Embracing Your Demons: an Overview of and Commitment Therapy RUSSELL HARRIS

Acceptance and Commitment Therapy is one of the recent mindfulness-based behaviour therapies shown to be effective with a diverse range of clinical conditions. In contrast to the assumption of ‘healthy normality’ of Western psychology, ACT assumes that the psychological processes of a normal human mind are often destructive and create psychological . Symptom reduction is not a goal of ACT, based on the view that ongoing attempts to get rid of ‘symptoms’ can create clinical disorders in the first place. RUSSELL HARRIS provides an overview of ACT against a background of the suffering generated by experiential avoidance and emotional control. A case study illustrates the six core principles of developing psychological flexibility; defusion, acceptance, contact with the present moment, the observing self, values, and committed action.

magine a therapy that makes no , the of terminal cancer, of barriers, in the form of unpleasant attempt to reduce symptoms, , PTSD, anorexia, heroin and unwanted ‘private experiences’ butI gets symptom reduction as a by- abuse, marijuana abuse, and even (thoughts, images, , sensations, product. A therapy firmly based in the schizophrenia. (Zettle & Raines, 1989; urges, and memories). ACT teaches tradition of empirical science, yet has a Twohig, Hayes & Masuda, 2006; mindfulness skills as an effective way major emphasis on values, , Bond & Bunce, 2000; Dahl, Wilson to handle these private experiences. acceptance, , living in & Nilsson, 2004; Branstetter, Wilson, What is mindfulness? the present moment, and accessing a Hildebrandt & Mutch, 2004). A study transcendent sense of self. A therapy by Bach & Hayes (2002) showed that When I discuss mindfulness with so hard to classify that it has been with only four hours of ACT, hospital clients, I define it as:‘Consciously described as an ‘existential humanistic re-admission rates for schizophrenic bringing awareness to your here-and-now cognitive behavioural therapy’. patients dropped by 50% over the next experience with openness, and Acceptance and Commitment six months. receptiveness.’ There are many facets Therapy, known as ‘ACT’ (pronounced The goal of ACT to mindfulness, including living in as the word ‘act’) is a mindfulness- the present moment; engaging fully based behavioural therapy that The goal of ACT is to create a rich in what you are doing rather than challenges the ground rules of most and meaningful life, while accepting ‘getting lost’ in your thoughts; and Western psychology. It utilizes an the pain that inevitably goes with it. allowing your feelings to be as they eclectic mix of metaphor, paradox, ‘ACT’ is a good abbreviation, because are, letting them come and go rather and mindfulness skills, along with a this therapy is about taking effective than trying to control them. When wide range of experiential exercises action guided by our deepest values we observe our private experiences and values-guided behavioural and in which we are fully present and with openness and receptiveness, even interventions. ACT has proven engaged. It is only through mindful the most painful thoughts, feelings, effective with a diverse range of action that we can create a meaningful sensations and memories can seem less clinical conditions; , life. Of course, as we attempt to create threatening or unbearable. In this way OCD, workplace stress, chronic such a life, we will encounter all sorts mindfulness can help us to transform

 PSYCHOTHERAPY IN AUSTRALIA • VOL 12 NO 4 • AUGUST 2006 our relationship with painful thoughts rather than following a manualised feelings, so that we no longer perceive and feelings, in a way that reduces their protocol, ACT allows the therapist them as ‘symptoms’. Instead, we learn impact and influence over our life. to create and individualise their own to perceive them as harmless, even if How does ACT differ from other mindfulness techniques, or even to co- uncomfortable, transient psychological mindfulness-based approaches? create them with clients. events. Ironically, it is through this Another primary difference is process that ACT actually achieves ACT is one of the so-called ‘third that ACT sees formal mindfulness symptom reduction—but as a by- wave’ of behavioural therapies—along as only one way of many to product and not the goal. with Dialectical Behaviour Therapy teach mindfulness skills. Mindfulness Another way in which ACT is (DBT), Mindfulness-Based Cognitive skills are ‘divided’ into four subsets: unique, is that it doesn’t rest on the Therapy (MBCT) and Mindfulness- • acceptance; assumption of ‘healthy normality’. Based Stress Reduction (MBSR)—all • cognitive defusion; Healthy normality of which place a major emphasis on • contact with the present moment; the development of mindfulness skills. • the observing self. Western psychology is founded on the assumption of healthy normality: Acceptance and Commitment Therapy is one of the recent mindfulness-based that by their nature, humans are In stark contrast to most Western psychologically healthy, and given a behaviour therapies shown to be effective with a diverse range of clinical conditions. In psychotherapy, ACT does not have healthy environment, lifestyle, and contrast to the assumption of ‘healthy normality’ of Western psychology, ACT assumes social context (with opportunities that the psychological processes of a normal human mind are often destructive and symptom reduction as a goal. This is based for ‘self-actualisation’), humans will naturally be happy and content. create psychological suffering. Symptom reduction is not a goal of ACT, based on the on the view that the ongoing attempt From this perspective, psychological view that ongoing attempts to get rid of ‘symptoms’ can create clinical disorders in suffering is seen as abnormal; a the first place. RUSSELL HARRIS provides an overview of ACT against a background to get rid of ‘symptoms’ actually creates disease or syndrome driven by unusual of the suffering generated by experiential avoidance and emotional control. A pathological processes. a clinical disorder in the first place. Why does ACT suspect this case study illustrates the six core principles of developing psychological flexibility; assumption to be false? If we defusion, acceptance, contact with the present moment, the observing self, values, examine the statistics we find that and committed action. Created in 1986 by Steve Hayes, ACT The range of ACT interventions in any year almost 30 percent of the was the first of these ‘third wave’ to develop these skills is vast and adult population will suffer from therapies, and currently has a large continues to grow ranging from a recognised psychiatric disorder body of empirical data to support its traditional on the (Kessler et al, 1994). The World Health effectiveness. breath through to cognitive defusion Organization estimates that depression The ‘first wave’ of behavioural techniques. is currently the fourth biggest, most therapies, in the fifties and sixties, What is unique to ACT? costly, and most debilitating disease in focused on overt behavioural change the world, and by the year 2020 it will and utilized techniques linked to ACT is the only Western operant and classical conditioning psychotherapy developed in principles. The ‘second wave’ in conjunction with its own basic research the seventies included cognitive program into human language and interventions as a key strategy. cognition—Relational Frame Theory Cognitive-behaviour therapy (CBT) (RFT). It is beyond the scope of eventually came to dominate this this article to go into RFT in detail, ‘second wave’. however, for more information see ACT differs from DBT, MBCT, www.contextualpsychology.org/rtf. and MBSR in many ways. For a start, In stark contrast to most Western MBSR and MBCT are essentially psychotherapy, ACT does not have manualised treatment protocols, symptom reduction as a goal. This is designed for use with groups for based on the view that the ongoing treatment of stress and depression. attempt to get rid of ‘symptoms’ DBT is typically a combination of actually creates a clinical disorder in group skills training and individual the first place. As soon as a private therapy, designed primarily for group experience is labeled a ‘symptom’, it treatment of Borderline Personality immediately sets up a struggle with it Disorder. In contrast, ACT can be because a ‘symptom’ is by definition used with individuals, couples and something ‘pathological’; something groups, both as brief therapy or long we should try to get rid of. In ACT, term therapy, in a wide range of the aim is to transform our relationship clinical populations. Furthermore, with our difficult thoughts and Illustration: Savina Hopkins

PSYCHOTHERAPY IN AUSTRALIA • VOL 12 NO 4 • AUGUST 2006  be the second biggest. In any week, and all of these processes rely on are therefore highly adaptive for us as one-tenth of the adult population is human language. Thus in ACT, the humans (and indeed, teaching such suffering from clinical depression, and word ‘mind’ is used as a metaphor for skills has proven to be effective in the one in five people will suffer from it at human language itself. treatment of depression). Given this some point in their lifetime (Davies, Unfortunately, human language is a problem solving approach works well 1997). Furthermore, one in four adults, double-edged sword. On the positive it in the outside world, it’s only natural at some stage in their lifetime, will helps us make maps and models of the that we would tend to apply it to suffer from drug or alcohol addiction. world; predict and plan for the future; our interior world; the psychological There are now over twenty million share knowledge; learn from the past; world of thoughts, feelings, memories, alcoholics in the United States alone imagine things that have never existed, sensations, and urges. Unfortunately, (Kessler et al, 1994). and go on to create them; develop rules all too often when we try to avoid More startling and sobering is the that guide our behaviour effectively, or get rid of unwanted private finding that almost one in two people and help us to thrive as a community; experiences, we simply create extra will go through a stage in life when communicate with people who are far suffering for ourselves. For example, they consider suicide seriously, and away; and learn from people who are virtually every addiction known to will struggle with it for a period of two no longer alive. mankind begins as an attempt to avoid weeks or more. Scarier still, one in ten The dark side of language is that we or get rid of unwanted thoughts and people at some point attempt to kill use it to lie, manipulate and deceive; to feelings, such as , , themselves ( and Strosahl, 1995). spread libel, slander and ignorance; to anxiety, depression and so on. The In addition, consider the many incite , prejudice and violence; to addictive behaviour then becomes self- forms of psychological suffering that make weapons of mass destruction, and sustaining, because it provides a quick do not constitute ‘clinical disorders’— industries of mass pollution; to dwell and easy way to get rid of cravings or loneliness, boredom, alienation, on and ‘relive’ painful events from the withdrawal symptoms. meaninglessness, low self-esteem, past; to scare ourselves by imagining The more time and energy we spend existential , and pain associated unpleasant futures; to compare, judge, trying to avoid or get rid of unwanted with issues such as racism, bullying, criticise and condemn both ourselves private experiences the more we are sexism, domestic violence, and divorce. and others; and to create rules for likely to suffer psychologically in the Clearly, even though our standard ourselves that can often be life- long term. Anxiety disorders provide a of living is higher than ever before constricting or destructive. good example. It is not the presence of in recorded history, psychological Experiential avoidance anxiety that comprises the essence of suffering is all around us. an anxiety disorder. After all, anxiety Destructive normality ACT rests on the assumption that is a normal human that we all human language naturally creates experience. At the core of any anxiety ACT assumes that the psychological psychological suffering for us all. One disorder lies a major preoccupation processes of a normal human mind way it does this is through setting us up with trying to avoid or get rid of are often destructive, and create for a struggle with our own thoughts anxiety. OCD provides a florid psychological suffering for us all, and feelings, through a process called example; I never cease to be amazed sooner or later. experiential avoidance. by the elaborate rituals that OCD Furthermore, ACT postulates that Probably the single biggest sufferers devise, in vain attempts to get the root of this suffering is human evolutionary advantage of human rid of anxiety-provoking thoughts and language itself. Human language is language was the ability to anticipate images. Sadly, the more importance a highly complex system of symbols, and solve problems. This has enabled we place on avoiding anxiety, the which includes words, images, sounds, us not only to change the face of the more we develop anxiety about our facial expressions and physical gestures. planet, but to travel outside it. The anxiety—thereby exacerbating it. It’s We use this language in two domains: essence of problem-solving is this: a vicious cycle, found at the centre of public and private. The public use of Problem = something we don’t want. any anxiety disorder. (What is a language includes speaking, talking, Solution = figure out how to get rid attack, if not anxiety about anxiety?) miming, gesturing, writing, painting, of it, or avoid it. A large body of research shows singing, dancing and so on. The private This approach obviously works well that higher experiential avoidance use of language includes thinking, in the material world. A wolf outside is associated with anxiety disorders, imagining, daydreaming, planning, your door? Get rid of it. Throw rocks depression, poorer work performance, visualising and so on. A more technical at it, or spears, or shoot it. Snow, rain, higher levels of substance abuse, term for the private use of language is hail? Well, you can’t get rid of those lower quality of life, high risk sexual ‘cognition’. things, but you can avoid them, by behaviour, borderline personality Now clearly the mind is not a ‘thing’ hiding in a cave, or building a shelter. disorder, greater severity of PTSD, or an ‘object’. Rather, it is a complex Dry, arid ground? You can get rid of long term disability and alexithymia. set of cognitive processes—such as it, by irrigation and fertilisation, or Of course, not all forms of analysing, comparing, evaluating, you can avoid it, by moving to a better experiential avoidance are unhealthy. planning, remembering, visualising— location. Problem solving strategies For example, drinking a glass of wine

 PSYCHOTHERAPY IN AUSTRALIA • VOL 12 NO 4 • AUGUST 2006 to unwind at night is experiential make room for them, and allow them a process similar to motivational avoidance, but it’s not likely to be to come and go without a struggle. interviewing. Clients identify the ways harmful. However, drinking an entire The time, energy, and money that they they have tried to get rid of or avoid bottle of wine a night is likely to be wasted previously on trying to control unwanted private experiences. They are extremely harmful, in the long term. how they feel is then invested in taking then asked to assess for each method: ACT targets experiential avoidance effective action (guided by their values) ‘Did this reduce your symptoms in the long strategies only when clients use them to change their life for the better. term? What did this strategy cost you, in terms of time, energy, health, vitality, relationships? Did it bring you closer to the ACT assumes that the psychological life you want?’ ‘Michael’ was a 35 year old processes of a normal human mind are accountant who suffered from significant social anxiety, and had seen a often destructive, and create psychological number of therapists to no avail. On the first session we ran through the many suffering for us all, sooner or later. strategies he had used to avoid or get rid of his social anxiety. They included: drinking alcohol, taking Valium, being to such a degree that they become Thus ACT interventions focus a ‘good listener’ (asking lots of questions, costly, life-distorting, or harmful. around two main processes: but sharing little of himself), arriving ACT calls these ‘emotional control 1) developing acceptance of late, leaving early, avoiding social events strategies’, because they are attempts unwanted private experiences altogether, deep breathing, to directly control how we feel. Many which are out of personal control, techniques, using positive affirmations, of the emotional control strategies that 2) commitment and action towards disputing negative thoughts, analysing clients use to try to feel good (or to living a valued life. his childhood, blaming his parents (who feel ‘less bad’) may work in the short What follows is a brief summary were both socially avoidant), telling term, but frequently they are costly of some core ACT interventions, himself to ‘get over it’, self-hypnosis and and self-destructive in the long term. illustrated with vignettes of clinical so on. Michael realised that none of For example, depressed clients often work with a client called ‘Michael’. these strategies had reduced his anxiety withdraw from socialising in order to Confronting the agenda in the long term. Although strategies avoid uncomfortable thoughts—‘I’m such as taking Valium, drinking a burden’, ‘I have nothing to say’, ‘I In this step, the client’s agenda alcohol, and avoiding social events had won’t enjoy myself ’—and unpleasant of emotional control is gently and reduced his anxiety in the short term, feelings such as anxiety, fatigue, of respectfully undermined, through they had created significant costs to his rejection. In the short term, canceling a social engagement may give rise to a short-lived sense of relief, but in the long term, the increasing social makes them more depressed. ACT offers clients an alternative to experiential avoidance through a variety of therapeutic interventions. Therapeutic interventions

In general, clients come to therapy with an agenda of emotional control. They want to get rid of their depression, anxiety, urges to drink, traumatic memories, low self-esteem, fear of rejection, , and so on. In ACT, there is no attempt to try to reduce, change, avoid, suppress, or control these private experiences. Instead, clients learn to reduce the impact and influence of unwanted thoughts and feelings, through the effective use of mindfulness. Clients learn to stop fighting with their private experiences—to open up to them,

PSYCHOTHERAPY IN AUSTRALIA • VOL 12 NO 4 • AUGUST 2006  quality of life. His ‘homework’ was to it’s not a problem. Sure, it’s unpleasant. • acceptance; notice and write down other emotional We don’t like it, or want it, but at the • contact with the present moment; control strategies, and to assess their same time, it’s nothing terrible. With • the Observing Self; long-term effectiveness and costs to his the struggle switch OFF, our anxiety • values, and; quality of life. levels are free to rise and fall as the • committed action. Control is the problem, situation dictates. Sometimes they’ll Each principle has its own specific not the solution be high, sometimes low and sometimes methodology, exercises, homework and there will be no anxiety at all. Far more metaphors. Take defusion, for example. In this phase, we increase clients’ importantly, we’re not wasting our time In a state of cognitive fusion we are awareness that emotional control and energy struggling with it. caught up in language. Our thoughts strategies are largely responsible for Without struggle, we get a natural seem to be the literal truth, or rules their problems; that as long as they’re level of physical and emotional that must be obeyed, or important fixated on trying to control how they discomfort, depending on who we are events that require our full attention, feel, they’re trapped in a vicious cycle of and the situation we’re in. In ACT, we or threatening events that we must get increasing suffering. Useful metaphors call this ‘clean discomfort’. There’s no rid of. In other words, when we fuse here include ‘quicksand’, ‘the struggle avoiding ‘clean discomfort’. Life serves with our thoughts, they have enormous switch’, and the concepts of ‘clean it up to all of us in one way or another. influence over our behaviour. discomfort’ and ‘dirty discomfort’. We However, once we start struggling Cognitive defusion means we are able might deliver these metaphors like this: with it, our discomfort levels increase to ‘step back’ and observe language, Remember those old movies rapidly. This additional suffering, we without being caught up in it. We where the bad guy falls into a pool of call ‘dirty discomfort’. Our struggle can recognise that our thoughts are quicksand, and the more he struggles, switch is like an emotional amplifier— nothing more or less than transient the faster it sucks him under? In switch it on, and we can have anger private events—an ever-changing quicksand, struggling is the worst thing about our anxiety, anxiety about our stream of words, sounds and pictures. you can possibly do. The way to survive anger, depression about our depression, As we defuse our thoughts, they have is to lie back, spread out your arms, and or about our guilt. much less impact and influence. float on the surface. It’s tricky, because Obviously, these metaphors are If you look through the wide variety every instinct tells you to struggle; but tailored to the particular feelings of writings on ACT, you will find over if you do so, you’ll drown. the client struggles with. With the a hundred different cognitive defusion The same principle applies to struggle switch ON, not only do we techniques. For example, to deal with difficult feelings: the more we try to get emotionally distressed by our own an unpleasant thought, we might fight them, the more they overwhelm feelings, we also do whatever we can to simply observe it with detachment; us. Imagine that at the back of our avoid or get rid of them, regardless of or repeat it over and over, out aloud, mind is a ‘struggle switch’. When it’s the long term costs. We draw clients’ until it just becomes a meaningless switched on, it means we’re going attention to the many ways they’ve sound; or imagine it in the voice of a to struggle against any physical or tried to do this—through more obvious cartoon character; or sing it to the tune emotional pain that comes our way; strategies such as drugs, alcohol, food, of ‘Happy Birthday’; or silently say whatever discomfort experienced, we’ll TV, gambling, smoking, sex, surfing ‘Thanks, mind’ in for such an try our best to get rid of it or avoid it. the net—to less obvious emotional interesting thought. There is endless Suppose the emotion that shows control strategies, such as ruminating, room for creativity. In contrast to CBT, up is anxiety. If our struggle switch is chastising themselves, blaming others not one of these cognitive defusion ON, then that is completely and so on. (As mentioned earlier, many techniques involves evaluating or unacceptable. This means we could control strategies are not an issue, as disputing unwanted thoughts. end up with anger about our anxiety: long as they are used in moderation.) Here’s a simple exercise in cognitive ‘How dare they make me feel like this?’ Michael was able to connect with defusion for yourself: Or about our anxiety: ‘Not these metaphors readily, especially the Step 1: Bring to mind an upsetting again. Why do I always feel like this?’ idea of the struggle switch. We were and recurring negative self-judgment Or anxiety about our anxiety: ‘What’s able to refer back to this in subsequent that takes the form ‘I am X’ such as ‘I wrong with me? What’s this doing to sessions whenever he experienced am incompetent’, or ‘I’m stupid.’ Hold my body?’ Or a mixture of all these anxiety. ‘Okay, right now, you’re feeling that thought in your mind for several feelings. These secondary are anxious. Is the struggle switch on or off?’ seconds and believe it as much as you useless, unpleasant, and unhelpful, and Once the emotional control agenda can. Now notice how it affects you? a drain upon our vitality. In response is undermined, we then introduce the Step 2: Now take the thought ‘I am we get angry, anxious or guilty. Spot six core principles of ACT. X’ and insert this phrase in front of it: the vicious cycle? Six core principles of ACT ‘I’m having the thought that . . .’ Now But what if our struggle switch is run that thought again, this time with OFF? Whatever emotion shows up, ACT uses six core principles to help the new phrase. Notice what happens. no matter how unpleasant, we don’t clients develop psychological flexibility: In Step 2, most people notice a struggle with it. So if anxiety shows up, • defusion; ‘distance’ from the thought, such

 PSYCHOTHERAPY IN AUSTRALIA • VOL 12 NO 4 • AUGUST 2006 that it has much less impact. Notice party. When I asked him to scan his conversations; i.e. keeping his attention there has been no effort to get rid of body and notice where he felt the on the other person, rather than on his the thought, nor to change it. Instead anxiety most intensely he reported a own thoughts and feelings. the relationship with the thought has ‘huge knot’ in his stomach. I asked 4. The Observing Self: accessing a changed—it can be seen as just words. him to observe this sensation as if transcendent sense of self; a continuity There now follows a brief description he was a curious scientist who had of consciousness that is unchanging, of the six core principles, with reference never seen anything like it before; to ever-present, and impervious to harm. to the case of Michael. notice the edges of it, the shape of it, From this perspective, it is possible to 1. Cognitive Defusion: learning to the vibration, weight, temperature, experience directly that you are not perceive thoughts, images, memories pulsation, and the myriad of other your thoughts, feelings, memories, and other cognitions as what they sensations within the sensation. I had urges, sensations, images, roles, or are—nothing more than bits of him breathe into the sensation, and physical body. These phenomena language, words and pictures—as ‘make room for it’; to allow it to be change constantly and are peripheral opposed to what they can appear to there, even though he did not like it or aspects of you, but they are not the be—threatening events, rules that must want it. Michael soon reported a sense essence of who you are. be obeyed, objective truths and facts. of calmness; a sense of being at ease In session five, I took Michael In session two, Michael, said he with his anxiety, even though he didn’t through a mindfulness exercise experienced frequent distress from like it. ‘Homework’ included practising designed to have him access this thoughts such as ‘I’m boring’, ‘I have this technique with his recurrent transcendent self. First, I asked him to nothing to say’, ‘No one likes me’, and ‘I’m feelings of anxiety—not to get rid of close his eyes and observe his thoughts: a loser’. As the session continued, I had them, but simply to learn how to let the form they took, their apparent Michael interact with these thoughts them come and go without a struggle. location in space, the speed with which in a number of different ways, until 3. Contact with the present moment: they were moving. Then I asked him: they began to lose their impact. For bringing full awareness to your here- ‘Be aware of what you are noticing. example, I had him bring to mind and-now experience, with openness, There are your thoughts, and there is you the thought ‘I’m a loser’, then close his interest, and receptiveness; focusing on, noticing them. So there are two processes eyes and notice where it seemed to be and engaging fully in whatever you are going on—a process of thinking, and a located in space. He sensed it was in doing. process of observing that thinking.’ Again front of him. I asked him to observe In session four, I took Michael and again, I drew his attention to the thought as if he was a curious through a simple mindfulness exercise, the distinction between the thoughts scientist, and to notice the form of it: focused on the experience of eating. that arise, and the self who observes whether it was more like something he I gave him a sultana, and asked him those thoughts. From the perspective could see, or something he could hear. to eat it ‘in slow motion’, with a total of this Observing Self, no thought is He said it was like words that he could focus on the taste and texture of the dangerous, threatening, or controlling. see, and he noticed that as he ‘looked’ fruit, and the sounds, sensations and 5. Values: clarifying what is most at it, it became less distressing. I asked movements inside his mouth. I told important, deep in your heart; what him to imagine the thought as words him, ‘While you’re doing this, all sorts sort of person you want to be; what is on a Karaoke screen; then change the of distracting thoughts and feelings significant and meaningful to you; and font; then change the colour; then may arise. The aim is simply to let what you want to stand for in this life. imagine a bouncing ball jumping from your thoughts come and go, and allow In session six, Michael identified word to word. By this stage, Michael your feelings to be there, and keep your important values around connecting was chuckling at the very same thought attention focused on eating the sultana.’ with others, building meaningful that only a few minutes earlier had Afterwards, Michael said he was friendships, developing intimacy, brought him to tears. ‘Homework’ amazed that there was so much flavour and being authentic and genuine. We included practising several different in one single sultana. I was then able discussed the concept of willingness. defusion techniques with distressing to use this experience to draw an The willingness to feel anxiety doesn’t thoughts—not to get rid of them, but analogy with social situations, where mean you like or want it. Instead simply to learn how to step back and Michael would be so caught up in his it means you allow it to be there in see them for what they are—just ‘bits thoughts and feelings that he wasn’t order to do something you value. I of language’ passing through. able to engage fully in conversation, asked Michael, ‘If taking your life in the 2. Acceptance: making room for and missed out on the ‘richness’. direction of these values means you need to unpleasant feelings, sensations, ‘Homework’ included practising make room for feelings of anxiety, are you urges, and other private experiences; full engagement with all the five willing to do that?’ His reply was ‘Yes.’ allowing them to come and go without senses in a number of daily routines 6. Committed Action: setting goals, struggling with them, running from (having a shower, brushing his teeth, guided by your values, and taking them, or giving them undue attention. and washing the dishes) as well as effective action to achieve them. In session three, I asked Michael to continuing to practise his defusion and Continuing session six, we moved make himself anxious by imagining acceptance techniques. He agreed also to setting goals in line with Michael’s himself at a forthcoming office to practice mindful engagement in values. Initially, he set the goal of

PSYCHOTHERAPY IN AUSTRALIA • VOL 12 NO 4 • AUGUST 2006  going for lunch with a work colleague like: ‘I don’t want you to think I’ve got Dahl, J., Wilson, K. G., & Nilsson, A. (2004). Acceptance and commitment every day, and sharing some personal my life completely in order. It’s more as if therapy and the treatment of persons at information on each occasion. In you’re climbing your mountain over there risk for long-term disability resulting from subsequent sessions, he set increasingly and I’m climbing my mountain over here. stress and pain symptoms: A preliminary challenging social goals, and continued It’s not as if I’ve reached the top and I’m randomized trial. Behavior Therapy, 35, to practice mindfulness skills to handle having a rest. It’s just that from where I 785–802. the anxious thoughts and feelings am on my mountain, I can see obstacles on Davies, T. (1997), ABC of Mental Health, that inevitably arose. At the end of your mountain that you can’t see. So I can British Medical Journal, 314, 27.5.97: ten sessions, Michael reported that point those out to you, and maybe show 1536–39. he was socialising a lot more, and you some alternative routes around them.’ Hayes, S. C., Bissett, R., Roget, N., more importantly, he was enjoying it. Conclusion Padilla, M., Kohlenberg, B. S., Fisher, G., et al. (2004). The impact of acceptance Thoughts of being ‘a loser’ or ‘boring’ or and commitment training on stigmatizing ‘unlikeable’ still occurred, but usually The experience of doing therapy attitudes and professional burnout of he did not take them seriously or pay becomes vastly different with ACT. It substance abuse counselors. Behavior them any attention. Likewise, feelings is no longer about getting rid of bad Therapy, 35, 821–836. of anxiety still occurred in many social feelings or getting over old trauma. Kessler, R.C., McGonagle, K.A., Zhao, situations, but no longer bothered him Instead it is about creating a rich, full S., Nelson, C.B., Hughes, M., Eshleman, or distracted him. Overall, his anxiety and meaningful life. This is confirmed S., Wittchen, H.U., and Kendler, K.S. levels had diminished considerably. by the findings of Strosahl, Hayes, (1994), Lifetime and 12-month Prevalence of DSM-III-R Psychiatric Disorders in This reduction in anxiety was not the Bergan and Romano (1998) who the United States, Archives of General goal of therapy, but was a pleasant showed that ACT increases therapist Psychiatry, 51 (Jan 1994): 8–19. by-product. This illustrates how ACT effectiveness and Hayes et al (2004) Strosahl, K. D., Hayes, S. C., Bergan, J., can result in good symptom reduction who showed that it reduces burnout. If & Romano, P. (1998). Does field based without ever aiming for it. First, a lot I had to summarise ACT on a t-shirt, training in behavior therapy improve of exposure took place, as Michael it would read: ‘Embrace your demons, clinical effectiveness? Evidence from the engaged in increasingly challenging and follow your heart.’ Acceptance and Commitment Therapy social situations. It is well known that References training project. Behavior Therapy, 29, 35–64. exposure frequently can lead to reduced anxiety. Second, the more accepting Bach, P. & Hayes, Steven C. (2002). The Twohig, M. P., Hayes, S. C., Masuda, use of Acceptance and Commitment Michael became of his unwanted A. (2006). Increasing willingness to Therapy to prevent the rehospitalisation experience obsessions: Acceptance and thoughts and feelings, the less of psychotic patients: a randomized Commitment Therapy as a treatment for anxiety he had about those thoughts controlled trial. Journal of Consulting and obsessive compulsive disorder. Behavior and feelings. Indeed, practising Clinical Psychology, 70, 1129–1139. Therapy, 37:1, 3–13. mindfulness of unwanted thoughts and Bond, F. W. & Bunce, D. (2000). Mediators Zettle, R. D., & Raines, J. C. (1989). feelings is a form of exposure in itself. of change in emotion-focused and problem- Group cognitive and contextual therapies The ACT therapeutic relationship focused worksite stress management in treatment of depression. Journal of interventions. Journal of Occupational Clinical Psychology, 45, 438-445. Health Psychology, 5, 156-163. ACT training helps therapists to develop the essential qualities of Branstetter, A. D., Wilson, K. G., compassion, acceptance, , Hildebrandt, M., & Mutch, D. (2004). Improving psychological adjustment respect, and the ability to stay among cancer patients:ACT and CBT. psychologically present even in the Paper presented at the Association for midst of strong emotions. Furthermore, Advancement of Behavior Therapy, New ACT teaches therapists that, thanks Orleans. to human language, they are in the Chiles J., and Strosahl, K. (1995), same boat as their clients—so they The Suicidal Patient: Principles Of don’t need to be enlightened beings or Assessment, Treatment, and Case Management, American Psychiatric Press, to ‘have it all together’. In fact, they Washington, DC. might say to their clients something

AUTHOR NOTES

RUSSELL HARRIS M.D. is a medical practitioner and psychotherapist in private practice in Melbourne. He provides training in ACT and is the author of ‘The Trap’, due for release in March 2007. Comments: [email protected]

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