When faced with a timing decision, I have found it helpful to make a distinction between whether it is time to work on something explicitly or more indirectly. For example, my client may do or say something that points directly to a core ACT process, but that doesn’t mean it’s the best time to talk explicitly about that process. In such cases I might choose to work with it indirectly, filing away whatever the client had revealed for use when the timing is more optimal for direct discussion. Consider the following scenario: The therapist is conducting his second ACT session with his client, a thirty- eight- year- old male who is seeking therapy for help with depression and “anger issues.” So far, it is apparent that the client is highly fused with his thought content (for example, he has a trove of stories about the people in his life and the ways they “trigger” his anger), and believes that reasons are causes (for example, that others make him angry and that his anger causes his aggressive behavior and temper outbursts). He is also quite experientially avoidant—anger and other uncomfortable emotions are a sign that something is wrong; any emotion that arises in session is quickly talked away. He has poor ability to be in the present, staying in the moment with the therapist only briefly before being reeled back in by his thoughts about the past. Finally, he holds a conceptualized view of himself as “man with very bad temper.” He claims to value relationships and feels that getting rid of his anger is a requirement for building and improving his relationships with family and friends. So much to do!
I find it easier to approach this discussion by talking about what I wouldn’t suggest doing in this situation. For example, it doesn’t seem that it would be very effective to explicitly tackle the client’s notion that others need to change (so that he doesn’t experience anger) before he can make behavioral choices that take him closer to his values around relationships. This is where we hope he will eventually arrive (not that the notion will change, but that he won’t continue to buy it), and the shift will require having all the core processes under his belt. I also wouldn’t start explicitly talking about how he has a conceptualized and misleading view of himself— such discussion would entail concepts such as the Self being distinct from private events, and is beyond where the client is at this point. If someone is unable to look at his thoughts rather than from his thoughts, it is pretty hard to access a self that’s distinct from such processes. I have observed providers make such moves, though, and what often happens is that the therapist easily falls into a persuading, teaching mode that actually counters the model. For example, consider if the therapist says to this client: “You have a view of yourself as Angry Man, but that’s just a thought, something you learned and associated with yourself.” If this statement were made in the context of explicit work on the role of self- as- context and the role of language, it is more likely that the client would understand the statement as intended in ACT. Early in the therapy, however, before concepts such as cognitive defusion have been put in place, this sort of statement can function as an endorsement of the idea that something is wrong with the client’s thinking— in other words, “You need to have a different view of yourself because I say so.”
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Advanced ACTThat you have decided it is not the time to address something explicitly, however, does not mean you need to ignore it. There are many ways to begin addressing issues of clinical significance that, while indirect, can be quite effective. Taking the first idea as an example (that the client thinks others need to change so that he can feel the way he wants, so that he can then have good relationships), the therapist can begin to work on this idea by simply delineating and highlighting the system currently in place:
Therapist: “You mentioned that you aren’t happy with your relationships. Can you tell me more about that?”
Client: “Well, my wife and I hardly talk unless it’s something about the kids, and then it’s always about some problem. She’s constantly complaining about this or that; there’s always something that I haven’t done right. She just keeps on me till I just finally lose it, then it’s my fault, you know! I just mostly avoid her these days… . At least we won’t get in some stupid argument.”
Therapist: “So help me understand this a bit better. Can you say more about your experience when she’s ‘keeping on you’? What goes on with you when she does that?”
Client: “You mean when she’s nagging me to death?”
Therapist: “So that’s what it feels like? Is that a thought that comes up at those times: ‘She’s nagging me to death’?”
Client: “Yeah.”
Therapist: “And then what happens?” Client: “I go off.”
Therapist: “What does that look like?”
Client: “I don’t hit her or anything. I’ve never hit her or the kids… .I just get mad, throw stuff, cuss her out sometimes.”
Therapist: “So she’s saying something, you have thoughts about her nagging you to death, and then…anger shows up at some point.”
Client: “Yeah. All of a sudden I just feel this rage. I feel like I’m gonna explode.”
Therapist: “What are you feeling right now?” Client: “Huh?”
Therapist: “Looking at you, it seems as though you are feeling some of that right now, that anger.”
Let’s Talk About Timing
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Client: “Yeah, just talking about it makes me angry all over again.” Therapist: “But you aren’t exploding. At least you haven’t thrownanything yet.”
Client: “Well…you’re not her.” (Laughs.)
In this exchange, the therapist is actively working with several core processes, even if they are not being explicitly put on the table. Let’s pull them out:
Therapist: “You mentioned that you aren’t happy with your relationships. Can you tell me more about that?”
Client: “Well, my wife and I hardly talk unless it’s something about the kids, and then it’s always about some problem. She’s constantly complaining about this or that; there’s always something that I haven’t done right. She just keeps on me till I just finally lose it, then it’s my fault, you know! I just mostly avoid her these days… . At least we won’t get in some stupid argument.”
Therapist: “So help me understand this a bit better. Can you say more about your experience when she’s ‘keeping on you’? What goes on with you when she does that?” (Here the therapist is pointing to self- as- context and self- as- process while subtly shifting emphasis from what the wife is doing to how the client responds.)
Client: “You mean when she’s nagging me to death?”
Therapist: “So that’s what it feels like? Is that a thought that comes up at those times: ‘She’s nagging me to death’?” (Again, self- as- context, self- as- process, and laying some groundwork for cognitive defusion.) Client: “Yeah.”
Therapist: “And then what happens?” (Self- as- process, although the client could potentially take this as a question regarding what his wife does next in these scenarios. If so, the therapist could simply redirect him to his own experience.)
Client: “I go off.”
Therapist: “What does that look like?” (The therapist is subtly pointing to self- as- context, asking the client to relate to his behavior as an observer.)
Client: “I don’t hit her or anything. I’ve never hit her or the kids. I just get mad, throw stuff, cuss her out sometimes.”
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Advanced ACTTherapist: “So she’s saying something, you have thoughts about her
nagging you to death, and then…anger shows up at some point.” (Self- as- process, self- as- context.)
Client: “Yeah. All of a sudden I just feel this rage. I feel like I’m gonna explode.”
Therapist: “What are you feeling right now?” (The therapist goes to the present moment, both to continue to help the client build awareness of himself as the Experiencer and to begin to undermine experiential avoidance. The therapist is helping the client become aware of, and therefore have— if even for a moment— his emotions.)
Client: “Huh?”
Therapist: “Looking at you, it seems as though you are feeling some of that right now, that anger.” (Still assisting the client to become an observer of his thoughts and feelings, working on building willingness.)
Client: “Yeah, just talking about it makes me angry all over again.” Therapist: “But you aren’t exploding. At least you haven’t thrown
anything yet.” (The therapist is undermining the idea that emotions cause behavior.)
Client: “Well…you’re not her.” (Laughs.)
Hopefully it is clear in this exchange how the therapist is advancing core ACT processes while paving the way for more explicit work in the future. It should also demonstrate a point made in the first chapter of this book— the importance of lan- guage in ACT. Nearly every exchange can be used to further the work. In fact, I some- times imagine language in ACT as a sort of chisel that therapists hold throughout the therapy so they can chip, chip, chip away.
This section described just another way to approach the decision- making process in ACT, one that emphasizes considering indirect versus explicit intervention. I have found this approach helpful, as it takes me out of falsely thinking I have to make an “either/or” decision and seems to enhance my clinical flexibility.