In this exercise, the client is asked to begin by writing a one- or two-page narrative of the life events that have unfolded and conspired to lead the individual to become depressed. This is generally assigned as homework, although it can be done in the session if the client has significant prob-lems with homework compliance. In the session after this assignment has been completed, the client is asked to read the life story narrative aloud to the therapist. At this time, the therapist may wish to make an internal note of any significant themes that have been brought up in the writing, as this provides good fodder for motifs to look for throughout therapy with this client. The client is then asked to go through the written
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product and underline those things that could be considered facts – that everyone could agree actually occurred. The therapist may need to assist with this at first, as some clients will think that everything they have written is an indisputable fact. The example below provides a condensed example of such a story:
I grew up in Wales, the eldest daughter of four children. When I was 10 years old, my mother died suddenly in a car accident, and I was devastated. Because my father was a selfish bastard, he ignored my needs and just assumed that I would step into my mother’s role, so all of the household and childcare responsibilities fell to me. I worked hard to take care of my brothers and my sister, but I was miserable inside. I think I started to become depressed basically the moment that my mom died. From that point on, I was never allowed to live the life of a normal child. I always had to be the caretaker. Finally, at the age of 18, I couldn’t take it anymore, and I married a boy from the next town over, just so that I could escape the hell of my home. I haven’t ever been happy in my marriage, and I have ended up being just as much of a caretaker for him and our three children as I was for my father and siblings. I don’t see that there is any real way out of the situation that I’m in, and that hopelessness just makes me more and more depressed.
In this example, the therapist helps to identify those parts of the story that are irrefutable facts. These are generally the parts that describe overt behaviours or events that others could agree did occur. Descriptions of emotional states and all-or-nothing statements, such as ‘I was never allowed to live the life of a normal child’ or ‘I wasn’t ever happy in my marriage’, cannot be considered facts, as other observers could poten-tially point out instances where these statements were factually incor-rect. Similarly, statements about the cause of her depression or the probability of her recovery are verbal attributions, not observable facts.
After going through this process with the client, the therapist would then request that the client rewrite the life story, so that it ends in some other way than with the client being depressed.
The therapist should make clear that it is not required that the new story have a happy ending. The goal is simply to demonstrate how these same facts could add up to a different result. For example, the client could have become riddled with guilt that she should have reminded her mother to be safe the morning that she was killed. Or she could have become highly anxious and never agreed to travel by car again. Or she could have gone on to become a safety advocate, championing new seat belt laws in her country. The client is asked to rewrite the story two or three times, each time using the same facts that were underlined in the first version, but tying them together in different ways and ending with a conclusion other than the client being depressed. The goal of the exer-cise is not to convince the client that she should not be depressed, but rather to help her defuse from this aspect of her conceptualized self and loosen up from the story that she has been holding on to as if it were the
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truth. The idea is that if she can see that her depression is not a foregone conclusion or a reason that her life cannot change, she may be able to begin to engage in more flexible and effective behaviour, rather than being defined by her conceptualized self and life story.
The final component of an ACT-based conceptualization of depression involves an analysis of withdrawal from values-based action. Individuals who are depressed frequently report low energy and loss of interest in things that previously had been enjoyable. They may often begin with-drawing from activities and situations in which they would have usually participated. Such withdrawal may initially occur in order to escape pain or protect oneself in the short term, but over time, it can significantly constrain behaviour and reduce the amount of natural reinforcement available in the individual’s environment. This restriction on valued behaviour also means that not only is the client not moving forward with her life, but she is also not able to deal with current life problems directly.
As Strosahl and Robinson (2008) have described this trade-off, the client can either manage her mood, or she can manage her life.
For these reasons, it is extremely important within the ACT model to work with the client to reconnect with her values and identify targets for building committed action. For some clients who have been depressed for a long span of time, the years of generalized dampening of responses may make it very difficult to connect with those things that are truly important and valued to them. The therapist can refer to the strategies for identifying values described in Chapter 7 to inform ways of working with clients to reconnect with their values. With a chronically depressed individual, it can also be useful to ask the client to go back to the last time in her life that she was not depressed. For example, the client whose life story is described above might be asked to try to recall what was important to her as a child before her mother was killed, as well as the dreams that she might have had for her life at that time. Although the specific goals that she had for her life at the age of 9 or 10 may or may not be achievable or relevant any longer, this work can help identify the values that she likely still has in place. It is more important to work with clients next to develop small, achievable goals that can be accomplished in the service of those values than to develop grand behavioural commit-ments. In order to break out of the cycle of depressed behaviour, it is most essential to have the client work on successive behaviours that are value-driven, such that she can begin to contact the naturally reinforcing prop-erties of engaging in values-consistent behaviour within her environment.
Using ACT wiTh sUiCiDAl BehAvioUrs
Consistent with the general ACT conceptualization of depression, suicidal ideation and other suicidal behaviours are also seen as a common
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experiential escape strategy. Because of the high frequency of suicidal behaviour in depressed individuals (Angst et al., 2002), therapists should routinely assess for suicidal thoughts and behaviours with all depressed clients. However, it is also important to note that suicidal thoughts and behaviours are quite common in general, regardless of whether someone meets the criteria for a psychiatric diagnosis or not (Chiles and Strosahl, 2004), and thus such an assessment is likely more broadly applicable. Individuals who have thoughts of killing themselves are sometimes overwhelmed and frightened by their own suicidal idea-tion. Thus, when the issue of suicide is brought up clinically, the ACT therapist has the opportunity to reframe suicidal ideation and suicidal behaviour as more examples of how the client has been trying to get rid of, change or control his emotions. Once clients have a new way of look-ing at these thoughts, it can be easier to defuse from them slightly and see them for what they are (the products of a mind looking for an escape route), rather than feeling like this is something external and mysteri-ous that is happening to the client (Zettle, 2004). In addition, by provid-ing clients with a meanprovid-ingful way of understandprovid-ing thoughts of suicide, when those thoughts next emerge, it can serve as a cue for clients to identify the thoughts and feelings that they are currently unwilling to have and then mindfully practise other strategies, such as defusion and willingness, to engage with those experiences.
Chiles and Strosahl (2004) identify that suicidal behaviour often serves both an instrumental and an expressive function, occurring when the client experiences private events that he views as intolerable, ines-capable and interminable. Interpersonally, communicating that one is depressed or suicidal may also keep people from making demands on the depressed individual. Thus, suicidal behaviour may have short-term consequences that provide reinforcement for such behaviour. However, the ACT therapist is encouraged to work with the client to examine both the short- and long-term workability of engaging in suicidal behaviour (Strosahl, 2004). Although suicidal thoughts and behaviour may work temporarily to provide relief from ongoing, uncomfortable private events, this pattern of behaviour generally leads to disconnection from valued living in a variety of domains. In addition, if the client follows through on the ultimate escape strategy of committing suicide, then he perma-nently loses the opportunity to improve his life and move forward with what is important to him.
Because suicidal ideation is simply part of the common human expe-rience, the goal of ACT cannot be the elimination of suicidal thoughts and behaviours entirely. Instead, the ACT therapist must learn to be accepting of the fact that clients will sometimes experience suicidal idea-tion and to be able to sit non-judgementally with the client when this does occur. This is not to minimize the magnitude of the problem of sui-cide. Certainly, clients do kill themselves, and this is a tragic outcome to be avoided to the highest possible extent. However, if the therapist balks
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and drops everything to deviate from the ACT treatment model each time the client becomes suicidal, this just reinforces the escape function of the behaviour and takes the client off track. The ACT therapist must find the balance between validating the client’s desire to escape from the current pain, while coming down firmly on the side of life (Strosahl, 2004). (For a more comprehensive model describing practical strategies for managing suicidal risk within an ACT-consistent framework, please see Chiles and Strosahl [2004].)