In support of the model described in this chapter, it can be very helpful to have basic worksheets for the client to use to organize goals, actions and barriers in an easy-to-follow format. Examples can be found in Hayes et al. (1999) or on www.contextualpsychology.org. However, it is not required that any specific worksheet or written format must be used when working on commitments. At the same time, it can at least be use-ful to write down what the person commits to doing each week, provid-ing a copy for both client and therapist at the end of each session. This level of public commitment can assist with follow-through in action.
However, the therapist must also ensure that he follows up to ask about the status of the committed actions in the following session. It can be very demoralizing when the therapist forgets or doesn’t bother to ask about whether the client has followed through with the commitment from the past week. ACT therapists obviously work to reduce pliance, even to perceived rules provided by the therapist, but by assisting the client with follow-up, therapists can help model effective ways to moni-tor behaviour and be accountable to oneself. Similarly, if doing this work in group therapy, it can be useful to have each group member (including the therapist) make public commitments and then follow up the next week. Within such a structure, the other members of the group need to also be prepared not to rescue, judge or overly praise the individual based on whether he does or does not follow through with the commit-ment the following week.
The issue of how the therapist can work to respond non-judgementally, regardless of whether or not the client follows through on a given com-mitment, will be addressed in more detail in Chapter 11. However, it is important to clarify the general approach that the ACT therapist takes toward client commitments. The therapist works to clarify that when one makes a commitment, it is not a promise or a prediction that one can make with certainty, but a general stance that is in alignment with con-tributing to a valued life. Even if someone is 100 per cent committed in the moment that the commitment is made, we all fall short sometimes.
It may be useful to return to the metaphor of learning to ride a bicycle referenced earlier in this text. Riding a bicycle requires balance and relies upon the general value of remaining upright, but it is not an all-or-nothing action in which one will always be fully upright. Sometimes the rider will be off balance to one side, sometimes to the other side.
However, it is extremely important that cyclists be committed to remaining upright as a general direction, even though they will hover slightly off
72 essentials of Acceptance and Commitment Therapy
from vertical at multiple times during each ride. Furthermore, if the rider falls, there is another choice point. He can choose to lie on the ground, analysing exactly how he got there, or complaining about the unfairness of the bumps in the road. Or, as with committed action in ACT, he can choose to recognize where he is now and get back up to keep moving in the valued direction. The results of any particular action are never certain; thus, ACT requires a commitment to the process of valued liv-ing and mindful action, not to an unpredictable outcome. In sum, committed action requires a willingness to take risks, when those risks occur in the service of living in a way that is consistent with one’s values.
Furthermore, although commitments are specific and about moving toward a particular goal, they have to be flexible enough to incorporate new information or changes in circumstances without judgement. It may not always appear that one is making progress. Returning to the metaphor of riding a bicycle up a mountain from Chapter 2, if one is rid-ing up a particularly difficult or uncharted path, one may sometimes need to move back down part of the mountain to find another path, rather than doggedly continuing up a path that is treacherous or impassable. The client must learn to have faith that sometimes even moving down the mountain in the short term can be in the service of moving effectively up the mountain in the long term. The effectiveness of any action is not measured solely in one moment. Instead, the client must ask herself on an ongoing basis: if I take this next action, is it in the service of bringing me closer to or further from my chosen values in the long term?
Overall, for commitments to change to be successful, individuals must be willing to accept responsibility for changing their own lives. For some clients, this may mean that they need to recognize any investment they may have in keeping things the way they are. It may seem counter-intuitive that someone would stay stuck or continue to live in ways that are not working if she had other options. However, for some people who have truly been ‘wronged’ by someone else, it can feel like they will let the other individual who has wronged them ‘off the hook’ if they are able to move forward. Most people are not cognizant of the fact that they may be holding on to ‘reasons’ such as this for not taking action to move their lives forward. However, through defusion and metaphor, the skilful ACT therapist can carefully point out these somewhat perverse contingencies for staying stuck without invalidating the client’s truly real and valid pain.
Although the focus on committed action will seem altogether practical and straightforward to some therapists, other therapists who are new to behavioural ways of conducting therapy may not feel comfortable with such a directive style in therapy. Some clinicians do not initially gravi-tate to the commitment component of ACT, because they themselves are
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not as willing to work with clients to pin down specific goals each session.
This is another example of how it is important for therapists to watch their own reactions in the session and ensure that they themselves are not shying away from certain pieces of work that bring up personal feel-ings of discomfort. ACT therapists are reminded that working with the client to identify very specific goals and actions is in the service of the client’s self-defined values, and if the client’s characteristic ways of approaching such circumstances were going to work, they would have done so already. Even very straightforward and directive portions of ACT are in the service of the client’s best interests.
Beyond the metaphors, exercises and tools of ACT, the core of this behavioural therapy involves assisting the client with moving forward with his life in valued ways. The ACT therapist works with each client to identify specific goals that are important destinations along the client’s valued directions. Each goal can be further broken down into clearly defined actions that clients can take to move forward. The ACT model then assists clients with developing plans to address both internal and external barriers to progress along those dimensions, creating larger and larger patterns of committed action over time.
Actions: smaller, practical steps that one takes in order to accomplish one’s larger goals.
Barriers: internal or external challenges that could get in the way of accomplishing valued actions if not effectively addressed.
• Describe how you would respond to a client who asked you, ‘Why should I even bother committing to do these things? I always fail at everything I set out to do’.
• What are two different ways that the therapist could work with a client on identifying potential barriers to effective action?
• How would you distinguish between an internal and external barrier?
Depending on that analysis, how would you then approach internal and external barriers differently with a client?
Points for Review and Reflection Key Terms
Summary
74 essentials of Acceptance and Commitment Therapy
Further Reading
Dahl, J.C., Plumb, J.C., Stewart, I. and Lundgren, T. (2009) The Art and Science of Valuing in Psychotherapy: Helping Clients Discover, Explore, and Commit to Valued Action Using Acceptance and Commitment Therapy. Oakland, CA: New Harbinger Publications.
Hayes, S.C., Strosahl, K.D. and Wilson, K.G. (1999) Acceptance and Commitment Therapy: An Experiential Approach to Behaviour Change. New York:
Guilford Press.
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• Working with anxiety disorders provides one of the most straightforward opportunities to practise ACT and all of its processes.
• Anxiety has a distinctly future-oriented, verbal component at its core, which makes the ACT approach a particularly relevant model for the treatment of anxiety disorders, including panic disorder, obsessive compulsive disorder (OCD) and post-traumatic stress disorder.
• As with all effective treatments for anxiety disorders, ACT incorporates exposure exercises, but with a focus on increasing psychological flexibility and valued living, rather than decreasing anxiety.
Since the inception of ACT in its original form as ‘Comprehensive Distancing’ in the early 1980s, anxiety disorders have been seen as a highly appropriate clinical target for ACT. One important reason for a focus on anxiety disorders is simply because of their high prevalence in the general population (Narrow et al., 2002) and high rates of chronicity and associated functional impairment. In addition, although there are several existing effective treatments for anxiety disorders (see Barlow [2002] for detailed descriptions of these primarily cognitive behavioural approaches), a significant number of individuals who receive traditional treatments fail to respond, and even responders often report notable symptoms and problems in functioning after treatment (Orsillo et al., 2004). Importantly, there are several aspects of an ACT-based model that are extremely relevant to the conceptualization of anxiety disorders (Eifert and Forsyth, 2005; Forsyth and Eifert, 2007); this chapter will focus on those aspects of the application of ACT to anxiety disorders that are most notable.