Because of the shared focus on increasing follow-through with commit-ted behaviour, many therapists wonder about the similarities and dif-ferences between ACT and behavioural activation (Martell et al., 2010) for depression. A basic analysis demonstrates that both approaches underscore a focus on committed action, and both therapies endeavour to get people in touch with the reinforcing qualities (e.g. a sense of com-pletion and satisfaction, natural social contingencies) of taking action.
However, behavioural activation does not include an emphasis on those actions being directed by the client’s values, and only ACT includes the focus on defusion, willingness and self-as-context (Zettle, 2007).
Although behavioural activation does not explicitly teach mindfulness, it does suggest that ‘attending to experience’ is a strategy that can be practised as an alternative to rumination (Martell et al., 2001). Thus, the theories and methods of behavioural activation and ACT are cer-tainly consistent with one another; however, the rationale for engag-ing in committed action and the centrality of behavioural action in each approach is slightly different. (For a further analysis of the simi-larities and differences between these two behavioural treatments, see Kanter et al. [2006].)
As was described in Chapter 8, it is useful to look for potential barri-ers to clients being willing to move forward with their lives, and this is certainly true when working with depressed individuals. Many depressed clients have become invested not just in their story of what has led to their depression, but also in fulfilling the role of the ‘martyr’ (Zettle, 2004). For those clients who see suffering as part of their identity (see the life story above as one example), it can be difficult to let the martyr status go, in the service of moving forward with life. Similarly, for those individuals who have been wronged or truly harmed by others, it can also be extremely difficult to let go of what may be very valid resent-ments that have defined the client’s identity and major life choices over time. For this reason, Strosahl (2004) has conceptualized forgiveness as an act of willingness. From an ACT perspective, the goal of forgiveness is not to forget what happened or imply that what has happened was good or right. However, if the client is living her life in order to prove that she was wronged by a specific person or by life circumstances, then
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she can’t live her life in a way that moves it forward in the service of her values. Choosing forgiveness is about setting yourself free, so that you can move on with your own life.
As implied throughout this chapter, it takes strong clinical skills to be able to work on these issues with depressed clients without invalidating their very real experiences and losses. None of this work can be done without first building a trusting, compassionate therapeutic relation-ship. Compassion does not always mean being soft though. The ACT therapist can demonstrate immense compassion for the client by always bringing choices back to workability and demonstrating that the most important thing is helping the client to move on from her suffering and reclaim her life now!
The ACT model conceptualizes both depression and suicidal behaviours as serving to help an individual escape from private events that are painful or aversive. However, when this strategy becomes the characteristic way that the individual interacts with the environment, it can lead to notable constrictions on values-based behaviour. When working with depressed clients, the ACT therapist uses all of the core processes of ACT to help the client come into contact with the present, defuse from thoughts and conceptions that are not helpful, increase willingness to experience the full range of private events and re-engage with valued living.
• Describe how the ACT conceptualization of depression indicates a focus on each of the ACT core processes: willingness, defusion, present-moment awareness, self-as-context, values and committed action.
• What is the goal of the Life Story exercise? How would you approach this exercise with clients so that they would not feel invalidated by the suggestion that their lives could possibly be different?
• Try the life story exercise for yourself. What do you notice about that experience?
• Describe two differences between the practices of ACT and behavioural activation for depression.
Chiles, J. and Strosahl, K. (2004) Handbook for the Clinical Assessment and Treatment of the Suicidal Patient. Washington, DC: American Psychiatric Press.
Points for Review and Reflection Summary
Further Reading
(Continued)
94 essentials of Acceptance and Commitment Therapy
Kanter, J.W., Baruch, D.E. and Gaynor, S.T. (2006) Acceptance and Commitment Therapy and behavioural activation for the treatment of depression: description and comparison. The Behaviour Analyst, 29: 161–85.
Strosahl, K.D. and Robinson, P. J. (2008) The Mindfulness and Acceptance Workbook for Depression: Using Acceptance and Commitment Therapy to Move through Depression and Create a Life Worth Living. Oakland, CA: New Harbinger Publications.
Twohig, M.P. (2008) ACT Verbatim for Depression and Anxiety. Oakland, CA:
New Harbinger Publications.
Zettle, R.D. (2007) ACT for Depression: A Clinician’s Guide to Using Acceptance and Commitment Therapy in Treating Depression. Oakland, CA: New Harbinger Publications.
(Continued)
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• Problematic substance use behaviours can be conceptualized within a framework of experiential avoidance.
• The ACT approach to the treatment of substance abuse focuses less on abstinence or substance use reduction as goals unto themselves, and more on how to return the client to a present-moment focus that allows for committed action based on the client’s values.
• ACT can facilitate the treatment of substance use that is comorbid with anxiety, depression or a myriad of other problems, because each of these problems can be seen together as experiential avoidance disorders, rather than as distinct problems requiring separate interventions.
As with the other disorders highlighted in this text, substance use disorders are highly prevalent and can be conceptualized easily within an experi-ential avoidance framework. There is a growing body of evidence that suggests that individuals use substances as a way to try to regulate neg-ative private events and that substance abuse is frequently a form of emotional avoidance, especially for those with high levels of anxiety symptoms (e.g. Armeli et al., 2003; Bonn-Miller et al., 2010; Stewart and Zeitlin, 1995). Although initial forays into substance use by some indi-viduals may be primarily related to attempts to chase positive mood states, by the time that people present for treatment in a clinical set-ting, this balance has often tipped more significantly toward avoiding negative private events.
In addition to evidence that substance use is correlated with experiential avoidance (Forsyth et al., 2003), multiple treatment studies also reinforce