ACT, and the second section (see Figure 7.4) describes the commitment and behavior change processes in ACT. The main goal of ACT is to create psychological flexibility: that is, contacting the present moment fully, as a conscious human being with a history, and based on what the situation affords, changing or persist-

Act Hexaflex With Questions
FIGURE 7.3. Acceptance and mindfulness processes of the ACT model.

INTERVENTIONS

Contact with the Present Moment

Commitment and Behavior e processes

Ac cep tance

D efusión

Contact with the Present Moment

Ac cep tance

D efusión

Act Hexogram

Committed Action

Values

Self as Context

Committed Action

Values

Self as Context

FIGURE 7.4. Commitment and behavior change processes of the ACT model.

ing in behavior in the service of chosen values. This goal is embodied in the following question and is illustrated graphically in Figure 7.5 on top of the hexagram: "Given a distinction between you and the things you are struggling with and trying to change, are you willing to have those things, fully and without defense, as they are, and not as what they say they are, and do what takes you in the direction of your chosen values at this time, in this situation? We briefly review the goals of ACT below and show how acceptance might be integrated into a treatment approach for trauma.

The first goal of ACT is to foster a state of creative hopelessness (Hayes et al., 1999). This state emerges when clients recognize the unworkability of their efforts to rid themselves of negative emotional content and begin to open up to the possibility of truly new ways of living. Typically clients feel that if they had had a different history (one without sexual abuse, disaster trauma, or war trauma), then their problems would be solved and they would no longer be in emotional turmoil; they would feel better. However, as they repeatedly try this line of thinking as a solution to their discomfort, the behavioral relevance of their painful history is only magnified, and they must search for still more "solutions." In ACT, the solutions the client has been trying are viewed as part of the problem. Metaphors are often used to demonstrate the client's situation:

THERAPIST: Here is a metaphor that will help you understand what I am saying. Imagine you are blindfolded and given a bag of tools and told to run through a large field. So there you are, living your life and running through the field. However, unknown to you, there are large holes in this field, and sooner or later you fall in. Now remember you were blindfolded, so you didn't fall in on purpose; it is not your fault that you fell in. You are not responsible for being in the hole. You want to get out, so you open your bag of tools and find that the only tool is a shovel. So you begin to dig. And you dig. But digging is the thing that makes holes. So you try other things, like figuring out exactly how you fell in the hole, but that doesn't help you get out. Even if you knew every step that you took to get into the hole, it would not help you to get out of it. So you dig differently. You dig fast, you dig slow. You take big scoops, and you take little scoops. And you're still not out. Finally, you think you need to get a "really great shovel," and that is why you are here to see me. Maybe I have a gold-plated shovel. But I don't, and even if I did, I wouldn't give it to you. Shovels don't get people out of holes—they make them.

CLIENT: So what is the solution? Why should I even come here?

THERAPIST: I don't know, but it is not to help you dig your way out. Perhaps we should start with what your experience tells you; that what you have been doing hasn't been working. And what I am going to ask you to consider is that what you have been doing can't work. Until you open up to that reality, that bottom line, you will never let go of the shovel

Psychological Inflexibility Hexaflex Act

FIGURE 7.5. The "ACT question" as it relates to the ACT model: (1) Given the distinction between you and the things you are struggling with and trying to change, (2) are you willing to have those things, fully and without defense, (3) as they are, and not as what they say they are, (4) and do what takes you in the direction (5) of your chosen values (6) at this time, in this situation?

FIGURE 7.5. The "ACT question" as it relates to the ACT model: (1) Given the distinction between you and the things you are struggling with and trying to change, (2) are you willing to have those things, fully and without defense, (3) as they are, and not as what they say they are, (4) and do what takes you in the direction (5) of your chosen values (6) at this time, in this situation?

because as far as you know, it's the only thing you've got. But until you let go of it, you can't take hold of anything else.

As a therapist working with trauma survivors, it is very important to take extra care that the client does not feel blamed when working on this goal. When clients are told that they are responsible for their "digging," they can easily misunderstand the message as one of blame. It is important to acknowledge, as the metaphor makes clear, that it is not the client's fault that he or she fell into the hole and that given this circumstance, he or she is responding in the only way he or she knows how. Responsibility is couched as the "ability to respond," an opening up to opportunities to do things differently.

The therapist should always operate from a place of compassion for clients' situations and the struggles in which have been engaging. At this early point in therapy, it also helps to explain to trauma survivors that it is the agenda that is not working; the clients themselves, and their lives, can experience all possibilities, based on what they choose to do from here. This point may take some special emphasis in the case of clients who have been diagnosed with chronic PTSD. These individuals often evaluate themselves as hopeless, in the usual sense of that term, and do not yet have the tools to turn this perception into an incentive for positive action. Understanding this perspective comes later in the therapy. At times, when it seems relevant to the situation, we will say that we do have hope for the possibility of a better life for the client. Thus paradoxically the actual emotion most commonly felt in this phase of therapy is relief/hope.

Gaining an understanding that control of private events is the problem (Hayes et al., 1999) is the second goal of ACT. Attempts to exert emotional and cognitive control are explored as barriers to successful solutions to clients' problems in living; that is, conscious, purposeful efforts to get rid of, escape, or avoid negative thoughts and feelings actually may be preventing clients from behaving in ways that are consistent with what they value, and may be exacerbating the very events they are trying to control. If a trauma survivor is trying to escape something, a specific memory, perhaps, then (1) that is what the client is doing rather than some other, more productive form of action; and he or she has the added problem that (2) the memories are likely to increase in frequency and negative impact.

This stage of therapy focuses on how efforts to control may not only prove ineffective but may even lead to increased difficulty. One of the metaphors introduced by the therapist that points to this issue is as follows:

"Are you familiar with the Chinese finger trap? This toy is a tube generally made of straw. You place your two index fingers in the tube and then try to pull them out. What happens is that the more you pull, the tighter the straw tube clamps down on your fingers, making it virtually impossible to escape the trap. The more effort you put into escaping, the more uncomfortable you feel—the more trapped you become. Trying to escape negative emotional experience can work like a Chinese finger trap. The harder you try not to have the emotions, the more the emotions "clamp" down on you. Examples of this kind of problem include excessive drinking to escape anxiety. Now you not only have the problem of anxiety, but you also have the problem of excessive drinking and all that that brings with it."

One important note here is that many trauma survivors are triggered by issues related to control, and much of what they are trying to do involves getting back in control of their disrupted or chaotic lives. Many traumas occur under circumstances in which there is loss of a personal sense of control. Therapists hear clients report that they "just want to get their lives back." An important message to make is that ACT therapists are not asking clients to give up control, as it is viewed culturally, but rather they are asking clients to give up control of their internal experience so that they can regain—or gain for the first time—control of their lives.

Distinguishing "I" as content from "I" as context is the third goal (Hayes et al., 1999). In this phase of therapy, the goal is to create a place in which clients can learn to see themselves as context rather than content, which, in turn, defuses the literal content of their self-talk. It is from the position of "I" that clients, and all of us, struggle; that is, it is as if the words that a person says or thinks and the actual person become fused. For example, when thinking "I am bad" from the position of self-as-content, the statement is experienced as an actual truth rather than as just a thought about oneself. From this self-as-content position, the client has to fight against feeling "bad" in essence. Now, suppose that "I am bad" could be viewed as a passing thought with which the client did not have to identify; rather, he or she could "deliteralize" or become "de-fused" from the thought. In the ACT approach, this defusion is only likely from an experiential perspective in which "I" is equated with an ongoing awareness (context). Much like a walking mediation, ACT attempts to establish a winner place from which abandonment of control is not threatening, because the private events are mere content, not "who you are."

There are three aspects of the self that are important to this issue and that can be addressed in ACT sessions. First is the conceptualized self, which is created by our ability to interact verbally with ourselves and others. We can categorize, evaluate, explain, rationalize, and so on. This is what might be called "self as content," a conceptualized self that we create verbally to make sense of ourselves, our history, and our behavior. A problematic issue occurs in this area when we hold the content of this conceptualized self to be literally true. If a person makes the comment "I am messed up because I was abused as a child," the problem to be solved becomes unworkable because no other childhood will occur. Therefore, acceptance of the conceptualized self, held literally, is not desirable.

The second self is the self as a process of knowing. We know about ourselves and can respond to others about our feelings and reactions. This knowing is valuable in terms of socialization and civilization. Through a process of training, we can report when we are hungry or when we are in pain, and so on. We can categorize our own and others' behavior based on this process. When a person's training in this kind of knowledge is deviant, then he or she may not know how to behave in relation to the social environment. For instance, suppose a young boy is sexually abused and his reactions to the abuse are ignored, denied, or reinterpreted. This type of developmental history could set the stage for a person to be unable to know or report to others accurately what he or she is feeling. one can imagine other histories where the process of accurately describing or expressing feelings appropriately is inhibited. Given this kind of history, ACT seeks to reorient the client to a process of knowing that includes both historical and current experience. one can observe oneself or see oneself as a process of ongoing behavior. Helping the client to identify current emotion and thought states is a helpful step toward the goals of mindfulness and acceptance.

The third sense of self is self as context. This is the self in which "I" is the place from which an individual responds verbally. It is the sense of one's own perspective or point of view. This self is consistent and present at all times. If we ask you questions about yourself, you always answer from your perspective. The content of your answers will change; however, the context from which you answer does not.

It is not too difficult to help clients experience this sense of connection to self as context. Localizing past memories and events as well as current situations easily puts the client in contact with this sense of "I." The only reasonable thing to do is to engage self as context, because much verbal behavior is based upon it, and we cannot function effectively as nonverbal organisms. It is also this form of self that allows other forms of acceptance. If self as context is always present, various kinds of content may come and go, but a stable sense of "I" will remain. In this state a person may experience pain or horrible memories, but they do not make the person literally those experiences. They too shall pass as new content emerges, but the sense of "I" will remain unchanged.

In the ACT approach, many techniques are used to deliteralize language and establish self as context. These include (1) imagery exercises in which thoughts are allowed to flow as leaves on streams, without being "bought," believed, adopted, or rejected; (2) repeating thoughts rapidly for dozens or hundreds of times; the thought thereby loses its meaning and allows the client to see it for what it is—a sound or thought; (3) use of imagery exercises that turn emotions and thoughts into objects to be viewed and inspected— private experiences are given shapes, sizes, colors, and so on; and (4) am extensive use of metaphor. An example of a useful metaphor is the chessboard (adapted from Hayes et al., 1999, pp. 190-191):

"Imagine a chessboard that goes out infinitely in all directions. It's covered with black pieces and white pieces. They work together in teams, as in chess—the white pieces fight against the black pieces. You can think of your thoughts and feelings and beliefs as these pieces; they sort of hang out together in teams too. For example, 'bad' feelings (such as anxiety, depression, and resentment) hang out with 'bad' thoughts and 'bad' memories. Same thing with 'good' ones. Now in the game of chess the goal is to win the war. So it seems that the thing to do is to defeat the team that you don't like or want. So you get upon the pieces that are 'good'—and the battle begins. You work hard to kick the 'bad' pieces off the board. But there is a big problem here—huge pieces of yourself are your own enemy. And what you find as you engage the battle is that the pieces never leave the board; remember, it stretches out infinitely in all directions. So you fight harder. And if you fight hard and long enough, your life becomes a battle to not have what this game has to offer. You have the sense that you can't win and you can't stop fighting. If you are focused on the piece level, a move-by-move battle seems the only thing to do. However, there is another place to focus in this game. Do you know what it is? The board level—the board holds all the pieces but it doesn't have to be invested in the battle at all. And notice that the board is not the pieces. You are not your content."

The concept of self as context can prove difficult for some clients. Therapists may encounter clients who report that they have no sense of self. For instance, women who were sexually abused as children (often being revictimized) may have a difficult time locating the sense of self that experiences emotions and thoughts. That is, their sense of self has been so shattered by historical events that they glean who they are only from others or have difficulty viewing themselves as separate entities. The therapist can work with these clients to reestablish a sense of self that is continuous and can observe personal behavior, including thoughts and feelings. At relevant times the therapist can ask "Who is saying this right now?" "Who is this person in the room talking with me? And can that person see that you are talking to me?" The therapist, then, begins to help the client reconnect to that observer self through gentle questioning. It is not too difficult to help clients experience this sense of connection to self as context. Localizing past memories and events and current situations easily puts the client in contact with this sense of "I." It is also this form of self that allows other forms of acceptance. The client may experience difficult memories or pain, but that does not make the client literally those experiences. They too shall pass and new content will be present, but, as noted, the sense of "I" will remain.

There are also clients who are overidentified with their sense of self. For instance, many Vietnam veterans who have chronic PTSD strongly identify themselves as "Vietnam veterans," along with all of the cultural characteristics that accompany that identity. This identity is tightly held and seems to define the individual at nearly all levels of personal existence. Here the ACT therapist can work with the client on the conceptualized self or the self as content. Both self-as-context and deliteralization techniques are useful when addressing this issue.

Letting go of the struggle is the fourth goal of ACT (Hayes et al., 1999). In this stage of therapy the client is encouraged to let go of the agenda of control. This stage is a "willingness move"; that is, the client is asked to be willing to have whatever thoughts, feelings, memories, or bodily sensations that might show up without having to gain control over them. He or she simply experiences them for what they are. Private events are brought into the therapy room and dissembled into component pieces (e.g., thoughts, memories, feelings). The goal is not to gain control but to experience without attempts to escape or modify. Many "willingness exercises" are used at this point and generally include imagery and experiential exercises. When working with a trauma survivor in this phase, a great deal of emotional exposure is done.

The fifth goal of ACT is making a commitment to valued action and behavior change (Hayes et al., 1999). It is at this point in therapy that clients commit to engaging in actions that are specific to their chosen values and goals. Through previous work, the client has acquired the ability to discriminate between unworkable solutions to a problem (i.e., control and avoidance of emotions) and workable solutions (e.g., commitment to behavior change). The client can begin to lead a valued life and choose directions that support that life. In this phase of therapy with a trauma survivor, the issues turn from making room for one's own history to creating a valued life. For example, concrete steps to develop more productive relationships might be taken, while simultaneously monitoring inner responses to prevent needless struggles with private experiences that might arise.

Was this article helpful?

0 0
Anxiety Away

Anxiety Away

The strategies revealed within Anxiety Away are fast acting, simple and guaranteed to work even if you have suffered from anxiety for a long time!

Get My Free Ebook


Post a comment