Acceptance and Commitment Therapy: Responses to Frequently Asked Questions (50 FAQs in Counselling and Psychotherapy) [1 ed.] 1032429372, 9781032429373

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‘A superb text. Entertaining, informative, well-written, easy-to-read, and highly relevant for every ACT practitioner. The authors brilliantly answer all those common questions that just about everyone grapples with in their ACT journey, from the technical stuff like functional contextualism and relational frame theory to the hands-on practical stuff like how to actually work with self-as-context. I wish I’d had access to a book like this when I was learning ACT. It would have saved me so much confusion!’ Russ Harris, M. D., and Author of ACT Made Simple and The Happiness Trap ‘I’ve been in and around ACT for over 15 years, and so when I saw the title of this book, I assumed that I’d already know the answers to the FAQs. That was not the case. There have been niggling questions over the years about the ACT model that I’ve semi-ignored, and this book now gives me the answers to those questions in a comprehensive, clear, and accessible way. I guess that’s what I find most remarkable about the book: it will be useful to both a total newbie and to those more experienced with ACT.’ Nic Hooper, Ph.D., Lecturer in Psychology at Cardiff University, UK and Author of The Unbreakable Student ‘Here is a book that could only be written by people with deep knowledge, years of clinical practice and teaching, and direct experience of living by the ACT model. They home in on the key questions that really matter to new (and indeed experienced) practitioners. They answer them with clarity, with precision, depth, as well as with warmth and humour. Above all this is a supremely practical book; not obsessed with people getting ACT ‘right’, but with helping people to become more confident and effective in using ACT to help themselves and others. It should be on the bookshelf of any new ACT practitioner, and also anyone who teaches or supervises them. I know my copy will become well-thumbed.’ Ray Owen, DClinPsy, Consultant Clinical and Health Psychologist, Peer-reviewed ACT Trainer, and Author of Facing the Storm and Living with the Enemy

‘This book is a true gem. Not only does it provide you with the most useful answers to various ACT questions. It’s well written, wisely organised, easy-to-read, and very practical too. This book is a musthave for every practitioner wanting to develop their skills in ACT.’ Rikke Kjelgaard, Psychologist, Peer-reviewed ACT Trainer, author of Samtal som förändrar: en Guide till ACT i Praktiken, and chief rock’n’roller at www.rikkekjelgaard.com ‘This is the book I wish I had while I was teaching and supervising ACT trainees. A must-have resource for anyone learning or teaching Acceptance and Commitment Therapy. It will answer all your burning questions in a thorough yet concise and understandable format. Highly recommended!’ Jill Stoddard, Ph.D., author of Be Mighty: A Woman’s Guide to Liberation from Anxiety, Worry, and Stress Using Acceptance and Commitment Therapy and The Big Book of ACT Metaphors: A Practitioner’s Guide to Experiential Exercises and Metaphors in Acceptance and Commitment Therapy ‘The book was a real treat to read, both as an ACT practitioner and as an ongoing student of the model. I found it especially useful because I often encounter many of these questions in my practice with clients. I recommend this book to newcomers and seasoned practitioners alike. It offers a good starting point for learning about the principles of ACT and at the same time offers the possibility to revisit fundamental theoretical and practical ideas. The book is very well structured, so the reader can jump to any question to get a specific answer.’ Gabriel Roseanu, Ph.D., Cognitive Behavioral Psychotherapist and Lecturer in Psychology at the University of Oradea, Romania

‘If you are an ACT practitioner looking to dive more fully into the ACT model, then this book is for you. It’s jam packed full of pearls of wisdom, answering all the questions you ever wanted to ask about ACT but were too afraid to ask. Highly recommended.’ Joe Oliver, Ph.D., Founder of Contextual Consulting and co-author of The Mindfulness and Acceptance Workbook for Self-Esteem ‘This is such a useful book! As a quick reference guide, the authors have created a go-to resource for accessible answers to questions that you will find yourself asking or find that others ask of you. More than that, this book is also a really absorbing and stimulating read, inviting us to think more about the how of ACT rather than the what. It makes a perfect accompaniment to many other ACT core texts.’ Elizabeth Burnside, DClinPsy, Clinical Psychologist and Academic Director of North Wales Clinical Psychology Programme ‘What a great read. This will be very useful for professionals and teachers who want to learn more than just the Hexaflex. The reader can dive into the under-the-hood aspects of ACT, deepen their therapy skills, and they will become more flexible in their work. You’ll find answers to all your commonly asked questions answered instantly and be entertained in the process. A great companion to dip into whenever questions arise.’ Louise Hayes, PhD, Clinical Psychologist and co-author of Get Out of Your Mind and into your Life for Teens, Your Life Your Way, The Thriving Adolescent and What Makes You Stronger

Acceptance and Commitment Therapy

Acceptance and Commitment Therapy (ACT) is an evidence-based contemporary psychological approach to behaviour change that promotes the idea of people living more in line with their values whilst providing them with practical strategies for managing adversity. In this book, Dawn Johnson and Richard Bennett have collated fifty of the questions that have most frequently been put to them whilst delivering ACT training and supervision to a wide range of therapists and other helping professionals. This book is the first of its kind to provide concise answers to a range of philosophical, theoretical, conceptual, and practical questions raised by practitioners who are learning ACT. It will be of interest to psychotherapists, clinical psychologists, counsellors, psychiatrists, and a broad range of other mental health practitioners and trainees. It serves as a useful resource for those new to the practice of ACT, and for more experienced practitioners who might want to consider these questions themselves. Dawn Johnson works as a Clinical Psychologist in private practice, offering therapy, teaching, training, supervision, and consultation. She previously had a long career in the National Health Service and has extensive experience of adapting ACT to work with people with intellectual disabilities, neurodiversity, and severe mental health problems. Richard Bennett works as a Clinical Psychologist and Cognitive Behavioural Psychotherapist. He lectures at the Centre for Applied Psychology at the University of Birmingham and works at Think Psychology, the independent psychology practice he founded, which offers therapy, supervision, and training.

50 FAQs in Counselling and Psychotherapy

Windy Dryden PhD is Emeritus Professor of Psychotherapeutic Studies at the Goldsmiths University of London. He is an international authority on Rational Emotive Behaviour Therapy and is in part-time clinical and consultative practice. He has worked in psychotherapy for more than 45 years and is the author and editor of over 250 books.

Edited by Windy Dryden, the 50 FAQs in Counselling and Psychotherapy Series provides answers to questions frequently raised by trainees and practitioners in a particular area in counselling and psychotherapy. Each book in the series is written by experts based on their responses to 50 frequently asked questions, divided into specific sections. The series will be of interest to practitioners from all orientations including psychotherapists, clinical, health and counselling psychologists, counsellors, psychiatrists, clinically-oriented social workers and trainees in these disciplines. Single-Session Therapy Responses to Frequently Asked Questions Windy Dryden Pluralistic Therapy Responses to Frequently Asked Questions Frankie Brown and Kate Smith Acceptance and Commitment Therapy Responses to Frequently Asked Questions Dawn Johnson and Richard Bennett

Acceptance and Commitment Therapy

Responses to Frequently Asked Questions

Dawn Johnson and Richard Bennett

First edition published 2024 by Routledge 4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN and by Routledge 605 Third Avenue, New York, NY 10158 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2024 Dawn Johnson and Richard Bennett The right of Dawn Johnson and Richard Bennett to be identified as authors of this work has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. British Library Cataloguing-in- Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in- Publication Data Names: Johnson, Dawn (Clinical psychologist), author. | Bennett, Richard (Psychologist), author. Title: Acceptance and commitment therapy : responses to frequently asked questions / Dawn Johnson and Richard Bennett. Description: First edition. | Abingdon, Oxon ; New York, NY : Routledge, 2024. | Series: 50 FAQs in counselling and psychotherapy | Includes bibliographical references and index. | Identifiers: LCCN 2023010880 (print) | LCCN 2023010881 (ebook) | ISBN 9781032429380 (hardback) | ISBN 9781032429373 (paperback) | ISBN 9781003364993 (ebook) Subjects: LCSH: Acceptance and commitment therapy— Miscellanea. Classification: LCC RC489. A32 J64 2024 (print) | LCC RC489. A32 (ebook) | DDC 616.89/1425 — dc23/eng/20230527 LC record available at https://lccn.loc.gov/2023010880 LC ebook record available at https://lccn.loc.gov/2023010881 ISBN: 978 -1- 032- 42938 - 0 (hbk) ISBN: 978 -1- 032- 42937-3 (pbk) ISBN: 978 -1- 003-36499-3 (ebk) DOI: 10.4324/9781003364993 Typeset in Times New Roman by codeMantra

This is for you. With love and light.

Contents

List of figures List of tables Acknowledgements Introduction

xv xvii xix 1

PART 1

Defining the philosophy and theory of ACT

3

1 What is the best way to describe ACT to a client?

4

2 Which kinds of issues can ACT help with?

7

3 What are the basic assumptions that ACT makes?

10

4 How does evolutionary theory apply to ACT?

13

5 What is functional contextualism?

16

6 Why do ACT practitioners answer every question with “it depends”?

19

7 What is the most important behavioural principle to remember?

22

8 What on Earth is relational frame theory?

25

9 Why does ACT use so many metaphors?

28

10 What is the relationship between ACT and other cognitive behavioural therapies?

32

xii Contents PART 2

Conceptual questions about the ACT model

37

11 What is psychological flexibility?

38

12 What does ‘creative hopelessness’ mean?

42

13 Is ‘contact with the present moment’ the same thing as mindfulness?

46

14 What is self-as-context and how does it differ from defusion?49 15 Doesn’t acceptance just equate to giving up and letting life steamroller you?

53

16 What is meant by ‘transformation of stimulus functions’?

56

17 How do I tell values apart from goals or rules?

59

18 How can I tell the difference between toward and away moves when clients are taking action?

62

19 How does the concept of compassion fit with ACT?

65

PART 3

Putting ACT into practice

69

20 Do I need to know RFT in order to practise ACT?

70

21 How do I know whether ACT is the right intervention for someone?

73

22 Can ACT be adapted for diverse populations?

76

23 Where do I start with introducing ACT to a client?

79

24 Should I show the Hexaflex to my clients? 

82

25 How do I explain each component of the Hexaflex?

87

Contents xiii

26 In which order should I work through the components of the psychological flexibility model?

91

27 How can I encourage people to tune in to the present moment?

94

28 How do I actually do self-as-context work with a client?

97

29 How do I promote acceptance in sessions?

100

30 How do I know which defusion procedure to use?

103

31 How do I deal with values conflict?

106

32 So, I just get people to work out their values and encourage them to do value-driven behaviour all the time, right?

109

33 Do I have to address all the processes in every session?

112

34 How do I apply ACT with (insert diagnosis here)?

115

35 How many sessions should a course of ACT intervention include?

118

PART 4

Developing skills as an ACT practitioner

121

36 What do I need in place in order to practise ACT safely and effectively?

122

37 Should ACT practitioners practise ACT for themselves?125 38 Why is experiential learning better than didactic learning?128 39 Why is there no formal qualification in ACT?

131

40 How can ACT practitioners shape their learning?

134

41 Do I need ongoing ACT supervision?

138

xiv Contents PART 5

Critical questions about ACT

143

42 How strong is the evidence for ACT?

144

43 Traditional CBT has a well-established evidence base. Why does the world need ACT?

147

44 Isn’t ACT just another case of ‘the emperor’s new clothes’?151 45 ACT uses a lot of eye-catching tools and techniques. Isn’t this all just a bag of tricks?

154

46 How does ACT fit within a culture where the medical model dominates?

157

47 Is it not harmful to encourage people to tune into and accept their pain and discomfort?

160

48 What if people have harmful or antisocial values?

163

49 The client says, “I’ve done everything you suggested but it hasn’t taken away my discomfort”. What do I do next?

166

50 What do I do if a technique does not work out like it is supposed to?

170

Index

173

Figures

9.1 Relational networks contained in the metaphor of ‘getting straight back on the horse after a fall’ 10.1 A comparison of cognitive therapy and acceptance and commitment therapy (adapted from Gillanders, 2013a) 11.1 The three-column version of the Hexaflex 19.1 Compassion and the Hexaflex 24.1 The Inflexahex (adapted from Bach & Moran, 2007) 24.2 The ACT Matrix (adapted from Polk et al., 2016) 24.3 Mapping Hexaflex terms and derived relations using the Matrix 43.1 The five areas model (adapted from Williams & Garland, 2022)

29 34 40 66 83 84 85 149

Tables

2.1 Issues for which ACT is recommended in national guidelines 14.1 A comparison of the concepts of defusion and self-as-context by process, procedure, and outcome 27.1 Modelling, evoking, and reinforcing present moment behaviour in and out of session

9 52 96

Acknowledgements

We would like to express our gratitude to everyone within, and connected to, the ACT and contextual behavioural science community for influencing the development of our practice. Many of the ideas and concepts presented within this book have been inspired by our colleagues, as well as the clients with whom we and they have worked. Due to the collaborative ethos of the ACT community, it is not always clear from where certain ideas have originated. We have endeavoured to reference and credit people where possible. We would like to thank the Responses to Frequently Asked Questions series editor, Windy Dryden, for giving us the opportunity to contribute to this range of books. We are also very grateful to Tien Kuei, Ayesha Shahid, and Fabian Olaz for reviewing our initial book proposal, and to Grace McDonnell for guiding us through the publication process.

Introduction

Acceptance and Commitment Therapy (ACT) is a contemporary form of Cognitive Behaviour Therapy (CBT) that blends cutting edge research into verbal behaviour with the ancient wisdom traditions. It is a pan-diagnostic approach to behaviour change that has broad application across a wide range of settings. It has a rapidly expanding evidence base, and it is gaining traction in a number of different areas of healthcare and psychology more broadly. It is recommended by the World Health Organization and in the national guidelines of several countries. We have delivered thousands of hours of ACT trainings across a range of settings over a period of approximately ten years. During training and supervision sessions we are often asked questions about the ACT model, regarding theory, application, and the ongoing learning and development journey of budding ACT practitioners. In this book we have selected the 50 questions that we are most frequently asked. We hope that gathering them together in one clear and accessible volume will provide a helpful resource for anyone looking to develop their knowledge and skills as an ACT practitioner. This book is suitable for anyone working in a helping professional capacity including psychotherapists, clinical, health, counselling, sport, and occupational psychologists, counsellors, psychiatrists, coaches, physiotherapists, occupational therapists, clinically oriented social workers, as well as trainees in these disciplines. It will be best suited to people who have had some prior exposure to ACT, whether through training or self-directed learning. The book is divided into five sections, with each part addressing a different focus for the most common enquiries.

DOI: 10.4324/9781003364993-1

2 Introduction

1 2 3 4 5

Defining the philosophy and theory of ACT Conceptual questions about the ACT model Putting ACT into practice Developing skills as an ACT practitioner Critical questions about ACT

Each chapter is written as a stand-alone answer to the chapter title, so you are free to choose whether to read cover to cover, or just dip into the question at the forefront of your mind. We have chosen to write in a way that is as inclusive as possible. The questions will be answered without specific focus on any particular condition or area of application in order to make it more accessible. We have referred to the professional role as ‘practitioner’ throughout the book, and referred to the receiver of the intervention as ‘client’. We have also used the singular pronoun “they”, which we hope will work for the majority of readers. We are honoured to be part of your learning and development. Many thanks for joining us on this journey.

Part 1

Defining the philosophy and theory of ACT

Acceptance and commitment therapy (ACT) is a contemporary psychological approach to behaviour change. It has been at the forefront of the third wave of Cognitive Behaviour Therapy (CBT), blending cutting edge research into verbal behaviour with ancient wisdom traditions. ACT represents a transdiagnostic approach to behaviour change that has broad application across a wide range of organisational and healthcare settings. This section of the book addresses frequently asked questions about the philosophical and theoretical basis of ACT. The chapters aim to describe ACT, placing it within the context of evolutionary and behavioural theory, and the philosophy of functional contextualism. The section also describes relational frame theory (RFT), the basic science of language that informs ACT’s approach to intervention. Finally, it explores the relationship between ACT and other approaches within the cognitive behavioural tradition.

DOI: 10.4324/9781003364993-2

Chapter 1

What is the best way to describe ACT to a client?

It depends. This is one of the answers that you will see time and time again when reading this book and hear when talking to ACT practitioners. We will further explore the reason for this in Chapter 6. In relation to explaining ACT to a client, how you describe it will depend on factors like their existing knowledge of ACT and other psychological concepts, and what they are hoping to gain by discussing the model with you. Some people may have some psychological knowledge that they want to check out with you. Others may have had little or no exposure to psychological models, and therefore they will have a very different reason for enquiring about the theory behind your sessions together. So, it follows that there is no one ‘best way’ and any way will depend on the factors listed above, as well as others like intellectual ability and level of emotional arousal in the moment. If you find yourself in a position of having to explain ACT to a client, it may be more helpful to ask yourself, “What would be most helpful in this moment, for this person in front of me?” rather than, “What is THE best way to explain ACT?”. In our experience, explanations that have the most utility have an experiential element, such that the client is actively engaged in doing something, rather than passively listening to the practitioner. The more active the client is in a session, the more we may be able to move them away from a rehearsed ‘intellectual’ approach to life, and in the direction of a more ‘felt’ or ‘experienced’ way of engaging with their world. Having said all of that, it wouldn’t be a particularly helpful chapter if we simply left it at “it depends”. So, here are some ideas on how to approach this question with clients in a more experiential way. The ‘ACT in a nutshell’ exercise (Harris, 2009) is a simple and clear way

DOI: 10.4324/9781003364993-3

What is the best way to describe ACT to a client?  5

to explain how we humans get stuck by our use of language. ACT suggests that we have two main strategies that we draw upon when facing unwanted thoughts and feelings, namely, fusion, and experiential avoidance. ACT in a nutshell demonstrates these strategies using a piece of paper. You can invite the client to write down a thought or feeling that they are struggling with; for example, the client might write “I am worthless” on a post-it note and use this for the exercise. If you are comfortable enough with self-disclosure, it can be very useful modelling for you as the practitioner to join in with the exercise by writing your own uncomfortable thought on a piece of paper too. Start by holding the paper up to your face, and invite your client to do the same. Whilst in this position, explore with the client what they experience. What can they see in their world now the paper is up close, and what might they be missing out on? If they were to leave your session in this position, what costs would it have for their life? You can model the answer too by sharing what you can no longer see, or safely engage with, as the piece of paper is firmly blocking your view. You and your client will likely have a good view of the words you have written on the piece of paper. Is it helpful to have this so close? This is a demonstration of fusion, and when we allow our fused thoughts to dominate our life, we end up with a very blocked perspective of the world. Conversely, then invite your client to push away the piece of paper. Hold it at shoulder height, and push it away as hard as you possibly can. These thoughts and feelings are, after all, unwanted. However hard they are pushing, ask them to push harder, and really try to make them be as far away as possible. Now invite the client to notice what is grabbing their attention. Can they notice the tiredness in their upper arm or shoulder? What if they were to continue pushing for another hour!? And in all seriousness, this is what many of us humans do with our unwanted thoughts and feelings. We exhaust ourselves with working so hard to keep them away that we are physically and emotionally spent. And what else have we missed out on whilst we made sure we were keeping those things at bay? Have we missed out on important life experiences? Perhaps our children have been through a developmental milestone that we weren’t really able to attend to? What have been the costs of so heavily investing in keeping these things at arm’s length? This part of the exercise demonstrates the use we make of experiential avoidance, and its associated costs.

6  Defining the philosophy and theory of ACT

Next invite your client to rest their tired arm, still holding the post-it note in their lap. What do they notice? Relief? A reduction of tension? A broader ability to focus their attention on other things? For example, they may suddenly make eye contact with you for the first time! You can curiously enquire about what it feels like to let this set of words just lie in their lap. Leaving the post-it note there, you can point out that now you can both move your hands, which, in the demonstration of fusion and experiential avoidance, you were less able to move freely. What else could they turn their attention to if they were able to leave those words gently resting in their lap? What if they were to fold the post-it note and put it in their pocket? What could they then do in their lives that they are currently unable to do? Alternatively, an overarching metaphor can also be a helpful tool for explaining the ACT model. ‘Passengers on the bus’ is a very commonly used metaphor for helping clients to understand the impact of how our thoughts can direct our behaviour, and how this doesn’t have to be the case. See Chapter 9 for a more detailed discussion of the use of metaphors. Explaining the model to clients and/or helping them experience it can be an important part of helping them to understand why ACT practitioners may approach things slightly differently to how they have experienced them before. However, our focus in doing this is always about the importance of psychological flexibility. It can therefore be helpful to explain the model as learning a set of new ‘flexibility’ skills, and that in each session, the focus will be on the development of these skills. See Chapters 11, 24, and 26 for more on seeing ACT as six separate skills. Of course, the urge to engage in ‘explaining’ behaviour may come from you, and, if so, the question to ask yourself is, “What is the function of sharing the detail of the model with someone who doesn’t really need to know it?”. If this is you, see Chapters 7 and 18 on toward and away moves, and reflect on this in relation to your own behaviour as a practitioner.

Chapter 2

Which kinds of issues can ACT help with?

We are frequently asked whether ACT can be useful in situation X, Y, or Z. There are probably two ways to answer this question, specifically, either from a conceptual or an empirical perspective. This is to say that there is potentially a difference between the kinds of issues that processes and procedures within ACT can usefully be applied to, and the kinds of issues that ACT has been shown to be effective in helping. Each of these will be dealt with in turn. From a conceptual point of view, ACT is intended as an approach to adaptive behaviour change and psychological wellbeing that is broadly applicable across any situation which people experience. Indeed, in describing their own ACT-based self-help course, the World Health Organization states that it is, “suitable for adults who experiences stress, wherever they live and whatever their circumstances” (WHO, 2022). Thus, it is a reasonable starting point to assume that ACT principles might be helpful in any situation that might come to the attention of people that work in helping roles. Whilst any specific context will give rise to unique stressors, and the nature of people’s thoughts, feelings, and behaviours will differ, ACT takes the stance that psychological flexibility and its sub-processes are universally applicable. Support for this stance can be seen in the diverse range of contexts where ACT has been applied to date, and in the variety of methods of its delivery. Whilst individual psychotherapy in physical and mental health settings is probably where ACT has been most widely used, its reach is much broader than this. Whilst psychotherapy is most often concerned with helping people address deficits or problems in their lives, ACT has also been used to increase performance in otherwise healthy individuals. Applications in the workplace and in sport are

DOI: 10.4324/9781003364993- 4

8  Defining the philosophy and theory of ACT

examples of the latter. ACT also provides a basis for working on issues faced by groups of individuals, such as teams of people within organisations or wider community groups (Atkins et al., 2019). One of the most notable examples of the application of ACT on a larger scale is in the training of health professionals, community workers, and the public in Sierra Leone during the Ebola crisis, where the principles of psychological flexibility were used to foster behaviour change and reduce the number of new infections (Stewart et al., 2016). Turning to the second way to answer this question, many would argue that one can only determine what kind of issues ACT can actually help with is with reference to evidence from randomised controlled trials (RCTs) or other types of outcome research. Whatever claims might be made about the utility or impact of any model, the proof of the pudding is in the eating. There are also those who say that you can never really trust the efficacy of a psychological intervention until it has received a lot of research attention and there is enough evidence available for researchers to conduct systematic reviews or metaanalyses of the data from the research trials. Fortunately, ACT has been the subject of a significant programme of research right back to the roots of its inception in the 1980s, and in considering this question, we can draw on a large body of outcome data as well as the findings from various types of reviews. One of the problems of answering this as an empirical question in a book such as this is that any answer that we give will be out of date by the time the book is out, such is the rate at which new ACT research is published. We find ourselves constantly updating our training slides on ACT research. Our advice to you if you are wanting an answer to this question is to try to keep yourself abreast of the latest research findings. This can be quite a task given that so far in 2022, RCTs looking at the effectiveness of ACT are being published at the rate of at least one each week. In terms of useful resources, Hooper and Larsson’s (2015) very helpful book charting ACT’s research journey provided a detailed analysis of the empirical literature up until the time of its publication. However, books are not the best place to look given their somewhat static nature. Fortunately, the Association for Contextual Behavioural Science (ACBS) maintains a dynamic list of RCTs, systematic reviews, and meta-analyses on the ‘research resources’ section of its website (Hayes, 2022). If you want to look at the state of the ACT evidence at any given point, this is the best resource that we have found.

Which kinds of issues can ACT help with?  9

At the time of writing this book, ACT has a significant evidence base for being helpful across a wide range of physical and mental health issues, with the three strongest research areas being anxiety, depression, and chronic pain. It also has utility in organisational settings as an intervention to help manage workplace stress and prevent burnout (Flaxman et al., 2013). The first review of ACT meta-analyses (Gloster et al., 2020) covered research on over 12,000 participants and concluded that ACT was efficacious wherever it was applied, being superior to inactive control conditions and most other active interventions. It performed as well as traditional forms of CBT. We will conclude our answer to this question with the current list of issues for which ACT is recommended by the national guidelines of several of the world’s countries (see Table 2.1). This is not an exhaustive list of the issues where ACT can demonstrate evidence of its effectiveness. However, it is included as an indication of the range of issues where the evidence base is substantial enough to have led to the recommendation of ACT at a national level. Table 2.1  Issues for which ACT is recommended in national guidelines Australia

Netherlands United Kingdom United States

Generalised anxiety, social anxiety, panic, borderline personality, depression, health anxiety, obsessions and compulsions, pain, psychosis, problematic substance use, binge eating, body dysmorphia Depression, multiple sclerosis with depressive symptoms Chronic pain, tinnitus Depression, chronic pain, mixed anxiety, obsessions and compulsions, psychosis, problematic substance use

Chapter 3

What are the basic assumptions that ACT makes?

In more recent years, ACT has become synonymous with the Hexaflex (see Figure 11.1) and the six core skills that support the development of increased psychological flexibility. However, when these are looked at in isolation, the essence and complexity of the ACT model is lost. This may feel disheartening to read. Perhaps you came to this book with the desire to increase your ability to work on these core skills in the service of being a more efficient and successful practitioner for the clients that you serve. When focusing solely on the Hexaflex to effect behaviour change, there will undoubtedly be some success for many clients. Research suggests that developing any of the Hexaflex skills positively impacts psychological flexibility and other wellbeing outcomes (Villatte et al., 2016a; Levin et al., 2020). However, the precision of the model comes from having a good grounding in the wider scientific knowledge, theory, and underpinning philosophy, within which practitioners can embed their work on the ACT core skills to more finely tune the interventions that they provide. As is the case for any science-based work, including psychological models, there are some basic premises that underlie ACT, and practitioners will benefit from understanding these from the outset. These basic assumptions are not simply points to remember, rather, they are the very bedrock of the model. They are the foundation from which the model has expanded, layer by layer. This chapter alone is too short to cover the detail of the history of behaviourism, the exact journey of the development of ACT, and the complex ideas that have been interwoven to contribute to this body of work. Further chapters aim to offer more detail and suggest further reading on many of the points mentioned here. This chapter aims

DOI: 10.4324/9781003364993-5

What are the basic assumptions that ACT makes?  11

to offer an overview of the key assumptions that underpin the ACT model, in order that their importance becomes clearer. It also provides a rationale for further implementing them into your ACT work, rather than relying solely on the Hexaflex. ACT relies on an underlying science of language and the behaviour of relating concepts together, known as relational frame theory (RFT). This is summarised and explored in relation to its intervention application in Chapter 8. The underpinning philosophy of the model is based on the world view of contextualism, specifically functional contextualism. This is further explored in Chapter 5. Arising out of both of the aforementioned scientific and philosophical foundations, the following are some basic assumptions that are made from a contextual behavioural standpoint, which are therefore central to ACT practice.

Everything is behaviour The work of Skinner (1953) advanced the earlier understanding of behaviourism to also include attention to internal events such as thoughts, feelings, and language. ‘Radical behaviourism’ formed the ‘first wave’ of what became CBT. The field moved more in the direction of cognition during the 1970s, forming what is known as the ‘second wave’ of CBT. The ‘third wave’, which includes ACT (Hayes et al., 1999), focuses on the importance of the relationship between the behaviour and the context within which it occurs. ACT assumes that all human experience is behaviour, encompassing both internal events and externally observable actions. This idea is captured in the well-known and often utilised tool, the ACT Matrix (see Chapter 24). Whilst internal and observable behaviours are separated by the horizontal line, with internal behaviours below and observable behaviours above, the Matrix seeks to describe the impact of all human behaviours, and the further behavioural choices that people may have in response to them.

Behaviour is not random By accepting a functional contextualist world view, which in summary holds that all behaviours are acts-in-context, it follows that behaviours are not random. They do not occur in a vacuum or appear out of nowhere. They have a history, and a specific behaviour occurring

12  Defining the philosophy and theory of ACT

would be predictable given the historical context of the person and the current context within which the behaviour happens. The complexity of human behaviour may appear to suggest that specific actions are random. However, a thorough functional analysis would help to identify complex behaviour patterns that are embedded in a complex history, which could theoretically explain all of the observed behaviours presented by an individual.

All behaviour is purposeful There are no coincidences or accidents with actions. There are only behavioural patterns that are in an individual’s repertoire because they have previously been utilised. If the behaviour was effective for the person with regard to a desired outcome being achieved, the behaviour is more likely to be utilised again, and the behavioural pattern will be reinforced. All of the behaviours in a person’s repertoire are available for them to engage in at any point that the conditions around the person evoke their occurrence. The likelihood of a behaviour happening will increase if the behaviour has previously afforded them a desired outcome, either moving toward something of meaning to them, or away from something uncomfortable or unwanted. In relation to either moving toward or away from something, all behaviour is seen as purposeful and functional.

No absolute truth One of the most asked questions in ACT-consistent interactions (training, supervision, or therapy) is, “Is that behaviour helpful?”. The underlying philosophy of functional contextualism adopts a different view of ‘truth’ to that which most people are familiar with. Largely truth is assessed by the similarity between a verbal description and a lived experience of a situation. Functional contextualism instead focuses on ‘truth’ as effective action, hence the question about whether a behaviour is helpful in leading a person toward their intended goal. If the action was helpful in achieving a specified end goal, the behaviour would be considered ‘true’. Thus, functional contextualism adopts a more pragmatic truth stance, rather than one assessing any sense of an ontological truth. ACT-consistent interventions require that all of these basic assumptions are held in mind as they form the foundation from which any ACT tools and techniques can be utilised to effect behaviour change.

Chapter 4

How does evolutionary theory apply to ACT?

Some models of psychotherapy, notably Beck’s (1979) cognitive therapy, are predominantly models of dysfunction in that they start from a position of the client being ill and aim for recovery, usually measured by a reduction of distress. ACT is different in that it is a model of function. As part of the discipline of contextual behavioural science (CBS), ACT seeks to understand how human beings operate in the world, and then uses this understanding to explore how they might fill their lives with meaning and purpose. There is a big emphasis on helping people develop psychological flexibility to manage the challenges they encounter in the context of their environment, as well as the challenges posed by their own thoughts and feelings. Of course, ACT can be usefully applied to help people who might traditionally be described as ‘ill’, whether mentally or physically, although it tends not to lean too heavily on diagnostic frameworks or subscribe to a medical model of difficulty or distress. Rather than see people as ill or broken in some way, thereby locating all of the problem within an individual, ACT prefers to see people in distress as stuck. This places the emphasis on the interaction between a person and the context in which they find themselves. Every psychological model needs a theoretical foundation, and functional contextualism, RFT, and ACT all lean on evolutionary theory to explain why it is that people get stuck. ACT views psychological difficulties as adaptive variations to environmental challenges, rather than as diseases or disorders (Hollon, 2021). Whilst a detailed examination of evolutionary theory is beyond the scope of this book (see Sloan et al., 2018 for an in-depth look at the relationship between evolutionary theory and CBS), we will cover the main issue of relevance, namely the development of human language. DOI: 10.4324/9781003364993- 6

14  Defining the philosophy and theory of ACT

The human mind is different to that of other animals because of its much broader cognitive abilities. The precise reason for this is still a matter of some debate, although it seems clear that human cognitive and language abilities evolved alongside humanity’s development as a predominantly co-operative species. We developed the ability to flexibly communicate on a large scale by exchanging speech sounds with one another. We began to attach sounds to objects in the real world, enabling the symbolic transfer of information and ideas (Hayes et al., 2001). We could talk about people who were not present, relive events that had occurred in the past, and even describe imagined situations that we had never experienced. Whilst it is easy to take these everyday abilities for granted, there is no other species on the planet that communicates in the range of ways that humans do, or that has the same powers of imagination. However, the same ability that is responsible for our seemingly limitless creativity and co-operation is also responsible for most of our suffering. No other animal ruminates over their past failures or worries about their future. Our cognitive and language abilities make it very difficult for us to live in the moment. For a modern human, the normal developmental business of acquiring language makes a certain amount of psychological suffering inevitable and an almost infinite amount of suffering possible. To try and cope with the suffering we experience at the hands of our own thought processes, we get stuck in unhelpful patterns of fusion and experiential avoidance. To make matters worse, we frequently heap further self-criticism upon ourselves for using these strategies. In short, language is both a gift and a curse for our species. For the reasons stated above, the theory and practice of ACT is intertwined with the theory of human evolution. RFT, which is the theory of language that ACT allies itself with, is interested in relating (the behaviour of linking stimuli using language, e.g., ‘lions’ and ‘dangerous’) and the subsequent functions of that relating (e.g., the behaviours of worrying and avoidance that occur as a consequence of associating ‘lions’ with ‘dangerous’) (Barnes-Holmes & McEnteggart, 2020). The theory of evolution by natural selection (Darwin & Kebler, 1859) offers the most convincing account of why human beings have developed as they have, and ACT leans on this account of human development to explain why we experience psychological suffering in the way that we do. The practice of ACT also shares some features of the Darwinian model in its approach to behaviour change. Nature produces genetic

How does evolutionary theory apply to ACT?  15

variations in organisms, some of which are selected and retained if they give that organism an advantage in terms of survival. In much the same way, ACT practitioners encourage variation and flexibility in behaviour, inviting clients to notice what behaviour works for them with regard to navigating the world, and further encouraging them to select and retain those adaptive behaviours. A related question here is whether an ACT practitioner needs to subscribe to the theory of evolution to practice effectively. This is relevant given that the theory runs counter to the beliefs of some clients and practitioners, particularly those with strong religious convictions. Our position here would be that whilst some discussion of evolutionary development to reinforce the idea that human suffering is ubiquitous and entirely expected can be extremely validating for many clients, it is not an essential component of how ACT is practiced ‘in the room’. As with most aspects of ACT practice, some flexibility is recommended, and practitioners would be wise to tune in to their client and the context of their work together to determine if any, and if so, how much, discussion of evolutionary theory would add value in any given moment.

Chapter 5

What is functional contextualism?

Functional contextualism is a philosophical world view. Of numerous world views, Pepper (1942) identified contextualism as one of four that came close to the ideal level of precision and scope. Every philosophical world view has its own root metaphor and truth criterion. A root metaphor is a common-sense understanding of an event, and within contextualism the root metaphor is the act-in-context. A truth criterion provides the basis by which the accuracy of truth can be assessed and is inextricably linked with the root metaphor. In the case of contextualism the truth criterion is concerned with the function of an action, which can be defined as true or valid if there is an achievement of a goal, not by its reflection of reality. In essence, the underlying philosophy of ACT is that it is concerned with exploring the function of any behaviour inside the context within which the behaviour happens. This reflects the root metaphor of the act-in-context. This can feel like a tricky concept to fully understand, so we will use some examples to illustrate the interplay between function and context, and why, from an ACT perspective, they are unable to be understood in isolation and are wholly dependent on one another. To consider the context of a behavioural event is to consider where the event happens. This can refer to where in a person’s timeline the event happened, such as whether it is happening in the present, or whether it can be explained with reference to its historical context, for example, current avoidant behaviour in the context of an abusive history. Each of these time points provides us with information about the behaviour being described and will shape our formulation about how the event is experienced inside the client’s life. Context can also

DOI: 10.4324/9781003364993-7

What is functional contextualism?  17

refer to the physical context, for example, the people and location surrounding the event, or the psychological context, such as “In the context of my current struggles…”. Again, the setting of the internal and external context provides a large amount of information that can be added to a functional analysis or formulation. Any minor change to the context can change our understanding of the behaviour, so it is really important to have a clear understanding of the context for it, in all of the ways described above. The function of an event refers to the effect that it had. This is different to intention, and it is important not to confuse these two concepts. Suppose a client informs you that they intended to pay someone a compliment, however, the receiver of their words took offence. Whether that was intended or not we would classify the function of the comment as aversive, from the receiver’s point of view. Let us further explore the ideas of function and context by looking at a language example concerning the impact of context. Imagine being in a nightclub and the DJ shouts, “Put your hands in the air!” just as your favourite song starts. What do you notice? Perhaps you would smile. You may willingly raise your hands and you may notice feelings of joy and excitement. Now let us switch the context. You are in the queue at the bank on a busy Friday afternoon, paying in a large amount of cash. Someone walks in and shouts, “Put your hands in the air!”. What do you notice now? You are likely not smiling in this context. You may raise your hands, although this may not be with the same vigour and willingness than you had in the above example. You may notice a wholly different range of thoughts, feelings, and physiological sensations to the ones that you felt in the nightclub scenario. Whilst the stimulus, in terms of the language used, was the same, and maybe resulted in the same behaviour (raising your hands), the context in which that happened evoked very different reactions. Changing the context leaves you feeling very differently about hearing, “Put your hands in the air!” because the different contexts changed the function of the words. In the above example, the form of the behaviour remained the same (your hands were in the air) but the function was appetitive in one scenario and aversive in the other. We can also consider function in a different way, whereby the form of a behaviour might change whilst the functions remain the same. This is something that can be tricky to catch in clients’ behavioural patterns. However, it is an important skill for practitioners to hone and can increase the precision with which

18  Defining the philosophy and theory of ACT

functional contextualism is utilised in intervention work. Imagine a client who is struggling to connect emotionally during sessions. Each time you raise an issue that feels aversive for them, they find a way of avoiding it, and you find you never really get near the emotional content underlying their behavioural choices. There are numerous ways in which this avoidance might manifest. The following list contains several examples: • • • • • • •

Cancelling a session Turning up very late to reduce the amount of time in session Using humour Asking about you Talking about other topics that are less emotional Spending a lot of time describing something that could have been easily summarised Showing you photos of their new puppy

All of these are different forms of behaviour, i.e., they each look different to one another. However, the function of all of them is the same in that they serve to keep you at arm’s length. Whilst each of the above could genuinely be toward moves in some contexts, it is only when we identify the common contextual factor (getting close to emotional content) that we may realise that these behaviours all serve the same avoidant function. From a functional contextualist perspective, no behaviour can be judged as intrinsically right or wrong. Instead of making judgements about behaviour, we would always encourage ACT practitioners to ask, “What’s the function?” and seek to explore how workable any particular behaviour is for an individual within the particular context in which it occurs.

Chapter 6

Why do ACT practitioners answer every question with “it depends”?

As tempting as it is to simply write “it depends” in response to this question, we will attempt a fuller answer that gets to the heart of this admittedly irritating habit, which seems to become part and parcel of being an ACT practitioner after any significant length of time. If you’ve read the preceding chapter on functional contextualism, you will have hopefully taken away the key principle that the function of a behaviour, and the context in which it occurs, are concepts that are inextricably linked. The function of any behaviour is dependent on the context of its occurrence, and it is impossible to truly make sense of any behaviour in isolation. Removing one’s clothes in the privacy of one’s own bedroom is one thing. Removing them in the freezer aisle of one’s local grocery store is something else entirely. It’s exactly the same behaviour on both occasions, and yet the two different contexts completely change the function. Doing that same behaviour in those two different contexts carries a different meaning and will likely lead to different consequences for the person doing it, not to mention any unsuspecting shoppers. Since a functional contextualist perspective tends to reject the notion of absolute truth, it is rarely possible to give an absolutely definitive answer to any question. The answer will always depend on the context of the question. It has become a feature of the trainings we give to those learning ACT for the first time to address this issue. When any of us are new to something it is natural to want a ‘handbook’ or a step-by-step procedure for how to approach a task or situation. If we lack experience in something it often feels like it would be useful to be told exactly what to do. We can experience a craving for rules, and for a practitioner using a new model there is a certain sense of safety to

DOI: 10.4324/9781003364993- 8

20  Defining the philosophy and theory of ACT

be gained by having a clear set of rules or a defined protocol for how to practise. Thus, it can be quite disheartening for an ACT trainer to answer honest questions with “it depends”, although there is a sound rationale for doing so. There is experimental research (e.g., Hayes et al., 1986; McAuliffe et al., 2014) suggesting that teaching people to follow rules has a detrimental impact on their ability to react effectively to subsequent changes in a situation. Those who have been taught to follow a rule are more likely to continue to try and apply the rule, even when the situational changes mean that following it has become ineffective. In contrast, teaching people to figure out for themselves what is going on in a situation, and to respond flexibly to any changes, tends to produce a much more agile response style. This is because rules can tend to take on a life of their own, and following the rule, purely because it is the rule can become more important than noticing what is happening in the situation. In short, rigid rule following can reduce our ‘context sensitivity’, making it more difficult for us to see what is actually happening around us. To illustrate this, consider the satellite navigation systems that many car drivers use to get them from A to B. There have been several news reports of people having to be rescued after doing things like driving into rivers, because they were following the instructions issued by their Sat Nav. These are clear examples of how rule-governed behaviour has reduced context sensitivity, in that those people only drove into the river because the Sat Nav told them to. They would have stopped short of the river otherwise. We can extend the driving metaphor to help us as we come back to the importance of “it depends”. If you want to drive to a new destination, it may well be helpful to use a Sat Nav. It will help you answer the question of how you get from A to B. However, it might also be useful to hold the instructions from the Sat Nav lightly and be flexible with the rules that it is issuing. For example, if you see a river in front of you, it might benefit you to take the left turn ahead of you so that you don’t submerge your car, even though the Sat Nav is telling you to go straight ahead. Whilst the Sat Nav is giving you one solution about how to get from A to B, the reality is that there are usually several different routes, and which one you ought to take depends on various factors. For example, it depends on whether you want the quick route or the scenic route, whether you want to take or avoid the toll road, and whether the amount of rainfall we have had recently means that the shallow ford that is usually passable is now a deep river.

Why do ACT practitioners answer every question with “it depends”?  21

ACT practitioners often say “it depends” because saying so encourages whoever is asking the question to be sensitive to the context around the question. From a functional contextualist perspective it is preferable to orientate people to the contingencies in their environment and invite them to track those contingencies for themselves, rather than to simply give them advice. This is the case whether it is an ACT trainer answering a question from someone in a workshop, or whether it is an ACT practitioner answering a question from a client. We want to position ourselves as helping others to develop their skill in tracking what the most workable action might be in any given situation, rather than simply telling others what to do. The old adage of ‘give someone a fish and you feed them for a day but teach someone to fish and you feed them for life’ seems relevant here. Fishing, like any skill, is not learned solely through a simple set of ‘do this and then do that’ instructions. Whilst a certain amount of basic instruction is inevitable, it is much more useful when accompanied by encouragement to be flexible with those instructions, based on the tracking of variations in the context.

Chapter 7

What is the most important behavioural principle to remember?

Tracking the distinction between making toward and away moves is one of the most useful things that a client can learn about their own behaviour. The discrimination between these two functionally distinct classes of behaviour is firmly rooted in the behavioural theory of appetitive and aversive control. The theory describes the difference between an organism moving toward a stimulus that it wants or has an appetite for, and away from something it does not want or finds aversive. Such behaviour has been observed in a wide range of organisms, including single cell protozoa, suggesting that the survival instinct to both seek resources and avoid threat precedes the evolution of human beings, dating as far back as 600–700 million years ago (LeDoux, 2019). Due to its evolutionary history, there is an argument that this basic discrimination is absolutely central to life. As LeDoux (2020) puts it, “life is all about not being dead – without life, ‘danger’ would be a meaningless notion”. Survival requirements predict different survival tactics for different species, and these biological needs find their expression in the observable behaviours of approaching or avoiding different stimuli. These behaviours are associated with emotional and cognitive responses, but those responses do not tell the whole story. For example, even amongst humans, whilst danger is universal, the subjective experience of fear will vary between individuals and across cultures. In any given moment, based on a complex reaction of biological impulses, emotional experience, and cognitive appraisal, humans produce behavioural responses to stimuli, and we can classify these responses as either being toward or away moves. Humans are different to every other species on the planet when it comes to our ability to communicate at the level of complexity that we

DOI: 10.4324/9781003364993-9

What is the most important behavioural principle to remember?  23

do. Our language ability has afforded us great benefits, and as we discussed in Chapter 4, it has also enabled us to forward plan, imagine, create scenarios in our minds that may never happen, problem-solve such scenarios, and worry a great deal about our possible demise with complete ease. Our ability to do all of the above has certainly been helpful to our species’ success at staying alive. You may even be able to bring to mind times in your lives where you have been able to consider possible scenarios or outcomes and prepare for them, or avoid them altogether. Deciding that something is so aversive that we want to move away from it is a completely valid option, and will most certainly have kept us all alive at times. However, an issue arises when we apply the same logic to our internal or ‘mental’ processes. For example, if you have the thought “I am not good enough” as you are about to do something meaningful, you will likely experience bodily sensations that feel uncomfortable, or perhaps even painful. This stimulus is screaming loud and clear “do not do that thing, it is big and scary, and we like to be safe!”. If you tune into those physiological cues you could quite easily conclude that you need to back out of that activity. In the short term, this may feel like a very rewarding decision to have made. You will experience immediate relief from discomfort as those bodily sensations subside, and may be noticing the thought, “Phew!”. However, taking an away move to turn down the volume of internal stimuli can often feel less rewarding in the longer term, as multiple applications of this cycle of choosing away moves would very quickly mean rejecting and moving away from anything at all in life where “I am not good enough” shows up. Just consider for a moment how many wonderful and meaningful activities you may have rejected if you responded in this way every time that thought popped into your head. Toward moves often feel different in their quality. Instead of relief at the avoidance, we are often connected to a longer-term sense of fulfilment that comes with taking the actions that we feel are important. It is essential to state that toward moves are not easy, and in fact, they are often harder than away moves. They require us to really consider our values and the value-driven actions we actively commit to taking. Helping our clients to learn to track their toward and away behaviours in line with their own values is a key part of the work from an ACT perspective. Any behaviour can be a toward or away move. It is only when we consider the context that it occurs in that we are able to identify the

24  Defining the philosophy and theory of ACT

function. The functional class of the behaviour can contain many varied and creative forms of behaviour. For example, as away moves, how many of us have very ‘productively’ tidied our desks, made an ‘urgent’ phone call to a long-lost friend, made a convoluted nutritious meal that took us many hours, or watched TV when we had something difficult to engage in? These behaviours could be labelled as ‘productive’, ‘connecting’, or ‘nurturing’. It is only when we understand that the function is actually more about avoidance of a difficult task that we can see, from a CBS perspective, that they are in fact away moves. In the same way, toward moves also include a huge variety of forms of behaviour. If a client wants to expand their self-care repertoire, they might act on this by spending time reading a book, having a bath, or hiking a new trail route through a high mountain enjoying some alone time and the nature all around them. We may often meet with our clients and hear summaries of their behaviour between sessions. It is always helpful to ask them, “Was that a toward or away move for you?” as it will only be them that really knows whether they did something that would expand their behavioural repertoire in line with their values, or not.

Chapter 8

What on Earth is relational frame theory?

What RFT seeks to do is offer a behavioural account of human language, in terms of how it functions. It builds on basic behavioural theory and has attempted to address the earlier criticisms of Skinner’s verbal behaviour theory (Skinner, 1957), since it seemed inadequate in describing the functions of language and how it appears able to transform other types of learning (Hayes et al., 2001). With its emphasis on a bottom-up, basic science approach, RFT sets out a way of empirically testing hypotheses about language. It has built up a rapidly expanding research programme over the past 20 years (Montoya-­ Rodríguez et al., 2017), which has been very influential in shaping how ACT is practised. The relationship between RFT and ACT is interesting. To use a metaphor, one might describe them as cousins, and whilst they may have grown up in different houses, their frequent meetings have influenced each other’s development to the point that neither would have matured in the same way without the other. As a basic science program, RFT research helps answer questions about what ACT interventions ought to look like in practical terms. At the same time, the practice of ACT helps RFT researchers think about what questions they should be finding answers to. It is not easy to explain RFT in a short chapter such as this (see Törneke, 2010 for a well-written and accessible book on the subject). In brief, it is an attempt to explain the human ability to relate any stimulus to any other stimulus. Humans can take any two objects, ideas, or concepts, no matter how random, and form a relation between them. Let us take ‘birdsong’ and ‘cheese’ and use them as an example. If you pause for a moment and notice what you are doing right

DOI: 10.4324/9781003364993-10

26  Defining the philosophy and theory of ACT

now, you may notice a nagging urge at the edge of your consciousness to try and relate these two concepts. You might be thinking about how different they are (birdsong is quite distinct from cheese), ways in which they are similar (birdsong and cheese both originate from living organisms), or how they might be associated (birdsong comes before cheese in an English dictionary). Indeed, once we have suggested the two things to you in the same sentence, it is really quite difficult not to engage in the behaviour of deriving relations between them. This ability to derive relations and the subsequent tendency to engage in this behaviour almost without knowing we are doing it is right at the core of human language. A relational frame uses the idea of a frame as a metaphor to describe how two concepts are related to each other and specifies the nature of that relationship. For example, “This is cheese” is a co-ordination relation, which specifies that the symbolic noise “cheese” is the same as that block of yellow stuff in your refrigerator. Almost from the moment we are born, humans are taught the ability to derive such relations, and to use them in ways that they are persistently reinforced for. Most infant humans very quickly master the ability to derive relations between stimuli in increasingly complex ways (e.g., is the same as/is different to/comes before/is next to/is a part of) and they go on to develop complex language skills in an incredibly generative and flexible manner. There are many things about relational framing that are remarkable, as well as being very important considerations for the practice of ACT. One of these is that many of the relations that we derive, and then proceed to completely take for granted, are arbitrarily derived. For example, the sound “cheese” has no connection to actual cheese in the real world, aside from the fact that, in the English-speaking world at least, we have just decided to agree that it does. However, once the relation has been formed in your mind, no matter how arbitrary it is, the mere mention of the sound “cheese” might be enough to make you salivate (or retch, depending on your history with cheese). The behaviour of arbitrarily applicable relating produces other behavioural functions, which is why ACT practitioners are so interested in the kinds of relations that dominate a client’s thinking. A fuller understanding of why people do the things they do becomes possible when we know more about the relations they have made. For example, someone’s risky sexual behaviour might be much easier to understand and develop an intervention for once we understand that sexual intimacy is strongly co-ordinated with a sense of feeling cared for. Equally, a strong need

What on Earth is relational frame theory?  27

to feel cared for might be dictated by a learning history in which that individual was treated unfavourably, such that they learned that, in a hierarchical sense, they were worth less than others. Another remarkable ability of humans is that we can infer relations between stimuli without directly being taught. A child can learn that crossing the road is dangerous simply by being told by a parent that it is. Unlike other species, who largely have to be injured, or witness an injury, to learn the danger posed by something, humans benefit from this powerful form of indirect learning, that adds another dimension to respondent and operant conditioning. Of course, this is not purely a benefit. Language enables humans to be frightened of things that have never happened to them, which might be helpful in the case of crossing the road but is much less helpful when someone is experiencing paralysing anxiety about an interview that they have never actually experienced. With its emphasis on the importance of symbolic learning, RFT helps us understand why humans get distressed simply by relating words and ideas together, and how we can make use of those same processes to form our interventions. Human distress is ubiquitous because almost all of us have the capacity for language. This is a central claim of both RFT and ACT. RFT research has been able to examine a range of diverse aspects of human ‘languaging’ behaviour including naming, understanding, analogy, metaphor, and rule-following (Hayes, n.d., a). It holds the view that crucial to understanding all of these, as well as other verbal activities, is the concept of arbitrarily applicable relational responding. ACT leans heavily on this same understanding, and close scrutiny of many ACT interventions reveal that they are built around this and other core concepts of RFT. This close relationship begs another question, and that is whether an ACT practitioner needs to really know RFT in order to practise ACT. This question is addressed in Chapter 20.

Chapter 9

Why does ACT use so many metaphors?

Nursery rhymes, sea-shanties, and millennia-old folk songs. These are all examples from human history of using language for storytelling. The function of the storytelling is often one of learning, whether that be passing on knowledge or information, to heed the warnings of historical actions, or signposting people in a different direction to prevent previous errors. Within the world of behaviour change practice, and especially in ACT, the use of metaphors has a similar function. Simply put, metaphors are used to aid learning. Learning is transferred from one situation, in which we have an existing understanding of relational networks, to a novel situation where the network is comparable (Törneke, 2017). This is RFT at work with a practical application. When a metaphor is used to describe the situation within which we feel stuck, it can produce those ‘a-ha’ moments that help us get a fresh perspective and see that other, more workable, behavioural responses are available. Some metaphors may be used as one-off examples; for instance, the metaphor of ‘getting straight back on the horse’ following a fall is a common example of how we use metaphors in our day-to-day language. We might say the above to someone, meaning not to let the fear grow before tackling the same challenge again, and even if they have no experience of riding horses, this meaning will generally be understood. This understanding can be used to promote insight into the unhelpful functions of experiential avoidance in the long term. The verbal relations contained within this metaphor are illustrated in Figure 9.1. Other metaphors may be overarching metaphors, that can be used throughout ACT practice with a client as a means of developing insight

DOI: 10.4324/9781003364993-11

Why does ACT use so many metaphors?  29

Avoiding riding following a fall Relation of causation

Increased anxiety about riding

Experiential avoidance Relation of co-ordination

Relation of causation

Increased anxiety in the long term

Figure 9.1  R elational networks contained in the metaphor of ‘getting straight back on the horse after a fall’

around more complex sets of relations. As an example, imagine a person experiencing a sense of stuckness in their life using the metaphor of being lost in the middle of a jungle. They are surrounded by dense foliage, tall trees, and overgrown, disused paths. There are also hidden bogs and a river somewhere out of sight. In addition, there is the knowledge that out there somewhere in the jungle are many dangerous animals that could attack and kill for their next meal. It certainly is a scary place to be. This could be used as an overarching metaphor for how the client is feeling about life. They feel frightened and overwhelmed. ‘Fear’ stems from the idea that other creatures know the territory better than they do. ‘Insecurity’ also comes from not having the basic things we all need in life to feel safe, such as somewhere to sleep with ease, friendly company, and connection. Considering life in this way could make a great deal of sense to a client who can empathise with the feelings associated with being alone in a jungle. It is something they would not want for themselves, and metaphorically, something they have. Imagine if the client’s real life was privileged in certain ways, and this served to offer reasons as to why they believed they did not deserve a compassionate perspective on their predicament. Thoughts like “but I am healthy”, “I have a nice place to live”, or “I have a nice car” will tend to take them down a judgemental path, and one that veers away from compassion, understanding, and associated value-driven action. Using the jungle metaphor as a way of talking about their emotional world (i.e., that they felt alone, unheard, and abandoned) might help the client consider some of the basic needs that one might have. This could open a door to a discussion about self-care in a way that seems

30  Defining the philosophy and theory of ACT

much harder when talking about their real life. The metaphor could be developed as a way to start to discuss self-care. If you were stuck in the jungle, what would be the first steps you would need to take? Perhaps it would best for there to be some investment in building a shelter to provide some safety in your immediate environment. This would help with surviving the storms and provide respite from the heat of the sun. This could open a conversation about what self-care in the client’s life would look like. Sometimes that might be about ‘building the shelter’ in the sense of investing in their own home. At other times that might be about hunkering down in the shelter until an emotional storm passes, perhaps by watching some comforting TV or reading a book by the fire. The metaphor could also enable a discussion about acceptance. Let us say the client imagined that a helicopter would fly over the jungle and miraculously spot them in amongst the tall trees. This would be an unlikely event, no matter how much they wished it to be true. It might help them see that in their real life, no matter how much they want others to be more supportive, or to take the feeling of responsibility for a while, their current context does not suggest that that will happen. They might learn that engaging in this wishful thinking is an away move that is not helping them over the longer term. As an alternative, they could choose to be more accepting of the uncomfortable feelings that arise in their day-to-day life from the realisation that they can only impact their own behaviour and no-one else’s. They could ask themselves the question, “What do I need when the jungle is feeling stormy, when the shelter is falling down, or when I am tired of hacking away at the overgrown foliage?” By thinking in this metaphorical way, they could defuse from the judgement that arrives in their actual life in the form of thoughts like “Why can’t I cope like everyone else?” and “Why can’t I just get on with things?”. The metaphor of life as feeling like being stuck in a jungle might enable the client to see that whilst they enjoy certain privileges, they are nevertheless emotionally stuck in a place where they feel unsafe and unconnected. Using the metaphor enables a visual image of them choosing their responses to the inhospitable jungle environment. Do I have the energy today to take the overgrown path? Will I stay in the shelter today or will venture out and harvest some food? The client can then translate this decision making into their real life, and choose more value-driven actions as a result.

Why does ACT use so many metaphors?  31

Metaphors are helpful because they simplify the complex into a known or imagined (as above) situation within which the client can more easily see (and feel) the relational networks at play. In the above situation, the client may be able to empathise with someone being stuck in a jungle, and therefore are able to offer genuinely compassionate responses such as “That’s really hard, it’s no surprise you’re struggling” and “Struggling doesn’t equal failure, look how hard you’re working”. For any metaphor to work, it is important that it holds resonance for the client. There are some excellent resources full of ‘off the shelf’ ACT-consistent metaphors (e.g., Stoddard & Afari, 2014), although the best metaphors are often the ones that come from clients themselves. We would encourage you to listen intently to your clients’ stories and ensure you take advantage of any metaphorical gems that they contain. Active listening can also help you identify areas of a client’s knowledge, interest, and expertise that can be used as the basis for a metaphor that will resonate with them.

Chapter 10

What is the relationship between ACT and other cognitive behavioural therapies?

Which is better, CBT or ACT? This is a common question for people to ask when first learning about ACT, and the moment the question is asked, one is invited to bring ‘ACT’ and ‘CBT’ together in a relational frame. Whilst it is tempting to get into the “it depends” spiel once again, there might be a range of intentions behind the question, and so, genuinely, the answer does depend on what is meant by ‘ACT’, ‘CBT’, and ‘better’. If ‘better’ is about effectiveness, then this is an empirical question, which we have addressed in Chapter 2. However, ‘better’ may also be about personal fit with the values or philosophy of the practitioner, or the satisfaction of the client, and both may have a bearing on effectiveness. It’s complicated. A further complication, which brings us more squarely to the question we want to address in this chapter, is what is meant by ‘ACT’ and ‘CBT’. We are going to assume that having been attracted to this book, you probably don’t need a lengthy definition of what ACT is. And…in brief, ACT is an approach to behaviour change and well-being aimed at helping people to live life more in the present, with more attention to important values and goals, and with less attention on unwanted internal experiences. It promotes engagement with unwanted thoughts and feelings through acceptance and mindfulness techniques, with the aim of developing more flexible responding, to help build more functional patterns of behaviour. It offers a way of managing suffering via encouraging people to choose to live a life based on what matters most (ACBS, n.d., a). ACT is based on functional contextualism as a philosophy of science, and on behavioural and evolutionary theory as expanded by RFT. Consequently, ACT does not specify a particular set of techniques or adhere to any explicit protocol.

DOI: 10.4324/9781003364993-12

Relationship between ACT & other cognitive behavioural therapiess  33

‘CBT’ is a little more difficult to define. Whilst it is often spoken about as if it is a unitary thing, it is more accurate to describe CBT as a school of thought or as a psychotherapeutic tradition. In the modern era, CBT is best viewed as a combination of models and approaches that have evolved and come together over time and are likely to continue to do so. Approaches within the CBT tradition tend to share an interest in explicitly attempting to balance attention between observable behaviour, and internal phenomena such as thoughts and emotions. Different approaches within the CBT tradition might place greater emphasis on behaviour (e.g., behavioural activation (Martell et al., 2001)) or cognition (e.g., rational emotive behaviour therapy (­Ellis, 1962)), although all are concerned with the interaction between a person’s thoughts, emotions, behaviours, physiological sensations, and the environmental or historical context in which these experiences occur. CBT is often retrospectively described as having three distinct ‘waves’ in its evolution. The ’first wave’ had a focus on observable behaviours and events, with a view to measuring, predicting, and controlling behavioural responses. This gradually expanded to embrace the study of internal events, including thoughts, feelings and the processes of language (Skinner, 1953). Responding to criticism that an approach focussed mainly on behaviour was too reductionist led clinical psychology to look more toward the emerging cognitive sciences. An increased focus on cognition, alongside the development of techniques for modifying thoughts and beliefs marked the ‘second wave’ of CBT (e.g., Ellis, 1962; Beck, 1976). The ‘third wave’ of CBT is typified by a focus on the relationship between behaviour and the contexts in which it occurs, with techniques focussing on modifying the way that individuals relate to thoughts, behaviours, and events. Characteristically, third wave CBTs place greater emphasis on modifying the context in which thoughts and feelings are experienced, rather than aiming to change their content. As a consequence, these more contemporary forms of CBT harbour little interest in the primary concerns of ‘second wave’ practitioners, such as cognitive restructuring or symptom reduction. ACT (Hayes et al., 1999), Mindfulness Based Cognitive Therapy (Segal et al., 2002) and Dialectical Behaviour Therapy (Linehan, 1993) are among the most prominent examples of ‘third wave’ CBT. In terms of specifying the relationship between ACT and other cognitive-­behavioural therapies, it is sufficient to describe it as a ‘third

34  Defining the philosophy and theory of ACT

wave’ CBT that has developed from the behavioural elements of the tradition. Comparing ACT and CBT as if they are two entirely separate approaches is like comparing apples and fruit and is not a helpful comparison (Bennett & Oliver, 2019). It is more intellectually honest to view ACT as one form of CBT, just like apples are one form of fruit. A complicating factor in such comparisons is the dominant role of cognitive therapy (CT; Beck, 1976) within the CBT landscape. Because of its large body of outcome research, and its adoption of a more medical model of psychological distress, it has become so prominent that it is almost synonymous with CBT itself. Thus, it seems that when people draw comparisons between ACT and CBT, what they often really mean to do is compare ACT (a newer ‘third wave’ CBT) with CT in its position as the most widely known approach within the more traditional ‘second wave’ iteration of CBT. This is a justifiable thing to do in that the two approaches have several notable similarities and differences. Practitioners trained in both approaches can offer clients a choice between the two, or even a hybrid method that incorporates concepts and techniques from both. Figure 10.1 illustrates how ACT and CT differ significantly in terms of their philosophical assumptions, with ACT resting on a functional

CT Techniques & Interventions

ACT Techniques & Interventions

Concepts and Theory Philosophical Assumptions

Concepts and Theory Philosophical Assumptions

Figure 10.1  A  comparison of cognitive therapy and acceptance and ­c ommitment therapy (adapted from Gillanders, 2013a)

Relationship between ACT & other cognitive behavioural therapiess  35

contextualist foundation and CT drawing its inspiration from mechanistic metaphors and the logic and reason of Stoicism. That said, the closer one gets to the level of technique, the more the similarities begin to emerge, particularly when it comes to the use of behavioural techniques, such as exposure or behavioural activation. Whilst these techniques might look the same it is important to remember that ACT and CT practitioners might be doing them for different reasons and with different goals in mind.

Part 2

Conceptual questions about the ACT model

As is the case with any psychological model, practitioners new to ACT are faced with the challenge of learning, understanding, and applying a number of novel concepts. Building on the philosophical and theoretical foundations of the first section, this section of the book seeks to outline and further define a number of concepts that are key to ACT. It begins by defining the core construct of psychological flexibility, before addressing frequently asked questions about the six components of the psychological flexibility concept, namely, contact with the present moment, self-as-context, acceptance, defusion, values, and committed action. This section also devotes chapters to describing the technical term ‘creative hopelessness’ and exploring how the concept of compassion fits with ACT.

DOI: 10.4324/9781003364993-13

Chapter 11

What is psychological flexibility?

ACT is centred around the notion of helping people develop greater psychological flexibility. It may surprise you to know that the Hexaflex was a later addition to ACT, implemented to visually represent the component skills that people can develop to move toward being more psychologically flexible. However, the ACT model is not just the Hexaflex per se. So, let us turn to the heart of the model and consider exactly what psychological flexibility is. When we speak of psychological flexibility, we are referring to an ability to connect with the moment you are presently in, and making an active choice about how you would like to respond to your experience, choosing behaviour in line with the person you would like to be. When we look at how to do this, we can draw on the Hexaflex in identifying six core components, with each promoting a skill that can increase our repertoire of psychologically flexible choices. A quick recap of the six core skills within the model might be helpful at this point: •

Acceptance is often a really difficult word for people to swallow. It can be referred to as a person’s willingness to allow an emotional state to be present in their lives. This is not about encouraging people to accept the situation per se. For example, we are not wanting people to say, “I’m being abused, and now I have to learn to accept it”. This skill is more about supporting people to have the willingness to acknowledge the impact of their given situation on their internal world, and learning to accept whatever thoughts, emotions, or sensations that are present. Emotional flexibility is the key to the acceptance process.

DOI: 10.4324/9781003364993-14

What is psychological flexibility?  39

•

•

•

•

•

Defusion focusses on expanding a person’s cognitive flexibility. The target process (‘fusion’) is evident when we observe people taking the language of their thoughts literally, despite the resulting behaviour not being workable for them, and sometimes even being harmful. Defusion can be summarised as getting some space between you and your thoughts. Contact with the present moment skills are about expanding people’s attentional flexibility. Our minds are often drawn to future planning, or past worries, and living in the present moment is a skill that can be developed so that we are better able to act in the present. Attentional flexibility can be honed to enable people to move their attention around. We might learn to focus our attention like a useful torch-beam, rather than an overbearing and unhelpful light that constantly shines in the least helpful places (such as the past or future, where taking action is less available). Self-as-context is a simpler concept than the language might suggest. It refers to developing the skill of seeing alternative perspectives to the often ‘fixed’ views we hold of ourselves. We are the thinker and not the thought. Any kind of container metaphor does a good job of helping us to see that we are more than the things we struggle with. When we can see the world from this broader perspective, we learn to free ourselves from the control of the narratives that keep our world small. Values identification is about choosing who we are and how we want to be in the world. This work helps us select the qualities that we want to embody, whilst holding each lightly, so we can flexibly choose which value we want to respond to. Our values provide a stimulus for flexibility in our choice of action in any given moment. Committed action is about putting our feet down and moving in the direction that we decide, based on our chosen values. This skill is about widening the behavioural repertoire that we have for ourselves, so we become open to more and more opportunities in our lives.

Psychological inflexibility can result in a narrow behavioural repertoire, making our world smaller, and leading to a sense of feeling stuck. Psychological flexibility provides us with a set of skills that start to open us up to alternative possibilities, with the aim of bringing us closer to a more purposeful and meaningful life.

40  Conceptual questions about the ACT model

The ACT model can also be simplified into three columns, ‘open’, ‘aware’, and ‘active’ (see Figure 11.1). The open column encapsulates the skills pertaining to being open to your experience. Are you willing to have this experience, and can you get some space between you and ‘it’? The aware column focuses on being in contact with the present moment and developing the skill of observing oneself in a hierarchical fashion – after all, if you can observe yourself noticing that you are ‘incompetent’ you cannot BE incompetent, as it is a separate concept to you. You can however be the place where some ‘incompetent’ thoughts and behaviours happen. The ‘active’ column pertains to identifying one’s values and taking steps in line with those. This simplification of the Hexaflex into these three columns can be helpful; however, it is also important not to forget that each column has more than one skill that contributes to the development of psychological flexibility. One of Steven C. Hayes’s many wise one-liners about ACT is, “the only mistake you can make in ACT is to get stuck” (Bennett, 2017–­present). We invite you to recall a time you painted a room. Most likely, the can of paint had a solid tin lid, and to access the paint you would have had to use something flat like a screwdriver or the end of a spoon to lever the lid away from the can. If you pick one single point, stick to it, and force the lid open from there alone, you will likely have to work really hard to remove the lid, and probably ruin the lid OPEN

AWARE

ACTIVE

Contact with the Present Moment

Acceptance

Values

Psychological Flexibility Defusion

Committed Action

Self as Context

Figure 11.1  The three-column version of the Hexaflex

What is psychological flexibility?  41

in the process of trying. However, by applying gentle pressure, then stopping, twisting the can around slightly, and applying gentle pressure somewhere else, the lid will eventually lift off without damage. In the same way, developing psychological flexibility requires us to move around the various ACT components, just like you would move around the lid of a paint can, rather than focussing on just one area. Next time you feel stuck with a client, imagine a paint can with a Hexaflex drawn on the lid. Consider which aspect of psychological flexibility you might need to direct your attention to in order to create some movement and try not to get stuck at any one point. Of course, these skills are utilised in the context of the broader foundational science and philosophy that underpins the entire ACT model, discussed in earlier chapters, which also contributes to increasing psychological flexibility.

Chapter 12

What does ‘creative hopelessness’ mean?

There are anecdotes to suggest that the originators of ACT now wish that they had used some different terms to describe various concepts and procedures within the model. ‘Creative hopelessness’ is very possibly one of them, since the word ‘hopelessness’ carries undesirable connotations for many, notably a sense of despair. Given that creative hopelessness procedures are often suggested as one of the first things that an ACT practitioner should engage a client in, the aversive functions of the term can make it feel like an odd place to start. Far from being a procedure that induces despair, it is intended to be validating of the position that someone finds themself in at the point that they first reach out to a practitioner for help. It refers to the process of validating a client’s experience of being caught in a struggle with their own thoughts and feelings, helping them recognise the futility of this, and setting the stage for creatively identifying more workable ways forward (Luoma et al., 2007). A creative hopelessness conversation or activity is about opening up to the new possibilities for taking value-­ driven action, once a client can face up to the reality that whatever they have been doing to try and rid themselves of their distress up to this point has not worked. The experience of psychological distress is highly aversive for most people, and there is a logic behind wanting to get rid of the internal experiences (unwanted thoughts, emotions, urges, or sensations) that comprise that distress. An agenda of wanting to control internal experiences is often a prominent feature of a client’s presentation at the start of intervention, and highly rehearsed methods of eliminating, suppressing, or avoiding them are commonplace. At best, such strategies tend to only confer some short-term benefits, and at worst they

DOI: 10.4324/9781003364993-15

What does ‘creative hopelessness’ mean?  43

can form the basis of ingrained behavioural patterns that cut people off from opportunities for reinforcement or cause genuine harm over the long-term. As an example, someone experiencing significant social anxiety might use several avoidant strategies to reduce the chances of having to risk experiencing negative evaluation from others. This is understandable, although controlling anxiety in this way is a behavioural process that maintains it: if we avoid engaging with others, how will we ever learn that they might not judge us negatively? The practitioner needs a procedure that can validate the client’s desire to reduce their anxiety without unhelpfully reinforcing the behaviours that are feeding it. Creative hopelessness procedures are designed to help the practitioner carefully and sensitively navigate this difficult terrain early in the therapeutic process. There are many ways that creative hopelessness can be approached, and, as with everything in ACT, the function of the dialogue is more important than its form. In the very first ACT textbook, Hayes et al. (1999) described creative hopelessness as focussing on three main questions in respect of the client’s lived experience of the issues they are seeking help with: 1 What does the client want? 2 What has the client tried? 3 How has that worked? These questions are designed to draw out example ‘problem-solving’ strategies from the client’s history to ascertain if these reflect any underlying rule. They then help the client contact the short- and longterm consequences of following that rule. Rules that underlie control strategies (for example, “If I don’t get close to other people then I won’t get hurt”) often dictate behavioural responses because they feel beneficial, at least in the short-term. Following the above rule is likely to be negatively reinforced by a reduction in anxiety and it is important that functions such as this are recognised and validated. People engage in avoidance because it works for them. This can then be contrasted with the long-term costs of rule-following, shining a light on its limitations. Doing this can engender a sense of hopelessness about the current strategies, which, whilst uncomfortable for the client, also provides the impetus to consider doing something different. It is helpful for the practitioner to functionally cluster previous strategies as

44  Conceptual questions about the ACT model

various manifestations of the same rule-following so that it is clear that something new and creative is required (Bennett & Oliver, 2019). The over-arching rule that many people follow is that controlling internal experiences is equivalent to living successfully. The long-term workability of this can be challenged using creative hopelessness procedures, and this paves the way for standard ACT interventions to be introduced. Our experience of supervising numerous ACT practitioners is that where ACT interventions fall flat with their clients, it is often because not enough time has been spent doing the work outlined above. As stated previously, creative hopelessness work can take many forms, using stories, metaphors, discussions, or experiential exercises, and most introductory ACT practitioner books and trainings will include examples of these. Metaphors like Chinese finger traps, struggling in quicksand, or engaging in a tug of war match with a monster (Hayes et al., 1999) essentially describe a rigged game, whereby no matter how hard the client tries to rid themselves of the adverse aspects of the situation, doing so will simply make the situation more and more difficult. The procedure we most frequently use and recommend is adapted from Strosahl et al. (2012), which involves having a conversation with a client based around five key questions. Once the nature of the issue that client is seeking help with is ascertained, the following questions can be explored: 1 In the context of this situation, what really matters to you? 2 What is getting in the way of you pursuing what really matters? a) External obstacles (e.g., lack of time or other resources) b) Internal obstacles (e.g., the uncomfortable thoughts and feelings that arise when the client tries to pursue what matters) 3 What have you already tried in the service of overcoming the internal obstacles? 4 How have those things worked out for you? a) In the short-term b) In the long-term 5 What has doing those things cost you? a) In the short-term b) In the long-term

What does ‘creative hopelessness’ mean?  45

This procedure involves touching on several concepts relevant to ACT’s psychological flexibility model. The first question essentially elicits values, whilst the second and third obtain information about fusion and experiential avoidance. Questions four and five enquire about the workability of existing strategies for managing the discomfort that almost always arises when people try to engage in value-driven actions. This conversation usually orients people to the function of their efforts to avoid discomfort, helping them see that whilst avoiding discomfort generally works in the short-term, it reduces the likelihood of contacting reinforcing consequences in the long-term. In turn, this often reduces the appetitive functions of avoidant behaviour, and opens people up to the idea of approaching their distress differently going forward. As such, creative hopelessness is an important part of the engagement process in ACT and worth devoting significant consideration and time to, prior to introducing other interventions.

Chapter 13

Is ‘contact with the present moment’ the same thing as mindfulness?

Mindfulness has become a commonly used, and perhaps over-used, word in recent years. Its growth in popularity has enabled many people to experience the benefits of its practice. However, its popularity and the misunderstanding around its practice has also now taken on a different function, and one that seems to be aversive to many lay people. How many times have you had a client say, “I’m not doing any mindfulness stuff, that doesn’t work”? What they often really mean is “I did an exercise once and I still felt anxious afterwards”, ergo, “because my anxiety remained, tuning in to my experience again will not be helpful”. Mindfulness practice can take many forms. Its origins lie in the histories of Eastern religions, namely Buddhism and Hinduism. Formal mindfulness practice has been used in these contexts for millennia. From a Buddhist perspective, mindfulness is considered to be the first step to enlightenment. The practice and principles of mindfulness became more well-known and used in Western societies following the introduction of this work in therapeutic treatment programmes for stress and mood. Examples of such programmes include MindfulnessBased Stress Reduction (MBSR; Kabat-Zinn, 2013) and MindfulnessBased Cognitive Therapy (MBCT; Segal et al., 2002), both of which have significant empirical support. When considering ACT’s position on mindfulness, a Venn diagram is helpful (see Figure 13.1). There is undoubtedly some crossover with formal mindfulness practice, as is there within other forms of psychotherapy and other practices such as yoga and body meditation. However, ACT procedures facilitate a lot of work outside of mindfulness, related to the other components of the Hexaflex. Even the skill

DOI: 10.4324/9781003364993-16

Is contact with the present moment the same thing as mindfulness?  47

Yoga

Body Meditation

Mindfulness Spiritual practice

ACT

MBCT MBSR

Figure 13.1  The relationship between mindfulness and related practices

of ‘contact with the present moment’ does not have to include formal mindfulness practice. When we think from a functional perspective, the purpose of a client being able to be in the present moment is the clarity this can offer them. We often work with clients who get caught up in the busy-ness of day-to-day life, where seconds, days, weeks, months, and years all roll away from them in a way that feels inevitable, and where they live an existence in which they feel like they miss out on much of their own experience. The human brain can operate on a kind of auto-pilot setting, which is time-efficient and can reduce cognitive demand. However, being stuck in auto-pilot for all of our interactions and our most precious connections can have a detrimental impact on the quality of life we experience. As illustrated by the Hexaflex diagram (see Chapter 19) each of the six core skills are linked to one another. Strengthening one of those skills enables a stronger foothold to further improve each of the others. Being in contact with the present moment is a pre-requisite for developing all the other skills on the Hexaflex. The skill here is being able to tune in to one’s experience, often simultaneously inviting a process of slowing down and noticing more. This can increase our connection with ourselves, other people, and the wider world, which in turn can offer greater choice about how we want to respond in any moment. We have often asked people, “If you do not notice your own emotion, how can you choose how to respond to it?”. This can help people to understand why tuning in to their internal world can open a whole new choice of actions. For example, imagine discussing a situation with

48  Conceptual questions about the ACT model

a client in which they reported anger toward their partner, who was feeling sad and frustrated about the inequality of tasks done within the house. The client describes feeling angry that their partner had raised this, stating that it felt like a “low blow”, and a way of having a go at them when they were happy. The ACT practitioner might enquire about how their conversation had evolved, asking questions like, “If you recall your partner’s face during your interaction, what do you notice?”. This might enable the client to see that they had spent their entire interaction responding from their mind, driven by thoughts like “I must be heard”, “They are being unfair raising this”, and “I want this to stop”. When the process is slowed down, the client might be able to see that they had not really responded to their partner standing in the kitchen in front of them, rather they had moved to a metaphorical battle zone and were responding from there. If they were actually responding to their partner’s tear-stained face, they might have taken a calmer, more compassionate perspective, and genuinely listened to why their partner was so sad. In this case, turning up the ‘present moment’ skill could increase their acceptance of the discomfort of the situation, their connection with their values (who they want to be in the face of relationship difficulties), their chosen action, their ability to see alternative perspectives on the situation, and an ability to defuse from the idea of needing to be heard. All of that could enable them to move to a position of wanting to listen when concerns are raised by their partner. A helpful metaphor in relation to our present moment awareness is that of a torch beam. Imagine holding a torch. Switching it on is like turning on our awareness. We now have our eyes on the thing in front of us. And this is very helpful because we get to see more than we could before. By practicing this noticing skill, we can start to help our clients to broaden or narrow their beam of attention, just like some torches allow us to broaden or narrow the beam of light they yield. This can have a direct link with achieving a sense of self-as-context, in that when we broaden that beam of attention, it is possible to see additional perspectives than we previously could, and allows us to take action in the service of our values.

Chapter 14

What is self-as-context and how does it differ from defusion?

This is a very good question and if someone asks it, it is usually evidence that they are a keen student of ACT and have been paying attention to the nuances of the underlying theory. It feels like a challenge to come up with an answer that is as good as the question, partly because the concepts of defusion and self-as-context are closely linked, as indicated by the line that connects them on a Hexaflex diagram, partly because they have evolved with time (Harris, 2013; Blackledge, 2015), and partly because they are not very clearly delineated within ACT literature. This chapter will address these issues as well as presenting what we hope is a workable way to discriminate each of these terms from the other. The issue of the lack of clarity in defining these terms needs to be addressed up front. ACT has received some justifiable criticism, mostly from RFT researchers and applied behaviour analysts, for its reliance on ‘middle-level terms’. This refers to its use of concepts that are not empirically grounded, and thus lack precision or clear utility at a functional analytic level. They act as a bridge between a scientific way of speaking about something, and how a practitioner might speak about something to a client. As Wilson (2016, p. 70) stated, “Middle-­ level terms are “middle level” in the sense that they are more precise than lay language, but less precise than technical ways of speaking”. ‘Self-esteem’, ‘beliefs’, or ‘therapeutic alliance’ are examples of middle-­ level terms. They lack accuracy in any empirical sense (for example, one cannot clearly define and observe the behavioural processes of ‘self-esteem’ in an experiment), although they are useful shorthand for communicating a broad concept to another person. If a client says to a practitioner that their ‘self-esteem’ is low, both parties will likely have

DOI: 10.4324/9781003364993-17

50  Conceptual questions about the ACT model

a workable sense of what this means in the context of the work they are doing together. The problem is that when ACT theory evolved to include middle-­ level terms (see Hayes et al., 2006), arguably making it more accessible to greater numbers of people, it sacrificed some precision, and concepts like defusion started to become used in different ways to the point that their meaning can become difficult to pin down. Many ACT practitioners, ourselves included, have probably used defusion to mean each of the following three things at some point: 1 A process (as in a problematic behaviour pattern that we want to work on with a client: “I think we could spend the next session working on defusion”) 2 A procedure (as in an intervention we engage a client in: “I want to introduce you to some defusion exercises”) 3 An outcome (as in an endpoint we want to achieve by using a procedure with a client: “Your ability to stand back from your thoughts about worthlessness really demonstrates your defusion skills”) This process/procedure/outcome distinction (Barnes-Holmes & McEnteggart, 2020) provides a helpful framework that illustrates just how slippery middle-level terms can become because of their imprecise nature. Like defusion, self-as-context is used differently across ACT literature, both to mean something akin to the Buddhist notion of a transcendent sense of self (e.g., Hayes, 2019) and as flexible perspective-­taking (e.g., Harris, 2013). From a functional contextualist perspective, some of this is no surprise in that the function of any term depends on the context in which it is being used. From a scientific or practical point of view however, it is not very helpful for any theoretical model to have any one concept meaning different things at the same time. It is probably fair to say that ACT might have some work to do in this area, and that more care with the use of both concepts would lead to less confusion. At the very least, one practical step that ACT practitioners could take when they hear someone else using terms like defusion and self-as-context, is to enquire whether they are using it to refer to a process, a procedure, or an outcome. Having acknowledged the difficulties with ACT’s adoption of middle-­level terms as part of its core model, we can return to the initial

What is self-as-context and how does it differ from defusion?  51

question regarding how best to define and differentiate defusion and self-as-context. In our view, regarding the process/procedure/outcome discrimination, both are best thought of as referring to outcomes. That is, they provide ways of talking about patterns of behaviour that we generally want clients to produce more of. It is only useful to use them to describe behaviours that have been observed to have established themselves (usually post-intervention) as ‘real’ environmental variables (Wilson et al., 2022). The target processes relevant to these outcomes might best be referred to as fusion and self-as-­content respectively. Table 14.1 shows how procedures might be applied to each of these processes with a view to achieving the desired outcome. If we are attempting to be precise here, ACT, as a model that relies on RFT, should only be concerned with the behaviour of forming verbal relations, and other behaviours that occur consequent to that relating (Barnes-Holmes & McEnteggart, 2020). Once we attempt this, it is evident that whilst the two concepts can be differentiated, they are somewhat similar, and one might even argue that they overlap, with self-as-content representing a subset of fused relations. As a footnote to the above, we should come clean and admit that we may be slippery in our use of these terms, even in this book. This is because it is genuinely quite difficult to talk about the various concepts used in ACT without also falling into the trap that the ACT literature has built for itself with its reliance on middle-level terms. We will endeavour to try and make the process/procedure/outcome discrimination clear whenever potentially ambiguous meanings might be inferred.

52  Conceptual questions about the ACT model A comparison of the concepts of defusion and self-asTable 14.1  context by process, procedure, and outcome As applied to defusion Process

Procedure

Outcome

As applied to self-as-context

Self-as-content: observable Fusion: observable behaviour is rigid and behaviour is rigid and regulated by excessive coregulated by adherence ordination of the self with to the literal meaning internal language about the of language self E xample: A client inhibits E xample: A client turns down emotional expression a potentially benef icial because of the rule “It’s opportunity because the weak to show emotions” thought “I am worthless” dictates that they are undeserving of it Interventions that promote Interventions that ‘dea hierarchical relationship literalise’ language, between self and internal such that there is a language about the self, such loss or weakening of that the self can be seen as the meaning of that containing any such content language E xample: Introducing container E xample: Practicing metaphors, such as ‘the sky repeating “It’s weak to and the weather’ show emotions” out loud in the voice of a cartoon character Defusion: flexible patterns of behaviour are enacted that are independent of the literal meanings of language E xample: Noticing the thought “It’s weak to show emotions” whilst choosing to open up emotionally to a friend

Self-as-context: flexible patterns of behaviour are enacted that are independent of internal language about the self E xample: Tuning into the experience of noticing having the thought “I am worthless” whilst choosing whether or not to take up a potentially benef icial opportunity

Chapter 15

Doesn’t acceptance just equate to giving up and letting life steamroller you?

A common misconception from both early career ACT practitioners and clients alike is that acceptance equates to giving up and submitting to being steamrollered by life events. This is a far cry from the purpose of acceptance within ACT, and helpful to address in the early stages of a practitioners’ training, and a client’s experience with ACT. As we have discussed in many of the chapters of this book, language is a powerful and evocative tool. In this case, the mere use of the word ‘acceptance’ often lands awkwardly with clients, as a common colloquially used definition of this word is indeed akin to rolling over or giving up. So, here is an invitation as we work through what acceptance is and is not: notice the different ways that you can use language with clients so as to help evoke a meaning for them that may feel more useful, and that is ACT-consistent. A well-spoken ACT phrase is, “The problem is not the problem, the solution is the problem”. Clients often come to seek support because they are experiencing an internal struggle, or because their life is feeling that it lacks the importance and emphasis they would like it to have. This has often happened as a result of their behavioural attempts to avoid uncomfortable internal (and external) stimuli, thus making life feel easier in the short-term as they do less and take fewer risks. ACT refers to this pattern of choices as ‘experiential avoidance’. This essentially moves us away from difficult internal struggles, resulting in short-term gains, although often at the cost of longer-term suffering. From an ACT perspective, we would only address experiential avoidance when it is having a detrimental impact on a person’s life. For example, there is nothing too concerning about occasionally binge-watching a TV series when you have a difficult task to do.

DOI: 10.4324/9781003364993-18

54  Conceptual questions about the ACT model

However, engaging in experientially avoidant behaviours such as drinking alcohol or taking drugs to block out the emotional struggle one experiences about similar tasks is more problematic. Such behaviour, particularly if sustained over time, would be more akin to the patterns of experiential avoidance that warrant a therapeutic intervention. The focus here is on whether it is workable in the long term to live life in this way. Is the ‘smaller sooner’ reward of avoiding discomfort worth the ‘larger later’ cost of limiting one’s life and missing out on the reinforcement that often comes with value-driven action (see Chapter 12 for more on workability). One error often made is that people think ACT is about wanting people to accept the external circumstances that may be causing suffering. We are not suggesting that anything external needs to be blindly accepted, for example, someone being bullied at work. There is no tolerance required, or passive ‘acceptance’ of, “This is just the way life goes”. Instead here, the more ‘engaged’ parts of the Hexaflex (values and committed action) would be utilised to consider how someone would like to respond to their circumstances. It is helpful then to consider what ACT practitioners are inviting someone to accept as part of the therapeutic process. The focus on acceptance from an ACT stance is more directed at an internal process. In the above example of workplace bullying, we would instead look to invite someone to connect with how they feel in that situation, and to consider their willingness to make space for the emotions that arise, instead of pushing them away. This is a deliberate choice to undertake an action, not about experiencing an event as a passive bystander. It is one that involves leaning right into the discomfort (fear, terror, or worry) that will inevitably arise as they move through their day-to-day existence. The function of acceptance is to help people to really tune in to their life experiences (there is a link here with ‘contact with the present moment’) and to consider whether they would like to continue to make their current choices, or to take different steps in response to the situation they are experiencing. In the above example, we would argue that tuning into the reality of the experience of being bullied is more likely to facilitate a committed and effective response, as opposed to trying to avoid feeling the true pain of it, which is more likely to fuel minimisation and inaction. In this way, acceptance is very much linked with an individuals’ values. A question often asked of clients is, “Are you willing to experience that discomfort, in the service of the things that really matter to

Doesn’t acceptance just equate to giving up  55

you?”. This is a helpful question to link the experience of, and purpose of, internal suffering. It makes suffering part of valuing. It is a valid response for a client to say no to an invitation of accepting their inner discomfort. It is our job as practitioners to help clients to weigh up the costs to their life experiences of their behavioural choices. It is not our job to decide whether a client should or should not tolerate any particular felt emotion or physiological sensation. Thus, the function of acceptance is always about helping people to consider their valued action, and whether they assess the costs (the internal discomfort) to be worth experiencing in order to take steps in line with their values. Some things are just not worth suffering for. Some things, we suddenly realise, are absolutely worth experiencing discomfort for because doing so will ultimately fill our lives with richer and more meaningful experiences, and broaden our behavioural repertoire in the service of experiencing a more fulfilling life.

Chapter 16

What is meant by ‘transformation of stimulus functions’?

Like most other approaches within the CBT tradition, ACT adopts the view that cognitive processes, such as reasoning, or making rules and judgements, are responsible for much of the suffering that humans experience. Most of what we do, we do because our cognitions tell us to, and this includes all of our unhelpful attempts to cope with adversity. Whilst, like other animals, we learn through respondent and operant conditioning, symbolic learning via our cognitive and language abilities is an additional and powerful influence over our behaviour. Therefore, CBTs have sought to develop interventions that target cognitive processes with a view to weakening the control they exert over behaviour. Second-wave CBTs attempt this by challenging the logic, utility, or empirical validity of thoughts (e.g., Dryden & Branch, 2008). Such interventions are aimed at changing the form or content of an individual’s thinking and encourage them to arrive at more logical, helpful, or ‘true’ thoughts as a consequence. ACT takes a different approach for several reasons. Aside from the evidence from certain studies that so-called ‘cognitive restructuring’ techniques add little to CBT over and above behavioural interventions (e.g., Jacobson et al., 1996; Dimidjian et al., 2006; Lorenzo-Luaces & Dobson, 2019), there is a philosophical rejection of the notion of absolute truth. This means that a search for ‘true’ thoughts via empirical disputation is incompatible with the contextualist philosophy that underpins ACT. Rather than challenge the content of thoughts, ACT interventions seek to modify the context that thoughts are experienced in, so that the stimulus functions of those thoughts are transformed. The concept of ‘transformation of stimulus functions’ comes from RFT and refers to an event where, “The functions of one stimulus alter

DOI: 10.4324/9781003364993-19

What is meant by ‘transformation of stimulus functions’?  57

or transform the functions of another stimulus in accordance with the derived relation between the two, without additional training” (Dymond & Rehfeldt, 2000, p. 239). It is probably helpful to use an example to deconstruct the meaning of the previous sentence, so let us imagine that you are someone who eats an exclusively vegan diet due to holding firm principles around animal welfare. You are in a restaurant where you have ordered a vegan pizza, which you have eaten and thoroughly enjoyed. As you are contemplating ordering dessert, the waiter attends your table and offers a profuse apology because they have just been informed that due to some confusion in the kitchen, your pizza may have contained regular cheese rather than the vegan cheese that you expected. You are horrified to discover that you may have eaten an animal product, and furious at the restaurant for their incompetence. With reference to understanding this event from an RFT perspective, the functions of the pizza have been transformed. Any positive feelings of enjoyment that you might have experienced upon eating the pizza will have long disappeared and any memory of eating it is likely to now provoke feelings of anger and disgust instead. Following the waiter’s intervention, which has introduced doubt about what you might have eaten, you will have derived a stimulus relation between the pizza and consuming an animal product, between the restaurant and anger, and possibly several other relations that didn’t exist in the same way previously. Once a novel stimulus relation has been derived, it is not possible to ‘un-derive’ it, and we will respond to the relation, even though the stimulus itself has not changed. Although the pizza is still the same pizza, and there is only the suggestion of regular cheese, your conception of it and the restaurant you ate it in will be altered forever. In RFT terms, the stimulus functions of the pizza have been transformed, despite nothing about the actual pizza having changed. Transformation of stimulus functions is the process by which stimuli or events with certain functions acquire new ones (Törneke, 2010). It is a characteristic feature of the way that language works, and numerous ACT interventions harness this capacity to focus change efforts on the function rather than the form of unwanted or unhelpful thoughts. Far from being an obscure theoretical notion, transformation of stimulus functions is central to the practice of ACT. Altering the way that stimuli function, be they thoughts, emotions, memories, or physiological sensations, is an identifiable aim of a variety of ACT interventions, as can be seen in the examples below.

58  Conceptual questions about the ACT model

Values and committed action An ACT practitioner can work to increase the appetitive functions of an exposure exercise that a client might be anxious about engaging with by relating it hierarchically to the client’s values. If doing something that is presently co-ordinated with the prediction of fear can be seen as part of taking value-driven action, this may increase the likelihood of the client engaging with it. Relating the exposure activity to valued action can transform something that is scary into something that is scary, and worth being scared for.

Defusion Classic ACT procedures such as taking an unwanted thought and changing the way it is presented are clear examples of utilising transformation of stimulus functions. Singing a thought, or saying the thought in a humorous voice, often results in clients laughing at the thought or seeing a lighter side to their experience. Relating the thought to the experience of lightness or humour by repeating such an exercise provides a very portable way of transforming the way it functions.

Acceptance Co-ordinating values with painful experiences is another staple of ACT practice. When clients express distressing thoughts and emotions, it can be helpful to explore how those experiences relate to the things that they care about. For example, grief about losing someone often speaks to how much that person was loved. Co-ordinating values and pain in this way often provides people with a reason to suffer, thus transforming the function of suffering. Whilst the experience is still painful, the pain has been connected to a sense of purpose.

Chapter 17

How do I tell values apart from goals or rules?

Values are often metaphorically referred to as a compass, in that they are a helpful guide to choosing a direction in life. Since they are always with us, they can be drawn upon at any moment to help us choose behaviours that best fit with the person we want to be. Sometimes these behaviours are not the easy option, for example, being compassionate to someone who you feel has wronged you. They can be described as the meaningful life choices we make when fusion and avoidance are not in the driving seat. When we connect with our values, we are reminded of our reason to accept discomfort. In the service of our values, we are often able to realise that the discomfort we experience along the way is manageable, and simply part of what happens when we pursue a life of meaning and purpose. We often work with clients who confuse values for goals, or even rules that they must follow. One of the principles that defines a value is that it represents a freely chosen direction. In any given moment, we can be aware of the value driving our behaviour. This present moment awareness of our values can enable our choices to have a more flexible quality, in the sense that behaviour becomes something that we choose rather than feel compelled to do. When we lose this flexible quality, we can slip into confusing values with goals or with rules. What do we mean by goals? Well, in this comparison, the easiest distinction to make is that a goal can be ticked off on a to-do list, whereas a value is not something that you achieve and then stop enacting. For example, it is possible to set a goal of being kind to the person who serves you in the coffee shop tomorrow morning. This meets the criteria for being a SMART goal (specific, measurable, achievable, realistic, and time-limited). However, if kindness was a value that you

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60  Conceptual questions about the ACT model

want to live by it would not be consistent to be kind to the person in the coffee shop but then really mean and short-tempered with everyone else you encounter for the rest of the day. Goals are generally either in front of or behind us, whereas values are ever-present, and if kindness is a value for you, there are any number of ways in which you could choose to be kind, both tomorrow morning and for the rest of your life. When compared with the flexible quality of value-driven behaviour, rule-governed behaviour suggests increased rigidity. When we behave in line with rules, we start using language like, “I am…”, or “I must…”. It is often the justification that is given for a behaviour that can help identify if the behaviour was value-driven or rule-governed. For example, “I was told in my childhood to be nice to people, so I was nice to the person in the coffee shop” would suggest a rule is being followed, rather than a value being freely chosen on each visit to the coffee shop. When looking at value-driven choices, it is not simply a question of, “Is this a toward or away move?”. It is very much about identifying the value from which you are operating. We all have a range of values that we may act upon in any given moment. Imagine sorting through a pack of values cards. There are many cards to choose from, and we each have our own priorities. We may wish to act on little-practised values in some contexts, whilst others feel much more rehearsed and consistent in our day-to-day lives. For example, we might not practise assertiveness very often, despite it being an important value. However, it is in our repertoire when we need it, such as when chairing a difficult meeting at work. Conversely, values like kindness and compassion might be much more ‘front and centre’ in life, and we choose to embody these in almost all of our daily interactions. It can be helpful to consider values as if they are a menu, because just like a food menu in a restaurant, not everything on it is available all of the time. As an example, consider a client who works in the armed forces. The context of their training means that they will have been more highly reinforced for their choice of behaviours driven by a value of ‘cooperation’, as opposed to ‘autonomy’. The client returns from a combat zone talking about having seen horrific atrocities against fellow human beings and yet they stood by and did nothing because they were following orders. This evokes guilt, shame, and judgement of their actions. Not only does the context matter (they were following orders in a war zone), it is also a matter of exploring

How do I tell values apart from goals or rules?  61

whether the individual had their whole values menu available to them at the time they acted as they did. If you jointly identify with the client that the values most highly reinforced during combat are compliance and cooperation, the client may see that in that context, their personal values of justice, assertiveness, and autonomy were highly unlikely to have been available to them. Such discussions can help clients appreciate the influence of contextual factors on their choice of behaviours, and mitigate against values being treated rigidly, as if they are hardand-fast rules. Each value can be thought about as having an associated skill set. If the skill set associated with the value feels new, or it is under-­ rehearsed, one may need to learn a whole new skill set in order to be able to carry out value-driven actions. This process takes time. Whilst behaviours may be within someone’s value set, it does not mean they do not incur costs of discomfort. For example, a war veteran living in line with their value of autonomy after having lived for so long under conditions of compliance may find the period of adjustment very challenging. As practitioners, we can flexibly move around the Hexaflex to utilise other ACT skills to help the client manage this. We can help them notice their discomfort and this repetitive pattern (contact with the present moment), unhook from any resistance (defusion), identify that this is a part of themselves that they would like to bring to the fore in this particular moment (self-as-context), reconnect with their value and chosen associated behaviours (committed action), and try again at embodying something that feels difficult to them in the service of said value (acceptance). As a practitioner, working to consistently notice and reinforce the use of these skills, and bringing clients’ awareness to the development of their new skill set is key.

Chapter 18

How can I tell the difference between toward and away moves when clients are taking action?

The theory of appetitive and aversive control is described in more detail in Chapter 7, and in our view, is one of the most important ideas that ACT practitioners can impart to their clients. To briefly recap, the theory is concerned with discriminating between different functional classes of behaviour. Based on basic survival needs, the behaviour of humans, as well as a whole host of other organisms, can be seen as either moving toward stimuli that have appetitive functions, or away from stimuli that have aversive functions. In short, organisms approach (or move toward) what they want and avoid (or move away) from what they do not want. Discriminating between toward and away behaviour in non-verbal organisms is relatively straightforward. For example, plankton drift toward sunlight and away from toxins for reasons that are obvious. Dogs will approach sources of food and retreat when threatened, in a manner that is similarly transparent. When it comes to applying the toward and away discrimination to humans, whilst the principle is the same, the added complexities of cognition and language can make the functional classification of behaviours somewhat less straightforward to discern. This leads practitioners to the question posed by this chapter, and to the very practical concern of how to identify the function of between-session behaviours once the client has described their form. The client will almost certainly know what they did. Why they did it, and whether it was an adaptive move in the direction of the goals of intervention often requires a closer functional analysis. One of the complicating factors when it comes to human behaviour is that almost nothing that a person can do could be intrinsically considered as a toward or away move. Almost any behaviour that one

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How can I tell the difference between toward and away moves?  63

could mention can be either. Even something basic like eating, which on the face of it looks like a toward move since it involves a person approaching a stimulus for which they have an appetite, might be an away move. Someone might be ‘comfort eating’ to reduce their distress, eating a meal they really do not want to avoid the disapproval of the person who made it, or finishing up leftovers when they have already eaten enough because, “It would be a waste just to throw it away”. In each of the above scenarios, the behaviour of eating bears all the hallmarks of functioning as an away move. Alternatively, a client might report that they have visited the gym every day since your last session. This might have been a toward move, serving values around health and fitness, and, it might have served the function of getting them out of the house, and therefore away from a tense situation with their partner. So, how can we tell the difference? The first thing to say is that we should not be trying to tell the difference simply to promote toward moves and eliminate away moves, even if reducing reliance on away moves might be consistent with the overall trajectory of the intervention. Both are important for successful functioning – we can all benefit from knowing when to move toward our values and when to avoid pain. It is important to remember that ACT only targets repertoires of experientially avoidant behaviour when they are problematic. An ACT practitioner needs to be able to tell the difference between toward and away moves because part of their role is about helping clients to get better at tracking their own behaviour and tuning into its functions. This is in the service of clients improving the frequency with which they engage in behaviour that is workable, and consistent with a life well-lived in the context of their values and aspirations. One of the main differences between toward and away moves is in the flexibility of the behaviour. Let us use the behaviour of running through a country park as an example. As a toward move, perhaps in the pursuit of fitness, running can be a very flexible activity. Someone might choose to follow a running programme or not, vary the pace and duration of their run, take different routes through the park, or even stop for a while to enjoy the view. If that same person was running through that same country park because they were being chased by an assailant, their run will not have the same flexible quality. It is likely that they will run as fast and as far as they can in one direction only, namely away from their attacker. Many away moves are like this since they often do not feel like a choice. Think of it as the difference

64  Conceptual questions about the ACT model

between doing something because you want to and doing something because you have to. The latter condition tends to produce much more rigidity. Thus, exploring the flexibility/rigidity of a behaviour with a client is a useful step to take. Another way of spotting the difference is in the client’s psychological experience of their behaviour. If you are reading this book because it represents a toward move for you, the act of doing it will likely elicit certain psychological states. You might notice feeling interested, engaged, or even excited as you develop insights that might be useful to you in your practice. Reading it might represent a committed action as part of a repertoire of behaviour that serves the value of being helpful to others. If you are reading it because it’s on a reading list for an assignment that you’ve been set as part of a training course that you’re not that into anyway, and you wish your manager had not sent you on, the experience will feel quite different. Encouraging clients to notice the experience of enacting a behaviour can help you both access internal events like emotions and physiological sensations. These different feelings offer a clearer sense of whether any given behaviour is a toward or away move. Only the client can really know the functions of their behaviour, so helping them learn how to notice, track, and describe their inner experience is crucial to effective ACT practice.

Chapter 19

How does the concept of compassion fit with ACT?

Firstly, let’s start by clarifying what we mean by compassion. Who better to consult for this than our Compassion Focused Therapy (CFT) colleagues? The Compassionate Mind Foundation (n.d.) defines compassion as “…a sensitivity to suffering in self and others with a commitment to try to alleviate and prevent it”. If we take this as a starting point to explore compassion within the ACT model, it feels immediately clear to us that there is a huge overlap between the therapeutic aims of both ACT and CFT. If we were to draw a Venn diagram relating these third-wave CBT models, the commonalities would include their focus on human suffering and a desire to alleviate this, the idea of a common humanity, the inclusion and importance of the self and other (compassion and acceptance are both principles that have a focus on the self and others), and their emphasis on the teachings of evolutionary science. The difference in the models is more about their points of origin, with CFT drawing on attachment theory, Buddhism and developmental approaches, and ACT coming more from the behavioural science tradition, and ultimately holding psychological flexibility as the foremost important tenet. With the increase in scientific support around the importance of compassion, including research studying the effects of compassion practice on the brain (Lutz et al., 2008), it is predictable that these two approaches will continue to co-exist and work alongside each other. There is much to learn from each. ‘The ACT Practitioner’s Guide to the Science of Compassion’ (Tirch et al., 2014) is a very helpful and eloquent guide about how to incorporate more of the CFT model and its learnings into your ACT practice.

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66  Conceptual questions about the ACT model

It is often a misconception of people learning ACT that it is somehow void of compassion, and that an ACT approach is more a set of ‘forced’ experiential exercises than anything compassionate. This could not be farther from the truth when ACT intervention is practised in a manner faithful to the model. The name of the model is certainly evocative of ‘doing’, of ‘action’. The words ‘acceptance’ and ‘commitment’ are indeed guiding people undertaking this work to be aware of its active approach. However, it is an injustice to the entire body of work to attempt to undertake ACT intervention without the complete and transparent presence of compassion. In our training and supervision of other therapists, we have long been talking about wrapping the word compassion around the Hexaflex (see Figure 19.1). The visual representation of the entire ACT model being encompassed by compassion suddenly seems to evoke a renewed perspective of the ‘what’ and ‘how’ of the work. Compassion is something we endeavour to bring to all human interaction as practitioners, in whatever capacity we work with people. When considering how to turn up the volume of compassion in your

Contact with the Present Moment

Acceptance

Values Psychological Flexibility

Defusion

Committed Action Self as Context

Figure 19.1  Compassion and the Hexaflex

How does the concept of compassion fit with ACT?  67

ACT work, it can be helpful to hold compassion as a stance that we take in how we choose to behave in the world, both toward ourselves and to those we engage with. The idea of doing something compassionate with another person implies that this would then stop when the exercise is over. However, the idea of being compassionate to them and their needs, as well as toward you and your own needs is something that can be consistent and sustained throughout the work. From a behavioural perspective, we know that there are three main ways to help someone to acquire a new skill. For example, if the goal of our work together were to be that you learn to swim, we could model how to swim, we could invite you into the water and evoke swimming behaviours, and we could reinforce your efforts to move around in the water. The principles of modelling, evoking, and reinforcing behaviour to effect behaviour change are something we can hold in mind in relation to compassion as well. If we consider how this would be helpful in our intervention work regarding compassion, we can literally model compassion to our clients in every single interaction we have with them. We can then strategically choose how to evoke more compassionate behavioural choices from our clients, and reinforce any compassionate choices that our clients make. A helpful metaphor to bring this to life is driving a car. Imagine yourself in the driver’s seat, hands on the steering wheel, backside in the chair, feet on the pedals. To even move the car forward a few metres you need to take a number of strategic actions. Just consider what is involved – your hands will change gear, your feet will move the pedals, your entire body will be making minor movements and adjustments to action the required events that will get the car to move forward. And then you’re off! Driving down the road at speed. But what about awareness? You don’t suddenly pull over and think, “Oh now it’s time to do the awareness” (we hope!). You need to drive with awareness all the time, and even if this has become second nature to you through practice, you would still notice someone walking into the road, the movement of other cars, and other features on the environment in which you are driving. Compassion is just the same at that, it’s a skill and a quality that we aim to bring to all of the work we do. It’s not something ‘extra’ that we offer on top of our ACT knowledge and skill. It is how we do ACT.

Part 3

Putting ACT into practice

Once practitioners understand the philosophical and theoretical basis of ACT, they can begin to turn their attention to learning how to apply its concepts in practice. Attempting to meet the challenge of how to apply the theory to the complexities of the real-life situations brought by clients is when the most questions about the model tend to be generated. The largest section of the book is devoted to answering frequently asked questions about putting ACT into practice. Several chapters in this section answer questions concerning interventions and techniques for addressing the six components of the psychological model, as well as related questions about assessment, formulation, and how to structure and order ACT interventions. Questions about the applicability of ACT with diverse populations and different diagnostic presentations are addressed, as is the issue about to what extent ACT practitioners need to be familiar with the finer points of RFT.

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Chapter 20

Do I need to know RFT in order to practise ACT?

There is a simple and honest answer to this question, which is ‘no’. You do not need to know RFT inside out to practise ACT. And…there is a lot more nuance in a considered position of the relevance of RFT to ACT, which we would like you to think about before coming to your own view. A useful metaphor for this issue is that of a musician and whether they need to know musical theory or have an in-depth knowledge of their instrument to play it. Clearly, once again, there will be many musicians around the world who can play proficiently without this knowledge. They might have been self-taught and simply figured things out as they went along, drawing on their own experience of what works as they progress in their musical development. However, one could argue that there may be times in their practice of music when a knowledge of musical keys, scales, and time signatures, or an understanding of how their instrument is constructed would be of great use. Perhaps that lack of knowledge will limit them in terms of the music they are able to write and play, or perhaps the instrument develops a fault that they will not know how to correct. Of course, they can turn to other people for help at any such times, and maybe there will always be ways in which they are at a disadvantage to another musician who has that additional theoretical understanding. We always include a significant section on RFT in our ACT trainings, particularly at an introductory level when people may be coming across ACT for the first time. Our view is that it is very important for ACT practitioners to understand at least the fundamental concepts of RFT. It is fair to say that it is not everyone’s favourite part of the training, yet without it, it feels difficult to root ACT’s core assumptions

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Do I need to know RFT in order to practise ACT?  71

in anything solid. As stated by Dixon and Hayes (2022, p. 5), “ACT makes no sense without RFT”. Learning ACT procedures (the how of ACT) without learning the theory behind why you are using them feels very much like giving people a bag of tools without passing on any understanding of what each one of them is for. How would they choose which one of them to use and when? In our experience of supervising ACT practitioners, this issue frequently presents itself in the questions asked by those with little training or interest in RFT. For example, they might have run into obstacles trying to help a client defuse from an unwanted thought. In good faith, they might have tried several different procedures drawn from the ‘defusion’ section of a textbook, and then brought the issue to supervision, because none of them have helped weaken the behavioural control exerted by the thought in question. Part of the problem here relates to the imprecise nature of some of ACT’s concepts and its reliance on middle-level terms (see McEnteggart, 2018), as discussed in more detail in Chapter 14. In noting the client’s thought, the practitioner has observed a process that they recognise as cognitive fusion and applied procedures aimed at reducing that fusion. However, fusion is not a precise concept, and saying that the client is fused with a thought says nothing about the specific relations involved. We would argue that an understanding of RFT can provide greater specificity in this situation and would enable the practitioner to target their interventions with greater precision. For illustrative purposes, let us assume that the thought in question is, “I’m just not who I was before. I’m less able than others. I’m worthless”, and the client has been plagued by this thought ever since they experienced a life-changing physical injury. The thought has the function of lowering the client’s mood and narrowing their behavioural repertoire. They have become withdrawn and lack motivation to engage with valued activity. An RFT formulation of this thought would specify certain relational frames that are contained within it, as follows. “I’m not who I was” – ‘I-NOW’ is in a frame of opposition with ‘I-THEN’ “I’m less able than others. I’m worthless” – ‘I’ is in a frame of hierarchy with ‘others’ in which ‘I’ is inferior (worth less) than ‘others’

72  Putting ACT into practice

Many of ACT’s defusion procedures aim to create a frame of distinction between the noticing part of a person’s consciousness and the content of their thoughts that the noticing part notices. For example, the ‘leaves on a stream’ exercise creates a distinction between thoughts that are placed on the leaves as they float down the stream and the person on the riverbank watching them come and go. However, as demonstrated by Barnes-Holmes (2015), the exercise might also be considered to contain elements that target values, acceptance, and self-as-context outcomes. It is a somewhat scattergun procedure, and whilst it may well have some benefit in terms of helping with the issues the client is facing, it is probably not the most efficient way to work and cannot really be said to be utilising a functional analytic approach. With reference to the RFT formulation above, it might be more effective to specifically target the opposition and hierarchical relations, since neither of these suggest that a distinction procedure is indicated. The opposition relation could be addressed by using procedures that promote co-ordination (or continuity) between ‘I-NOW’ and ‘I-THEN’. Whilst acknowledging that there are some differences between now and before, it would be useful to orient the client to ways in which they are the same. What about them has not changed? Do they still aspire to the same values? Is there a sense of who they are that is more than just the things that they can or cannot do? The hierarchical relation, whereby the client sees themselves as less than others could be targeted by perspective-taking interventions and/or self-as context procedures such as container metaphors. For example, would the client judge someone else with the same physical injuries as worthless in the same way? Would they see something that is part of a person’s experience as being equivalent to the whole of them? (e.g., does one bad deed, blonde hair, or a physical injury define a person in their entirety?) Whether interventions that pay attention to the specifics of RFT fare better than more generic ACT interventions is an empirical question that remains to be answered. The field is in its relative infancy regarding this question and cutting-edge interventions firmly rooted in ‘clinical’ RFT (e.g., Barnes-Holmes et al., 2020) are only now beginning to establish themselves. In the interests of balance, we should state that our belief that a knowledge of RFT can benefit the practice of ACT does not go unchallenged and there are those of the opinion that the links that are claimed between RFT and ACT are empirically premature and somewhat oversold in the ACT literature (see McLoughlin & Roche, 2022).

Chapter 21

How do I know whether ACT is the right intervention for someone?

There are many ways to answer this question. One could take an empirical approach and examine the evidence-base for using ACT with a client’s presenting issue, or one could look more intra-personally, both at the client and ourselves. We will reflect on each of these approaches to the question in turn. When starting to use ACT in your practice, it is certainly helpful to familiarise yourself with the evidence-base for the efficacy of the model (see Chapter 2 for more on this). There is a growing evidencebase for the use of ACT with a wide range of presentations. This includes applications with people who may present with diagnostic mental health labels, such as depression, anxiety disorders, and problematic substance use, as well as applications of the model to several physical health diagnoses like chronic pain, cancer, diabetes, and bowel diseases (Hayes, 2022). Thus, it is advisable to turn to the literature to see whether there is evidence that ACT would be of benefit with reference to any given issue that someone seeking help might bring. For some of these diagnoses, there are also specific protocols available (see Hayes, n.d., b), as well as an array of books on specific application to a particular presentation. More broadly, there is also a growing evidence-base for the psychological flexibility model itself. There are studies that look at whether individual ACT procedures are indeed doing what the theory claims they should. For example, does introducing a defusion procedure actually help a client to have more distance from their thoughts, and achieve an outcome characterised by defusion? One helpful overview of this work is the meta-analysis of laboratory-based component studies by Levin et al. (2012). This meta-analysis identified that numerous

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component studies did suggest that individual ACT procedures were helpful in increasing psychological flexibility via the component process they stated they were acting upon. These component studies, as well as the outcomes from meta-analyses, reinforce the idea that the model is not only suitable in the context of a few specific diagnostic labels. Rather, they suggest that this is a flexible model that can be applied in different ways to various aspects of human functioning, either to alleviate suffering or to promote adaptive change. Taken in the round, ACT research data suggest that the specific context within which human suffering takes place is less relevant, and that the model is applicable whatever the cause of distress or ‘stuckness’. This can be observed in the variety of studies that support the use of ACT in non-clinical settings, including studies on relationship difficulties (e.g., Rahimi et al., 2020; Amini et al., 2021), staff burnout in work environments (e.g., Hayes et al., 2004; Montaner et al., 2022; Prudenzi et al., 2022), and coaching (e.g., Hochard et al., 2021; Potts et al., 2022). Aside from the evidence-base, there is of course an intra-personal perspective as to whether ACT is the ‘right’ therapy for someone. There are a number of therapeutic approaches out there, and as individuals we each bring personal choice to the type of support we may wish for at any given moment in our lives. ACT is an active intervention, and one that requires to some degree that the client takes at least an equally active role to that of the practitioner. A good metaphor here is rowing a boat. If the practitioner and the client each hold an oar and the practitioner rows hard whilst the client takes a more laidback approach, the boat will turn in circles. The client is required to be willing to engage in an active therapeutic model (and row at least as hard as the practitioner) to achieve the forward momentum of behaviour change. Of course, at times, clients may wish for a more personcentred, non-directive counselling approach. There is validity to this choice and it is likely that this choice will suggest ACT is not the most helpful approach for your client at this moment in their lives. Another factor that might suggest that ACT is not the best fit for your client is a desire to explore childhood issues in great depth, which may lean more toward a psychodynamic psychotherapy model. Equally, another contraindication for ACT might be where a client requests another specific model, for example, traditional CBT, because they like the structure of thought diaries, or want a practitioner to directly challenge their thoughts. Of course, you can provide information about ACT to all of these people and even advocate why you think

How do I know whether ACT is the right intervention for someone?  75

psychological flexibility could be a helpful approach for them. It may indeed be a more helpful approach than the one they are requesting, although it is also important to respect a client’s choice and be honest with them about what you will and will not be able to offer them. There is also an important question around whether ACT is an appropriate match with your clients’ needs and abilities. There are some basic cognitive functions that people need to have to enable them to access talking therapies of any kind. These include the ability to comprehend the relevant language being used, to be able to encode and retain relevant information and engage in a basic exchange of language using both listening and communication skills. ACT is unlikely to be best suited to people who are intoxicated or require emergency care (Smout, 2012). ACT is used with a variety of human populations, including people who have diagnoses of intellectual disability, autistic spectrum disorder, and acquired brain injury. Some of these differences will impact the way you would explain the concepts of the model, or whether you are able to effectively use abstract concepts like metaphors. Whilst the evidence-base for these populations is still small, clinical experience from practitioners around the world is indicative of its efficacy. The important question here is not, “Can my client understand the model as explained in a textbook?”, but rather, “Do I understand the science and philosophy of the model enough to adapt the application, so my work is still ACT consistent?”. Sometimes asking this question suggests a different perspective from the question in the title of this chapter, in that goodness of fit might be just as much about a practitioner’s skill set, than it is about the suitability of the client.

Chapter 22

Can ACT be adapted for diverse populations?

This question can be approached in two ways, namely, a consideration of the interest in applying ACT among diverse populations, and the evidence of the effectiveness of the same. We will consider the second of these issues first. A significant problem for all scientific literature is the bias toward collecting data from what can be referred to as ‘WEIRD’ nations. WEIRD is an acronym utilised by Henrich et al. (2010a) to refer to Western, educated, industrialised, rich, and democratic nations. It is suggested that up to 85% of the world’s scientific studies come from WEIRD nations, whilst at the same time, only 12% of the world’s population are resident there. The problem applies to psychological research, as reported by Arnett (2008) in a paper looking at studies published in prominent psychology journals between 2003 and 2007. Arnett found that 74% of the authors and 96% of the participant samples were American, whilst only 5% of the world’s population are American. Consequently, it would be wise to always approach psychological research data with some caution, particularly in respect to generalising any findings to groups of people who may have been under-­represented in the studies. It is evident that the extant data within behavioural science is drawn from a small percentage of all human diversity and whilst many people might assume that any findings from WEIRD nations generalise to all humans, there is a strong argument to suggest that this is not the case. People vary enormously in terms of psychological processes like visual perception, memory, spatial reasoning, fairness, and co-operation, and WEIRD people are not typical of the species as a whole. In short, the fact that a huge majority of studies utilise WEIRD participants presents a significant

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Can ACT be adapted for diverse populations?  77

challenge to our understanding of human psychology and behaviour (Henrich et al, 2010b). So how does ACT research compare in respect of these limitations? As has already been suggested (see Chapter 2), any answer we can provide about research data at the time of writing may well be out of date within a few months, such is the rate at which new ACT studies are published. That said, at the present time there are just short of 1000 randomised controlled trials attesting to the efficacy of ACT as an intervention for a wide range of behavioural issues. Of these, approximately 250 originated in low and lower middle-income regions, as defined by the World Bank (ACBS, 2022). These include studies published in Algeria, Egypt, Ethiopia, Gaza Strip, India, Indonesia, Iran, Nigeria, Sierra Leone, South Sudan, and Uganda. Whilst this figure does not come close to addressing the over-representation of WEIRD people in the ACT outcome data, it does give some indication of the broad applicability of ACT across cultures. As always, firm conclusions about applicability cannot be achieved by counting studies, and practitioners are encouraged to seek out individual studies to examine their quality and relevance to any population that they might be providing a service to. In addition, it is important to interrogate studies to find out more about the demographics of the participants in their samples and the overall cultural competence of the researchers (Woidneck et al., 2012). Another indicator of the diversity of interest in ACT comes from the fact that ACBS, the worldwide organisation overseeing the development of ACT, has chapters in Asia, Australia/Oceania, Europe, South America, and North America. There are ACT textbooks in more than 20 different languages and ACT measures in over 40 languages (ACBS, n.d., b). One influence on this worldwide interest might be that ACT draws inspiration for its theory and practice from both the East and the West. It is interested in both ideas from ancient wisdom traditions (e.g., mindfulness, acceptance, and a transcendent sense of self) and modern science (e.g., behaviourism and an emphasis on evidence-­based practice). The active research programme in Iran and the growing interest in ACT training and literature in China are just two examples that attest to the appeal and applicability of the model outside of WEIRD nations. As a note of caution, we should underline that interest and applicability is not hard evidence of efficacy in terms of culturally diverse applications. The WEIRD issue is only one way of thinking about diversity. Hays (2016) uses the ADDRESSING acronym to help practitioners think

78  Putting ACT into practice

about the ways in which people identify and are diverse. The acronym indicates the following influences on cultural diversity. • • • • • • • • •

Age and generational influences Developmental disabilities Disabilities acquired later in life Religion and spiritual orientation Ethnic and racial identity Socioeconomic status Sexual orientation Indigenous heritage Gender

These are not discrete categories, and the notion of how they might intersect for any given individual or group is important to consider when thinking about how applicable ACT procedures might be to them. Something of use to an ACT practitioner considering intersectionality in this way is the proposed universality of ACT as a model for approaching human behaviour. Whilst every client brings a different specific context for the practitioner to work within, the ACT model is the same everywhere, since the processes are intended to be universal. Of course, certain contextual concerns will need to be given more prominent consideration when any of Hays’s above list of cultural influences are a significant feature of a client’s presentation. Thankfully, there is a significant body of ACT literature already available that practitioners can look to in these circumstances. There are books and/or research papers on ACT with older adults (Davison et al., 2017), developmental disability (Byrne & O’Mahony, 2020; Williams & Jones, 2022), disabilities acquired later in life (Owen, 2013), religion and spiritual orientation (Nieuwsma et al., 2016; Robb, 2022), racism and racial trauma (Matsuda et al., 2020; Payne, 2022), low-income countries (Geda et al., 2021), gender and sexual identity (Skinta & Curtin, 2016; Stitt, 2020), and indigenous populations (Dousti et al., 2021). As a footnote to this chapter, it feels important to stress that the effectiveness of using any psychological model with diverse populations relies on an interaction between the skills of the practitioner and the model they are using. Using an ‘ACT for X’ protocol is unlikely to be enough on its own, and it is incumbent upon all ACT practitioners to seek to equip themselves with knowledge and skills for working in a manner that is informed by the principles of intersectionality.

Chapter 23

Where do I start with introducing ACT to a client?

We could answer this question from a number of perspectives; where you are at in your ACT practitioner training, where your client is in relation to their presentation and the issues they are bringing to your work, or, by considering what the model would suggest as a ‘good’ place to start. We will address each of these in turn. Much about where you might start with introducing ACT to a client will depend on where you are in your own ACT practitioner journey and how skilled you feel with each of the components of the Hexaflex. It will also be impacted by what other CBS knowledge you have guiding your interventions, such as the underpinning science and philosophy of ACT, notably functional contextualism, behaviourism, and the clinical application of RFT. If you are reading this book, it is likely that you have some experience of ACT. It may also be possible that you have previous training in other psychological models or behaviour change approaches, like CBT, psychodynamic psychotherapy, or coaching. If that is the case, then it can be helpful to reduce some of the pressure brought by the thought, “How do I change from X to ACT in my next session?”, and instead start to ‘flavour’ your existing work with more ACT consistent ideas and strategies. One example of this is to increase the focus on values work within your existing practice, to help people turn up the volume on what is important to them in their lives. You might do this via a specific strategy. For example, you could alter existing exposure interventions to include a value-driven perspective, or you could utilise a specific tool such as values cards (e.g., Nikolic, 2019). If that goes well, you might feel increasingly motivated to want to explore what your next intervention steps might be from an ACT perspective. In this way, your learning experience can feel more like a natural integration of new and existing knowledge. DOI: 10.4324/9781003364993-27

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If you are in the early stages of learning ACT and are looking for additional structure to follow, it can be helpful to draw on the various session-by-session protocols that are available (e.g., Zettle, n.d.). These give you scripts for exercises and even timed breakdowns of entire sessions. Each protocol has its own starting point and will therefore introduce you to a variety of helpful strategies for you to implement into your developing practice. An alternative place to start introducing ACT to a client is picking up on where the client is at. This is often the flexible approach that more advanced practitioners take. This may involve identifying the client’s strengths in relation to psychological flexibility skills and expanding on them in an ACT-consistent manner. For example, if people can access their existing values menu, further work on values can be a great way to build on their strengths and increase the appetitive functions of the work to come. Alternatively, you may start by focussing on their struggle, helping them to use this to inform therapeutic goals, aims, and desires. Giving airtime to hearing someone’s struggle and validate their experience is a valid choice as long as it does not excessively function as an away move for either the practitioner or the client. The starting point with every client can differ, based on several factors, and making choices around selecting the most helpful first step is a skill that you can hone with practice. With regard to where the model would tell you to start, there is no rigid rule to follow about which component comes first. As described above, you may wish to start where someone holds some existing skill, or at the place of greatest deficit. This will usually become quite clear to you during your initial assessment conversation. Irrespective of which part of the Hexaflex you choose to focus on first, there are some helpful tools to use to assist the sharing of the model with clients. As discussed in Chapter 12, creative hopelessness is a strategy to aid clients to buy into the function of addressing difficulties in a new and novel way. Highlighting the futility of the struggle that clients may have been stuck in for years is one key to increasing motivation for behaviour change. Another strategy to explain the model in a client-friendly manner is the use of an overarching or introductory metaphor (see Chapters 1 and 9 for more on metaphors). ‘Passengers on the Bus’ is a common ACT metaphor that encompasses all the Hexaflex components. Bennett and Oliver (2019) describe this metaphor, and how to enact it within a group setting. As this metaphor includes each of the six aspects of the psychological flexibility

Where do I start with introducing ACT to a client?  81

model, it is not only a helpful overview of ACT’s perspective on the world, it is also a helpful tool to repeatedly return to in supporting clients’ learning of each Hexaflex skill. If, at the start of sessions, clients specifically ask, “What is ACT?” or, “How is it different to CBT?”, it can be helpful to summarise some of the following. In brief, ACT can be described as a third wave CBT, meaning that it still acknowledges the links between thoughts, behaviours, emotions, and physiological sensation. It also utilises mindfulness and acceptance practices from ancient wisdom traditions. It is a values-based model, meaning that the client will be invited to tune in to what matters most to them, and take active steps to move in that direction. It is a very active model for a client to engage with, so whilst we, the practitioner, will offer them our dedication and support, the active change process will come from them being willing to take different actions based on greater clarity around their values. Chapter 1 offers some further thoughts on socialising clients to the ACT model.

Chapter 24

Should I show the Hexaflex to my clients?

When learning ACT, whether through an introductory training or a basic ACT textbook, practitioners will almost invariably be introduced to the Hexaflex. This diagram, which is a way of visually expressing ACT’s psychological flexibility model, has been referenced in various previous chapters and the diagram itself can be found in Chapter 11. The concept of psychological flexibility, described more fully in Chapter 11, comprises six components, namely acceptance, defusion, contact with the present moment, self-as-context, values, and committed action. Whilst these components are often referred to as processes, with reference to the process/procedure/outcome discrimination described in Chapter 14, they are perhaps better thought of as outcomes, in that they represent aspects of the behaviour of a more psychologically flexible individual. For example, we want our clients to be mindfully in contact with the present, in touch with the part of themselves that can notice and choose responses, willing to accept discomfort, able to stand back from unhelpful thoughts, clear about what values are important to them, and taking meaningful action. As opposed to that description, the target processes indicating that an individual might benefit from ACT procedures relate to a state of psychological rigidity or inflexibility. These processes are also sometimes represented on a similar hexagonal diagram, known colloquially as the Inflexahex (see Figure 24.1). The Inflexahex is a useful conceptual tool to help an ACT practitioner map and describe the target processes when arriving at a formulation of a client’s situation. It is helpful in providing an overview of some of the main issues of stuckness, and in guiding the selection of interventions. Both the Hexaflex and the Inflexahex diagrams have

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Should I show the Hexaflex to my clients?   83 Rumination and worry Lack of values clarity

Experiential avoidance Psychological Rigidity Fusion with unhelpful thoughts, rules, and judgements

Inaction or unworkable action Attachment to a conceptualised sense of self

Figure 24.1  T  he Inflexahex (adapted from Bach & Moran, 2007)

been used as the basis for worksheets that practitioners and clients can complete together in the service of gathering information about the nature of presenting difficulties and organising it with reference to ACT’s theoretical framework. The ‘ACT Advisor’ assessment worksheet is a good example of this, combining both process and outcome as a means of formulating and tracking progress over time (ACBS, n.d., c). We do not have any issue with the Hexaflex or Inflexahex as useful ways of visually representing the component parts of psychological flexibility. They are useful conceptual tools in ACT training, and in organising assessment information. However, we would argue that their practical utility is limited insofar as they do not depict functional relationships between processes and outcomes or illustrate how the concepts translate into observable behaviour. For that reason, we do not recommend sharing them with clients. That is not to suggest that we do not think it is important to communicate a shared psychological understanding of the client’s experience. We do. It is just that we think that there are more functional tools available for achieving this. Clearly, this position begs a second question, concerning which tools we would recommend ACT practitioners to use to share their formulations. Whilst there are several candidates, in our view, the one with the

84  Putting ACT into practice OBSERVABLE BEHAVIOUR

What might we see you do when you are acting on what is important to you?

What might we see you do when this discomfort is present? YOU NOTICING

AWAY

What discomfort shows up to get in the way of you acting on what is important?

TOWARD

What is important to you in this situation?

INTERNAL EXPERIENCES

Figure 24.2  The ACT Matrix (adapted from Polk et al., 2016)

most practical utility in the widest number of situations is the ACT Matrix (Polk et al., 2016). It is a versatile tool that emphasises the functional discrimination of observable toward and away moves, and links this to the components of the Hexaflex in a very accessible manner. The Matrix diagram (see Figure 24.2) comprises two intersecting lines, thereby creating four quadrants. The vertical line represents the discrimination between behaviour under appetitive or aversive control, and the horizontal line creates a further distinction between internal, covert experiences (e.g., values, thoughts, or emotions) and observable behaviours. These distinctions enable several functional relations to be specified. Considering the bottom half of the Matrix, the bottom left quadrant captures the discomfort that can show up in response to pursuing one’s values in the bottom right quadrant. This serves to helpfully illustrate the co-ordination relation that exists between valuing and suffering (for example, anxiety coming hand-in-hand with the experience of being courageous) and is helpful in emphasising the utility of accepting discomfort in the service of enabling valued action. This co-ordination relation is useful to build into a client’s understanding since clients often come to ACT practice with an opposition relation regarding values and discomfort (e.g., the notion that they would like to act more in line with their values, but they can’t because their anxiety stops them). The understanding that discomfort is not the enemy,

Should I show the Hexaflex to my clients?   85

and that it can be seen as simply the ‘price tag’ of holding something to be really important, is often revelatory. The left side focusses on unwanted internal experiences and the observable away moves that characterise experiential avoidance. This can be used to illustrate the appetitive nature of away moves, and how discomfort often serves as the automatic cue for them. The left side can further illustrate how away moves are perpetuated through a maintaining cycle of negative reinforcement (e.g., reducing anxiety through avoidant behaviour becomes an ingrained pattern precisely because it works in achieving its aim). However, no matter how effective these away moves are at reducing discomfort, they rarely, if ever, help someone pursue their values, and this understanding can help create a frame of opposition between the two, thus also helping away moves acquire aversive functions. The right side of the Matrix focuses on specifying a client’s values and the observable toward moves associated with taking value-driven action. It helps to show how one’s behaviour can look quite different when it is motivated by moving toward values, as opposed to moving away from discomfort. The behaviour specified in the top right quadrant often has appetitive functions, so taking time to explore it is an important part of completing a Matrix. The Matrix is most often drawn with a circle in the middle, which represents the observing part of the client’s self, and speaks to the OBSERVABLE BEHAVIOUR

Fusion

OPPOSITION

Self-ascontext

CO-ORDINATION

Committed action

HIERARCHY

AWAY

OPPOSITION

Experiential avoidance

TOWARD

Values

Acceptance INTERNAL EXPERIENCES

Figure 24.3 Mapping Hexaflex terms and derived relations using the Matrix

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ACT concepts of present moment awareness and self-as-context. From this part of themselves, the client can see all the quadrants of the Matrix and how they fit together as different parts of their overall experience. The client is often invited to notice the different functional choices specified in the top two boxes and to work toward seeing their discomfort as the cue to mindfully choose a response in any given moment, rather than the ‘auto-pilot’ response of their usual pattern of away moves. Figure 24.3 illustrates how the middle-level terms of the Hexaflex, and the derived relations outlined in previous paragraphs, can be mapped onto the Matrix. We use the Matrix so often because it summarises lots of RFT and ACT concepts in one accessible diagram. It can also be used to address specific situations or much more general formulations of repeating behaviour patterns. Its applications include individual psychological wellbeing (e.g., Oliver & Bennett, 2020), or with teams of colleagues in organisations (e.g., Atkins et al., 2019). In our view, it offers much more to such situations than versions of the Hexaflex can.

Chapter 25

How do I explain each component of the Hexaflex?

ACT training and intervention work is experiential in nature as it utilises the learning experience of fully engaging in an exercise, rather than it solely being verbally explained. Take a moment to reflect on your own experiences of ACT. What moments in your training stand out in your mind as memorable? Which were particularly poignant for you? Were those moments halfway through a long didactic explanation, or were they during an experiential exercise that you were invited to do, and then reflect upon? We would take a punt that for most people at least, it was the latter. It is for this reason that ACT also makes its intervention work experiential, and our best advice would be to engage the client in experiencing each component of the Hexaflex, rather than getting caught up in a long-winded verbal explanation. That said, sometimes a client may want a little more information about the work they are about to embark upon, so below are short narratives for each component, and an associated exercise or metaphor that can be useful to further embed the learning in a more experiential manner. Note that in each of the sample narratives below, the ACT term is omitted. The aim here is to provide a functional definition of the skills, not to impart technical ‘middle-level’ terms to the client.

Acceptance Narrative: One of the skills that is helpful to develop is our willingness to allow all our experiences to simply be with us, without judging them or trying to make them go away. The reason we can benefit

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from this is that we are then often more able to decide how we would like to respond to an experience, rather than focussing our attention on how to change it, or make it hurt less. Metaphor: A useful metaphor for helping explore the futility of struggle, and therefore the utility of acceptance as a means of expanding behavioural responses is ‘Room full of duct tape’ (Vuille, 2013, as cited in Stoddard & Afari, 2014, p. 39). This describes the scenario of a leaking pipe, to which a person’s response is to cover the small crack with duct tape to stop the dripping water. The problem is solved, momentarily. Inevitably the water finds its way through the tape and the dripping continues. If we limit our behavioural response to using duct tape each time the pipe leaks, we will eventually have a room full of duct tape and still the water will drip. Acceptance would involve the willingness to acknowledge the leak, and choose a response that feels most effective, even if this is a more difficult task.

Defusion Narrative: Sometimes it can be helpful to catch our minds in flight and notice the tricky thoughts that affect the decisions we make in life. Stepping back from our thoughts allows us to see that they are simply that, thoughts. They don’t actually have to guide our behaviour. Exercise: There are various categories of defusion exercises as described in Chapter 30. One involves creating distance from our thoughts, effectively providing space to look at them, rather than from them. An example of this is imagining thoughts as if they appeared as text on a computer screensaver. One can invite the client to imagine seeing them like this and explore whether this would influence the process of choosing how to respond to them.

Contact with the present moment Narrative: It is helpful for us to develop the skill of tuning in to our internal and external worlds. Once we improve our ability to notice what

How do I explain each component of the Hexaflex?   89

we are experiencing in any moment, we have a better chance of being able to choose how to respond. For example, it is hard to think how we can respond differently to our anger if we don’t even know we are feeling angry. Exercise: Helping people tune in to the present moment can be as simple as asking them, “What are you noticing right now?”. Longer, more focussed, guided mindfulness scripts are also available. The ‘Observing Thoughts’ exercise (Kates, 2013, as cited in Stoddard & Afari, 2014, p. 92) invites clients to notice the movement of their thoughts, akin to noticing their breathing. This non-judgemental noticing invites developing the ability for thoughts to simply come and go, like a bubble or a passing cloud.

Self-as-context Narrative: We can often describe ourselves by using the words, “I am ___”. This can be helpful in some circumstances. For example, saying, “I am hungry” can efficiently lead to a fairly obvious solution. However, when we use “I am” to describe qualities of ourselves, like “I am worthless”, we can often end up reducing our own life experiences in order to fit the ‘worthless’ story we have told ourselves. It is helpful to us to see that our stories are often quite skewed, and that when we have a different way of seeing them, we often have a different response. Metaphor: Reducing fusion with self-stories is part of self-as-context work. We can target exercises that challenge a self-as-content perspective, broadening a client’s willingness to see that they are more than any one narrative they may hold about themselves. The ‘Sky and the Weather’ (Harris, 2009) is a helpful self-as-context container metaphor.

Values Narrative: In our work together we will talk a lot about the qualities you would like to bring to your life, to be the person you would most

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like to be. These qualities often bring us a feeling of vitality and meaning, and they feel intrinsically good when we embody them, even when that might be a difficult or unpopular choice to make. It is not about focussing on goals (like getting a car or a bigger house), and more about focussing on qualities we bring to our actions. We are often able to summarise these qualities in one word, for example ‘courage’, ‘independence’, or ‘integrity’. Exercise: Activities that include perspective taking can be useful to help clients grasp the kind of person they would like to be, for example, ‘Writing Your Autobiography’ (Stern, 2013, as cited in Stoddard & Afari, 2014, p. 136). This exercise invites the client to reflect on the content of their autobiography, including what they would like to be able to write about themselves and what they would feel most proud of.

Committed action Narrative: We know that if we do what we’ve always done, we’ll get what we always got, so one of the important parts of our work together is to commit to putting our feet down differently in the world, in order to get different results. What actions you choose to take will be linked to the qualities you would like to embody, and the aim of committing to these actions will be to bring you a greater sense of living a life of vitality and meaning, even when it feels difficult. Exercise: The ‘The Rope Bridge’ (Gillanders, 2013c, as cited in Stoddard & Afari, 2014, p. 163) invites the client to consider their choices when faced with the scenario of being on a high cliff and seeing the life they desire on the other side of the canyon. The route to access that life is across a rope bridge, which looks a little unsafe. The choice for the client is to decide whether the life on the other side of the canyon is worth crossing the rope bridge for, and if so, to take steps across the bridge with purpose in the service of accessing the life they desire.

Chapter 26

In which order should I work through the components of the psychological flexibility model?

This chapter should be read in conjunction with Chapter 23 since the questions addressed here and there often arrive together. That said, whilst the questions of where to start and how to proceed are related, they are sufficiently different that a separate chapter feels warranted. As we discussed previously regarding the starting point, it is not helpful here to give a single definitive answer about the order of ACT interventions. The model is designed to be flexible, and the context presented by each practitioner-client interaction will be different. However, from a functional perspective, our aim in this chapter is to offer some guiding principles. If you are the kind of person who likes clear structure and direction, there are numerous ‘manualised’ ACT protocols available, such as have been developed for research trials, standardised individual and group-based interventions, and self-help literature. These can be particularly helpful for those new to ACT, much like a map or a Sat Nav are helpful when going somewhere for the first time, since they walk you through a whole intervention programme step-by-step. Each such protocol will have been designed with different contexts in mind and will move through the components of the Hexaflex in a different order. Thus, it is not possible to reproduce a generic guide here based on their content, although it is helpful to know that they are available. At the same time, it is perhaps equally helpful to know that there is no set order in which you should conduct your ACT interventions. You can make decisions based on whatever the situation indicates, safe in the knowledge that you will not be doing it ‘wrong’, as there is no such thing. It is not even a pre-requisite to address all the components of the Hexaflex during a course of intervention, since there is research

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(e.g., Levin et al., 2012) indicating that procedures that address any one of ACT’s processes have an impact on psychological flexibility. Thus, it seems permissible to build an ACT intervention based on a functional analysis of the client’s presentation, and as long as the selected procedures target the key processes, there is no single prescription for whether particular procedures are included, or for how they are ordered. Given how different people are in their attitude toward structure, whilst there are likely to be practitioners reading the above who are contacting a liberating sense of freedom in this moment, there will be others looking for firmer guidance on how to structure their work. If you are in the latter camp and you work in a way that involves offering a series of sessions, you might find the following principles helpful. 1 It almost goes without saying, but it makes sense to begin working with a client by assessing the issues that have prompted them to seek help. Many practitioners will have a preferred method for eliciting the information that they feel is relevant to this. We do not have a strong view about exactly what practitioners should ask about, although our guiding principle is that less is more. Many clients only ever attend one session so we need to think carefully about how we use that first contact. Interrogating clients about every aspect of their life is probably not necessary and might even feel quite aversive. Without entirely neglecting a client’s history, keep the focus on the processes that are maintaining their difficulties in the present. 2 Work on developing a shared formulation of the behaviours key to the client’s presentation, as seen through an ACT lens. At this stage you might use a tool such as the Matrix (see Chapter 24), which might help communicate the information more effectively than an open conversation alone. Whatever method you choose, the formulation should be firmly rooted in the principles of functional analysis (see Ramnerö & Törneke, 2008) so that clients develop insight into the function of their behaviours, as well as their form. 3 Engage the client in a creative hopelessness procedure (see Chapter 12 for a detailed description of a useful technique). This will help to address the workability of the client’s current strategies for managing their difficulties, and hopefully build willingness for finding new ways of responding that are less reliant on experiential

In which order should I work – psychological flexibility model?  93

4

5

6

7

avoidance. This stage of the work also lays the foundations upon which subsequent interventions can be built. The client’s new direction should be charted with reference to the things that bring them meaning and purpose, so some values work is often indicated at this point. This goes hand-in-hand with building acceptance skills, since pursuing valued directions is likely to mean that the client is about to get out of their comfort zone. Secure a commitment to engaging in valued actions both within and between sessions and begin the process of planning and implementing behaviour change. In each session, the concept of committed action needs to be reinforced. This comprises new behaviours, as well as using ACT procedures to manage fusion and experiential avoidance when they threaten commitment. In this later stage, the work is likely to involve the purposeful recycling of stages 3–5 as the client practices the flexible pursuit of value-driven living, learning and utilising new skills across every component of the Hexaflex. Lastly, when the client has learned what they can from attending sessions regularly, some discussion about how they will use what they have learned going forward is useful, as is some consideration of how they might manage the inevitable setbacks when they eventually come along.

If you work in a setting that involves shorter contacts and/or fewer sessions with clients, the above stages might need to be collapsed or selected from, as fits the context of the work. Whether you work within a structure or adopt a more fluid approach (moving around the model in relation to what is happening in the room, as more experienced ACT practitioners tend to favour), a willingness to practice with a degree of flexibility is central to ACT. We like the sentiments expressed by Steven C. Hayes when talking about the development of a practitioner’s ability (Bennett, 2017–­present). He suggested that with any client we should be able to move from any point on the Hexaflex to any other point at any time, and with all the options that the model presents, getting stuck in one place is really the only way that you can go wrong.

Chapter 27

How can I encourage people to tune in to the present moment?

One could propose that this skill underlies all of the other aspects of psychological flexibility. We know from the Hexaflex (see Figure 19.1) that each of the skills is linked to one another. However, it seems inconceivable that anyone would be able to practise any of the other skills without being able to tune into their internal world at least a little. How can anyone identify their values if they are not able to turn inward and explore what is important to them? And how can one unhook from their thoughts if they have no ability to notice thoughts come and go? The key to developing any skill is practice, and being aware of the present moment is no different. As discussed in Chapter 13, there are both formal and informal practices that can be undertaken, and any of these could be done under the guidance of a practitioner or completed by a client alone as part of between-session work. It is important to ensure a good balance of practice in both of these contexts, especially as in-session practice allows the practitioner to give live feedback to the client, enabling the skill to be shaped. Some ACT practitioners favour starting each session with a mindful pause or exercise, enabling the practitioner and client to each land together in the space they are sharing. The precise nature of any such exercises may differ from client to client, depending on their existing skill and preference. However, the joint acknowledgement of arriving in a new context together can prove to be a connecting way to begin working together. Regarding how we encourage clients to tune into the present moment, noticing their internal and external worlds, we can turn to the work of Kohlenberg and Tsai (1991) and the notion of effecting

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How can I encourage people to tune in to the present moment?  95

behaviour change by modelling, evoking, and reinforcing target behaviours. Table 27.1 suggests some ideas for both in-session and out of session options for encouraging people to better hone this skill as part of developing psychological flexibility. The concept of modelling, evoking, and reinforcing behaviour in relation to a getting present exercise might appear simple in theory. However, as we know when we introduce language into any situation, the complexity increases, and the same is true here. For example, in Table 27.1 we have discussed saying, “Thank you for slowing down with me in this moment” as a reinforcing behaviour. This may indeed increase the likelihood that your client will be more willing to repeat this behaviour again in future sessions, hence it being described as a reinforcer. However, you may also be modelling to them by your own actions, pace, and tone of voice how to slow down, which will hopefully continue to evoke and reinforce their behaviour of slowing down. Whilst it is unhelpful for us to get too caught up in labelling our behaviour as modelling, evoking, or reinforcing of our client’s behaviour, it is important to keep your eyes clearly on the function. Inviting a client to tune into their body during a session or inviting the completion of present moment exercises between sessions is one thing. With regard to the development of psychological flexibility it is much more meaningful if the practitioner then uses this noticing to help the client to develop their skills in relation to other components of the model. From an ACT perspective, honing the ability to contact the present moment is important, although connecting this with implementing other psychological flexibility skills is what will effect long-term behaviour change in line with a client’s goals and values.

96  Putting ACT into practice M odelling, evoking, and reinforcing present moment behaviour in Table 27.1  and out of session In-session Modelling behaviour

Evoking behaviour

Reinforcing behaviour

Out of session

Providing examples of what Anything where you notice you do in your daily life to your own body or internal encourage your own practice world in the session. You of tuning into your own could say, “I’m noticing it experience is really warm in here”, or, “I’m noticing I’m feeling anxious about raising this topic with you”. Set homework tasks to hone the Inviting people to tune ‘getting present’ skill. These into their bodies in the could be basic exercises that session. This can be practise the skill of noticing, especially useful when like noticing the temperature you notice that they have of the washing up water, or responded to something emotions as they ebb and flow with strong emotions, whilst doing a familiar task. or in a manner that is Alternatively, you may agree different to their previous with clients that they will responses. utilise apps, watch YouTube videos, or engage in other ‘mindful’ practices between sessions. You may reinforce a client’s Ensure here that the client is not just being compliant with ‘present moment’ skill in a between-session tasks. In the number of ways. next session, it is imperative Verbally: e.g., “Thank you to explore any task that they for slowing down with engaged in and reinforce the me in this moment”, or, moments when they were able “It looks like you are to tune into their experience. considering this differently They may have not noticed the right now” (and then temperature of the washing up further evoke a response water, however, they may talk such as, “Can you tell me about noticing their feelings what is going on for you of anger and upset when their right now?” to further partner shouted at them. We develop the practice). want to be hot on reinforcing Gesturally: e.g., smiling, the skill, not any one specific a gentle nod, a visible behaviour. This is definitely slowing down of your own about function over form. pace of interaction to gently meet them in their present moment.

Chapter 28

How do I actually do self-as-context work with a client?

In our experience of providing ACT training and supervision, it is consistently the case that if there is one concept within the model that practitioners struggle to grasp, it is that of self-as-context. It follows that the subject of this chapter, how to deliver procedures that promote self-as-context repertoires, is also one that perplexes many students of ACT. Whilst Chapter 14 deals with the issue of defining self-as-context in some depth, it is worth briefly re-stating a working definition, since it is something of an abstract idea. ACT literature has traditionally described the self as being comprised of three parts, the self-as-content, the self-as-process, and the self-as-context. Content is a term used to describe internal experiences like thoughts, images, memories, emotions, and sensations, and selfas-content suggests a pattern of relating whereby observable behaviour is rigid, and regulated by excessive co-ordination of the self with this content. For example, taking the thought, “I am useless” literally is likely to narrow an individual’s behavioural repertoire. It equates “I” with “useless”, such that the functions of each word become interchangeable. A healthier psychological state in respect of the relationship between self and content is self-as-context, in which “I” is the context within which internal experiences (such as “I am useless”) occur. It is not equated with such experiences, rather, it is differentiated from them as the container that holds them, much like the sky is the container for the weather. Thoughts do not notice themselves; there is a part of the human mind that does the noticing. It is this ‘observing self’ that self-as-context is trying to capture. The final term, self-asprocess, is used to refer to the part of an individual’s experience that is neither content nor context, but is the process of noticing, in the sense of ongoing, moment-to-moment awareness. DOI: 10.4324/9781003364993-32

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At a practical level, if an ACT practitioner is working in this area with a client, the intention is likely to be to widen the client’s behavioural repertoire, helping them to enact flexible patterns of behaviour that are not controlled by internal experiences, even highly salient ones like, “I am useless”. The aim is usually to foster a sense of the self as the context from which those experiences can be heard or felt. A practitioner might say something like, “There is a part of you that is the thinker, rather than the thought”, or, “You are the place where your thoughts and emotions happen”. Such interventions are a kind of defusion procedure, structured hierarchically (Foody et al., 2013) to create a discrimination between the whole (the self) and a part of the whole (the experiences that the self has). Consistently speaking in this hierarchical manner, taking care not to reinforce relations of equivalence between the client and their content is crucial to good work in this area. Using language carefully and consistently to support the work is probably more useful than trying to explain the concept to the client. It is so abstract that clients can get hooked by trying to figure it out in a way that detracts from their direct experience. Kelly Wilson once offered an excellent example of this kind of dialogue in a conference session (Holman et al., 2015) when describing talking to a client who was very fused with the content of self-critical thoughts. He described saying to the client, in response to their negative global self-­evaluations, “I wish you could see all that I see when I look at you”. This statement takes a little unpacking. It sets up a frame of distinction between practitioner and client, and suggests that there is another perspective (the practitioner’s), different from the client’s, from where the client can be seen and experienced. It also implies that whilst the practitioner can see the client’s distress, they see them as being more than that, thereby reinforcing the hierarchical relation between the client and their self-critical content. Villatte et al. (2016b) offer a detailed analysis of how interactions between practitioner and client can be structured to make the most impactful use of hierarchical relations, such as have been described above. In addition to representing the concept using language, specific techniques can be employed to help clients to better relate to a sense of themselves as containers for their experience. A classic ACT metaphor (e.g., Harris, 2009) uses the phrase, allegedly of Buddhist origin, “You are the sky. Everything else is the weather”. With reference to RFT, this metaphor creates a hierarchical relationship between the sky and

How do I actually do self-as-context work with a client?   99

the weather in that the sky is bigger than the weather and acts as its container. The phrase further establishes a frame of co-­ordination between ‘the sky’ and ‘you’, and the same between ‘the weather’ and the client’s content. It suggests the notion that ‘you’ are bigger than any thoughts and feelings that you might have, and that ‘you’ can and do contain them, without being defined by them. This same hierarchical relation can be used as the basis for any container metaphor. As always, the precise form of the metaphor is less important than the functions that it conveys. One of our favourite ways to physicalise this relationship is to use a glass jar since it literally functions as a container. Session by session, the jar can slowly be filled with post-it notes, each containing statements detailing the kind of thoughts, emotions, and behaviours connected to the reason that the client has sought help. It can also be filled with post-it notes containing the client’s values, qualities, achievements, or indeed anything else that forms a part of their experience. In this physical metaphor, the client is the jar, and the post-it notes are their content. Whilst each note is a valid part of their experience, no single one defines their whole self, and any notion of the self is better thought of as comprising all of them.

Chapter 29

How do I promote acceptance in sessions?

Acceptance can often feel like one of the hardest Hexaflex skills to directly target because of the intangible nature of what it is. Remember, ACT’s perspective on acceptance is a focus on internal experiences rather than accepting an external set of stimuli or events. For this reason, acceptance can often end up being woven into other tools and strategies used to target the other parts of the Hexaflex, all with the ultimate outcome of increasing psychological flexibility. A very simple example of this is that when discussing values, it is common to ask, “In the service of pursuing this value, are you willing to accept (insert discomfort)?”. Given that there are few elongated exercises that work on the skill of acceptance alone, it is important to ensure that it is not neglected in our work with clients. From a behavioural stance, we suggest that it is possible to effect behaviour change by either modelling, evoking, or reinforcing the behaviour that we would like to see the client do more of (Kohlenberg & Tsai, 1991). All three options can be used as ways of promoting acceptance behaviour. We will look at each of these in turn in relation to promoting acceptance in a behaviour change setting. Practitioners can model acceptance in the way they conduct their own behaviour and what they demonstrate to the client in all of their interactions. Problematic experiential avoidance is the process we are targeting in acceptance work, since this is what narrows the client’s repertoire of behaviours, thereby making it harder for them to live a value-driven life. Oftentimes, clients turn down the volume of difficult internal events (thoughts, memories, emotions, and physiological sensations) by avoiding the discomfort that they elicit, and consequently also turn down the opportunity to select value-driven choices. As

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How do I promote acceptance in sessions?  101

practitioners, we can model acceptance of our own thoughts, for example, “I feel anxious about raising this subject”. With this behaviour we are modelling that we can experience discomfort and still function well in the situation. We are noticing our own discomfort and choosing to engage in the behaviour of raising a sensitive topic anyway, thus demonstrating to the client that we can experience unwanted thoughts, notice our emotional responses, and opt for the choice that is value-driven, even in the context of feeling uncomfortable. The value-­driven choice in this example illustrates raising a difficult topic because it would be in the best interest of the client’s behaviour change journey. The experiential avoidance option would be to avoid doing this because you would rather escape your own discomfort. It is also possible to model acceptance in sessions via the pace and rhythm that you bring to your work. Sometimes, your conversation will be free-flowing, and it is helpful to retain a pace to the conversation that may feel more like any other kind of conversation. However, the pace of your work can also be a way in which you can model acceptance to clients. Skilfully knowing when to slow the conversation down is a way of inviting acceptance into the room with you. ACT practice is going to be full of moments where people contact discomfort, whether in the context of discussing painful histories, current stressful situations, or talking about what they most care about. When distress shows up in the room with you, lean into it. These are golden acceptance moments. A well-timed slower pace of the work is a gentle invitation to the client to pause. By not speeding past upsetting things in session, you are able to model how to ‘be’ in the presence of something that feels difficult. You can hold that jointly with your client, and you can model to them how they can generalise this behaviour outside of the consulting room too. In these ways, you as the practitioner can use yourself in a very live way in the behaviour change process for your clients. It is also possible to evoke acceptance in others, which serves the function of inviting them to notice their own discomfort and ultimately decide about how they would like to respond to it. We can do this by verbally drawing people’s attention to discomfort to elicit descriptions of it (e.g., “What’s going on for you right now?”) when we notice the client experiencing a difficult thought, emotion, or sensation in front of us. This move illustrates the direct link between acceptance and contact with the present moment as seen in the Hexaflex. Once we have invited the client to notice what they are actually sitting with, we

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are then able to continue to shape their behaviour by bringing to the fore the choices they have available in response to it. The discomfort that us as practitioners may feel in bringing clients’ attention to their own discomfort is addressed in Chapter 47. In brief, it is safe to say that their uncomfortable internal experiences are present with them anyway, so us holding a safe space in which they can learn to do something different in the presence of them is more of a gift than it is harmful. Inviting clients to then make a more aware and active choice about what to do next is helping them to develop the skills of tuning in to the present moment, noticing the content, and choosing a toward or away move, dependent on the context. It is important to remember that making an away move is a valid choice, it is just unlikely that it will lead to long-term adaptive behaviour change. The key word here is choice, and we want to bring that to the fore, which is why evoking acceptance is an important practitioner skill. The final behavioural strategy to effect behaviour change is to reinforce the client for behaviours that they have stated they want to do more of or behaviours that are clearly helpful to them. Reinforcement needs to be a personalised strategy, as what will be reinforcing or aversive for one client may differ wildly from what would be reinforcing or aversive to someone else. However, the key point here is that you can note a client’s level of acceptance of discomfort and use this in future sessions to reinforce any changes that have occurred. For example, you might say to a client, I notice that we are talking about something quite difficult right now, and I see that you are staying with me on this. It feels like you are able to tolerate this more than in previous sessions. It is wonderful to see you being more able to sit with this when it shows up for you.

Chapter 30

How do I know which defusion procedure to use?

As has been stated previously in this book, the term ‘fusion’ is used to describe a situation where people respond to their thoughts as if they represent literal truths. It is a normal by-product of the development of language and there is nothing intrinsically problematic about it. If the owner of a blue car has the thought, “My car is blue”, and takes the thought literally, such that they consistently treat their car as if it is blue in colour, it is unlikely that this will cause them any problems. The same cannot however be said of the thought, “I will never achieve anything”. Thus, the first task of an ACT practitioner picking up on fusion within a client’s language and behaviour is to determine whether it is in any way problematic, and therefore, whether it should become a target for procedures aimed at defusion. Indicators of unhelpful fusion can normally be found in the client’s behavioural responses, for example, rigidity or narrowing of their repertoire, excessive reliance on experiential avoidance, or where acting in line with the thought restricts or prevents the client pursuing their values. Identifying problematic fusion is about pinpointing where certain thoughts exert undue regulation over behaviour to the extent that other stimuli or events in the client’s environment have little or no influence (Bennett & Oliver, 2019). In short, fusion is problematic when the client is responding solely to internal events and is not responsive to direct environmental contingencies. Where unhelpful fusion is apparent, ACT procedures aim to change the relationship between the person and their thoughts, such that they might no longer require a response or are experienced as less threatening. ACT and RFT literature suggest numerous procedures for creating distance from and/or deliteralising unhelpful thoughts, so it can be

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a challenge for the practitioner to choose between them in any specific situation. Given the importance of context in any such decision, there is no simple rule that we can give you to follow. That said, there some things that are important to consider. Chief amongst these is giving careful thought to the function of any chosen procedure. What is the outcome that you are trying to achieve? Blackledge (2015) provides a helpful structure for differentiating between defusion procedures, grouping them by function. We will look at each of the groups below and illustrate each with an example. •

•

•

Procedures that change language parameters • Example: Word repetition (Hayes et al., 1999). The client and practitioner excessively repeat a neutral word together (e.g., “milk, milk, milk…”), perhaps for about 30 seconds. The client is invited to notice what shows up for them as they do so. People frequently report that the meaning seems to drop away as they start to tune into the physical properties of the sound of the word. The procedure can then be repeated with a word or phrase that carries functions related to their distress or the reason they are seeking help (e.g., “loser, loser, loser…”). Procedures that create distance from thoughts • Example: Hands as thoughts (Harris, 2009). The client is asked to liken their hands to their uncomfortable thoughts and notice how their experience of the world changes when their hands are held right up in front of their face, dominating their vision. They are asked to slowly move their hands away and down from their face and are invited to notice changes in their experience as they do so. This is followed by a discussion of the potential benefits of trying to create distance between thoughts and the part of us that notices them, perhaps by calling to mind this physical metaphor as a means of achieving that. Procedures that undermine verbal rules and narratives • Example: Disobey on purpose (Hayes, 2019). The client is invited to perform an action, such as holding their arms above their head, whilst repeating the opposite out loud (e.g., “I cannot raise my arms above my head”). This exercise illustrates that it is entirely possible to have a repertoire-narrowing thought whilst engaging in the action anyway, and it can be slowly generalised to behaviours relevant to the client’s presenting issue.

How do I know which defusion procedure to use?  105

We might return to the problem of middle-level terms here. Broadly speaking, all these groups of procedures are aimed at creating defusion, although each group has a different specific function. Thus, good work in this area should always be based on a sound functional analysis. ACT practitioners should have a clear sense of what relations and functions they are targeting, and what outcomes would be helpful. This will help in selecting procedures with greater precision. For example, if a client reports finding it hard to resist the power of their thoughts, procedures that ‘de-literalise’ language, such that there is a loss or weakening of the meaning of that language might be indicated. Conversely, if a client seems to be reacting to thoughts or rules in an ‘auto-pilot’ fashion, without even realising they are doing so, procedures that slow thinking down and promote distinction between self and content would be more appropriate. Another relevant issue in selection of defusion procedures is that of trying to match them, as far as is possible, to the presentation and the needs of the client. It is important to tune in to your client and assess how each exercise might land for them. Some defusion procedures are effective because they introduce humour or a lighter tone to the work. However, to some clients at certain times, this might feel somewhat frivolous or inappropriate, and could end up having a very different function to that which the practitioner intended. Therefore, we would advocate careful thought over choice of procedures, picking your client and your moment carefully.

Chapter 31

How do I deal with values conflict?

One of the myths about values is that we get stuck when our values are in conflict with one another. This is rarely, if ever, the reality. Instead, what is often limited is our time, and that means that we end up feeling a sense of conflict by being pulled in different directions. For example, we may want to be attentive and loving partners, and we may want to be dependable and reliable colleagues. When both of these areas of our lives provide a sense of demand, and both are important to us, we can feel like our ‘loving partner’ value and our value of being a ‘dependable colleague’ are in conflict. However, from an ACT perspective, we would instead suggest that you are a single individual who literally cannot be in two places at any given moment. We do not cease caring about the thing we are currently not attending to, and unless our partner is also one of our colleagues, we simply cannot attend to the two different things at any one time. A ‘globe’ metaphor is often used to explain this. Imagine a globe and the country you live in. We live in the United Kingdom. We also have very dear friends who live in Australia, which is literally on the other side of the globe. If we were to visit them in Australia, we would have to leave behind our families, friends, and responsibilities in the United Kingdom for the time that we were away. We could spend our time in Australia learning new things about the world, connecting with our wonderful friends, and taking on new challenges. Whilst we were doing those things in Australia, we simply could not be attending to our families, or connecting with our friends in the United Kingdom in the same way, although they would never cease to be important to us. Because of the nature of the globe, we can only be in one place at a time. The context does not support us attending to both in the same

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How do I deal with values conflict?  107

way, and one must take priority. Values, and how we decide to focus our attention on them, can be viewed in the same way. If we are in work, we don’t stop caring about our families, wherever they are, and vice versa. We can only attend to the value-driven task at hand. It can be helpful to move clients away from the idea of values conflict and toward the notion of choice. As in the above example, one can choose to either be in one country or another, or attending to one specific task or another, and we can help clients to see those options as representing value-driven choices. Tuning in to the values behind their work and home lives can help people to prioritise one over the other in a way that feels functional. There are a number of key skills that may be helpful to strengthen, for example, we can help people to notice when their choice to work or fulfil the role of a loving partner is a toward or away move. As we know, any behaviour could be either, so really tuning in to why we are choosing to focus on one task over another can be helpful. Working all the time at home to avoid chores is an away move; working at home because you have a tight deadline may be a toward move, and one that you choose to do for a time-­ limited number of days or weeks. When considering our values, and the priority we may give each of them, it can be helpful to draw a distinction between micro- and macro-­examples of such situations. We may, for example, talk with clients about how we focus on our values within a microscopic interaction in our life, for example helping them to explore how they want to be in an upcoming work meeting that evokes anxiety. They may select values such as honesty, openness, assertiveness, and compassion. Tuning in to values in this specific context can help the client to select behaviours that would honour their chosen values, and best represent them as the kind of person they want to be. Alternatively, sometimes our discussion with clients about values is more on a macro-level of life. For example, clients may be embarking on goals around a new job or a new career pursuit, which will involve a much longer-term commitment. Whilst we can have several micro-level discussions about how they want to be along their aspirational journey, we can also highlight how they hold an overarching value as a broader guide. A client might have moved location to access a university course, and this may feel like it brings their home and work life values into conflict. In this scenario, we can invite the individual to consider that this period of their life may be more directed toward the pursuit of one value over another, and as such, they might live away from the family home for

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the duration of the course. It is also important to help them to see that any shift in context can be greeted with a corresponding shift in which of their values is prioritised. For example, should a family member need their support, they would be able to switch their attention back to their home setting and make choices accordingly. In this way, we are able to promote the flexible nature of values, and the importance of clients having clarity about their internal and external influences, when choosing value-driven behaviour. This is very neatly summarised by the Zen proverb, “Obstacles do not block the path. Obstacles are the path” (LeJeune & Luoma, 2019, p. 133).

Chapter 32

So, I just get people to work out their values and encourage them to do value-driven behaviour all the time, right?

Wrong. This is something that is quite easy to misunderstand when learning ACT, partly because of the potentially seductive nature of values work. In our experience of training and supervising other people, we have worked with a large number who have come to ACT with a solid background in other models that tend to have more of a problem focus. Beck’s (1976) cognitive therapy is a notable example. Aside from its commendable commitment to evidence-based practice, part of the success of cognitive therapy is due to the way it has allied itself to the medical model, adopting a disorder-specific focus to its research programme. Thus, a course of intervention tends to begin with some form of diagnostic assessment to inform the selection of a disorder-specific formulation and intervention protocol. ACT is different in that it seeks to identify process-based procedures rather than symptom-­driven protocols. Connecting people to their values is a large part of this endeavour. In looking at the values of the client, ACT steps into positive psychology territory and away from a symptom-based or problem-focussed orientation. This can often feel like a revelation for practitioners, and it can be exciting to be given permission to talk to clients about things that lie outside of their presenting problem. We have observed something of a ‘halo’ effect with this, and the values part of the work can sometimes be given too much energy and emphasis. In answering the question posed by this chapter we would like to both underline the importance of values work, and caution against overstating its role in ACT intervention as a whole. The first thing to be clear about is that the kind of toward moves associated with value-driven behaviour are no more or less valid than the away moves associated with avoiding the more aversive things in

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life. To do well in life, most organisms, human beings included, need to engage in both toward and away moves. Approaching or avoiding all stimuli in your environment are both sure-fire ways to find yourself in an early grave. The real skill in living a successful life is working out what to approach, what to avoid, and, most importantly, when to do either. Thus, an ACT intervention focussed solely on promoting value-driven behaviour would be problematic. Whilst it is important to work to widen repertoires of valued action, this should not be done at the expense of attending to the important functions of things like downtime, saying ‘no’ sometimes, or the simple protection afforded by avoiding or escaping stress. Whilst it is unlikely that a life focussed solely on away moves would be rewarding, it is critical that ACT practitioners promote flexibility in their work with clients, and balancing attention between toward and away moves is a key part of this. Indeed, one of the most useful things that a client can learn is the ability to track the consequences of their own behaviour in order that they improve their toward/away choices in any given moment. Another crucial point is that whilst toward and away moves are easy to discriminate in non-verbal organisms, the notion of values, relating as it does to verbally mediated behaviour (LeJeune & Luoma, 2019), muddies the water somewhat. For example, is a person who acquiesces to the wishes of an abusive partner making an away move (giving in to avoid their partner becoming violent) or a toward move (prioritising the value they place on their own wellbeing)? This is a complex question without a definitive answer, although if there is any resolution to be found, one needs to consider the context. If the context is a value of independence, then the above behaviour could be construed as an away move. If, however, the context is valuing self-preservation, perhaps it could be seen as a toward move. Thus, in any discussion of values and valued actions, we would encourage ACT practitioners to spend time on clarifying the context. The Matrix (see Chapter 24) is a useful tool for achieving this clarity. Another misconception related to the overall question is the idea that a life filled with value-driven behaviour will also be full of joy and free from distress. Nothing could be further from the truth, since choosing to prioritise one’s values can often make things harder, rather than easier. One of the most useful ACT-isms, which we find ourselves repeating all the time is, ‘in our pain we find our values and in our values we find our pain’. Taking a value-driven stance is often a difficult and costly thing to do, and valued action requires a willingness to

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experience discomfort. To return to the previous example, if a person decides to prioritise their overall wellbeing and autonomy with a decision to leave an abusive partner, this can come at great personal cost, particularly in the short-term, even if it is in their long-term interests. We should all be honest with our clients about the relative costs and benefits of valued action and allow them the flexibility to decide against taking it should they so choose. The overall workability of an action in the context of a client’s life is important to attend to. Lastly, another useful ACT-ism is the idea that we can all strive to pursue our values vigorously whilst ‘holding them lightly’. Even the most apparently benign value, like kindness for example, can become problematic if held too tightly, and turned into a rigid rule. If an individual being abused by their partner is relentlessly kind to them and about them, it will not serve that individual’s long-term interests. We probably all know someone who has prioritised other people to the point that it has become unhelpful to them, so learning when to relax one’s grip on a value is a useful skill. A useful metaphor here is that of using a pen to write or draw. One only needs to hold it lightly for it to be at its most effective, and the tighter it is gripped, the less useful it becomes.

Chapter 33

Do I have to address all the processes in every session?

ACT is often conceptualised using the Hexaflex. This visual representation of the model outlines six core components, with each having an associated skill that can be developed. In the centre of the Hexaflex lies a circle. This represents the main aim of the ACT model, which is to help clients develop greater psychological flexibility. See Chapter 11 for more information on this. Sometimes, in the process of first learning the model, we spend a large proportion of our time learning what each of the six components is about. We focus on finding a definition of each that would be suitable to share with clients, a list of tools, techniques, and resources for developing that particular skill, and even learning what to do when we get stuck in each area. However, the bigger picture is always about p ­ roviding clients with a wider repertoire of psychologically flexible behaviour, and this is best developed by using a fluid approach that interweaves attention to all the components of the Hexaflex, proportionate to what is relevant to the client. In Chapter 11 we introduced the idea of opening a paint tin being a metaphor for the flexible approach of ACT. The main aim is to get the lid off the tin. The most efficient and safe way of doing this is by applying gentle pressure at one point, and then moving the paint tin around, and applying pressure again. Repeating this pressure-movepressure-move routine creates a gap between the tin and the lid in various places, until it can be easily removed. Developing psychological flexibility skills is somewhat similar in a number of ways. •

Firstly, we are unlikely to most efficiently develop psychological flexibility if we only focus in one place. Just like with the paint tin, it is unlikely that you will achieve your end goal by only working in one part of the Hexaflex.

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•

•

Secondly, clients come to us with existing skills, and so we are not required to spend the same amount of time focussing on each part of the Hexaflex with every client. Imagine if we were trying to open a paint tin where the lid was already slightly ajar. We would not apply the same pressure to the part that was already free. We would just focus our attention on the parts of the lid that were more stuck. Lastly, when working around the Hexaflex processes, we might discover that clients need gentle reminders of skills that they have already developed. For example, in our intervention, we may have covered some work targeting fusion. Subsequently, the client might be invited to take some committed action, only to respond by saying, “Well maybe, but I think I am just too worried today. I might think about doing it tomorrow”. This indicates that in order for the client to take action, we might have to revisit fusion. Thus, ACT work can involve purposeful recycling of work targetting a number of processes in a cyclical fashion.

There are a number of factors that will depend on what processes are covered in a session. One of those factors is our own sense of competence with the ACT model, and this may be reflected by the stage of our learning journey. For early career practitioners, or those exploring the model in relation to new behavioural presentations, ACT protocols can be a useful resource to give guidance as to which process to focus on in any given session. Across a course of sessions, all processes will be touched upon, with the idea being that each contributes to a shift in psychological flexibility. More advanced practitioners rely less on a rigid structure for session content. Instead, in the course of a free-flowing conversation, it is likely that a skilled practitioner would move around the Hexaflex quite naturally. Even in a targeted piece of work, for example a values card sort, an experienced practitioner would bring in other processes, with the function of having a greater impact on the client’s psychological flexibility. In the example of a values card sort we might touch on the other processes as below.

Acceptance During the values discussion, it is likely we would enquire about whether the client is willing to accept the discomfort that arises when moving toward the things that matter to them.

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Defusion During the exercise the client might say, “I am not up to being the loving partner that I want to be”. We might respond with, “Thanks mind!”, as a way of evoking their reflection on the fusion they have with this thought.

Contact with the present moment We can set up a values card sort in a very present moment-based way, for example, by helping clients to notice any judgement they feel for selecting chosen values as they engage with the exercise. It can be helpful to introduce the exercise with something like, “If we were to do this exercise on a different day, you may select slightly different values. Let’s tune in to what calls out to you in this moment as we work through these cards”. We can also use moments where the client pauses to check in with how they are feeling and what they are noticing as they complete the exercise.

Self-as-context Sometimes values that people identify may feel strange or new to them, albeit that they represent qualities that they would like to bring more to their attention when choosing their actions. For example, ‘assertiveness’ might be a quality they would like to display more of, although they infrequently feel able to. We can invite them to consider that they contain the capacity for behaviours that align to the qualities of assertiveness, as well as being a person who can be passive. This can help them to see there are a range of behaviours in their repertoire and highlights the importance of choice.

Committed action We would conclude the exercise with some discussion about how the client will take steps in the direction of their identified value(s).

Chapter 34

How do I apply ACT with (insert diagnosis here)?

In most of the ACT trainings that we offer, we take a universalist approach to its application. Sometimes, however, organisations requesting training, or individuals that we supervise, ask about specific applications of ACT, and often these enquiries relate to the use of the model with people with specific physical or mental health diagnoses. This chapter will address the issue of how one might approach the application of a universal model to a specific presentation. It is important to remember that ACT is an approach to behaviour change founded on a specific philosophical and theoretical position. It concerns itself with the verbal behaviour of relating, and the impact of that relating on other behaviours. Where language processes and their functions are unhelpful to an individual or group, ACT practitioners intervene with procedures aimed at achieving adaptive change. Therefore, any ACT procedures or protocols that one might employ are, “instances of a general intervention strategy which is designed to be flexibly employed” (Hayes, n.d., b). This being the case, ACT cannot be defined as any one specific set of techniques or exercises, and it is perhaps better to describe any example of these as being an ‘ACT-consistent’ intervention rather than an ‘ACT’ intervention. Another consequence of this overall position is that there is no one true version of ACT for any given problem or presentation, although there are instances of ACT-consistent interventions being organised into specific protocols. In such cases, what tends to happen is that the psychological flexibility model and the general strategy of ACT is applied to a particular challenge, and a tailored protocol emerges. Such protocols include specific procedures designed to provide a best fit to the needs of the given population and the context in which the work

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is being delivered. Dependent on the context for their development, some such protocols are very detailed and specific, for example, the ‘ACT for Life’ group intervention for psychosis manual (Oliver et al., 2011) whilst others are designed to be more flexible, allowing for creativity and idiosyncratic variation, such as the ‘Togus Intensive Outpatient PTSD Program’ (Polk, 2008). The pairing of the flexibility of the ACT model with the creativity of the CBS research and practitioner community means that a wide range of specific ACT protocols are available, each tailored to a particular presentation. These include protocols for numerous diagnosable physical and mental health conditions, as well as non-clinical applications such as workplace stress (Flaxman et al., 2013) and athletic performance (White et al., 2021). Specific ACT protocols can be found on the ACBS website (Hayes, n.d., b) and there is a large and growing body of journal articles and books devoted to a wide variety of specific applications of ACT. With all that is now available, we would encourage readers with questions about using ACT in the context of particular diagnostic presentations to interrogate the available literature. Since the publication of the first book (Hayes et al., 1999), the growth in ACT literature is such that there is a very good chance that if you are asking the question about ACT and presentation X, someone else will have already asked it, researched it, and written about it. That answer is all very well if we are right about someone getting there before you. And what if we are wrong? Or, what if you don’t have the time or resources to search for articles and buy books? Luckily, all is not lost, and the flexibility of the model will come to the rescue if you trust it enough. It is useful to keep in mind the basic principle that even though each client that an ACT practitioner works with will present a unique context, the relevant processes of the psychological flexibility model are universal. If one retains a functional contextual approach to understanding behaviour, it should be possible to make sense of any presentation, whatever diagnostic label it might have attracted. By way of illustrating this, let us imagine that you are asked to help someone who is struggling with an apparent addiction to petty theft. This is not something that you have any prior experience of, and you find yourself asking, “How do I apply ACT for this?”. The client does not need the items they steal, and after the initial high of the theft fades, they tend to feel guilty and become besieged by self-­ critical thoughts. As these uncomfortable experiences build over the

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subsequent days, they find themselves in desperate need of something that will lift their mood, so they go out and steal again. You could respond to this referral in several ways, including by saying you do not have sufficient expertise in relation to stealing problems to help, by scheduling an urgent supervision session for help and advice, or by frantically searching for literature on ‘ACT for stealing’. Each of these responses would be valid, and we would argue that seeing the client’s situation through the lens of basic ACT principles might well give you all that you need. If we take out the specific behaviour of stealing from the above description, and think functionally about the situation, it starts to look very familiar. Here is a person experiencing some discomfort and engaging in a behaviour that has the short-term function of making the discomfort go away. We can formulate the behaviour as an away move, or in ACT terminology, as experiential avoidance. It is negatively reinforced by the reduction of discomfort, making it more likely to be repeated. The person does indeed repeat it and soon finds themself stuck in a maintaining cycle, where their behaviour becomes increasingly regulated by the desire to reduce discomfort. If you read back the last three sentences, does this look familiar to you? Does it remind you of any clients with whom you have worked? Maybe it describes a pattern that you have been in yourself at some point? It’s actually quite hard to think of a client we have worked with to whom those three sentences do not relate. In summary, we would argue that you do not need to be an expert in stealing, or in presentation X, Y, or Z, to help someone using ACT, as long as you keep the focus on the functions of behaviour and do not become too distracted by their form.

Chapter 35

How many sessions should a course of ACT intervention include?

This question suggests that there is some flexibility as to how many sessions of ACT intervention are offered, and of course, within some settings there is little choice. For example, insurance companies and healthcare providers often dictate the maximum number of sessions that can be offered, depending on the population that their service aims to support. In addition to identifying the target population, and the severity of a client’s struggle at the point that they make contact with a specific service, the decision-making is also influenced by several systemic factors. These include budget availability, waiting list times, contextual political focus, and guidance from advisory bodies like the National Institute for Health and Care Excellence (NICE) and the WHO. To that end, the context within which an ACT intervention is offered may limit the choice about the total number of sessions available. Given the pan-diagnostic nature of ACT, it has the potential to be safely and effectively applied to a range of behavioural presentations and other issues pertaining to psychological inflexibility. The reason that a client is seeking out ACT intervention will impact the number of sessions that may be required to help them make progress, with more entrenched difficulties taking longer to address. The empirical data are still growing in relation to the application of the model, for example, single-session work (Dochat et al., 2021) and group interventions (Ferreira et al., 2022), as well as more traditional 1:1 intervention. As more data are gathered, there will be more information available as to the research base for how many sessions are required for interventions to be effective. Given the many contextual factors that can impact the number of sessions available to the practitioner, it is more helpful to focus on DOI: 10.4324/9781003364993-39

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issues around planning ACT interventions, allowing for a more functional approach to the work. The modal number of sessions attended by clients is one (Brown & Jones, 2005; Hoyt & Talmon, 2014). Given that, it is helpful to make that first session as useful as possible. The work of Kirk Strosahl and Patricia Robinson on Focused ACT (FACT) helps in considering how first sessions are conducted, and can really help practitioners focus on how to maximise their efficiency. One example of this is their shortened version of an assessment process, whereby they limit questions to four main life domains: love/ connection, work, fun, and health (Strosahl & Robinson, 2015). Aside from specific risk questions that may be required, these questions gather enough information about an individual to begin a wholistic formulation of their life and identify areas impacted by psychological inflexibility. Whilst further assessment information will likely be gathered in other sessions, this more focussed approach leaves time for an intervention to be delivered within the first session, meaning that the client will also leave the session with a practical ACT technique for making change in their life. Should you work in a time-limited service model, protocolised manuals may help to provide a structured ACT intervention to fit the number of sessions available. The ABCS website is a very helpful resource for such manuals, providing guidance on where to start the intervention work and on how to move through each of the processes. ACT can also be utilised for much more complex psychological inflexibility work, such as targeting issues around childhood trauma, pervasive problems with self-acceptance, or difficult relational issues. These presenting issues will necessitate longer pieces of intervention work, such as might be more commonly seen in longer term service settings, like private practice. With longer-term work, it can be useful to provide your assessment, formulation, and interventions within a structure that you can purposefully recycle. One of these is the ACT Matrix, which is discussed at length in Chapter 24. This is a very useful tool due to its flexibility as an assessment, formulation, and intervention aid, and its ability to help translate some complex RFT ideas into something accessible for the client and the practitioner to share. Longer-term work needs to move flexibly around all of the components of the Hexaflex. This flexible approach is often referred to as ‘riding the ACT bicycle’, which describes the need to lean to both the right and left sides of the Hexaflex to keep the client moving forward. When riding a bike, if you lean to the right (or target the values and

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committed actions components in the ‘active’ column of the Hexaflex) you need to counterbalance yourself by then leaning to the left (by moving to the ‘open’ components, namely acceptance and defusion). The constant recycling of small movements to the left and right propel you forwards, much the same as leaning into values and committed action and then acceptance and defusion keep the client making progress toward greater psychological flexibility. Whatever the number of sessions available, it can be helpful to hold the ACT bicycle metaphor in mind, ensuring that the ‘aware’ components of self-as-context and present moment work are also incorporated.

Part 4

Developing skills as an ACT practitioner

As well as learning about the theory and practice of ACT, practitioners interested in developing their ACT practice over the longer-term often have questions about how best to structure their journey. This section of the book addresses frequently asked questions about developing as an ACT practitioner. It includes questions about the rationale for ACT having no formal route to certification, how best to structure the development of one’s practice, and what practitioners need to put in place to ensure that they can practise safely and effectively. This section also answers questions about ACT’s emphasis on experiential learning, whether that be through training courses, ongoing supervision, or the personal practice of ACT in practitioners’ own lives.

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Chapter 36

What do I need in place in order to practise ACT safely and effectively?

This is a difficult question to answer definitively given the wide variation of contexts that ACT practitioners work within, although it is included in this book because it is a question that we often get asked. The question relates in part to the stance currently taken by ACBS regarding there not being any formal process for accrediting as an ACT practitioner. Whilst this position is explored in greater detail in Chapter 39, suffice it to say here that the lack of clear rules and regulations around practicing ACT, and the somewhat ‘open source’ nature of the ACT community, often leads newcomers to feel unsure about the requirements for establishing oneself as someone practicing ACT. This chapter represents our thoughts on this issue, although we should be clear at the outset that what follows is unlikely to apply to absolutely everyone who offers ACT as part of their practice. As ever, it depends on the context. If you are in the business of offering ACT in any substantive way to members of the public, it is important that you have a solid grounding in the practice of psychological interventions. This might come from a professional training, as in the case of clinical psychologists or counsellors, or via some other co-ordinated programme of study, such as a coaching qualification. It is our view that reading about ACT or attending a few ACT workshops will not be sufficient to practise safely without some professional background training. This kind of prior training also usually brings with it some form of accountability, such as membership of a professional organisation or being a signatory to a specified code of conduct. Regarding creating a sense of safety, it is important that clients know that you are accountable to someone else and that they have somewhere to go if they are dissatisfied with the

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service they receive. In terms of our values as practitioners, issues like accountability and clear boundary setting feel like they are an important part of offering services to the public. As well as being connected to the organisation that represents your profession or working role, an ongoing connection to the ACT community in some form feels like a pre-requisite to offering a quality service. Given the relative youth of the model and the fast-paced nature of the ACT/RFT research programme, connecting with other ACT practitioners and researchers is a great way of keeping pace with developments. Whilst we are avid consumers of ACT books, research, training, and conferences, there is always something new that we miss, and conversations with colleagues are very helpful for catching up. ACBS itself is the mothership of all things CBS, ACT, and RFT, and it serves as the central point of contact for the community, with a well-resourced website, social media presence, and worldwide email groups for both public and professionals. It also organises an annual world conference, as well as many other regional conferences, local chapters, and special interest groups. Connection with other ACT practitioners is an important way to keep your practice true to the principles of the model. In particular, finding an ACT supervisor is of utmost importance. We have probably all had the experience of exposure to stimulating new ideas through reading or training, only for the impact of them to quickly evaporate after a few days back in the workplace. Regular supervision helps to keep us on track, and can function as quality control, a place to further learn and develop, somewhere to take difficult issues, as well as providing an opportunity for nurturance and support. We would urge you to find a supervisor who knows their stuff when it comes to ACT, someone who is open to using experiential methods of supervision with you, and someone who will strike a balance between being supportive and challenging you to push yourself. ACBS maintains a list of peer-reviewed ACT trainers (ACBS, n.d., d), many of whom offer supervision themselves or who will be well connected to help you find someone else with a good reputation for providing ACT supervision. Whilst all of the above rely on connecting with others, there are things you can do using your own resources to aid you in practicing ACT safely and effectively. It is important to keep learning, and fortunately there is a wealth of ACT literature available to help you develop your knowledge of the model and your application of it in practice. Journal articles, books, podcasts, blogs, and videos are

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widely available, and we recommend a regular diet of these as being helpful in keeping your ACT practice alive and in good shape. Your own private study can of course be supplemented by regular training, which is again widely available, particularly since the development of more online training as a consequence of the COVID-19 pandemic. Chapters 39–41 of this book are also relevant to this question, where some of the issues touched upon here are explored in greater detail.

Chapter 37

Should ACT practitioners practise ACT for themselves?

The word ‘should’ may feel a bit contentious here. We are not here to tell you what you ‘should’ or ‘should not’ do in your lives. However, there is a heartfelt question that we keep coming back to in our thinking in relation to this question, which is, “Why would you not practise ACT for yourselves?” ACT is a model of human functioning. Yes, it is most often utilised in our intervention work with clients at a point of distress or stuckness in their lives, and ACT is a model that provides us all with tools that help us consistently take steps in our own value-­ driven directions. To that end, there is no distinction between what we might find helpful and what our clients might find helpful, it may simply be different content that we apply the model to. Unlike physical surgery, which one would hope is only carried out for people who are sick or injured, ACT proposes skills, tools, and techniques for all of humankind to benefit from. Therefore, one does not need to be in a place of ‘illness’ or ‘dysfunction’ in order to also reap the rewards of increased psychological flexibility. Imagine that you want to improve your health, and you seek out the guidance and expertise of a personal trainer. They have a certificate on the wall to say that they have the required skills. However, this particular trainer generally adopts a very ‘do as I say’ approach to health, rather than modelling and living by what they preach. Let us assume that you give them the benefit of the doubt, and after a few initial sessions, you see some progress in your own health by following their instructions. Sometime into this personal journey, you start to hit a few blocks and your progress plateaus. Your trainer shouts louder at you to work harder, all whilst sitting on a chair and eating their favourite snacks. Your motivation fades, your frustrations build and you notice

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a growing reluctance to continue to follow the instructions. You subsequently leave their service and find a personal trainer with exactly the same qualifications, and they are someone who passionately lives by what they preach. They exercise, they are considered in their dietary intake, they are knowledgeable about supplements, and they are actively engaged in the sessions they run with you. You see results. Everything is great until then you hit some blocks and plateaux again. This time, your trainer is right next to you, talking you through each moment of the last few repetitions of your exercises. You know that they too have sweated hard and felt the burn of every muscle group in the service of their fitness, and this spurs you on, giving you the energy you need to finish the session. You might do this on repeat, trusting in your personal trainer because you know that they too have experienced what you are going through. There is no convincing to be done here. The questions are simply, “What kind of personal trainer would you rather work with?” and, “What kind of practitioner do you want to be?” The answers to those questions are yours and yours alone. From a learning perspective, the suggestion would be that ACT practitioners (and their clients) benefit from engaging experientially with the model as students. As outlined in Steven C. Hayes’s (n.d., c) fourstep plan for learning ACT (further discussed in Chapter 40) the first step for students is to experience the impact of psychological flexibility in their own lives. This explains the experiential nature of ACT training sessions, whereby attendees are invited to engage with their own personal content as a means of applying the theory being taught. This approach follows other CBT models in utilising self-exploration techniques in what is commonly known as ‘Self-Practice/Self-Reflection’ (SP/SR; Bennett-Levy et al., 2001). Research into this approach found that the experiential engagement of students increased the attunement between practitioner and client in the psychotherapeutic relationship (Gale & Schröder, 2014). When using ACT as a therapeutic model with a client, it is helpful to have prior experience of active engagement in the exercises yourself. We would never invite a client to do an exercise we had not done ourselves, the reason being that we want to know how it might feel to be in the ‘client’ seat when being invited to do any specific exercise. This is not because we are presumptuous enough to know how the exercise will make the client feel, since we cannot really know how an exercise will land for a client until they accept the invitation to try it out. However, it does help us to connect with our own emotional experiences through the lens of the exercise. This

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can help develop our sense of compassion and empathy as we will not only be offering the exercise to a client, we will be re-remembering what our own experiences of that exercise were for us too. Spendelow and Butler (2016) identified that increased compassion, empathy, and therapeutic presence were reported by therapists who had undertaken the SP/SR approach to learning the therapeutic model. Our number one piece of feedback from participants at our ACT training sessions is that they have gained as much from the training personally as they have professionally. So, it would seem that both empirical and anecdotal reports suggest the usefulness of this way of engaging with the work. The book ‘Experiencing ACT from the Inside Out: A Self-­ Practice/Self-Reflection Workbook for Therapists’ (Tirch et al., 2019) is a fantastic step-by-step guide to experiencing the model personally. It can be worked through alone, although working through it with other practitioners is the preferred route suggested by the authors. Whilst this will not be a substitute for any live training you are able to attend, engage in, and receive feedback from, it is a wonderful resource to enhance your experiential learning and practice of ACT. As a final point, this experiential approach has also been integrated into an experiential model of ACT supervision (Morris & Bilich-Eric, 2017). This model is further discussed in Chapter 41.

Chapter 38

Why is experiential learning better than didactic learning?

The word ‘better’ within the above question is possibly somewhat contentious and would benefit from clarification. ACT training often involves a significant amount of experiential learning, and students of ACT are encouraged to utilise experiential methods in their practice with clients. This is largely because doing so is consistent with the behavioural focus of the model, as this chapter will explore in more depth. Whether experiential learning is ‘better’ in the sense of leading to more desired outcomes is really an empirical question best answered by research. Whilst a thorough review of the evidence for the utility of experiential learning is beyond the scope of this book, there is a body of research to suggest that learning through doing has benefits over and above simply being didactically taught. A classic study by Hefferline et al. (1959) showed that when people are consciously aware of a rule, they follow it less consistently than when they are responding to actual environmental contingencies, even though these might be described by the rule. In the study, participants efficiently worked out how to turn off an aversive stimulus by making small thumb movements. On a second trial, when they were explicitly told that making these thumb movements was how they could turn off the stimulus, their performance deteriorated significantly. The authors concluded that experiential learning was more effective than didactic teaching, and similar results have been found in applied health and social care settings (e.g., Stiernborg et al., 1996; Weaver, 1998). When conducting a meta-analysis of ACT interventions, Levin et al. (2012) also found larger effect sizes for conditions including experiential methods, rather than conditions where participants were given the rationale for doing something without the actual practice. DOI: 10.4324/9781003364993- 43

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When addressing a problem that someone is seeking help for, giving advice or providing a set of instructions for a client to follow is easy for an ACT practitioner to do. Unfortunately, it is unlikely to be of great benefit to the client because a simple rule, such as might be contained in advice or instructions, will not be useful in all the circumstances that the client might face. It will not be flexible to variations in the client’s context, and thus is not a particularly functional way to proceed. Helping a client get better at tracking their experiences, including the consequences of their own behaviour, is much more likely to be useful to them long-term. This is what ACT practitioners are doing when they organise experiential exercises in session. They are inviting clients to contact the contingencies of their behaviour, rather than just talking about what those contingencies might be. For example, engaging a client in a tug-of-war exercise where the practitioner takes the role of their anxiety (see Hayes et al., 2011) involves the client physically experiencing the consequences of fighting against anxiety. Exercises such as this make the functions of the problem and any existing responses to it present in the session, if only in a metaphorical sense (Ramnero & Törneke, 2008). This is much more difficult to achieve by talking about the struggle, rather than actually engaging in the struggle. Talking about problems can be helpful up to a point, although it does not bring things alive in quite the same way. To draw a comparison, most people would agree that going on holiday is a much more vivid experience than listening to someone else talk about what the destination might be like if only you were to go there yourself. ACT puts a strong emphasis on experiential learning, both in practitioner training and in client sessions, because it is consistent with the principles of functional contextualism. It is about actively learning through experience about what works in the real world. Didactic teaching, without attention to direct experience, can lead to ‘pliance’, which is a state whereby an individual follows a verbal rule simply because it is the rule (Villatte et al., 2016b). Blind or rigid rule-­following is often problematic, and in many cases is the reason why clients have ended up seeking help in the first place (e.g., allowing the rule ‘showing emotions is weak’ to regulate behaviour, leading to feeling disconnected from others). If rule-following is identified as the problem, it is very unlikely to be able to provide the solution. Thus, it is largely unhelpful for ACT practitioners to encourage more rule-following, which tends to be what didactic teaching and advice-giving leads to. As suggested previously, the more useful thing that ACT practitioners can

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do is help clients notice their experience and learn to track it, alongside tracking the consequences of their behavioural responses. This is best achieved through experiential procedures, for example, noticing the consequences of what happens to you when you fight and struggle with anxiety in an effort to make it go away. Experiential learning helps a client figure out for themselves whether their responses work. When they learn to track successfully, any rules that might arise from their direct experience can continually be revisited, considered, and updated in line with changes in the context. Since rigid rule-following can interfere with tracking, procedures that reinforce the importance of noticing, describing, and responding to direct experience are generally much more useful. If you ever find yourself needing to help clients understand the value of experiential learning, we suggest that this too is achieved best through experiential means. Consider the following exchange. PR ACTITIONER:   (drops

pen on the floor) Oh no! I’ve dropped my pen! Whatever will I do? CLIENT:   Just pick it up PR ACTITIONER:   Huh? What do you mean? CLIENT:   It’s easy, just lean over to your right and pick it up with your hand. PR ACTITIONER:   How do I do that? CLIENT:   Are you serious? PR ACTITIONER:   Let’s suppose I am serious. Talk me through it. CLIENT:   Well, you’ll have to bend at the waist, reach down with your arm, and grab it. ME:   But that’s what I’ve got to do. I’m asking how I do that? CLIENT:   What? Well, I guess your brain tells your arm what to do. ME:   So how do I get it to do that? After all this, the pen is still on the ground, and it becomes obvious that verbal instructions are not really cutting it as an explanation of what needs to happen. Showing this difficult practitioner how to pick up the pen and inviting them to copy the movements might work better. When learning to ride a bike we learn much more from the physical feedback we get from balancing or falling off than we do from the verbal instructions we receive. In just the same way, whilst verbal explanations of ACT practices can help orient someone to what they need to attend to, ACT works best through doing.

Chapter 39

Why is there no formal qualification in ACT?

The ACT community lives by its underlying philosophy of science and the principles of the model, so the decision to not create a formal qualification in ACT is based on the values that the community holds as important. The main intention behind not introducing a formal qualification process was to avoid, or reduce, a hierarchical structure. One desire of the ACT community has been to continue the growth and development of science in the service of alleviating human suffering. The community includes researchers and practitioners from around the world and has seen collaboration and co-operation between different parties interested in how this science can benefit humanity. The introduction of a rigid hierarchical structure would inevitably restrict and slow down the development and dissemination of the model, due to the associated vetting of work that would be required. This approach has been modelled by the originators of ACT from the outset, as these words in their first textbook demonstrate: “We have little interest in our approach as a finished product or brand name, and we encourage the reader to apply and modify our work” (Hayes et al., 1999, p. ix). The founders of ACT continue to model openness and evoke interaction from other practitioners, scientists, and researchers by asking questions like, ‘What does the science tell us?’ and ‘Where can we go next?’. Contributions of any form are also highly reinforced in the community, for example, questions posted on the ‘ACT for Professionals’ listserv are generally answered with a willingness to support, develop conversation, and provide guidance. This humbling and open invitation to contribute to, and develop, the body of science for the benefit of the human population is an inspiring approach within the often more hostile environment of psychology. It can be contrasted

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with other professional circles where a more hierarchical approach is taken and contributions from the wider professional network are more limited. In line with the values of flattening the hierarchy, the ACBS website directly states, “There is no such thing as an officially certified ACT therapist” (Long, n.d.). This can feel like a double-edged sword in that whilst there are benefits to the community in adopting this approach, it is often comforting, especially for early career practitioners, to have a more certain development path, and a definitive end point. That said, ACBS is not void of tools in helping practitioners to develop their competency skills. There are tools shared in the community that help practitioners to reflect on their own skill sets and identify strengths, as well as areas of their practice that they would like to further develop. If you are a member of ACBS, there is free access to these resources via the website. One such example is the ACT Core Competency Self-Rating Form (Luoma, n.d., b), which is a helpful guide to understanding competencies attached to each of the Hexaflex processes. It enables practitioners to identify how they utilise or demonstrate different competencies in interventions sessions. It can also be helpful to take to supervision as the basis for reflection and discussion around how to develop additional competencies and advance a practitioner’s application of the model. As practitioners are unable to advertise themselves as being certified in ACT, it can raise the question of how to find a reliably qualified person to consult for ACT intervention work. Given the values of the organisation, one place to find people who sign up to the same values as ACBS is the membership. Observing how connected practitioners are to the ACT community, and whether they are working by the values upheld by the organisation can be a helpful marker of their commitment and dedication to the work. That is not to say that every person who uses ACT in their work must be a member of ACBS, and, a question might be raised regarding the knowledge and competence of someone who chooses to practise ACT whilst unconnected to the community within which it grows and develops so rapidly. Perhaps this could be a point of self-reflection. If you are currently not a participating member of the ACT community, what barriers get in the way for you? What would it mean to you to become someone who more actively contributes to developing the science and practice of ACT? Would doing so fit your values in terms of the kind of person and

Why is there no formal qualification in ACT?  133

practitioner you would like to be? And if so, what step could you take today to further embed yourself in the community? ACBS membership offers a number of ways to develop your knowledge and experience within a community of like-minded individuals. The values-based membership contribution affords you access to many shared resources including those related to research and clinical work, intervention protocols and assessment measures, articles in the Journal of Contextual Behavioural Science (JCBS), numerous special interest groups, and email forums related to a variety of topics. Should you wish to further develop your training skills and gain some form of recognition of your expertise, one option is to become an ACBS peer-reviewed ACT trainer. This system has a quality control function, ensuring that the dissemination of ACT is conducted by people who have undergone rigorous scrutiny from their peers. Peer-reviewed ACT trainers also take responsibility for contributing to the development of colleagues who also aspire to train others in ACT. As part of the peer review process, there are a set of values that one must agree to uphold. These include: • • • • • •

Competence Beneficence Nonmaleficence Responsibility Integrity Respect for People’s Rights and Dignity

In addition to agreeing to the above values, there is a requirement to hold a terminal degree in a relevant behavioural field of study, be known to be of good character, provide a number of pieces of work as evidence of competence as a practitioner and trainer and to provide evidence of knowledge of the basic science and philosophy of the model. Whilst the training route is not a mandatory process, it is the only version of anything ‘accredited’ within the organisation and affords trainers the ability to honour their training and experience.

Chapter 40

How can ACT practitioners shape their learning?

If you have read the previous chapter, you will be aware that at present there is no single formal route for ACT practitioners to follow should they wish to develop their expertise. From an accreditation or certification point of view, there is no such thing as an ACT practitioner, and yet there are many thousands of people practising ACT all around the world. It is interesting to consider what the learning journeys of these practitioners might have comprised, and highly likely that no two will have taken the exact same route. This is great from the point of view of practitioner flexibility, although does present some challenges for someone new to the practice of ACT. Many of the people we have trained have expressed concern about whether they are allowed to say that they practise ACT, or at what point in their learning journey it feels like a justifiable claim to make. More frequently, people simply ask what they should do next in terms of additional training, supervision, or other means of ensuring fidelity to the model. This chapter will attempt to address these issues. It is probably fair to state that the lack of any established consensus about exactly what the route to becoming a proficient ACT practitioner should comprise leads to a level of heterogeneity in the delivery of ACT that might not always be helpful. It has also led to the proliferation of one- or two-day ACT workshops at the same time as to a relative scarcity of long-form ACT training programmes. Courses that include assessments of competence are rarer still. Whilst there has been some good work done around developing measures of practitioner competence (e.g., O’Neill et al., 2019), progress toward the meaningful integration of such measures within systematic training

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programmes has been limited. Our hope is that as ACT becomes more established within the mainstream of psychological interventions, alongside the ever-growing evidence base and the inevitable inclusion of ACT in more national guidelines, more rigorous training programmes will emerge. Until such time as this happens, practitioners are left to make their own choices about how to achieve competence in their practice of ACT. Having attended and delivered thousands of hours of ACT training and developed long-form ACT training programmes ourselves (e.g., Bennett & Johnson, 2021) we would like to use this chapter to suggest on outline for the structure and content of a programme of study that aspiring practitioners could choose to follow. In describing this, we will make use of Steven C. Hayes’s (n.d., c) four-point plan for learning ACT. We should state at the outset that what follows ought not to be read as a rigid prescription, and rather as a suggested method for structuring an approach to learning ACT.

Experience the impact of flexibility processes in your own life As we explained in Chapter 38, when it comes to ACT there is no substitute for experiential learning. The best place to start is to learn something about the model from the inside out. Methods for achieving this could include attending an experiential introductory training or working through an ACT self-help book. Reading a book is one thing, and actually making behaviour change whilst tracking the processes and outcomes described by ACT’s psychological flexibility model is something else entirely. Thus, we would recommend experiential trainings, self-help workbooks, and self-help books in that order. In terms of books with a guided experiential component, Hayes (2005), Oliver et al. (2015), and Tirch et al. (2019) are excellent options.

Understand the theoretical and philosophical foundations of the ACT model Whilst we fully appreciate that learning about theory and philosophy are not what excites everybody, we are of the view that these topics are fundamental to understanding the stance that ACT takes on human

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suffering, and why it looks the way it does in the consulting room. Whilst it is not a pre-requisite to be able to explain every nuance of RFT or functional contextualism, a grasp of the basics feels important. Taking things back a stage, RFT and functional contextualism probably will not make a huge amount of sense to someone who does not have a decent grounding in the fundamental concepts of behaviourism, so it is wise to start there. Written from a functional contextualist standpoint, a helpful text to use as a starting point is Ramnerö and Törneke’s (2008) practical overview of how respondent conditioning, operant conditioning, stimulus control, and relational framing are relevant to the day-to-day work of behaviour change practitioners.

Learn to identify the flexibility processes and “read” them in a person’s behaviour There are numerous texts available for practitioners wishing to define and understand the components of ACT’s psychological flexibility model. Recommended ‘beginning ACT’ books include Hayes et al. (1999), Luoma et al. (2007), Harris (2019), and Bennett and Oliver (2019). These and many more ACT learning resources are listed on Jason Luoma’s (n.d., a) comprehensive list, which, at the time of writing, continues to benefit from regular updates. However, reading books or watching videos will only get you so far, and it is important at this stage of your journey to attend more experiential training, with a focus on practicing assessment and formulation skills in ‘real-play’ situations, preferably including live feedback. Peer consultation groups with a practice element, such as the Portland supervision model (Thompson et al., 2015) are another good way of gaining this kind of experience.

Gain the practical skills to use ACT methods, as well as methods you already know, to make the processes move It goes without saying that the regular practice of ACT is crucial to development at this stage of the learning journey. This should be done with the guidance of an ACT-trained supervisor with sufficient experience of the model to support and guide the practitioner. Ongoing supervision, experiential training focussed on practicing specific ACT-consistent techniques and interventions, reading about the latest developments, and connection to a community of ACT practitioners

How can ACT practitioners shape their learning?  137

are all important aspects of one’s development. We would recommend that only at this stage should you seek out presentation-specific ACT trainings (i.e., ‘ACT for X’), since it is important to understand and competently practice the universal features of the model, before learning about how it might be adapted to specific populations.

Chapter 41

Do I need ongoing ACT supervision?

Supervision is often stipulated as a mandatory responsibility of being a practitioner, whatever one’s professional background. It can be broadly defined as a process of professional development that provides space for reflection as well as the continuing development of knowledge, skills, and competence. Given the broad nature of this definition, there is little direction as to what needs to take place during the process of supervision, how often someone ought to engage with this process, for how long, or with whom. It is possible to differentiate between types of supervision, for example, the content of line management supervision might focus on the more practical aspects of a job role, such as caseload, annual leave, or sickness. In contrast, this chapter pertains to ACT-specific supervision, which is more focused on the above description of reflecting on and developing ACT knowledge and skills. Across the many professions practicing around the world that utilise the ACT model, there will be differing professional guidelines, or perhaps none at all, about supervision requirements. Whether or not your particular profession provides specific guidance on supervision, it can be helpful to consider the function of the supervisory process, rather than whether or not engaging in it is it a rule-governed behaviour dictated by an external agency. Our own perspective on this is that we would strongly encourage ACT practitioners to think about the helpful functions of engaging with ACT-consistent supervision, and seek regular supervision if it is at all practicable to do so. The difficulties, traps, pitfalls, and missteps that we might encounter as we embed and practice our ACT knowledge and skills are plentiful and varied. Even from within a ‘comfort zone’ where we feel very skilled in our work, supervision can still be helpful to ensure that we DOI: 10.4324/9781003364993- 46

Do I need ongoing ACT supervision?  139

are not becoming entrenched in specific well-practiced exercises at the cost of forgetting about the function of why we may apply them. Supervision can also help us to constantly expand and review the work we are offering within our practice settings. Despite supervision having been an important part of behaviour change work for many decades, it lacks the investment of research that intervention work has afforded (Milne, 2009). The introduction of a more experiential and self-exploratory form of training within the CBT arena in the 1990s (Bennett-Levy et al., 2001) opened up the idea of integrating personal experience into the theoretical learning of a model. Advancing this work into the supervision arena, Morris and Bilich-Eric (2017) developed a model of supervision that included more experiential factors and is firmly grounded in the underlying philosophy of contextual behavioural science. Whilst it is a very ACT-congruent model because of its underlying principles, the authors intended it to be applied to support the integration of theory and experiential application across any number of psychological approaches. Each of the features of their SHAPE model is included in the framework in order to increase the psychological flexibility of the practitioner and their use of experiential learning. The five features of the model are as follows.

Supervision values Values clarification as part of the initial supervision contracting phase can increase the likelihood of value-driven behaviours occurring during sessions where either party connect with uncomfortable experiences. Perhaps the supervisor would like to share a concern about the supervisee’s work, or the supervisee is connected with a feeling a shame and criticism. Having a basis of qualities that both have agreed to work in line with enables more open and honest conversations about the client work, and the learning and development of the supervisee.

Holding stories lightly This feature of the model brings light to the language used within supervision and draws on the CBS idea that what is ‘helpful’ is more important than what is ‘true’. That is not to say that the stories told about the client would be untruthful, rather, the focus here is on whether the

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language used to describe the client is the most helpful way of telling their story. As with the aim of any supervision model, the aim is to increase the helpfulness of the supervisee’s learning, so that their work has a greater impact upon the client’s behaviour change journey.

Analysis of function As is the case with client sessions, the use of functional analysis is key to the practice of supervision. The authors outline three main areas to focus upon: • • •

The client’s presenting problems and life circumstances The therapeutic relationship (i.e. the client and supervisee in session) The supervisory relationship

Functional analysis will include the broader context and support an understanding of the functions of behaviours that show up in each of the above areas.

Perspective-taking Utilising perspective-taking skills in supervision can increase the empathy and compassion of the supervisee for the client’s content, context, and presenting situation. This can be especially important when there is a disconnect from emotion, or where the supervisee is fused with judgements about the client’s situation. Perspective-taking can be enhanced by considering various perspectives on the client (i.e., considering other people’s experiences of the client), and other temporal or spatial perspectives in relation to the client’s situation.

Experiential methods This feature focuses on the promotion of learning by experience. This may be initiated by the supervisor via an invitation for the supervisee to engage in role-plays, or by reviewing live recordings of the supervisee’s therapy sessions. In-session experiential techniques used by the supervisor may also include the use of imagery, perspective-taking, or metaphors to encourage the supervisee to connect with the emotional

Do I need ongoing ACT supervision?  141

content of the client’s situation and evoke workable strategies for the supervisee to utilise in practice. Whilst the SHAPE model can be used by practitioners using any psychological model, it is certainly a helpful addition to supervision sessions that are aiming to have a more ACT-congruent focus to them.

Part 5

Critical questions about ACT

In order to provide a balance in the text, which is largely oriented toward advocating for the utility of ACT as an empirically supported approach to behaviour change, the book concludes by addressing some critical questions that have been raised about the model. These include an analysis of the quality of the evidence base that ACT has amassed, and a discussion about whether ACT offers anything genuinely new or adds value over the more traditional forms of CBT. Concerns about how ACT can be integrated within cultures where the medical model dominates, and where clients might expect to be ‘fixed’ are also explored. The issue of how the moral relativist stance adopted by ACT and functional contextualism might impact how values work is conducted is addressed, as are technical questions about how to proceed when ACT interventions do not work in the way that they are intended to.

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Chapter 42

How strong is the evidence for ACT?

The past 20 years have seen significant growth in all areas of research related to ACT, and the speed of growth is accelerating year on year. Of particular interest to the question posed by this chapter is the growth of outcome research, which is concerned with the effectiveness of ACT as an intervention. To use RCTs of outcomes as a metric, by the turn of the century there had been four studies, by 2010 there were 44 studies, and by 2020 there were 731. At the time of writing in late 2022 there are 949 (Hayes, 2022). However, whilst this growth is clearly encouraging from the point of view of research interest in ACT and the development of a wide-ranging evidence base, quantity does not equal quality, and one needs to interrogate the literature further before any conclusions can be drawn about the strength of the evidence. There is an advantage to having a large number of trials in that it makes it possible for other researchers to conduct systematic reviews or meta-analyses of the combined data produced by the individual studies. This kind of analysis has allowed for a more robust exploration of the ACT outcome literature, wherein conceptual, methodological, and statistical issues such as design, measurement, attrition, effect sizes, and bias have received greater scrutiny. To date there have been well over 300 such reviews, and more recently, meta-meta-­ analyses (meta-analyses of meta-analyses) have started to appear (e.g., Gloster et al., 2020; Cheng et al., 2022). The first comment to make about quality is that ACT research suffers from many of the same problems that plague almost all areas of research into the effectiveness of psychological interventions. Chief amongst these is the reliance on self-report measures as a proxy of the dependent variable in a study. For example, most research trials that seek to measure the impact of an ACT intervention on psychological DOI: 10.4324/9781003364993- 48

How strong is the evidence for ACT?  145

flexibility are not measuring psychological flexibility itself, but participants’ self-report of their psychological flexibility, which is not quite the same thing. Whilst there have been ACT outcome studies that have measured more objective variables (e.g., rates of re-­hospitalisation; Bach & Hayes, 2002, or violent re-offending; Zarling & Russell, 2022) such studies are relatively rare. Another common problem in outcome research is the extent to which one can be sure that the change in the dependent variable (e.g., psychological flexibility) is due to the independent variable (e.g., the ACT intervention). Whilst hundreds of ACT RCTs have demonstrated a correlation between receiving ACT intervention and an increase in scores on measures of psychological flexibility, proving that the intervention is solely responsible for the change is difficult. Another issue that has received widespread attention in the discussion of the problems with the quality of psychological research concerns the so-called ‘replication crisis’. This refers to the difficulties associated with being unable to reproduce the same results when a given study is repeated (e.g., Open Science Collaboration, 2015). Another related problem, which some ACT research has been criticised for (see Cihon et al., 2021) is that published articles sometimes do not contain sufficient detail in them to enable the studies they are reporting on to be replicated. Bias in psychology outcome studies is also a significant issue, and one that also impacts the extant outcome data for ACT. Most schools of thought in psychotherapy go through a similar developmental trajectory. Initial research is almost always conducted by the originators of a model, and as well as often being smaller and less robust in design, any such studies are likely to suffer from researcher bias. Subsequent studies are often conducted by those connected to the originators (e.g., other researchers in the ACT community who also have a vested interest), and it takes time for larger, well-designed studies undertaken by independent researchers to emerge. It is almost always the case that when these later studies are eventually published, they report smaller effect sizes than the early studies did. Since ACT is still a relatively young approach it has not fully progressed to this later stage of development. As well as concerns that are generic to most studies of psychological interventions, attention has been given to issues that are specific to ACT research. Two of these are clearly summarised by Mcloughlin and Roche (2022). Firstly, they argue that the link between RFT and

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ACT has not been empirically established to the degree that many ACT practitioners imply that it has. Whilst the conceptual links are clear, it is suggested that the claim that ACT interventions benefit from the findings of laboratory based RFT research has been overstated, and that any conception of ACT as ‘clinical RFT’ involves getting ahead of the data. Secondly, the authors express concern over the measurement of psychological flexibility. Whilst various psychometric tools are available to measure ACT’s core concept, most ACT research has used iterations of the Acceptance and Action Questionnaire (the AAQ; Hayes et al., 2004, or the AAQ-II; Bond et al., 2011). They report several studies that have indicated that neither version of the AAQ properly represents the supposed six-factor structure of the psychological flexibility model, and that the questionnaire might be better described as measuring other concepts, such as neuroticism. The quality of the data on the effectiveness of ACT is impacted by all of the above issues, as well as issues related to the dominance of WEIRD authors and participants, as discussed in Chapter 22. However, despite this, the data set does contain studies of sufficient rigour for ACT methods that have been validated by leading scientific institutions, such as the WHO and other organisations that have recommended the use of ACT at a national level, as detailed in Chapter 2 (Dixon & Hayes, 2022). From a diversity perspective, it should be noted that most scientific praise and criticism that ACT research has received also comes from WEIRD nations. Context matters, and in giving primacy to rigorous scientific method as the means to judge the strength of the ACT evidence base, we should remember that science is only one of many perspectives on what is useful. In attempting to retain a functional contextualist perspective, it is important to remember that anything that adds to the overall body of knowledge about ACT has some utility, whether that is to advance the scientific rigour of the evidence base, to provide information about the acceptability of ACT among diverse populations, or something else entirely.

Chapter 43

Traditional CBT has a well-established evidence base. Why does the world need ACT?

Human history is full of examples of different groups with similar aims spending significant time and energy competing with each other when their aims might have been better served by co-operating. Unfortunately, the fields of psychology and psychotherapy are not exempt from this phenomenon. Devotees of newer models will often loudly proclaim how they offer advancements over older ones, whilst followers of more traditional ideas will roll their eyes at the claim that anything original or better is genuinely on offer. Whilst not the case in all corners of the field, these kinds of exchanges have certainly taken place between advocates of traditional forms of CBT, and so-called ‘third wave’ models, such as ACT. It is certainly true that scientific progress necessarily involves healthy debate and frank exchanges of views; however, denigrating other approaches is rarely useful to this debate. In our view, this kind of adversarial discourse is largely unhelpful to the client groups that behaviour change practitioners serve, and to use a metaphor, if we have any spare bricks, maybe it is better to use them to build bridges rather than walls. Second wave CBT does indeed have a very established evidence base, particularly in respect of outcome data from research into the effectiveness of Beck’s CT, as used with people who have attracted various mental health diagnoses. Meta-analytic reviews have described the strength of the outcome data for traditional CBT (e.g., Hofmann et al., 2012), although further research is needed to clearly identify its specific cognitive and behavioural processes of change, beyond generic therapeutic factors such as the practitioner-client alliance and the use of between-session assignments (Kazantzis et al., 2018). However, as successful as it has been, it cannot be considered as an endpoint in

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the evolution of psychological interventions, particularly when rates of recovery amongst individuals receiving CBT remain as low as 50% (NHS Digital, 2022). As technology always moves forward, the field of psychotherapy constantly attempts to improve outcomes for clients through its endeavours in research and practice. In some ways, ACT has emerged as a viable alternative to the methods of traditional CBT precisely because it addresses some of its shortcomings. It offers a different option in the face of some of the common criticisms of CT, notably the reliance on a medicalised, disorder-­specific model of human distress, and the apparently limited utility of cognitive restructuring (e.g., Jacobson et al., 1996; Longmore & Worrell, 2007), which is arguably its main intervention strategy. ACT offers a model focussed on human function rather than assuming a starting point of illness or dysfunction. It also places much greater emphasis on value-driven behaviour change, thus including a ‘positive psychology’ emphasis lacking in diagnosis-driven approaches. In short, it offers some different things. As much as we are advocates for ACT, we do not think that advocating for ACT needs be done at the expense of traditional CBT. Indeed, that would be an intellectually dishonest position, given that rigorous comparisons of ACT and traditional CBT tend to point to them being equally effective (e.g., Arch et al., 2012a; Öst, 2014; A-Tjak et al., 2015, 2021; Gloster et al., 2020). Rather, we would like to advocate for ACT as being an effective alternative to traditional CBT, which, for a number of reasons, behaviour change practitioners might want to consider using in certain circumstances. All CBTs, ACT included, share a basic formulation, in that they position cognition as a mediating variable between a stimulus and an emotional response. Something happens, our minds interpret that something, and that interpretation influences how we feel and behave. Where ACT diverts from traditional CBT concerns how best to address cognitions if they result in psychological distress or unhelpful behavioural responses. Traditional forms of CBT would advocate working to change the content of thoughts in such circumstances, whereas ACT would promote the use of procedures aimed at changing the relationship that a person has with their content. The differences in these approaches can be illustrated with reference to Williams and Garland’s (2002) ‘five areas’ model, which is a standard formulation model used within traditional CBT (see Figure 43.1). With regard to cognition, traditional CBT targets the ‘thoughts’ box by explicitly

Why does the world need ACT?  149 Traditional CBT target Situation/context ACT targets Thoughts

Emotions

Physical sensations

Behaviours

Figure 43.1  T  he five areas model (adapted from Williams & Garland, 2022)

working toward cognitive change, whereas ACT offers procedures for targeting the arrows, thereby weakening the regulation that cognitions have over the other aspects of a person’s experience (Gillanders, 2013b). Both traditional CBT and ACT offer interventions for directly targeting behaviour change, albeit sometimes with differing rationales. In our experience of direct intervention work, different clients vary in their response to these contrasting ideas about how to deal with unhelpful thoughts. Some people like the idea of learning to think differently, whereas others do not respond well to attempts to challenge thoughts, finding the process invalidating, and leading to potential division between practitioner and client. Therefore, it feels important to consider the context of your work in deciding which method provides the best fit. An approach that resonates with the client is likely to be more effective. The same is probably true for the practitioner, in that if ACT resonates with them personally, they will probably be a more effective practitioner using ACT than they would if they attempted to use a different approach. ACT provides a different route to achieving similar ends. To use a decorating metaphor, a paintbrush and a roller both provide useful methods for painting walls, although the choice of either one will be

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determined partly by personal preference and partly by the specifics of the situation. Maybe it is useful to have both in the box of decorating tools. If traditional CBT does not provide a good fit in any given situation, whether due to practitioner or client preference, the nature of the presenting issues, or the broader context for the work, ACT is an empirically validated alternative, and vice versa. Practitioners interested in offering evidence-based interventions can serve their clients by learning techniques from each wave of CBT (Hayes & Hofmann, 2017). In the service of being flexible in how best to meet the needs of clients, we would argue that the development of ACT has given practitioners a greater number of options.

Chapter 44

Isn’t ACT just another case of ‘the emperor’s new clothes’?

To agree with this assertion, which we have heard people make, would be to take the position that ACT has offered nothing new or valuable to the worlds of psychology, psychotherapy, and behaviour change. It would be to suggest that the people that have benefitted from the work of ACT practitioners could just as easily have benefitted from older technologies and that ACT is simply a re-hash of pre-existing ideas. We do not agree with this assertion, and this chapter will outline why we think that it is not a reasonable stance to take. In the service of being clear from the outset, whilst we would argue against the idea that ACT has brought nothing new to the science of behaviour change, neither would we argue that it is wholly original. Psychology, like other scientific endeavours, is an iterative process, and any new developments inevitably stand on the shoulders of older ideas. Other authors have justifiably pointed out that some of the key features of ACT can be traced back to other models, both inside and outside of the cognitive behavioural tradition. For example, it is impossible to imagine ACT looking the way it does without the previous work of Titchener (1916), Skinner (1953), or Rogers (1961), all of whom were referenced in the first ACT textbook (Hayes et al., 1999). Indeed, the following quote from that same text acknowledges this very point: ACT is a collection, with components borrowed from many traditions…if there is anything novel about ACT, it is in the specific way it combines philosophy, theory, and practice. (Hayes et al., 1999, p. ix)

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Aside from those referenced above, one can see significant echoes of Ellis’s (1962) REBT in ACT’s emphasis on the importance of having a philosophical basis to its model of change, as well as stressing the centrality of acceptance and committed action. There are also notable similarities with Morita therapy (1928/1998)1 around the focus on encouraging clients to take meaningful action even in the presence of internal discomfort. There are those who have been vocal in their critique of ACT literature as a consequence of such similarities, as well as the perceived failure of certain ACT authors to give credit where it is due. For example, Velten (2007) suggested that ACT could be seen as having re-used ideas from modalities as diverse as general semantics, person-centred counselling, fixed-role therapy, logotherapy, values clarification, multimodal therapy, Morita therapy, CT, and REBT without its originators properly acknowledging those influences. Whether those that have been influential in the development and dissemination of ACT have been unwittingly influenced by other theories or have consciously replicated elements of them is not for us to judge. In any case, it seems clear that ACT theory and practice has developed in part out of what has gone before it, although a look at the history of psychological science would suggest that this is not unusual or even undesirable. The metaphor of waves, as used in describing the history of CBT, is a useful one. Each new wave is carried to the shore by the efforts of the previous one, and when it lands, it makes a mark that changes the shore forever (Hayes & Hofmann, 2017). We would support the view that ACT, alongside other third wave approaches, has brought sufficient originality and innovation, such that the field of behaviour change has changed markedly in a way that cannot be reversed. At its most basic, this change can be seen in the way that CBT is practised and written about. Staple ACT interventions that were once seen as somewhat ‘left-field’ by the behaviour change community as a whole (e.g., mindfulness and acceptance-based procedures, cognitive defusion exercises, or focussing on a client’s values) have been assimilated into the mainstream. Outside of what could be defined as ACT, such procedures now form part of standard evidence-based interventions for a range of presentations (e.g., Barlow et al.’s unified protocol, 2017). It is now common to see practitioners adding components of the psychological flexibility model to their theoretical discourse and practical work in fields as diverse as psychotherapy (e.g., Craske et al., 2014; Cotterell, 2019), applied behaviour analysis (Tarbox et al., 2020),

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and organisational psychology (Flaxman et al., 2013). If ACT was a simple re-hash of old ideas, its concepts would not have been able to exert such an influence upon these areas of practice. The central importance of such procedures seems unlikely to have been highlighted without the novel contribution of ACT. However, arguably the bigger influence of ACT has been felt in the greater attention to the psychological processes that those procedures operate upon. With its pan-diagnostic approach, ACT has spearheaded an evolution away from symptom-based protocols toward process-based procedures, and this change seems to be rapidly gaining pace. ACT has been a leading contributor to the conversation about which cognitive and behavioural processes are central to psychopathology, and therefore what the most effective interventions should comprise. The research evidence from moderation (e.g., Wolitzky-Taylor et al., 2012) and mediation (e.g., Hayes et al., 2022; Arch et al., 2012b) studies is increasingly pointing to the important role of psychological flexibility and its component facets as being central processes in understanding health and wellbeing. None of this would have happened without the ACT conceptualisation of human function, a research programme that has attempted to link the basic science of RFT with what is observed in the consulting room, and the application of a pan-­diagnostic intervention model supported by a significant body of outcome literature. As a consequence of the third wave, with ACT and RFT at its forefront, the changed shore of cognitive and behavioural intervention science has a sharper focus on the processes, moderators, and mediators of change, as well as the development of procedures that align with them. It remains to be seen how this shift toward a process focus, alongside the slowly waning influence of the psychiatric model, will impact behaviour change practices in the coming years. However, at the present time, the term ‘process-based therapy’ (e.g., Hofmann et al., 2021) is starting to be spoken about more and more, perhaps suggesting that a fourth wave might be about to hit the shore.

Note 1 The ground-breaking behavioural work with anxiety of Shoma Morita, whilst written in Japan in the 1920s, was not translated into English until the 1990s, hence the inclusion of two different publication dates.

Chapter 45

ACT uses a lot of eye-catching tools and techniques. Isn’t this all just a bag of tricks?

ACT certainly uses a vast array of creative experiential activities, which are designed with the function of maximising the client’s learning. The intention is that this experiential learning leads to effective behaviour change for the individual, and a life that feels more rich, vital, and meaningful to them. Given there are no formal training routes that categorically certify anyone as ‘an ACT practitioner’, the disparate nature of some people’s training journeys does mean that their practice might resemble a bag of tricks picked up from here, there, and everywhere. YouTube videos and half-read book chapters do not an ACT practitioner make! The generosity of the ACT community means that a lot of the useful tools and resources are freely accessible via Facebook, email lists, YouTube, and Twitter. Additionally, the values-driven nature of the community means that ACBS membership and associated training events are often available at affordable rates. However, learning bits of ACT from each of these is unlikely to help you learn and embed the underlying science and philosophy of the model. The skill of being an ACT practitioner comes from the complex theoretical knowledge behind applying the ‘simple technique’. It concerns the when and why around using ACT procedures, and not just the how. Consider something like the experiential metaphor, ‘tug-of war’, (Hayes et al., 1999) as an example. This is a commonly used exercise that involves the client getting out of their chair and interacting with the experience of being hooked by their thoughts. In summary, the practitioner embodies the client’s distress (e.g., their anxiety, or their low mood), and engages them in a ‘tug-of-war’ with their difficult content. Each time the client struggles with their content by pulling on the rope, the practitioner will pull back, which ensures a to-ing and DOI: 10.4324/9781003364993-51

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fro-ing of the struggle. The harder the client pulls to try and win, the harder the practitioner pulls back. Through the exercise, it is possible to see the futility of this struggle and engage the client in a discussion about trying other useful strategies. One such strategy would be to drop the rope. If the client opts for this, the practitioner can soon start to gently coax the client into picking it back up again, returning to the back and forth of the struggle. Exercises such as this will likely make for a memorable session, which is great if you utilise the exercise functionally, and it leaves the client with some new and effective learning. For example, the key points in this exercise could be: 1 To help the client see (and experience) the futility of struggle 2 To help the client see how easily they become engaged in their struggle again, without directly meaning to 3 To learn that there are alternative strategies for responding to difficult thoughts and feelings 4 To work with the client around identifying what any alternative strategies would look like and ways of implementing them On the surface of it, when observing a skilled practitioner execute this exercise, it could be understood as a way of encouraging clients to just, ‘Drop the rope!’, as if the exercise has a clear and pre-determined end point. However, clients are not predictable. They are unlikely to have read our textbooks, and they may not experience the exercise in any one particular way. Maybe they will resist the idea that acceptance is a useful strategy, and this exercise alone will not convince them otherwise. Or perhaps, for them, how they might ‘drop the rope’ in their own life requires some considered thought. They may have questions, or a different perspective that they want to share and explore. Perhaps this exercise would be wonderfully complimented by following up with a values clarification procedure, to help people consider what they could pursue more of if they were to give up some of their struggle. If you have only scripted ACT techniques in your toolkit as a bag of tricks, you will fall flat on your face in a session when someone does not respond as the textbook said they would, or as you observed when demonstrated to you in some training that you attended. Utilising interventions in a scattergun fashion, without being able to theoretically tie them together, may have some effectiveness, for some clients. However, using them in this way misses the main point of ACT, in

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that it offers a framework for a functional and contextual analysis of a client’s situation. ACT is not equivalent to any of its procedures, and using any of the procedures associated with ACT without using them in the context of a functional analysis is not really ACT. Throwing techniques at clients without a clear process-procedure-outcome structure to the work is unlikely to be particularly effective. We want clients to be consistently moving forward, making workable behavioural change, as assessed through a functional contextual lens. If ACT interventions are treated like a bag of tricks the strength of the model will be lost, and moments where your work could have evoked clear learning points will represent missed opportunities, keeping clients stuck in unhelpful patterns of behaviour for longer. One of our concerns around ACT not currently having any structured path to practitioner certification is that anyone can watch some Instagram videos, learn some exercises, and then state that they use the ACT model, in a way that does not feel legitimate. This kind of practice has the potential to damage the reputation of ACT and undermine public confidence in it. We would invite you to consider your own values when advertising yourself as ‘an ACT practitioner’, and suggest that you only do that when doing so genuinely is a fair reflection of your knowledge and skill in the use of the model. The wider ACT community offers a number of ways to support you in your ACT journey, both personally, and in your work with clients. The ACBS website is a great place to start for resources, information, connecting with others, seeking out high quality training opportunities, finding a supervisor, and developing your own input to the ever-growing field of CBS.

Chapter 46

How does ACT fit within a culture where the medical model dominates?

This question arises from what, at face value, seems to be a clear and irreconcilable disagreement between the fields of medicine and ACT on the view that is taken of psychological distress. The medical model, the practice of psychiatry, and some psychological models tend to see distress as symptomatic of some form of disorder or mental illness. Diagnostic classification systems like DSM-5 (American Psychiatric Association, 2022) or ICD-11 (WHO, 2019) cluster such symptoms into separate diagnostic categories that are used to guide interventions, usually in the clear direction of symptom reduction. The view that ACT takes of psychological distress is radically different in that what psychiatry might see as a symptom, ACT would see as behaviour, occurring as a consequence of an individual’s present and historical context. Whilst ACT and psychiatry might agree on this behaviour being problematic, particularly if it seems rigid and repetitive, ACT will see it as being functional within its context, rather than as indicative of some underlying disease process. Of course, part of any individual’s context is the language that is used to describe any such behaviour, including labelling an experience of painful emotions as a ‘symptom’. If it is treated as if it is bad, and part of a disease, this will transform the way that the experience functions, and, more often than not, it seems that relating to painful emotions as symptoms exerts a repertoire-narrowing effect. For example, if the internal experience of anxiety is related to as if it is indicative of illness, it seems likely that one might work hard at trying to get rid of it, thereby fuelling patterns of experiential avoidance. Medical language such as ‘negative thoughts’, ‘anti-depressant’, and ‘anti-psychotic’ frequently reinforces the idea that reduction,

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avoidance, or elimination of these so-called symptoms is the only way to go. Clearly, ACT adopts a different stance, in that its goal is to promote behavioural responses to distressing thoughts and emotions that are variable, flexible, and value driven. The large and growing evidence base that ACT has amassed suggests that building such patterns of responses benefits longer-term functioning more than experientially avoidant behaviour does on its own. ACT encourages clients to stand back from the diagnostic labelling or the symptom reduction advice, and focus on what works, whether that is making a move toward values or away from pain, with both being equally valid responses. An initial analysis of the above could easily lead to the conclusion that there is too much divergence here, and that ACT is not a good fit for any culture where the medical model dominates. However, our view is that there is room for these approaches to operate alongside each other, without the need for one to ‘win’ or preclude the other. It is highly likely that ACT practitioners, wherever they work, will find themselves having to find ways to address the question of how this might be achieved. The medical model is so embedded within many cultures (especially so in WEIRD nations) that the idea of getting rid of unwanted experiences will be at the forefront of lots of clients’ minds when they first engage with ACT. Wanting to feel happy or not wanting to have anxious thoughts are common goals expressed by clients, in part because they will likely have learning histories with healthcare systems where both client and practitioner are working toward a ‘cure’ for the ‘symptoms’. We would argue that it is rarely helpful to respond to a client holding this expectation by denigrating the medical model. Rather, it seems preferable to find a way of positioning the ACT stance as an additional or alternative perspective that might be worth considering if symptom reduction approaches have proved unproductive. Equally, it is probably not very helpful to come straight out and say that ACT will not help to reduce unwanted experiences. It is usually more beneficial to describe ACT as an approach that will focus on helping the client develop new skills to manage their thoughts and feelings more effectively, thereby reducing their impact and influence. It is important to remember that ACT is not against people experiencing fewer unwanted experiences, and there is nothing intrinsically problematic about someone feeling sad or anxious less often. It can be helpful to communicate this to clients. At the same time, it is also useful to communicate that this reduction will probably not come about by waging war on discomfort and trying to make it go away.

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After all, if that was going to work, it probably would have worked before now. It has a better chance of happening via learning the skills of psychological flexibility. The concepts of workability and flexibility, both pivotal to ACT practice, are also central to the idea of resolving any disagreements between ACT and the medical model. As an example, imagine a client who has been given a diagnosis of depression. They are taking prescribed anti-depressant medication and they are also seeing an ACT practitioner. Despite the apparent contradiction, there is no reason why the client should not be able to engage with both approaches, if doing so works for them. If anti-depressant medication is helpful, there is no reason why this means of managing the experience of low mood cannot be used alongside learning some useful skills around mindfulness, acceptance, and valued action. They could be invited to track the utility of both approaches, and make decisions about when, and how much, to invest in either going forward. One final thing to note is that in many of the outcome studies of ACT, whilst the interventions focus on increasingly psychological flexibility rather than reducing symptoms, some degree of symptom reduction, as measured by participants’ self-report, usually occurs nevertheless (see Gloster et al, 2020 for a review). Therefore, a useful message for clients who want to get rid of unwanted experiences is that one of the most useful things they can do in the service of that is to stop trying to get rid of them.

Chapter 47

Is it not harmful to encourage people to tune into and accept their pain and discomfort?

This is not intended as an introduction to how to manage a client’s discomfort in the room. The caveat to everything that follows in this chapter is that it is for each of us to work within our own professional competence and boundaries. It is possible to exacerbate a person’s struggle and trauma if there is no underlying expertise to receive it in a way that is helpful and containing. In Chapters 36 and 39, we discussed the journey of most ACT practitioners as a process of additional learning following a professional training programme. Our individual professions are then directly linked with an associated code of ethics and standards of practice, within which we all agree to work. So please, if this is not your training route, be responsible for your work, the services that you provide to clients, and ensure you have the necessary expertise to effectively manage distress. From here on in, this chapter pertains to the worries we experience as clinicians about our own discomfort around other people’s pain. A helpful distinction to make here is between ‘hurt’ and ‘harm’. We know from neuroscience that our emotions hurt and have similar neural pathways to how we experience physical pain. The poetic description of a ‘broken heart’ is not simply poetic; it is indicative of pain and a requirement of needing time to heal. By that understanding, when we are talking with people about experiences they have found difficult, we are directly walking into territory characterised by pain and discomfort. This can be described as hurt, since the pain experienced by the client genuinely will hurt. However, the definition of the word ‘harm’, implies more of an intention to cause injury. Therefore, when we consider whether encouraging people to tune into and accept their internal emotional pain is harmful, we suggest that whilst it may hurt, if managed well by the practitioner, it will not cause damage or be harmful. DOI: 10.4324/9781003364993-53

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Let us utilise a metaphor to develop this answer. Imagine that we all acknowledge our past difficulties as ‘skeletons in the closet’. For most of us, most of the time, the majority of those skeletons are keeping themselves to themselves, perhaps even asleep on the other side of that firmly closed closet door. We may have little knowledge that they are there, or perhaps they are only woken in certain circumstances, and, in the small ways that they ever bother us, they do not warrant any significant attention. However, for some of us, some of the time, those skeletons rattle loudly, banging on the door and we fear their imminent arrival, bursting out from the closet to terrorise us. We worry what they will do and how they will harm us when they appear. Our fears grow, and our response to manage them is to begin to pile up other furniture in front of the closet doors. This enrages the skeletons and they push harder, and rattle louder, and in response, we pile up more furniture and start to cover our ears to block out the noise. This is a clear pattern of experiential avoidance. Around and around it goes. What would happen if the skeletons were to suddenly be in the room with us? What would they do? If we believe the skeletons to be ‘harmful’ we might imagine they would somehow attack us and inflict physical pain. When we talk about tuning in and accepting pain and discomfort as being ‘harmful’ we are essentially judging that the skeletons themselves are the harmful concept. It would surely then make logical sense for the practitioner to help the person manage those skeletons by lending their own body weight to help barricade the door. However, whilst it may stop the skeletons’ fingers from reaching the door handle on the outside, it doesn’t stop them from making one mighty racket on the inside, and the problem remains unchanged. They’re still there, still feeling big, still scary, and still having all the same consequences of making the person’s life get smaller and smaller in the service of trying to manage them. One of the aims of ACT is to break this experiential avoidance loop. This enables us to respond differently to the presence of pain and discomfort and provide a safe place for those big, scary, angry, demanding, and terrifying skeletons to join us in the consulting room. Within the relational safety of the practitioner-client dyad, encouraging someone to tune into their pain is not harmful. What if we were able to offer the gift of creating a shared space in which we can talk to those scary creatures? Perhaps listening to what they have to say might even be helpful?

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As always, the question would be, “What’s the function?”. We would never encourage people to contact their emotional pain and leave them in suspended animation with no strategies to manage their discomfort. So, why would we consider that tuning into and accepting their pain could possibly be something of use in our intervention work? ACT utilises a number of psychological flexibility skills to help people to manage the presence of their loud, scary skeletons. It is our job as practitioners to provide a place where we can help people to see that they are bigger than any of their content. The self-as-context arena does this brilliantly, since it helps people to see that their content is exactly that; it is a part of what they contain. Values and committed action skills help us to work with people on how they want to grow their lives, and who they want to be in the world whilst being a person who contains some painful content. Tuning in and developing acceptance around painful content are like keys to all the other aspects of psychological flexibility. So, from that perspective, we would have to say that helping people to tune into and accept their pain and discomfort is not harmful. Rather, it can be a gift. It is important to remember that we are only inviting people to work toward accepting discomfort. We cannot make them, and neither would we want to. The invitation is for the client to develop acceptance in the service of their values, not just as a discrete exercise in experiencing pain for the sake of it. We have to ask the question, is this value worth suffering for, and the client has to be the one to honestly answer that. In knowing that this work will evoke hurt in the client, we can ready them for this by helping them develop self-compassion skills as part of the work. This enables them to have a skill set within which they can be more nurturing in the presence of their own pain and discomfort.

Chapter 48

What if people have harmful or antisocial values?

Whilst this question is often asked by ACT trainees and supervisees, it rarely arises as a genuine concern when engaging in values clarification work with clients. It seems to be something that many practitioners new to discussing the concept of values seem to worry about, and the question pre-supposes a scenario whereby clients express a desire to improve their skills in engaging in harmful or antisocial behaviour, because to do so would be consistent with their values. Obviously, this is not completely improbable, as some ACT practitioners might work with clients with histories of engaging in such behaviour. However, it does not seem to be an issue that makes its way into the consulting room very often. Since it is a question that has sometimes been posed by critics of ACT, this chapter will reference the underlying philosophy of ACT and the conceptualisation of values, before considering some useful responses in the event that practitioners find themselves facing the scenario imagined by the question. ACT has faced some criticism in respect of values work because it leans on functional contextualism as its philosophical basis. The reason for this criticism is that functional contextualism can be construed as a position of moral relativism in which there are no definitive moral principles. Essentially, a moral relativist, whilst having their own moral principles, will hold the view that another person might have a different set of moral principles and there can be no absolute position on who is ‘right’ (Harris, 2012). From a moral relativist perspective, moral judgements are made relative to any given individual and their principles, whether personally or culturally defined (Whittingham, 2022). Thus, the argument goes, that this gives rise to the possibility, however remote, that a client could espouse antisocial

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values and want to work with a practitioner on pursuing goals consistent with them. Furthermore, critics suggest that if ACT practitioners were really staying true to their functional contextualist roots, they would have to permit this and support such work to take place. It has been argued (e.g., McLoughlin & Roche, 2022) that this provides evidence that functional contextualism is an amoral stance that could lead practitioners to be unconcerned with what is right or wrong. In our view, such criticism confuses amorality (not having any moral principles) with moral relativism (the idea that different people will define their moral principles differently) and imagines a theoretical scenario that is somewhat far-fetched. We also think that, in reality, almost all practitioners who faced such a situation would address the issue head-on, and simply decline to support a client who wanted to develop their repertoire of antisocial or harmful behaviours. Whenever we put the question posed by this chapter back to those that ask it, they generally respond by saying that their personal and/or professional codes of conduct would preclude such work. It is certainly true that human beings can subscribe to a range of antisocial beliefs and behave in a variety of ways that are problematic. However, almost without exception, the clients that we have worked with engage in harmful behaviours when under aversive control, rather than because doing so representing a toward move for them. Our experience includes working with incarcerated individuals who have committed serious violent offences, as well as those who have behaved in harmful ways to others in the context of intellectual disability, addiction, or trauma. None of these behaviours were driven by values in the sense that ACT uses the word. Of course, it is possible that people may genuinely hold antisocial values. We just have not met anyone like this in the course of our ACT practice. Our sense is that even if we did, there would be significant problems in respect of the other aspects of psychological flexibility, whether that be fusion with dogmatic ideas, extreme avoidance of discomfort, or an inability to extend perspective-taking across time, place, and person. If we were to ask you to recall someone you know, or have heard of, who seems to value harming others, we could ask you to consider whether they appear to you to be someone skilled at psychological flexibility. We think it unlikely that you would say that they do. You might even look at your own history and the times that you have behaved destructively (Harris, 2018). Were you mindfully acting in line with your values in

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those moments, or were you hooked by fusion with your thoughts and engaging in experiential avoidance? The goal of values work in ACT is to help people contact and experience the patterns of living they might choose if they were completely free to choose. From an evolutionary perspective, the inherently prosocial and co-operative nature of human beings makes it unlikely, if people could genuinely be freed from the control exerted by their histories, that they would freely choose antisocial or harmful values. If clients choose words to name their values that seem antisocial, LeJeune (2021) has outlined some useful reflective questions that practitioners might ask themselves: • • • • • •

When you experience a client talking about a ‘value’ that you would label as harmful (e.g., racism/power/oppression), what is the quality of that conversation? If you were to look beyond the words being said, what might you notice? Is there a sense of free choice present? Is there willing vulnerability in the room? Does the energy in the room suggest liberty and vitality, or rigidity, fear, and disgust? What is the body posture of the client? Does it suggest openness?

The questions above feel very ACT-consistent, and they are useful in trying to move past the language that people use when describing their values, to a deeper exploration of the motives that lie in their hearts. Motivations that appear antisocial will often be reflective of rules that have developed for survival, rather than of deeply held values. We would refer the reader back to Chapter 17 for a more detailed exploration of the difference between rules and values.

Chapter 49

The client says, “I’ve done everything you suggested but it hasn’t taken away my discomfort”. What do I do next?

As we outlined in Chapter 3, ACT views everything as behaviour. That internal little scream that happens inside when clients say the above? That’s behaviour too! May we take this opportunity to reinforce your noticing skills and say “good noticing” to that little scream, and to any of the sensations of frustration or panic that ensue. Of course, our response to this statement depends on the context, and it might be different if we hear this in session two, versus at the end of session 43. This is a common statement, even from those clients that seem more engaged in the ACT model. Ultimately it is a demonstration that the client has still been holding onto a ‘fix it’ strategy in some capacity. A point to reflect on when we hear it is where the most helpful place to direct our attention might be. Often, it can be helpful to recap the work that has been done already, thereby reinforcing the learning about ACT as a model of behaviour change, rather than a model that is driven by reduction of symptoms. We can look at this through the different components of the Hexaflex and how they interact.

Values and committed action So where do we start with our response? It may not be as drastic as we might imagine. A helpful question to explore is whether, having utilised some ACT techniques, the client is doing more of their value-­ driven activities. Logically it makes sense that we want to rid ourselves of the discomfort of anxiety or low mood. It feels horrible in both mind and body, and we observe that our world feels worse when such feelings are around for us. In response, a common solution is to run away, aiming to get as far away from the discomfort as possible. This is an experientially avoidant pattern and suggests a difficulty or DOI: 10.4324/9781003364993-55

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unwillingness to be present with the content of our internal world. Avoidance as a strategy works well for physical threats. Leaving the room via the nearest exit is a completely workable strategy to avoid a lion that may have strolled into your office. This strategy would work time and time again. Each time the lion comes in, we make a sharp exit to avoid the danger the lion presents. However, when we use this same pattern of responses with internal stimuli, it is less effective because we cannot actually get away from whatever is going on inside of us. Ultimately, avoidant behaviour results in our world becoming smaller, and we get less and less reinforcement, either internally or from the environment. The irony here, and where ACT differs from other psychological models, is that we would fully expect anxiety to increase if someone were to start doing more of what they care about. It can therefore be a helpful starting point to enquire about their value-­driven actions, because if they are committing to doing more of them, it would be understandable that their discomfort has increased, rather than gone away.

Acceptance Should the client say that they are doing more in their lives that brings them vitality, we might then spend time working on their understanding of the frame of co-ordination that exists between values and discomfort, checking that the client does not hold them in a frame of opposition. As described in Chapter 24, what if the discomfort could be seen as the price tag for doing the things in life that matter to them? Would they be prepared to pay it? For example, is having a loving relationship worth the feelings of insecurity and jealousy that might show up from time to time? This conversation helps the exploration of the client’s willingness to accept discomfort, which is an important psychological flexibility skill.

Defusion When clients say that they have tried everything we suggested and they still feel discomfort, it can also be helpful to explore what thoughts or narratives they may be fused with. Whilst there are many, one of the most common words to look out for is ‘should’. When people use this word, it suggests that they have rigid views about how the world ‘should’ work for them (Ellis, 1962). This demanding viewpoint can

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often lead to a sense of frustration, injustice, or unfairness if the world does not appear to be following the rule as it ‘should’. If someone has suffered significant loss and bereavement it would be completely understandable if they felt that the world had dealt them a ‘bad hand’. The thought, “No-one should have to go through this” may be the consequence of many complex and unfathomable experiences. However, one might question whether being fused with this view of how the world ‘should’ be is helpful to them living the life they want to live? Assisting people to get some distance between their demanding thoughts, tuning into their direct experience, and seeing the way the world actually is can be a helpful skill to practice. Standing back from such judgements, and choosing not to buy into them, is more likely to facilitate movement toward greater value-driven living.

Contact with the present moment One thing to check out with ‘discomfort’ is whether clients can consistently be present with it, and accurately identify it for what it is. Sometimes, utilising the skill of contacting the present moment can help people identify more nuance than perhaps they may initially notice. Helpful ways of exploring this can include questions such as, “Is the discomfort the same as it previously has been?”, “Is it permanent?”, “Does it change at all? And if so, when, and how?” Acknowledging, labelling, and exploring the discomfort, and therefore being present with the experience of it can help clients with identifying the nuance of it, moment by moment. Such present moment awareness can also pave the way for the effective use of acceptance and defusion skills.

Self-as-context Tuning into the observing part of the self can help clients see that their whole self is bigger than any amount of discomfort they might feel. Furthermore, developing a sense of self that includes a part that can notice and choose how to respond to discomfort can enable a sense of containment. This ‘noticer’ part might be encouraged to tune into the values that are contained within the client’s experience, in addition to the pain. The client could be prompted to consider what a value-driven response to the thought, “I’ve done everything you suggested but it hasn’t taken away my discomfort” might be.

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It is important to remind ourselves that as practitioners we are not there to steer someone’s responses to their thoughts in any specific direction, or to judge whatever they might choose to do. We are simply there to help them to have a different relationship with their thoughts, emotions, and physiological sensations, and to make their own behavioural choices from there. This has to be a workable solution for them, and not one that we perceive as ‘better’. Ultimately, clients are free to pursue a ‘fix it’ strategy, even if it means that they probably will not gain much from ACT interventions.

Chapter 50

What do I do if a technique does not work out like it is supposed to?

Firstly, it would be helpful to explore a few of the key words in the question. What do we mean by ‘does not work’, and, what do we mean by ‘supposed to’? We can look at the first of these questions from two different perspectives: a functional contextualist perspective, and the perspective of a practitioner who experienced a different response from the client than the one they predicted. From a functional contextualist perspective, the idea of something ‘not working’ concerns it being unhelpful to the client’s goals. It suggests that the chosen technique did not result in an outcome that helped the client clarify the functions of their behaviour or find a helpful response within the context that they find themselves in. From a functional contextualist point of view, there is no categorical ‘right’ or ‘wrong’ response in any given moment. There is only the consideration of whether the person doing the behaviour was able to choose a value-driven response, and whether their chosen action was helpful in them making an effective toward or away move. When most practitioners ask this question in an ACT training session they are not doing so from a functional contextualist standpoint. What they are more often referring to is the question of what to do if a client gives a response to a technique that they were not expecting. This requires us to explore what we mean by ‘supposed to’. This speaks more to fusion on the part of practitioners. Our minds can lead us to feel mighty stuck when we are comfortably working through a technique only for it not to go to plan. The client’s response can suddenly lead to anxious thoughts like, “You weren’t meant to say that!”. They were. Behaviour is not random. They were meant to say exactly what they said. Their response was absolutely what was meant to happen because their current and historical context will have shaped their DOI: 10.4324/9781003364993-56

What do I do if a technique does not work out?  171

response to the world to be exactly what it was. It is only our fusion with a specific desired or predicted outcome that feels inconsistent with what is actually present in the room. The model can help us here, as can Steven C. Hayes’s (n.d., c) fourpoint plan for learning ACT (discussed in detail in Chapter 40). When the unexpected happens, we can utilise our skills of noticing and tracking processes, remind ourselves of the underlying foundations of the model, identify the processes in action for the client, and utilise our ACT toolkit to further explore what is helpful. A technique ‘not working’ in sessions provides helpful data. Behaviour change intervention consists of an ongoing cycle of a­ ssessment – formulation – intervention – reformulation – intervention etc. We never stop assessing the data we are gifted with in sessions, and we never stop formulating how all of that data fits together for the client. When holding this in mind, we can then see that a technique not going to plan can help us to reflect on our formulation, and what might really be going on for the client. That is sometimes different to what we think is going on for the client. A good practitioner is humble enough to be flexible in their work, to change their intervention based on the newly acquired data that they are presented with. This is where the underlying science and philosophy of the model are required, so you can, with precision, alter your work accordingly. Some helpful questions could include: • • •

What new data does their response provide? Based on this new information, am I working on the most helpful Hexaflex component in order to effect behaviour change? A key question to ask from a functional contextualist perspective is, “Whether or not the client gave the anticipated response, was the technique helpful to them in effecting behaviour change in line with their values and goals?”

When reflecting on our work, especially the parts that do not go quite as we may expect, it can be helpful to check on the function of utilising any specific technique at any particular time. It is always possible that the procedure we selected was not the most precise tool for the job we wanted it to perform. The middle-level nature of ACT’s terms can sometimes confuse our approach to the work, and more clarity can come from carefully considering the process/procedure/outcome discrimination. For example, if clients are fused with the literal meaning

172  Critical questions about ACT

of a word like ‘worthless’ it would make sense to address that with procedures that target the process of fusion. However, as identified in Chapter 30, there are different classifications of ‘defusion techniques’ that each function in slightly different ways. In this instance, selecting a technique to specifically target the de-literalisation of words might be indicated. Such a technique might help ‘worthless’ be experienced more as an arbitrary sound that carries fewer aversive functions, thereby changing the relationship that the client has with the word. In this instance, you could introduce the client to a word repetition procedure. They would be asked to repeat “lemon, lemon, lemon” over and over as fast as they can. Once they begin to experience the reduced effect of the word ‘lemon’ on their salivary glands, they could practise the same thing with ‘worthless’. This carefully selected procedure may then lead to the intended outcome of the client being less hooked by the impact of the word in their thoughts, which would then lead to an increased opportunity for them to engage in value-driven behaviours. In every aspect of ACT practice, it feels important for practitioners to try and let go of the idea that there is an absolute right and wrong way to do things. We can learn just as much from things that might be perceived as going wrong, as from things that seem to run smoothly. As the above example hopefully illustrates, the flexibility to revisit and adapt the techniques that we use is a helpful quality for any practitioner to possess, and, as always, the focus should be on the function of any procedure, rather than its form.

Index

Note: Bold page numbers refer to tables; italic page numbers refer to figures. Acceptance and Commitment Therapy (ACT): assumptions of 10–12; in contemporary context 1; describing ACT to a client 4–6; introducing ACT to a client 79–81, 84–86; issues for which ACT is recommended 7–9, 9; number of sessions 118–120; philosophy and theory of 3, 135–136; in practice 69, 115–117; relationship to other therapies 32–35, 34; when to choose ACT 73–75 acceptance part of ACT: co-ordinating values 58; explaining to a client 87–88; Hexaflex 113; misconceptions 53–55, 167; working with a client 100–102, 167 ACT for Life 116 ACT Matrix 11, 84–86 action see committed action active listening 31 antisocial values 163–165 Association for Contextual Behavioural Science (ACBS) 8, 77, 123, 132–133, 154 Australia, national guidelines 9 avoidance: discussing with a client 166–167; experiential avoidance

behaviour 28, 54, 161; toward and away moves 62–64 awareness, tuning in to the present moment 94–96 away see toward and away moves Beck, J. S. 13, 109–111, 147 behaviourism 11 behaviours: as acts-in-context 11–12; client’s presentation 92–93; functional contextualism 12, 17–18; as purposeful 12; toward and away 22–24, 62–64; tuning in to the present moment 95–96; values, goals and rules 59–61 bias in psychology 145 cognition 33 Cognitive Behaviour Therapy (CBT): Acceptance and Commitment Therapy (ACT) as part of 1, 3; differences with ACT 81; evidence base 147–149; first wave 11, 33; relationship to other therapies 32–35, 34; second wave 11, 33, 56, 147; third wave 11, 33–34, 81, 147, 153; traditional forms of 148–150, 149 cognitive function, in ACT client 75

174 Index cognitive restructuring 33, 56 cognitive therapy 109 committed action: Hexaflex 114; and values 58; working with a client 90, 166–167 compassion 65–67 Compassion Focused Therapy (CFT) 65 competencies see skills as an ACT practitioner component studies 73–75 contextualism 16; see also functional contextualism creative hopelessness 37, 42–45, 92–93 critical questions about ACT 143; discomfort and pain 160–162; ‘emperor’s new clothes’ criticism 151–153; evidence base 144–146; harmful or antisocial values 163–165; and the medical model 157–159; need for ACT 147–150; tools and techniques 154–156; when ACT is not working 166–172 cultural context: disagreement between the fields of medicine and ACT 157–159; diverse populations 76–78; WEIRD nations 76–77, 146 cultural diversity 78 defusion: explaining to a client 88; Hexaflex 114; relational frame theory 71–72; and self-as-context 49, 50–51, 51–52; which procedure to use 103–105; working with a client 58, 167–168 de-literalisation 171–172 Dialectical Behaviour Therapy 33 didactic learning 128–130 discomfort experienced by ACT clients 58, 160–162, 166 diverse populations 76–78 education see learning as an ACT practitioner ethics see moral relativism; values of the client

evidence base for ACT 144–146; see also research in ACT evidence base for CBT 147–149 evoking behaviour 95, 101–102 evolutionary theory 13–15, 22 experiential avoidance 28, 54, 161 experiential learning 128–130, 135, 136 experiential methods in ACT 140–141, 154–156 flexibility see psychological flexibility Focused ACT (FACT) 119 functional contextualism 16–18; behaviours 11, 12; “it depends” 19–21; moral relativism 163–164; toward and away 23–24; working with a client 170–172 goals of the client 59–61; see also values of the client Hayes, Steven C. 126, 135, 171 Hexaflex: ACT as synonymous with 10; compassion 66; explaining each component of 87–90; focussing on key processes of 91–92; introducing clients to 82–83; mapping to the ACT Matrix 85, 86; mindfulness 46–47; working with all processes 112–114, 119–120 historical context 11 hopelessness, creative 37, 42–45 human evolution 13–15, 22 human language 25 hurt experienced by ACT clients 160–162, 166 Inflexahex 82–83, 83 “it depends” 19–21 language 11; defusion procedures 104; de-literalisation 171–172; functional contextualism 17; in human decision-making 23; in human evolution 14; metaphors in

Index 175 ACT 28–31, 44; relational frame theory 25, 26, 27; self-as-context 98–99; value-driven behaviour 110 learning as an ACT practitioner: experiential vs. didactic 128–130; lack of formal qualification 131– 133; ongoing supervision 138–141; shaping your learning as an ACT practitioner 134–137 the medical model 157–159 metaphors in ACT 28–31, 29, 44 mindfulness 46–48, 47; see also present moment, tuning in to Mindfulness-Based Cognitive Therapy (MBCT) 33, 46 Mindfulness-Based Stress Reduction (MBSR) 46 modelling behaviour 95, 100–101 moral relativism 12, 163–164 national guidelines on ACT 9, 9 National Institute for Health and Care Excellence (NICE) 119 natural selection 14–15 the Netherlands, national guidelines 9 operant conditioning 56 pain experienced by ACT clients 58, 160–162, 166 peer consultation 136 perspective-taking skills 140 philosophy behind ACT 3, 11, 12, 16–18 practical skills 136–137 practitioners see skills as an ACT practitioner present moment, tuning in to 88–89, 94–96, 114, 168; see also mindfulness professional qualifications, lack of formal ACT qualification 131–133 psychological distress 42–43 psychological flexibility 10, 38–41; ACT in practice 115–117, 162; building skills in 96; component

studies 74–75; components of the psychological flexibility model 91–93; creative hopelessness 45; evidence base 144–145; experiential learning 135; should ACT practitioners practise ACT for themselves? 125–127; tuning in to the present moment 94–96, 95–96; using the Hexaflex 112–113 psychotherapy applications 7–9 qualifications, lack of formal ACT qualification 131–133 radical behaviourism 11 randomised controlled trials (RCTs) 8 REBT 152 reinforcing behaviour 96, 102 relational frame theory (RFT) 25–27; do I need to know RFT in order to practise ACT? 70–72; link with ACT 11, 145–146, 153; self-ascontext 98–99 replication crisis 145 research in ACT 8–9; component studies 73–75; evidence base 144–146; experiential learning vs. didactic learning 128–130; need for ACT 147–150; should ACT practitioners practise ACT for themselves? 126–127; see also critical questions about ACT respondent conditioning 56 rule-governed behaviour 60–61 self in ACT literature 97 self-as-context: and defusion 49–52, 51–52; explaining to a client 89; Hexaflex 114; present moment awareness 48; psychological flexibility 162; working with a client 97–99, 168–169 self-as-process 97 self-esteem 49–50 self-help approach 7

176 Index Self-Practice/Self-Reflection (SP/SR) 126–127 self-report measures 144–145 sessions, number of 118–120 sexual behaviour 26–27 SHAPE model 141 skills as an ACT practitioner 121; experiential learning vs. didactic learning 128–130; lack of formal qualification 131–133; ongoing supervision 138–141; shaping your learning 134–137; should ACT practitioners practise ACT for themselves? 125–127; tools and techniques 154–156; what do I need in place? 122–124 Skinner’s verbal behaviour theory 11, 25 SMART goals 59–61 stimulus functions 56–58 supervision, as an ACT practitioner 138–141 survival tactics 22, 62 symbolic learning 27, 56 theoretical foundations of ACT 3, 135–136

time limitations 118–120 toward and away moves 22–24, 62–64, 109–111 training see learning as an ACT practitioner transformation of stimulus functions 56–58 United Kingdom, national guidelines 9 United States, national guidelines 9 values of the client: committed action 58; conflicts around 106–108; discussing with a client 89–90, 166– 167; distinction from goals or rules 59–61; harmful or antisocial values 163–165; moral relativism 12, 163–164; should ACT encourage value-driven behaviour? 109–111; supervision 139 WEIRD (Western, educated, industrialised, rich, and democratic) nations 76–77, 146 World Health Organization (WHO) 7, 119