Earlier I stated that in ACT the theory is the therapist’s best friend. What I mean is that the basic learning principles and processes of ACT will guide you again and again through the morass of stuff that occurs in session. When you are operating from the objectives and behavioral principles in ACT, it’s as though you are looking at everything that happens in session (and in the client’s daily life) through an ACT lens. As a particular behavior unfolds— say the client suddenly changes the topic— rather than staying at the level of content (the words being exchanged), you observe what is happening at a process level. Not only does this require getting present; you must also be able to defuse from your own verbal content. You then home in on the behav- ior that seems most relevant at the moment— changing the topic, in this case— and consider its function. As discussed, function is always going to involve a consideration of context: what was happening just prior and what are the behavior’s consequences. This sort of functional analysis would lead you to an observation perhaps along the lines of the following: “The client changed the topic (behavior) just as we began to talk about her relationship with her kids (antecedent)… .She may be avoiding what this brings up (consequence) for her.” This observation, in turn, would point you to the potential processes in play, such as experiential avoidance and fusion, helping you to recognize that were you to stay at the level of content and go with the change in topic, you would risk reinforcing the avoidance. The client’s intended purpose of the behavior (avoidance of painful material, let’s suppose) would have been served, in other words, but at the same time a larger and problematic response pattern would have been rein- forced. By continuing to view the session through that ACT lens, you are better able to identify the intended functions of the client’s behavior, how the core processes are playing out, and how you might respond so that the client progresses in the therapy. The ability to identify these things will help you to remain ACT- consistent regardless of what your client brings to the session.
Here’s an example: Let’s say your client brings in something salient such as “I wasn’t able to go to Thanksgiving dinner because I found out my brother- in- law is
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having an affair.” It would be understandable to go straight to content and ask more about the situation with the brother- in- law, how your client found out about it, whether she told her sister, and so forth. However, in pursuing more content- level details around this situation, you are essentially aligning with the verbal content the client has already put forward, which is that her brother- in- law’s actions (having an affair) dictate her behavior (going to dinner). In contrast, when you keep the core processes in the forefront, it is easier to sift through a statement like this to make sure you work with it in a way that is consistent with the model.In the above example, experiential avoidance would be operating if the client decided not to go to the dinner in an effort to avoid discomfort, and cognitive fusion is there if she has bought what her mind is telling her about the situation (that she can’t go because it would be too upsetting). Avoiding discomfort in this way would be considered problematic if it served to move the client away from her values. So values also pertain, and you could consider whether your client holds certain values around supporting her sister— values about marriage, commitment, family dinners, and so on. Willingness comes in there as well: is she willing to experience the thoughts, feelings, and physical sensations that show up around this situation? And committed action is where you are ultimately headed with a situation like this: given this scenario and all it brings up for your client, how might she respond in a way that reflects her values, and is she willing to have the internal experiences that come along with that course of action?
So it’s not just that clinical opportunities are missed when we stay at the content level rather than working at the level of the processes. There is another cost. When we as therapists fuse with the client’s verbal content in session, we can work against their developing psychological flexibility. This can happen incredibly quickly, as seen in the following example.
In this scenario the therapist and client have completed a mindfulness exercise (“leaves on a stream”) and are talking it over:
Therapist: “What was that like for you?” Client: “It was okay.”
Therapist: “What do you mean by okay? What sorts of thoughts or feelings showed up for you?”
Client: “I was picturing the leaves but then started thinking about other things… .It’s been a crappy day— had a bad interaction with my mom this morning. She really gave me a hard time about dropping out this semester. She basically told me I have to move out of the house!”
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Advanced ACTClient: “Yeah! She said she’s not going to support me if I’m just going to be sitting around.”
Therapist: “When does she want you to leave?”
Here again the therapist has been pulled into the content of what the client is saying (the interaction with his mother), rather than sticking with the processes she was targeting in the mindfulness exercise (getting present, defusion, self- as- process). The problem isn’t the words themselves but how they function here. As soon as the thera- pist moves away from process and into content by asking the client, “When does she want you to leave?” she is working against the abilities she was hoping to advance in the session. More specifically, by asking for additional details around the thoughts that came up for her client during the exercise, she is reinforcing that verbal content. She is giving weight to his thoughts rather than helping him defuse from them. Rather than stick with helping the client learn to observe the flow of his thoughts, she gets pulled into them herself. This misstep is particularly common when content seems significant. Having to move out of his mother’s house is certainly an important development for this client. But there are ways to work with this information that are more in line with the model. For example:
Therapist: “What was that like for you?” Client: “It was okay.”
Therapist: “What do you mean by okay? What sorts of thoughts showed up for you?”
Client: “I was picturing the leaves but then started thinking about other things… .It’s been a crappy day— had a bad interaction with my mom this morning. She really gave me a hard time about deciding not to finish school. She basically told me I have to move out of the house!”
Therapist: “Wow, so some tough thoughts showed up! Did they take you downstream?”
Client: “What do you mean?”
Therapist: “When you found yourself thinking about the interaction with your mom during the exercise, were you on the riverbank noticing all the thoughts you have around it, or were you sort of lost in what happened this morning?”
Client: “Oh, I was totally lost in it. I just can’t believe she said that! She knows how stressful this semester has been— now what am I going to do?”
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Therapist: “I can hear the worry in your voice. Let’s just work with this fora moment, though. Did you notice the thoughts you just had? ‘She knows how stressful this has been’ and ‘Now what am I going to do?’”
Client: “Yeah.”
Therapist: “What other thoughts show up with those?”
Client: “She’s totally not supportive— never has been, actually.”
Therapist: “So not supportive, never has been… .What sorts of feelings come along with those thoughts? Like, what are you experiencing right in this moment?”
And so on. Now, just because the therapist is staying on track with helping the client learn to observe his experience, it does not mean the situation with his mother is going to be ignored. How they work with it will depend on where they are in the therapy, the key being that they will do so from within the ACT framework. Note that the therapist is not invalidating the client’s situation by sticking with the process. In fact, she is attending to his experience— his thoughts and feelings around it— but by staying at the process level, she helps her client explore self- as- process. She doesn’t align with the idea that his thoughts and feelings (or as he would probably argue, his mother’s actions) run the show.
The first therapist- client exchange in the leaves- on- a- stream scenario was intended to show how even slight inconsistencies are not necessarily benign. A point I want to stress is that fidelity to the model in ACT is not about right and wrong, but rather about either advancing or working against certain behavioral abilities. As we have seen, it is extremely easy to move off the model. Even while engaged with an exercise geared toward furthering self- as- process, the therapist inadvertently plugged into the client’s story and therefore supported verbal dominance.