Problems with acceptance are likely to be detected very early in treatment, as most clients come to treatment with an explicit agenda of avoiding or getting rid of unwanted thoughts and feelings. However, problems with acceptance may also show up later in treatment as progress is made. For instance, a client who enters treatment with social anxiety may make progress on accepting anxiety, and as she commits to interacting with others, she may find new phenomena to avoid, such as fear of being rejected or fear of intimacy. She may not be willing to accept the discomfort arising from “making others feel bad” when she turns down social invitations that don’t interest her. So while
problems with acceptance are likely to show up early in treatment, the therapist—and the client—should be on the lookout for them at all times.
Client behaviors that might suggest difficulty with acceptance include these:
Clients state the explicit goal of eliminating private events. Early in
therapy, many clients say, “I don’t want to feel sad (angry, nervous) anymore.” A slightly broader eliminative agenda can also be suggested by the client, such as “When this depression goes away, then I can get on with my life” or, more perniciously, “I just want to be happy.”
Clients also explicitly state frequent avoidance behaviors justified by
private events, such as “When I start feeling anxious, I have to leave.” Clients describe thoughts and feelings as causes of behavior; for example,
“I can’t make a new relationship work because I can’t stop thinking about my ex.”
Defusion
Defusion is a term coined by Hayes and colleagues (1999) describing the attempt to
reduce cognitive fusion, or the impact of the transformation of stimulus functions when a client is presented with a verbal event. The defusion process aims to disconnect (de-fuse) the person’s behavior from the stimulus control of the words. Defusion prac- tices are useful in their own right, and are often integrated into acceptance, contact- with-the-present-moment, and perspective-taking work. Cognitive fusion occurs when people fail to distinguish things from descriptions of things, including distinguishing themselves from their thoughts and feelings (see chapter 6). For example, instead of experiencing the thought “The future is bleak” as merely a thought, Rick is fused with the thought and regards the thought “The future is bleak” as if it were the same as the lived experience of a bleak future. Instead of experiencing “I’m a loser” as an evaluation, Rick experiences it as a truth about himself. He is fused with his thoughts.
Defusion means changing one’s relationship to thoughts and feelings. From a func- tional contextual perspective, thoughts and feelings are seen as psychological content, and defusion allows one to distinguish oneself from that content (Hayes et al., 1999, p. 73). When not fused with his thoughts, Rick is able to see his thoughts as thoughts and evaluations as evaluations. They are mere verbal content that shows up in certain situations and that he has little control over. Though the distinction between being fused with a thought versus seeing it as content seems subtle, the difference can have a massive impact on how one experiences events. In Rick’s case, when “the future is bleak” is treated as a definite statement that corresponds to the physical, nonarbitrary world, there is little incentive to change his behavior. From the functional contextual viewpoint, he has verbally cast his future as bereft of reinforcers, and the transformation of stimulus functions from this verbal event leads to a narrowed repertoire. When “the
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future is bleak” is merely received as a thought, Rick may be more willing to broaden his behavior instead of doing more of the same. With the defused stance, the transformation of stimulus functions of a bleak future does not govern his behavior.
Consider Rick’s notion of a bleak future. The future, by definition, is not here now. And yet, when fused with “The future is bleak,” Rick responds to events here/now in relation to the verbalized “bleak future” that isn’t and can’t be here now. This fusion can have destructive consequences. For another example, suppose a person we’ll call Susan was fused with the thought “I have the winning lottery ticket”—that is, Susan responds to the thought “I have the winning lottery ticket” in same manner as if she actually held the winning lottery ticket. She might quit her job, go on a shopping spree, give away money, and behave with respect to her finances as if millions of dollars would be coming her way shortly. Contrast this with her behavior if she noticed that she merely had the thought “I have the winning lottery ticket.” In that case, she might go to work, pay her bills, and budget her money while perhaps imagining what it would be like to actually win the lottery.
At a glance, this example may seem fanciful. No one would act as if they won the lottery just because they thought “I have the winning lottery ticket.” Is it really that much different from what we see our clients do (and maybe what we secretly do) when fused with thoughts and feelings? Being fused with “The future is bleak,” “No one likes me,” “I will have a panic attack if I go to the store,” “I can’t stand this pain any longer,” or “This depression is never going to end” is not substantively different from being fused with a thought such as “I have the winning lottery ticket.” Fusion with more bizarre thought content, such as thinking “I have the winning lottery ticket” when one does not or being fused with thoughts such as “They are all out to get me” or “I am not really alive” may be what distinguishes delusional beliefs from merely odd thoughts that show up now and again (Bach, 2005). The experience of responding to a fused thought (“The future is bleak”) as compared to responding to a defused thought (“I am having the thought that the future is bleak”) is quite different. Similarly, fusion to “No one likes me” is qualitatively different from the defused “I am having the thought that no one likes me.” Is the thought the problem, or is the client’s relationship to the thought the problem? The following exercise provides some of the answer.
In the above exercise, did you find the positive or negative self-evaluations more dif- ficult? If you are like most people, you probably found yourself resisting both the extreme positive and the extreme negative statements. And if you were able to have them all without resisting them, great, you are already good at defusion! Now say to yourself, “I am great at defusion” and “I am the greatest at defusion.” The point is, when we get entangled with content, it doesn’t much matter whether it is positive or negative. Fusion is fusion, and if a person is fused with thoughts, they are likely to struggle with positive and negative thoughts alike. For example, Shandra feels guilty when she thinks about her children’s problems and blames herself for causing those problems. She even feels guilty when she notices that she has not been thinking about her children’s problems because then she feels like a bad mother for not worrying more about their problems. She can’t win at this level of content. Defusion is not about changing thought content; it is about changing the client’s relationship to private events.