It is sometime in the fall of 2000, and Robyn Walser and I are conducting an ACT group for female veterans participating in a ninety- day residential treatment program for Post- Traumatic Stress Disorder (PTSD). For me, this represents doing ACT, at last, rather than just researching or reading about it. Robyn opens the session, and I listen carefully as she navigates the trickiness of gaining informed consent for a therapy that is hard to explain in advance. I sit back and observe as she skillfully presents the unworkability of the control agenda and the futility of trying to be “more, better, dif- ferent.” I take on the “man- in- the- hole” metaphor and find that I didn’t understand it quite as well as I thought I did. I look invitingly at Robyn and she steps in and makes it all make sense. Soon after, someone in the group asks me a question I didn’t expect; I look at Robyn expectantly. She handles it with ease. Later on, someone suggests this
Let the Theory Guide the Way
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therapy is a waste of time. I look at Robyn… .You get the idea. This tendency hung around for a while, too. “You say nothing’s worked but I’ve been sober for fifteen years now!” (Look at Robyn.) “Why is the bus driver the only one who can drive the bus?” (Look at Robyn.) “So I’m supposed to just be okay with what happened?” (Look at Robyn.) And I might as well go ahead and confess that what seemed important in those moments was to conceal my own unknowing— to look as though I was simply being collaborative rather than unsure of what to do. And all this while earnestly hoping to help the group see that attempting to control unwanted thoughts and feel- ings is problematic and unnecessary!There were several missteps here. One was to forget that the behavioral prin- ciples behind ACT applied to me as much as anyone else in the room, which meant I also missed the fact that I was fused with what my mind was telling me (not knowing = incompetence = bad). Another misstep was trying to address content rather than core ACT processes, and a third involved attempting to teach one thing (such as will- ingness) while doing the other (such as avoidance). All of these responses were moving away from the model, although I didn’t realize that at the time. As we will see as we explore the therapy together in this book, these sorts of missteps are easy to make, and can usually be resolved by returning to the core principles of ACT and operating from there. However, it can be a real challenge for therapists to avoid these sorts of missteps and darn near impossible if they haven’t fully bought into the theory in the first place.
I once worked with a supervisee who was up-front about having this sort of ambivalence prior to starting the therapy. This particular supervisee had a lot of train- ing and experience in cognitive behavioral therapy, and explained that even though he understood the theory behind ACT he just wasn’t “sold on the notion that it was always a bad idea to try to improve thinking that was clearly distorted.” Fair enough. Rather than try to persuade him to have different thoughts about ACT, I talked with him about how his position could potentially affect the therapy, particularly in terms of sending mixed messages to the client. We agreed to move forward, with the supervisee holding his ambivalence lightly as he strove to remain consistent with the model while in session.
We found that a certain type of misstep tended to occur. As an example, my supervisee would do a nice job of setting up a cognitive defusion exercise or a self- as- context metaphor, but if you listened closely you would hear that the point being put forth, to help the client have a “different perspective,” was actually about helping the client have a different (improved) thought process altogether, rather than learning to observe and simply experience whatever thoughts showed up. I think most of us can relate to feeling tempted to help our clients with thoughts that seem particularly “irra- tional” and needlessly painful, but if we allow ourselves to dip into content willy- nilly, tweaking this interpretation here and that conclusion there, we risk aligning with the very strategies that got the client stuck in the first place. What we are doing in such moments flies in the face of what ACT has to offer. However, these things can slip in despite our best efforts, and it is difficult to imagine being able to really stay the course if you aren’t fully on board with the theory.
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Advanced ACTBack to my supervisee: While perfectly pleasant, the sessions also lacked that “ACT feel,” the genuine connection, vitality, and authenticity that is present when ACT is done well. The consultee couldn’t get himself “in the room” in an authentic way. He was attached to his own verbal rules rather than present to the interactions unfolding in sessions.
Ultimately, there is no half- in with ACT because being half- out contradicts the “in” part, not just theoretically but in terms of what happens during the course of therapy. The consequences of not understanding or not buying into the theoretical underpinnings of ACT range from being completely adrift in sessions— as though you are on a sailboat without a rudder, buffeted and blown about by the content of the moment— to directly contradicting and working against yourself, to conducting a sort of tepid, in- the- head therapy with little clinical oomph. All these struggles will be explored in subsequent sections of this book.
I have stressed the importance of understanding and buying into the theoretical underpinnings of ACT, which in turn determines how the therapy is approached, both overall and in each individual session. These ideas form a fundamental component of any ACT text. Most of the trainees and consultees I’ve worked with get these ideas; most agree they make sense. And yet there can still be a disconnect between under- standing these precepts and keeping them front and center during the course of the therapy. It’s actually very understandable— there is a lot of content to ACT, lots of ideas that need to be conveyed, lots of metaphors to cover, lots of exercises to explain and process. We get hooked into all that and our minds start handing us rules about how it all needs to be mastered. Before we know it we’re caught up in the “what” rather than the “why.” As I wrote this last sentence I became aware of an image flitting through my mind— that of a fish trying to snap up a shiny and particularly enticing lure. This is what my mind does with the things clients say in session—it wants to address (expertly, of course) what has been said, rather than focusing on the function of what was just said. It is important that the fish sees the lure for what it is and that someone is fishing.