Another, related misstep I have observed is when the provider, in an effort to dem- onstrate understanding and support, actually strengthens the client’s cognitive fusion. For example:
Client: “I’m so fed up with my boss. He has never once told me I am doing a good job; in fact, he jumps at the chance to point out any little thing I do wrong. Even when I go above and beyond, it’s like it’s nothing.”
Therapist: “Like he’s taking you for granted.” Client: “Exactly! I might as well not bother.”
Therapist: “Have you tried to talk to him about being so critical?” Client: “He doesn’t care what I think.”
Therapist: “Doesn’t sound like a very good boss.” Client: “No, he sucks.”
This quick exchange is problematic from an ACT perspective because as a whole, it functions as a validation not of the client, but of what the client’s mind is handing
Style Matters
61
him. I have found it helpful to ask myself what I would be aligning with if I supported what the client is saying content- wise. Would I be supporting what the client ulti- mately wants from his life, or a thought process that, while compelling at the surface level—our minds just love right/wrong scenarios—actually ensnares him? Let’s take a look at each of the therapist’s responses:Client: “I’m so fed up with my boss. He has never once told me I am doing a good job; in fact, he jumps at the chance to point out any little thing I do wrong. Even when I go above and beyond, it’s like it’s nothing.”
Therapist: “Like he’s taking you for granted.” (The therapist is pulled into the content— his response could be perceived as agreeing with the client’s take on things.)
Client: “Exactly! I might as well not bother.”
Therapist: “Have you tried to talk to him about being so critical?” (The therapist is again pulled into content, has fused with the client’s evaluation of his boss, and is engaged in problem- solving aimed at fixing the boss.)
Client: “He doesn’t care what I think.”
Therapist: “Doesn’t sound like a very good boss.” (The therapist is again joining in the client’s cognitive fusion and aligning with the idea that “the problem” is his boss.)
Client: “No, he sucks.” (At this point the client may feel understood and “supported,” but is in no better position life- wise than when this exchange began. If anything, he is more firmly entrenched in the idea that his work life is, and will remain, terrible because of his boss’s attitude.)
Again, you don’t have to choose between furthering the therapy and demonstrat- ing that you understand and care about what your client is saying. You can go the following route instead:
Client: “I’m so fed up with my boss. He has never once told me I am doing a good job; in fact, he jumps at the chance to point out any little thing I do wrong. Even when I go above and beyond, it’s like it’s nothing.”
Therapist (nodding in understanding): “I can see this whole work thing is pretty upsetting.”
62
Advanced ACTTherapist: “So one of the thoughts you have around this is ‘I’ve had it,’ like, ‘I’m done.’”
Client: “Yeah.”
Therapist: “What sort of feelings show up? Seems like frustration is there… .” Client: “Frustration, anger…I mean, what happens if I really do lose
my job?”
Therapist: “So frustration, anger, you have thoughts about losing your job… . What emotion comes up with that one, with thoughts about losing your job?”
Client: “Fear.”
Therapist: “Yeah, I would think! Even now, as we’re talking about this, does fear show up?”
Client: “Yes, fear, and anger too. I don’t need this.”
Therapist: “So that’s another thought your mind just handed you: ‘I don’t need this.’”
Client: “Yes.”
Therapist: “What do you do at work when these sorts of thoughts and feelings show up? I ask because I’ve noticed that you have always seemed to work hard at your job.”
Client: “Yeah, I just try to do my job and not worry about what he thinks. But he’s such a jerk!”
Therapist: “That’s pretty amazing. Even though your experience of your boss is that he doesn’t notice or care about the work you do, you care enough to do it right.”
Client: “Yep. I’m just not comfortable putting my name on crappy work.” Therapist: “So let’s look at this carefully, because it’s a big deal. You have a value around work. You value doing good work, and you have put that value ahead of the thoughts and feelings you have about your boss. Even though he does his thing and you have your reactions to it, you make sure you do a good job.”
Client: “I guess that’s right.”
Therapist: “It looks to me like it’s you, not your boss, who decides how you are at work.”
Style Matters
63
The point of this section was to address a common misstep, where therapists, in an effort to be supportive of their clients, actually work against the therapy. Hopefully it is evident that there is no loss of empathy or caring in this last exchange. This example dialogue also highlights the point emphasized at the beginning of this book, which is that in order to conduct the therapy well, one must operate from the basic principles of ACT. The key is to continually look for and work with the processes in play. This approach often involves reframing what has occurred or been said in a way that highlights those core processes. In contrast to the first example, the second exchange moved the conversation from being about the client’s employer and the notion that the employer needs to change to establishing the client as the Experiencer who is capable of making valued choices. The therapist and client remain on course with the processes targeted in ACT and are poised to do some meaningful work on an important issue in the client’s life. Let’s look at this exchange again:Client: “I’m so fed up with my boss. He has never once told me I am doing a good job; in fact, he jumps at the chance to point out any little thing I do wrong. Even when I go above and beyond, it’s like it’s nothing.”
Therapist (nodding in understanding): “I can see this whole work thing is pretty upsetting.” (The therapist validates the client’s distress while refraining from agreeing with his thought process.)
Client: “Yeah! I’ve just had it!”
Therapist: “So one of the thoughts you have around this is, ‘I’ve had it,’ like, ‘I’m done.’ (The therapist demonstrates understanding while targeting cognitive defusion. Note that although the therapist adds the statement “I’m done” to demonstrate understanding, this is more a redundancy than the introduction of new content.)
Client: “Yeah.”
Therapist: “What sort of feelings show up? Seems like frustration is there… .” (The therapist is working against experiential avoidance, represented by the client’s tendency to complain and blame others— staying in the “head” rather than accessing the difficult emotions present in a situation like this— while building the client’s awareness of self- as- process.)
Client: “Frustration, anger…I mean, what happens if I really do lose my job?”
Therapist: “So frustration, anger, you have thoughts about losing your job… . What emotion comes up with that one, with thoughts about losing your job?” (Therapist refrains from being hooked by client’s
64
Advanced ACTworry about losing his job— that is, he doesn’t work with the worry itself but stays on track with defusion and self- as- process.)
Client: “Fear.”
Therapist: “Yeah, I would think! Even now, as we’re talking about this, does fear show up?” (Therapist joins in the experience, thus normalizing and validating, and moves to present-moment awareness and self- as- process.)
Client: “Yes, fear, and anger too. I don’t need this.”
Therapist: “So that’s another thought your mind just handed you: ‘I don’t need this.’” (defusion, present moment)
Client: “Yes.”
Therapist: “What do you do at work when these sorts of thoughts and feelings show up? I ask because I’ve noticed that you have always seemed to work hard at your job.” (The therapist is promoting self- awareness, particularly the distinction between the Experiencer and the experiences, or self- as- process, and is starting to point to values.) Client: “Yeah, I just try to do my job and not worry about what he
thinks. But he’s such a jerk!”
Therapist: “That’s pretty amazing. Even though your experience of your boss is that he doesn’t notice or care about the work you do, you care enough to do it right.” (Therapist again does not bite with the new “jerk” content but remains on target with the self- as- context and values processes.)
Client: “Yep. I’m just not comfortable putting my name on crappy work.” Therapist: “So let’s look at this carefully, because it’s a big deal. Sounds like
you have a value around work. You clearly value doing good work, and you have put that value ahead of the thoughts and feelings you have about your boss. Even though he does his thing and you have your reactions to it, you make sure you do a good job.” (Here the therapist leans in with “…it’s a big deal,” and spells out the distinction between the self that chooses and the thoughts/feelings of the moment. “Response- ability” for making valued choices is now resting squarely on the client.)
Style Matters
65
Therapist: “It looks to me like it’s you, not your boss, who decides howyou are at work.” (The therapist highlights the freedom this gives the client.)
Client: “Yeah!”
As you can see, this exchange is conducted at the process level. The therapist is not serving as an arbiter of the client’s work situation, but is homing in on the cognitive fusion and experiential avoidance that could keep the client from moving forward in his life according to his values. In terms of style, it is empathic, direct, and yet uncompromising when it comes to the notion that the client is fully able to make choices that move him closer to, not further from, his values.
At the risk of beating this into the ground, it can be informative to play with dif- ferent iterations of the therapist’s first response in this exchange as a way to highlight the functional differences of even slight wording changes:
Client: “I’m so fed up with my boss. He has never once told me I am doing a good job; in fact, he jumps at the chance to point out any little thing I do wrong. Even when I go above and beyond, it’s like it’s nothing.”
Therapist: “Like he’s taking you for granted.” (This response could function in a couple of ways. The therapist could have recognized the client’s cognitive fusion and meant to simply reflect back a version of what the client’s mind is giving him. However, because this isn’t made clear by his choice of words, and because the client is so fused with his thoughts, the therapist’s response would likely be received by the client as agreeing with the client’s perception, and would actually serve to extend the relational network by adding the taking for granted idea. It is not uncommon for therapists who are targeting a core ACT process to inadvertently undo what they are hoping to accomplish because of the language they use.)
Here’s another version:
“He’s taking you for granted.” (Here we have the same issue, although it seems even more likely the client will perceive this statement as the therapist endorsing his thought process. This response could also strengthen the pull to get caught up in right and wrong, as taking someone for granted is perceived as wrong in our culture.) And another:
“You feel like he’s taking you for granted.” (This is a bit better as it emphasizes the client’s experience rather than suggesting that the therapist agrees. However, with this statement the therapist has still added an interpretation that probably doesn’t serve the client so well— the idea of being taken for granted.)
66
Advanced ACT“So even when you have been working really hard you feel as though it’s
nothing to your boss.” (This statement is more on track, as it reflects back what the client has said without adding additional problematic content, and it indicates (albeit subtly) that this is an experience the client’s having.)
Notice that the first response I suggested in the remedial dialogue, to simply state something along the lines of “I can see this whole work thing is pretty upsetting,” lifts the therapist and client right up out of the content and onto the process level. The therapist immediately points to the client as Experiencer, and in doing so is able to offer support and compassion to the client- as- context, rather than aligning with his thoughts.
There are innumerable such decision points in the course of a single therapy session. Referring to the above example one last time, the response the therapist chooses can also depend on where the client is in the therapy, and I have promised to explore that issue further in chapter 6. This is one of the things I find most exciting about this work. There’s simply no one way to go, and no possible way to roll out all the various iterations to compare effectiveness. That means we are in an unending process of discovery, with no cap as to how clinically effective we can become. Woo hoo!
SUMMARY
This chapter has focused on therapist style as per the ACT model. My focus has been on some missteps and misunderstandings that commonly stand in the way of thera- peutic progress. I would like to add that therapist style is one of my favorite ACT topics to ponder and work on. It is fascinating how relatively small changes in tone or demeanor can make a significant difference in how a session goes, and how shifting one’s basic stance in the relationship can powerfully and positively impact both thera- pist and client. That is fun. And it is good news. In short, I mean for this discussion to be encouraging, rather than an indictment of some sort. Just as (if your life is anything like mine) there are innumerable ways we can improve how we relate to the people in our lives, so too can we continually build our skill in the therapeutic relationship.