Acceptance and Commitment Therapy – Part II of II

Self as Context

The concept of observing self or self as context refers to the perception of a universal self that is detached from behaviors and private experiences. It is the viewpoint from which we view our inner experiences (Hayes et al., 2006). It is simply the recognition of a self that notices everything else. Understanding the presence of an observing self is very helpful for clients; as it helps them realize that they exist separate from their actions or experiences. As a result they learn to identify their values and move through the flow of their experiences without attaching to them or becoming them. So a client experiencing a shame-filled thought is being separate from the thought. Clients experience many thoughts throughout their day or even life; some are shame-based while others are not. The goal is to realize that these thoughts are merely mental events or things the client is experiencing, therefore they cannot harm or change clients at the core of who they are. A common exercise that can bring awareness to one’s own consciousness is asking, “who is the one noticing” while performing mindfulness activities.

Values

According to Hayes (2006), values are chosen qualities that shape an individual’s life direction and can be lived in the present moment. They are what motivate the client’s committed action. The goal here is to help clients identify their values so they can build paths towards more fulfilling and satisfying lives. Some useful questions to discover values are, “What does this pain tell you about the kind of person you want to be?” “What do you want your life to be about?” or “How is your response to this pain/negative feeling helping you live out your values in the present moment?” A good example is a client who is experiencing shame-filled thoughts and as a result isolates from social interaction, but identifies being a good parent as a value. The therapist can inquire into how social isolation is helpful for the client in terms of being a good parent and what behavior would be more helpful and in line with the value. This kind of awareness can create change in behaviors. 

Committed Action

Once clients have identified their values, they can start to create plans to execute them. It is known as committed action in ACT (Hayes et al., 2006). This process is very similar to behavior therapy in that clients are encouraged to make plans, foresee challenges, and set goals. Clients do this by answering the question, “How can you live a value-driven life in the present while still at times experiencing the feeling of ……… triggered by your past?” When clients encounter obstacles (such as cognitive fusion or avoidance), therapists remind them of their values and utilize the other processes to help them move towards those values. For instance, in case of a client who identifies sobriety as the main goal, ACT techniques can be helpful for the client to accept the things he cannot change (his desire to drink), and change the things he can  (reach identified values). The client can identify his values and figure out the choices he would need to make to live those values out. If an identified value is maintaining the current relationship with his girlfriend and being a caring and supportive boyfriend, the client might find that he is better able to be that kind of a man when he is sober. So being sober is the behavior that helps him live in accordance with his values (Hefner et al., 2003).

ACT Techniques

ACT techniques are all focused on increasing the client’s psychological flexibility. There is not one right way to apply ACT, on the contrary, ACT encourages the use of any technique as long as it contributes to the development of the one of the core skills. Some of the most common techniques are metaphors, written exercises, and experiential exercises and they are described below.

Metaphors

Metaphors are mainly used to relate ideas to clients in new ways or to help loosen the rigidity of their thinking. The technique “confronting the system” often includes metaphors that liken the behaviors clients use to protect them from pain to sitting in a hole while attempting to dig out of it, or struggling in quicksand that only makes one sink faster (Hayes, 2004). Another effective metaphor likens accepting distress for the sake of moving towards a valued goal to wading through a swamp. The best way to get through the swamp is to move through it, even though most clients choose to sit in the swamp or fight it. This metaphor highlights how accepting personal experiences (swamp) with psychological flexibility (moving through it) is different from trying to control or eliminate the pain by fighting the swamp (Orsillo & Batten, 2005).

Written Exercises

Written homework, such as a logbook can be helpful for clients in the development of the core six skills (Harris, 2009). Clients can log their mindfulness exercises, where they had difficulties, and how they overcame them. Written exercises can help clients stay accountable for practicing what they learn in session and also to identify their cognitive fusion. A particularly useful written homework can be to list a client’s values, what they find important in life, or even to write their own obituaries. These values then can motivate committed action. Ultimately, the main goal of written exercises is to help clients practice the core skills outside of session.

Experiential Exercises

The most common experiential exercise in ACT is mindfulness. According to Hayes (2004), “mindfulness involves viewing thoughts as simple events in the world rather than viewing the world as being structured by one’s own thoughts”. Clients learn to look at their experiences nonjudgmentally, as an observer or scientist. Through the practice of mindfulness, they also develop acceptance, cognitive defusion, self as context and contact with the present moment (Hayes et al., 2006). Even though mindfulness can be spiritual, it does not have to be. Mindfulness can be practiced by imagining thoughts as leaves on a stream, noticing five things in the room and observing them very closely, or taking ten deep breaths while focusing on the sensation of the breath (Harris, 2009). The challenging part of these exercises is to allow thoughts and feelings to pass by without getting attached to them. Mindfulness also helps clients realize that they have a universal self that is detached and safe from their psychological experiences. This in turn reinforces that they can experience even distressful emotions in a safe way without fear (Hayes, 2004). 

As mentioned before, ACT is a flexible treatment approach that can be customized to the client’s particular needs. As long as interventions are focused on developing the six core skills and do not try to control the client’s private experiences, therapy can be creatively designed and applied.

Acceptance and Commitment Therapy References

Gutierrez, D., & Hagedorn, W.B. (2013). The toxicity of shame applications for Acceptance and Commitment Therapy. Journal of Mental Health Counseling, 35, 43-59.

Hayes, S. C, Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and Commitment Therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44, 1-25. 

Heffner, M., Eifert, G. H., Parker, B. T., Hernandez, D. H., & Sperry, J. A. (2003). Valued directions: Acceptance and Commitment Therapy in the treatment of alcohol dependence. Cognitive and Behavioral Practice, 10, 378-383.

Hayes, S. C. (2004). Acceptance and Commitment Therapy, relational frame theory, and the third wave of behavioral and cognitive therapies. Behavior Therapy, 35, 639-665.

Orsillo, S. M., & Batten, S. V. (2005). Acceptance and Commitment Therapy in the treatment of post- traumatic stress disorder. Behavior Modification, 29, 95-112.

Harris, R. (2009). ACT made simple: An easy-to-read primer on Acceptance and Commitment Therapy. Oakland, CA: New Harbinger Publishing, Inc.