ACT (Acceptance and Commitment Therapy)

Sources: Russ Harris, The Happiness Trap, Russ Harris, ACT Made Simple; Timothy Gordon & Jessica Borushok, The ACT Approach: A Comprehensive Guide for Acceptance & Commitment Therapy

Worksheets: ACT Made Simple; The ACT Approach

Happiness/Suffering. ACT holds that happiness is not our natural state (e.g., look at the statistics showing sky-high rates of depression and overall mental illness). Natural selection designed us to be on the constant lookout for danger; it also designed us to conform to group norms and freak out if we're not fitting in. Put differently, psychological suffering is part of human existence. (Happiness Trap)

Overview. The aim of ACT is "to create a rich, full, and meaningful life while accepting the pain that inevitably goes with it." This describes psychological flexibility (elsewhere defined as "the ability to be in the present moment with full awareness and openness to our experience, and to take action guided by our values"). (ACT Made Simple)

The Hexaflex (ACT's Core Processes)

1. Defusion means learning to “step back” and separate or detach from our thoughts, images, and memories.
2. Acceptance means opening up and making room for painful feelings, sensations, urges, and emotions.
3. Contacting the present moment means being psychologically present: consciously connecting with and engaging in whatever is happening in this moment.
4. Self-as-context refers to the observing self rather than the thinking self.
5. Values are desired qualities of ongoing action. In other words, they describe how we want to behave on an ongoing basis.
6. Committed action means taking effective action, guided by our values. (ACT Made Simple)

The ACT Triflex:

A = Accept your thoughts and feelings, and be present.  

C = Choose a valid direction.

T = Take action. (ACT Made Simple)

Suffering shuts us down, leading to depression, etc., when we engage in cognitive fusion or experiential avoidance. Cognitive fusion is the state of being "inseparable from our thoughts," being "so caught up in [them] that we lose contact with the world of direct experience," believing them to be ultimate truth. Example: "I'm a bad mom." When we engage in cognitive defusion, we recognize that our thoughts are simply words and pictures and might not be true. (Happiness Trap)

Experiential avoidance means "trying to avoid, get rid of, suppress, or escape from unwanted 'private experiences.'" "The more time and energy we spend trying to avoid or get rid of unwanted private experiences, the more we’re likely to suffer psychologically in the long run. Anxiety disorders provide a good example." The opposite of avoidance is acceptance, which means that not only do we simply tolerate a situation but we're not distressed by it. "Acceptance doesn't mean you have to like your uncomfortable thoughts and feelings; it just means you stop struggling with them. When you stop wasting your energy on trying to change, avoid, or get rid of them, you can put that energy into something more useful instead." (ACT Made Simple)

ACT doesn't so much care if a thought is true or false but whether it's helpful or workable. It's all about workability. You don't have to be mindful all the time, and there are times when it's okay to practice cognitive fusion and experiential avoidance. There are times when it's okay to try to change your thoughts, etc.

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Getting Started

Worksheet: Mapping Your Life Map

Five Questions to Set Up the Life Map:

1. Who and what is most important to you?
2. What gets in the way of moving toward who and what matters most to you?
3. What do you do to move away from those difficult inner experiences?
4. What are you doing or what do you want to be doing to move toward who and what is the most important to you?
5. Notice the difference? (ACT Approach)

Case Conceptualization Questions:

1. Defusion: What thoughts, sensations, memories, or feelings does this client take as literal?
2. Acceptance: In what way is this client attempting to avoid/escape their experience in problematic ways?
3. Present Moment: Is this client present with their experience? Are they stuck in the past or future?
4. Pure Awareness: What stuck stories does this client have about themselves?
5. Values: Who and what is most important to this client?
6. Commitment: What behaviors is this client already doing or could they be doing to move toward who and what is most important to them? (ACT Approach)

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Defusion (Watch Your Thinking)

• In Plain Language: Fusion means getting caught up in our thoughts and allowing them to dominate our behavior. Defusion means separating or distancing from our thoughts, letting them come and go instead of being caught up in them. 
• Aim: To see the true nature of thoughts: they are nothing more or less than words and pictures; and to respond to thoughts in terms of workability rather than literality (that is, in terms of how helpful they are rather than how true they are).
• Method: Notice the process of thinking; learn experientially that our thoughts do not control our actions. (ACT Made Simple)

Vincent Greenwood. The problem with cognitive fusion is that we lose the ability to separate our thoughts from reality. For example, we start to believe that the thought "I'm stupid" is true and not simply an opinion. We can also use cognitive defusion when our attempts to challenge a thought haven't worked.

Defusion techniques:

• I'm Having the Thought That... (a) Begin with thought "I am X" (e.g., "I am a loser"). (b) Now in front of that thought put "I'm having the thought that..." (e.g., "I'm having the thought that I am a loser") (c) Now in front of that second thought put "I notice I'm having the thought that..." (e.g., "I notice I'm having the thought that I am a loser"). (ACT Made Simple)
• Singing. (a) Think of a negative self-judgment (e.g., "I'm such an idiot"). (b) Think about it and try to believe it for ten seconds. (c) Silently sing the thought to the tune of "Happy Birthday." (d) Again think about the thought and try to believe it for ten seconds. (e) Silently sing the thought to the tune of "Jingle Bells." (f) Notice that you're no longer taking the thought as seriously. (Happiness Trap)
• Silly Voices. (a) Find a troubling thought and believe it as much as possible for ten seconds. (b) Have a cartoon character (e.g., Mickey Mouse) voice the thought. (c) Again believe the thought as much as possible. (d) Have a different cartoon character voice the thought. (d) Now you're probably not taking the thought as seriously. (Happiness Trap)
• Name your mind's favorite stories -- e.g., " the "my life sucks!" story or the "nobody likes me" story. When the story shows up, you "don't have to challenge it or push it away, nor do you have to give it much attention. Simply let it come and go as it pleases, while you channel your energy into doing something you value." Example: "Aha! Here comes the 'I can't cope' story." (Happiness Trap)
• Titchener's Repition. (a) Pick a noun (e.g., lemon) and say it aloud once or twice and notice what images come to mind. (b) Repeat the word over and over aloud as fast as possible for 30 seconds -- until it becomes a meaningless sound. (c) Repeat the exercise but with an evocative judgmental word like "incompetent" or "bad mother." (ACT Made Simple)
• If you notice a negative thought, simply observe it as a scientist would, not judging it to be good or bad. (Happiness Trap)
• ACT Improv (need cards) (ACT Approach)

A hook is "any experience that impacts our behavior." Worksheet: Know Your Hooks.

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Acceptance (Open Up)

• In Plain Language: Acceptance means allowing our thoughts and feelings to be as they are, regardless of whether they are pleasant or painful; opening up and making room for them; dropping the struggle with them; and letting them come and go as they naturally do. [It does not mean liking those private events.]
• Aim: To allow ourselves to have painful private experiences if and when doing so enables us to act on our values."
• Method: Make full, open, undefended psychological contact with unwanted private experiences.

Worksheets: Your Avoidance & Control; Your Avoidance & Control Strategies; Escape Avoidance & Control Strategies

Acceptance or expansion means making room for your emotions. You need to use the observing self; you need to observe your emotions, not think about them. Four steps of expansion. (1) Observe the uncomfortable sensations in your body (caused by the emotion). (2) Take slow, deep breaths. Imagine your breath flowing into and around the uncomfortable sensations. (3) When you breath in, it feels as though you're creating more space around the sensation. (4) Allow the sensation to be there. Once you go through these four steps, see if your body has another uncomfortable sensation, and if so, practice the four steps on that sensation. (Happiness Trap)

The Choice to Feel. "Suppose I could give you a choice. Option A: You never have to feel this painful feeling ever again -- ever. But it means you lose all capacity to love and care. You care about nothing and no one. Nothing matters. No one matters. Life becomes meaningless because you don't care about anything whatsoever. Option B: You get to love and care. People matter to you. Life matters. You care about what you do, and what happens. You care about friends and family. You get to build loving relationships. Life becomes meaningful. And when there's a gap between what you want and what you've got, painful feelings like this one will show up. Which option do you choose?" (ACT Made Simple)

Exercise to help bring together information you're collecting about client's experiential avoidance behaviors: "Which Life Would You Choose?" (ACT Approach).

What to do with urges. Urge Surfing. (1) Observe it. Notice where you feel it in your body. (2) Acknowledge, "I'm having the urge to do X." (3) Breathe into it and make room for it. (Don't try to suppress it.) (4) Watch the urge as it rises, crests, and falls. It might be helpful to score the urge on a scale of 1-10 -- e.g., "I'm having the urge to smoke, and it's now a 7." Keep checking on the urge and notice whether it's rising or falling. (5) Check in with your values. Ask, "What action can I take right now -- instead of trying to control my urges -- that will enhance my life in the long term?"

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Contact with the Present Moment (Be Here Now)

• In Plain Language: Contact with the present moment means being in the here and now, fully conscious our experience, instead of being lost in our thoughts. It involves flexibly paying attention to both the inner psychological world and the outer material world. 
• Aim: To enhance conscious awareness of our experience in the present moment, so we can perceive accurately what's happening, and gather important information about whether to change or persist in behavior. 
• Method: Notice what is happening here and now; discriminate between noticing and thinking.
• When to Use: When clients are overly preoccupied with the past or future, acting impulsively or mindlessly, "disconnected" in their relationships, lacking in self-awareness, or otherwise out of contact with their here and now experience.

One technique. "[W]hen a client reports to you that their 'brother-in-law is an asshole,' we might empathize and validate their frustration but more importantly, we focus on what happens for this client when the thought occurs to them" (ACT Approach).

Mindfulness. There's a difference between thinking and observing. Harris recommends a standard mindfulness activity -- take ten deep breaths, focus on breaths, then observe thoughts, letting them go. Harris also encourages being mindful during different activities -- e.g., doing chores, doing something pleasant. He calls this "connecting." (Happiness Trap)

Worksheet: Mindfulness of Breath; How to Practice Mindfulness; Body Scan for Mindfulness; Guided Imagery; Connecting to Your Future Self

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Self-as-Context (Pure Awareness)

• In Plain Language: Self-as-context is not a thought or a feeling but a "viewpoint" from which we can observe thoughts and feelings, and a "space" in which those thoughts and feelings can move. We access this "psychological space" through noticing what we are noticing... It is a "place" from which we can observe our experience without being caught up in it. 
• Aim: To connect connect with a transcendent sense of the self that is separate from thought and feelings, and the provides a safe and constant viewpoint from which to observe and accept themallow ourselves to have painful private experiences if and when doing so enables us to act on our values."
• Method: Most mindfulness practices lead to this; this is enhanced by exercises directly attention to one's consciousness.

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Values (Know What Matters). Values "describe how we want to behave on an ongoing basis." 

Usually talk about values in first session (ACT Approach). 

Can use Values Cards. One card at a time, client states whether he/she values item on each card.

Different areas of our values: work/education, leisure, personal growth/health, relationships.


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Committed Action (Do What It Takes). "Committed action means taking effective action, guided by our values." Put differently, "committed action means 'doing what it takes' to live by our values even if that brings up pain and discomfort." (ACT Made Simple)

Worksheets: Powerful Questions to Clarify the Life You Choose, Two Ways of Being Mindful (way to visualize living by your values), Mindful Walking, SMART Goals, Purposeful STEPS

Worksheets: Working Together (for couples), worksheets for children.