When making a case to establish a clear structure for your sessions, I pointed out that we make it harder on ourselves when we let clients’ habitual verbal processes (such as stories, history recounting, and reason giving) drive the session. We are then in a position of trying to make all that applicable and remain within the model and move things forward. I also provided some examples of how fusing with session content can mislead therapists into promoting ACT processes verbally while working against those same processes behaviorally. This is just one of many ways therapists can dip in and out of ACT and send clients contradictory messages.
Another way ACT- ish therapy can result is when the therapist does nothing with the content a client introduces. That is, he waits for the client to finish whatever she
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Advanced ACTis saying before moving on with what he had planned to discuss. It’s as though the therapist is saying, “Alrighty then, now back to ACT… .” Usually this sort of move comes from the therapist not knowing how to work with what the client has intro- duced or simply being more intent on what was planned for the session than what is actually happening in the session. Both of these, in turn, can arise from approaching the therapy at the level of content rather than processes. As a result, the therapist will miss working with ACT processes in the here- and- now. Such sessions seem disjointed, as there is no common thread pulling ideas together. Finally, clients can experience these sessions as invalidating.
Sometimes the therapist will make a sort of lunge to get ACT in there, as though she’s been at a loss and was just waiting for some sort of opening to talk about an ACT idea or exercise. As I said, there is an important difference between trying to squeeze in an ACT concept and working with whatever is happening in an ACT- consistent way. When you are working at the level of the processes, you are better able to trans- late functionally what is going on in a way that is genuine and that fits. In the follow- ing example scenario, the client, an eighteen- year- old male, has been complaining to his therapist about his relationship with his father.
Client: “And— I don’t know— my dad obviously thinks I’m a loser. Nothing I do is good enough. I’m just not the son he wanted… . He’s on me all the time! I’m so sick of it. Like, why bother? We’re never going to get along.”
Therapist: “Huh. This sounds like you’re a computer and you’ve got all this programming around your dad— about how you’re a loser, how you’re not the son he wanted.”
The therapist apparently wants to introduce an ACT metaphor called “two com- puters,” but this exchange seems forced. (For those readers who are unfamiliar with it, two computers is a common metaphor targeting defusion. It helps clients to see the difference between looking at thoughts and looking from thoughts. In this meta- phor, fusion is akin to sitting with your head actually buried in a computer monitor. In contrast, defusion is the ability to sit back and observe what is happening on the screen— a series of thoughts showing up, for example— while remaining aware that what you are seeing is text among more text.) Suddenly interjecting the metaphor here, however, doesn’t quite work. Or rather, it might work, but it feels as though the thera- pist is putting a new idea on top of what the client shared, rather than approaching what was shared— and how that functions— at the process level. There are many ways to further defusion without being stuck on a particular intervention (such as the two computers metaphor, in this case). With this in mind, let’s take another look.
Client: “And— I don’t know— my dad obviously thinks I’m a loser. Nothing I do is good enough. I’m just not the son he wanted… . He’s on me all the time! I’m so sick of it. Like, why bother? We’re never going to get along.”
Starting Off Well and Staying the Course
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Looking at these statements through that ACT lens, we see cognitive fusion in the client’s thoughts around his dad and their relationship. We also see fusion with a conceptualized self (for example, “not good enough”). In looking for function, we get a sense of the client giving up (“Why bother?”) as a way to escape or avoid the pain of this experience. So work on defusing would be a good idea, as would building self- as- process and acceptance of his thoughts and feelings, in place of avoidance. The two computers metaphor does get at these processes, but we don’t need to force it in. Rather, we can do in- the- moment work with what the client has offered. For example:Therapist (pausing to let the moment sink in a little): “What sorts of feelings come up for you around this? Like, what are you feeling right now when we’re talking about it?” (Here the therapist is undermining the avoidance by inviting the client to get present to his feelings around his father. She is also working on building the client’s ability to access self- as- process.)
Client (heavy sigh): “I feel hopeless, I guess.”
Therapist: “And what is that like for you, feeling hopeless around this situation with your dad?”
Client: “Sad! I feel sad. It really sucks!” Therapist: “Yeah.” (Sits with this a bit.)
Client: “It doesn’t matter; I’m out of here in two months anyway.” Therapist: “So that’s one thought that comes up: ‘I’m outta here.’” Client: “Yeah, thank God.”
Therapist: “Have you had that thought before?” Client: “Tons of times!”
Therapist: “And yet the sadness is still there.” (The therapist is homing in on experiential avoidance. She is working on how “I’m out of here” might be functioning for the client. Not only would leaving home literally be an escape move, but the thought itself likely functions as a way to move away from emotional pain. That is, when the client experiences the sadness and hurt around his dad, he quickly tells himself, “I’m out of here.” The therapist could have explored this avoidance mechanism explicitly with the client, but instead she chose to simply point to how this ultimately hasn’t worked. The therapist is also promoting self- as- process, which will be important in helping the client learn to defuse and detach from the conceptualized self.)
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Advanced ACTClient: “Yeah, it is. I just wish our relationship was better. We just fall into this…thing.”
Therapist: “Yeah. I’m noticing that right now—are you? That you are in this ‘thing’ that you have with your dad?”
Client (sighs heavily): “Yep.” (Both sit for a moment.)
Client: “Yeah, it’s always been that way with him.”
Therapist: “Is that one part of it too? I mean, have you had that thought before, that it’s always been this way?”
Client: “Oh yeah.”
Therapist: “It seems a little easier for you to talk about the thoughts you have around this than the feelings. I can hear feelings in what you’re saying, but it seems like it’s hard for you to go there.” Client (sits silently for a moment): “It is hard. I guess I’m tired of feeling
sad about this. It doesn’t change anything.”
Therapist: “And does saying that to yourself change anything?” Client (thinks this over): “No, I guess not.”
Therapist: “So despite the various ways you’ve tried not to be affected by this, you still are. And it’s clear there is a lot of stuff around it, a lot of painful feelings, and all sorts of thoughts— from “I’m a loser” to “I’m out of here” to “I wish we had a better relationship.” (The therapist is continuing with self- as- process.)
Client: “Yeah. Unfortunately that’s true.”
At this point the therapist has pulled out experiential avoidance as a strategy and has been repeatedly pointing to self- as- process as the client introduces various content. Now that these processes have been pulled out in the moment, it would likely work well to bring in a metaphor or exercise to advance these ideas using another modal- ity (rather than relying on dialogue alone). For example, two computers would work well now, using the idea that the client has a “Dad button” that brings up a particular computer program. There are any number of exercises and metaphors that could be used. The point is that the therapist is offering them in response to what is happening in the room, rather than pushing aside or supplanting what is happening in order to insert an ACT metaphor or exercise.
Starting Off Well and Staying the Course