My first year as a full-time therapist was a wild ride. I heard stories about trauma, abuse, addiction, and pain that eclipsed what I ever could have imagined. I wanted so badly not to be "new" because I didn't want any of my clients to feel short-changed in their treatment experience, and I explored and tried on new things as I started to learn what theories made the most sense to me, what interventions seemed most effective, and how to bring myself and my own personal "style" into the relationship with my clients both in groups and individual work. I encountered my own demons of insecurity, perfectionism, and anxiety, many times over.
Getting to know myself as a therapist -- which truly feels like an intersection of art and science -- has been an interesting and sometimes intimidating part of the job. I have come a long way already, and I know I will continue to evolve throughout my career just as I will in my personal life. Thankfully, I have gotten better at knowing what to do for myself when that perfectionism and anxiety show up, and -- as my supervisor likes to say, "allowing myself to be a young therapist." So the second year of the journey was more interesting than intimidating, most of the time.
Earlier this year, I stumbled into Acceptance & Commitment Therapy, or ACT (pronounced like the word, not the letters). I had heard of it in passing before, and I can't remember now what it was this year that first got me hooked (ACT people will appreciate the pun there), as I've since listened to dozens of interviews and podcasts and read several books on ACT. But whatever it was, I remember clearly at one point saying to myself, "YES! This makes SO much sense to me. This is what I've been waiting for. This is my thing. I found it!" (Also one of the cool things about ACT is that it is compatible with numerous other types of effective therapy models that I already use with clients, and it named a lot of the things I used but had no words for!)
I was thrilled to feel like I had found my identity as a therapist -- a way to clearly conceptualize client issues and choose effective interventions. To help people make sense of their experiences and know how to do what makes their lives work even alongside inevitable challenges and pain.
Another cool thing about ACT is that all of its principles can be used in the self-help format, and ACT takes the stance that clinicians are not these enlightened, perfectly sane and healthy beings, but rather are just regular people going through a parallel journey in life who experience their own pain and challenges, too. ACT uses a lot of metaphors, and the "two mountains" metaphor is helpful way of illustrating how therapist and client work side-by-side along the healing journey.
"It’s like you’re in the process of climbing up a big mountain that has lots of dangerous places on it. My job is to watch out for you and shout out directions if I can see places you might slip or hurt yourself. But I’m not able to do this because I’m standing at the top of your mountain, looking down at you. If I’m able to help you climb your mountain, it’s because I’m on my own mountain, just across a valley. I don’t have to know anything about exactly what it feels like to climb your mountain to see where you are about to step, and what might be a better path for you to take." (1)
At this point, I owe you a definition of ACT! Russ Harris, clinician and author of numerous ACT books, defines it like this:
"Acceptance and Commitment Therapy (ACT) gets it name from one of its core messages: accept what is out of your personal control, and commit to action that improves and enriches your life. The aim of ACT is to maximize human potential for a rich, full and meaningful life. ACT (which is pronounced as the word 'act', not as the initials) does this by: A) teaching you psychological skills to deal with your painful thoughts and feelings effectively - in such a way that they have much less impact and influence over you (these are known as mindfulness skills). B) helping you to clarify what is truly important and meaningful to you - i.e your values - then use that knowledge to guide, inspire and motivate you to change your life for the better."
Harris wrote a great non-technical overview of ACT you can read here, and one of ACT's co-founders Steve Hayes has another helpful and easy-to-read overview of it here. Steve was one of the main presenters at the ACT Bootcamp I attended in September, and I appreciated that he was both brilliant and humble. Please check out one of these articles if you're interested in ACT, because this post does not serve well as a comprehensive overview!
Unlike many other types of therapy, ACT's main goal is is not symptom reduction (i.e. stop bingeing/purging, stop feeling anxious, stop drinking). The goal is increasing Psychological Flexibility in the service of living a meaningful life. You can find lots of definitions of Psychological Flexibility (every ACT practitioner will take their own spin with it), but the crux of it involves “contacting the present moment fully as a conscious human being, and based on what the situation affords, changing or persisting in behavior in the service of chosen values."
Basically, it means being able to do the things that make our life work, without getting into familiar self-sabotaging patterns of behavior (acting on destructive impulses, excessive procrastinating, etc.) that we know don't work for us. So, "what works" is certainly sensitive to the context, and ultimately the goal is to connect with a rich, full, and meaningful life -- and sure, along the way, you may very well see "negative symptoms" reduce, but that's not really the main goal.
ACT uses a diagram called the Hexaflex to illustrate its six core processes that foster Psychological Flexibility. (It's also helpful to know what the opposite of these are, or what "psychological inflexibility" looks like, which the image linked above shows.)
I firmly believe that Experiential Avoidance and Fusion in particular account for a huge percent of suffering in modern society. Almost all of my clients have gotten to treatment because the ways that they learned to avoid or numb out their painful thoughts and feelings had stopped working and had started creating problems of their own -- enter drug addiction, eating disorders, self-harm, and so on. And internal misery is so often a result of becoming "fused" with thoughts that we cannot see past -- we forget that thoughts are merely a collection of words and pictures(2), and we give them free reign to control our lives.
Kelly Wilson (another ACT co-founder, and wonderful author/teacher), summarizes well what ACT has to offer in his book on ACT for substance abuse, The Wisdom to Know the Difference:
"In this very moment, will you accept the sad and the sweet, hold lightly your stories about what is possible, and be the author of a life that has meaning and purpose for you, turning in kindness back to that life when you find yourself moving away from it?"
My answer is yes.
And I know it won't always feel good. For me, the "turning back in kindness" part is a continual practice. I certainly take actions in my daily life that move me away from my values, but each time I become aware that has occurred in some small or not-so-small way, I will practice turning back in kindness: "Hey, self. Probably not great that you sat here and picked at your fingernails for 10 minutes. You're okay, though. How about going for a walk?" A far cry from my old internal dialogue that sounded more like, "God, seriously? You did it again? Way to go, genius. You'll never learn." -- and, as you can imagine, wouldn't typically lead to taking effective action toward something I care about.
What's your answer?
(1) Twohig, M. (2004). ACT for OCD: Abbreviated Treatment Manual
(2) This is by no means meant to trivialize the internal pain that many people are in, or the seriousness of the content of some thoughts, especially of trauma survivors. Yet, ultimately if people are unable to defuse from unhelpful thoughts, those thoughts will control the person's life. Practicing defusion in situations like that must be done delicately and with true acknowledgment and reverence for the person's painful experiences.
(3) Adapted from Russ Harris's Triflex
Hexaflex diagrams adapted from Hayes et al, 2006