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Dear Friends,

Welcome to part 2 of the ‘ACT In A Nutshell’ e-course. I hope you have practiced or tried out at least some of the suggestions from part 1. No problem if you haven’t, of course; you have the whole rest of your life to try this stuff.
In this email, we’re going to look at how you can quickly explain and introduce the different components of the ACT model to clients: didactically, experientially, and/or both. I aim, whenever possible, to do this on the first session. With high-functioning clients, coaching clients, and the ‘worried well’, this is relatively easy, because the content of email #1 can be zipped through relatively quickly. However, as a general rule, the more severe the client’s history, the greater the number of significant problems in their life, the more resistant or unmotivated they are, then the harder it is to achieve this: in which case, it can wait until the second session – with the first session ending with instructions to keep the ‘vitality versus suffering diary’. (Obviously the same goes if you are working in settings where you only have short sessions – GPs etc.)

Quick Refresher: The Aim Of ACT

The aim of ACT is to enrich life, make it meaningful, and get the most of it by:

  • Engaging fully in whatever you are doing
  • Willingly making room for whatever thoughts and feelings show up
  • Acting in line with your values

In other words, ACT teaches you to:

  • Be present
  • Open up
  • Do what matters

Alternatively you could say, ACT helps you develop:

  • Awareness 
  • Willingness
  • Valued action

ACT also gives you a good acronym:

  • Accept your thoughts and feelings
  • Connect with your values
  • Take effective action

The ultimate aim in ACT is to increase your ‘psychological flexibility’: your capacity to be fully aware of and open to your experience, and simultaneously act in line with your values. Once you have taken a history, explained the model, and obtained consent, basically in every session you are working to increase psychological flexibility. Your focus in any moment will either be on increasing vitality, reducing suffering, or increasing awareness around these polarities.


Introducing the 6 Core Processes of ACT

After completing the ‘vitality vs. suffering worksheet’ (or the brief conversational-style creative hopelessness) plus the ‘brief bull’s eye form’ (or the brief conversational-style values assessment), you have three options for rapidly introducing and explaining the 6 core processes of ACT. (Reminder: You don't have to do this; you certainly won't find this in many ACT protocols or textbooks; I am posting it here as I know that many therapists new to ACT value some guidance in this area. As with everything in this course: take it, leave it, or adapt it to suit you and your clientele.) Your options are:
      a)      Illustrate the model didactically with the modified hexaflex  
      b)      Illustrate the model experientially with the ‘ACT In A Nutshell’ metaphor 
      c)      Do both, one after the other

Is This Controversial?

Some authorities suggest – either overtly or covertly - that you should not explain the ACT model up front to clients; rather you should ‘hide it away’ until the client has been made fully receptive to an alternative agenda of willingness and acceptance, via an extended Creative Hopelessness intervention. Personally, I can’t see the logic in that. One theory is that the client will take on the model only at an intellectual level - will follow it at the level of, 'Oh yes: here's a good set of ideas for what I can do differently' . I haven't found that, myself. I find that clients first get it intellectually, as an idea, when you explain it this way - and then they readily go on to get it experientially, as you make it experiential. Certainly, there's no empirical data to support that particular theoretical concern. The fact is, many ACT therapists find it extremely helpful to explain the model up front. I’m certainly one of them (in case you hadn’t guessed). So here’s one way (amongst many) you can do it (if you wish).

 
a) The Hexaflex

The hexaflex is a great way to simply illustrate the whole ACT model. You can give this form out, and ask the client to keep it as a reference. It helps them to understand what you are doing. And you can refer back to it at any stage where the client seems to be confused about or struggling with the approach. And of course you can use it guide your sessions. You can even, in later sessions, ask the client which aspect(s) of the hexaflex they want to work on in this session. I have modified the terminology somewhat, to make it more understandable to clients. (I use the term ‘expansion’ instead of acceptance, and ‘connection’ instead of ‘contact with the present moment’ and ‘the observing self’ instead ‘self-as-context’. These are the terms I introduced in ‘The Happiness Trap’ – in the name of simplicity and clarity. If clients have read other ACT self-help books, you can explain these terms are synonymous.) I have also stuck in some simple catch-phrases to help clients remember these concepts, plus an extra diagram at the bottom of the page, which summarizes ACT in a different way. Down below, there are two versions of this form: first there is the version I use with clients, using terminology from ‘The Happiness Trap’ – and below that there is the version I use for professionals (eg if running a workshop or giving a presentation), which has the official ACT terminology

To download the modified hexaflex form FOR CLIENTS as a pdf, click here.

To download the modified hexaflex form FOR PROFESSIONALS as a pdf, click here.

Give the form to the client, and explain:

  1. This diagram may look complex, but it gives a concise overview of the whole ACT model, so it’s often helpful to spend a few minutes looking at it.
  2. Connection means being in the present moment: connecting fully with whatever is happening right here, right now.
  3. Defusion means learning to step back or detach from unhelpful thoughts and worries and memories: instead of getting caught up in your thoughts, or pushed around by them, or struggling to get rid of them, you learn how to let them come and go – as if they were just cars driving past outside your house. You learn how to step back and watch your thinking, so you can respond effectively - instead of getting tangled up or lost inside your thinking.
  4. Expansion means opening up and making room for painful feelings and sensations. You learn how to drop the struggle with them, give them some breathing space, and let them be there without getting all caught up in them, or overhwelmed by them; the more you can open up, and give them room to move, the easier it is for your feelings to come and go.
  5. We call these three processes ‘mindfulness skills’. Mindfulness is a mental state of awareness, openness and focus. It allows you to appreciate every moment of life. In a state of mindfulness, painful thoughts and feelings have much less impact, and you have much more control over what you do.
  6. The Observing Self is the part of you that is responsible for awareness and attention. We don’t have a word for it in common everyday language – we normally just talk about the ‘mind’. But there are two parts to the mind: the thinking self – i.e. the part that is always thinking; the part that is responsible for all your thoughts, beliefs, memories, judgments, fantasies etc. And then there’s the observing self – the part of your mind that is able to be aware of whatever you are thinking or feeling or doing at any moment. Without it, you couldn’t develop those mindfulness skills. And the more you practice those mindfulness skills, the more you’ll become aware of this part of your mind, and able to access it when you need it.
  7. Values are what you want your life to be about, deep in your heart. What you want to stand for. What you want to do with your time on this planet. What ultimately matters to you in the big picture. What you would like to be remembered for by the people you love.
  8. Committed action means taking action guided by your values – doing what matters – even if it’s difficult or uncomfortable.
  9. When you put all these things together, you develop something called psychological flexibility. This is the ability to be in the present moment, with awareness and openness, and take action, guided by your values. In other words, it’s the ability to be present,  open up, and do what matters. The greater your ability to do that, the greater your quality of life – the greater your sense of vitality, wellbeing and fulfillment.

Inevitably some clients will misinterpret some of this: they may think that they hear you saying that you will teach them new ways to control how they feel. But that’s okay. When you get to it experientially, they will discover what you really mean.

Struggle Versus Values Diagram

At the bottom of the sheet is a small diagram to further emphasize suffering vs vitality. The term ‘struggle’ stands for problematic cognitive fusion and experiential avoidance. You could say something like: 

  • ‘This diagram emphasizes what we aim to do here. This box represents your mind. Your mind does a lot of different things, and we are particularly interested in two of them: 
  • 1) Your mind helps you clarify your values, and turn them into goals., anhd convert them into actions. The more you take action (trace the forwards arrow with your finger) in line with your values, the greater your sense of vitality, wellbeing, fulfillment.
  • 2) Your mind sets you up for a struggle – with yourself, with your own thoughts and feelings, with your life, with other people, or with the world around you. The more you get caught up in this struggle, and the more you allow it to influence what you do, (trace the backwards arrow with your finger)  the more you get sucked into the black hole of suffering and X and Y and Z. (X, Y, Z = client’s presenting issues e.g. depression, anxiety, suicidality, drugs, low self-esteem, poor performance.)
  • Our aim is to get your life more and more moving in this direction – towards vitality – by focusing on your values. And we will look at how you can use mindfulness skills to handle difficult thoughts and feelings – so you can step out of that struggle, which so easily takes you in the opposite direction.’


A few Words About ‘Struggle’

ACT postulates that most if not all psychological suffering is due to cognitive fusion (getting caught up and entangled in your thoughts) and experiential avoidance (tryng to avoid or get rid of unwnated private experiences, such as thoughts, feelings, memories etc). Experiential avoidance and cognitive fusion are intimately connected – you won’t get one without the other. Basically, your mind says something is bad or wrong, and tells you that you need to do something about it. If you fuse with what your mind is saying, you will get caught up in a struggle with whatever your mind has judged as bad or wrong. If your mind judges your ‘private experiences’ (thoughts, feelings, memories, sensations etc) as ‘bad’ or ‘wrong’, and tells you that you have to get rid of or avoid them – and if you fuse with those cognitions – then you are set up for ‘experiential avoidance’. But you can also fuse with all sorts of other cognitions, that will set you up for a struggle with other aspects of your life (apart from your private experiences). For example, what happens if you fuse with the judgment that your partner is ‘useless’, or that ‘life sucks’ or your body is ‘repulsive’? That’s right: you are going to struggle with these things.

So although it will be necessary  to separate out these 2 different constructs of experiential avoidance and cognitive fusion, a lot of the time, to make life easier, I use one word to represent them both: ‘struggle’. By struggle, I mean, when experiential avoidance and cognitive fusion have ‘gone bad’. (Remember fusion and avoidance are neither ‘good’ nor ‘bad’ in and of themselves; in ACT we only consider them to be ‘negative’ or ‘problematic’ when they pull us into a self-defeating struggle with aspects of our life.)

Thus when I use the term struggle, I am talking of: 
        a)          the struggle with unwanted thoughts and feelings (experiential avoidance and cognitive fusion) 
         b)          the struggle with oneself – negative self-judgment, low self-esteem, self-loathing etc (experiential avoidance and cognitive fusion) 
         c)          the struggle with life, others, and the world (experiential avoidance and cognitive fusion) 
         d)          the struggle to remain psychologically present (experiential avoidance and cognitive fusion) 
         e)          the struggle with whatever is happening right here, right now, in this moment (experiential avoidance and cognitive fusion)

At different times, in different sessions, we may be focusing on some or all of these struggles. Thus I explain to clients, as the look at the struggle/values diagram:  ‘When I talk about ‘struggle’ I mean whatever you mind does to set you up for a struggle with yourself, your life, your own thoughts and feelings, other people, or the world. This struggle inevitably leads to suffering!’

Exercise 1:

  • Try reading the 2 scripts above out aloud right now, modifying the words, so that they are more like yours than mine.
  • Now try again, without looking at the text.
  • Now try again, once more reading the text.
  • And now again, improvising and modifying, without the text.
  • Practice this until it is fluent and natural
  • Then try it out on a colleague or friend
  • Then try it out on a client

b) The ‘ACT In A Nutshell’ Metaphor

This is a very simple physical metaphor that conveys the entire ACT model in a very short time span. (That’s why I’ve given it the above title.) Although it will take you a long time to read it, as written below, when you actually act it out, it generally takes less than five minutes.

Keep in mind, you can break this metaphor up into several different pieces, each of which you can bring in at pretty much any point in any session.  So they don’t have to come all together in one big metaphor, right at the very beginning, as written below. However, pieced together as below, you can cover a lot of ground in a short space of time. This is particularly useful for those of you who train ACT, or if you ever have to give talks about it; in those situations, I run through the whole piece as written. Generally, with new clients, I only do sections i to xi initially. I tend to save the rest of the exercise for a later session, when working more actively on values.  

i.

Use a large book or a firm clipboard or a thick folder for this. Pick it up and show it to the client

ii.

‘I want to demonstrate something, if it’s okay with you. I want you to imagine that this book represents all the difficult thoughts and feelings that you are struggling with.’ (Make it client-specific: eg this is all your feelings of depression, worries about the future, bad memories etc.)

iii.

Now, I’d like you to hold it up in front of your face, right up close, until it’s almost touching your nose.’  (Demonstrate what you mean: hold the book up in front of you, so that it obscures your entire face - then give it to the client and ask them to do the same.)

iv.

‘Now this is what it’s like to get all caught up in your thoughts and feelings. What’s it like trying to have a conversation with me? (Elicit an answer).Do you feel engaged, connected with me? (Elicit an answer.) What happens to the rest of the room when all your attention is centered on these thoughts and feelings? (Elicit an answer.) So when you get all caught up in this stuff, you start disconnecting form the world around you. You cannot be fully present with me when you’re all preoccupied with this stuff.

v.

Next stand up – while the client remains sitting down. ‘I want to demonstrate something else. I want you to put both your hands on one side here, and I’m going to put mine on the other side, and I want you to try as hard as you can to push it away from you. (As the client tries hard to push the book away you lean into it; the harder they push, the more you lean into it. Check that your client does not have neck or shoulder problems before you do this; if they do, push very lightly! If not, steadily increase the pressure.)

vi.

Maintaining this interaction – the client pushing and you resting your body weight against the book, say the following. ‘So here you are, trying very hard to push away all these painful thoughts and feelings; and are they going anywhere? Sure, you’re keeping them at arm’s length, but what’s the cost to you? How does it feel in your shoulders? (If client says ‘Fine’ or ‘Not too bad’ then push harder, and say, ‘Okay they’re fine now, but how will they be feeling after an hour of this;  or after a whole day of this?’)

vii.

Maintaining the struggle, say: ‘And if I asked you now to type on a computer, or drive a car or cuddle a baby or hug somebody you love, while you’re doing this – could you do it? And what’s it like trying to have a conversation with me while you’re doing this?’

viii.

Then stop resisting; totally ease off the pressure, and take the book back. Say: Okay, now let’s try something else. Just let it sit there on your lap. (Place the book on their lap.) Now isn’t that a lot easier? (You now sit down, leaving the book resting on their lap.) How are your shoulders now? If I asked you now to chop vegetables or cuddle a baby or hug somebody you love What’s it like to have a conversation with me now, as opposed to doing this (you now mime pushing the book away) or having it up here right in front of you? (you now mime holding the book in front of your face, positioning your hands as if they were the book – i.e. holding them in front of your face to obscure it from the client.)

ix.

Then say: Now I’m sure in the ideal world you’d like to do this. (You lean across, grab the book, and pretend to throw it on the floor). But here’s the thing: you’ve been trying to do that for years. (keep hold of the book) You’ve tried A,B,C,D,E, F, G (list at least 5 or 6 control strategies the clients have used) and it’s still showing up (point to the book in your hands).

x.

At this point, it’s often useful to ask, What’s the earliest you can remember struggling with these sorts of thoughts and feelings? (Often the answer is since childhood. You can then respond appropriately, as demonstrated in the following example.) Wow! So this stuff has been showing up in your life since you were fifteen years old. And now you’re how old? 36? So for 21 years you’ve been trying to get rid of this stuff – and yet, it’s still here.

xi.

Now I don’t know any way you can stop this stuff from showing up – at least, not for very long. Even if you push it away for a little while, sooner or later it comes back, right? And there’s a good reason for that. It’s called being a human being. Life is painful, and as a result, we all experience painful thoughts and feelings. Sure, some people experience more than others; but that’s beside the point. The point is, this stuff will keep showing up in one form or another – you don’t have a choice about that. But  you do have a choice about  what you do when it shows up. Do you do this (hold book in front of your face) or this (hold book out at arm’s length) or this (place book back on your lap). Which is easiest? Which gives you the most freedom, and takes the least effort?

xii.

Then say, Now I want to show you something else. Would you be willing to stand up? Thank you. (You both stand. You place yourself facing opposite the client.) I want you to imagine that over there, behind you (You point in the opposite direction, directly behind them.) lies a rich and meaningful life.. That’s the direction you need to move in, if you want to find vitality and fulfillment. Okay? (Then you hold up the book again.) Now I want you to place both your hands on this, and just like before, I want you to try pushing as hard as you can, to get it away from you. (As the client pushes, you allow them to push you backwards, maintaining just enough counter-pressure so that they follow you.) Now I just want you to notice, what direction are you moving in? Are you moving towards vitality or away from it? (Elicit an answer.)

xiii.

Then say: Okay. So if you want vitality, and meaning, and wellbeing, where do you need to go? (The client will point behind them.) Okay, so turn around now. And slowly take a couple of steps in that direction.(The client will start to walk off. You immediately shout out!) Whoa! Hold on. You forgot something. (You hand them the book.) You can’t leave this behind. This is a part of you. These are your thoughts and feelings and memories. Wherever you go, they go. The question is, how do you want to carry them? (The client will usually tuck the book under their arm.) Great. So you can take it with you, and it doesn’t stop you from doing whatever you want to do.

xiv.

The point has been well made already, so there’s no need to do this next step: it’s just an optional extra if you really want to emphasize the point. Are you sure that’s the best way? Just try carrying it right in front of your face, and see how that works. (Client will usually laugh.) Okay, now try carrying it in front of you, holding it out as far away from your body as possible, and see how that works. (Again, client may laugh or say something humorous.) Now try once more, hold it however you like. (Again client is likely to tuck it under their arm, or hold it to their chest). Great. When you hold it like that, you can go wherever you want to go, you can see clearly, and your hands are not tied up.

xv.

Then say: Thank you for indulging me. I realize that may seem a bit freaky, but I just wanted to get across to you what this work is all about. Mindfulness skills will enable you to handle your difficult thoughts and feelings in a new way – in a way that frees you up to do what you want with your life. Does that interest you? Would you be willing to spend some time learning and practicing these skills, so you can take your life in the direction you want?

Exercise 2:

  • Try and reading the text above out aloud right now (while you act it out with an imaginary client) - as before, modifying the words, so that they are more like yours than mine.
  • Now try doing it out again, without looking at the text.
  • Now try again, once more reading the text.
  • And now again, improvising and modifying, without the text.
  • Practice this until it is fluent and natural
  • Then try it out on a colleague or friend
  • Then try it out on a client

C) Do Both of the Above, One After the Other

I often do both a) and b) – I find they complement each other. However either one is useful in its own right. Again, it depends on how much time you have.


Problems You May Encounter

Most clients will respond favorably to the interventions above – but not all. (Damn it!!!) You might get this: ‘What do you mean? Are you saying, I have to put up with it?’  Or this: ‘But I came here to get rid of these feelings. What’s the point of coming here otherwise?’

Basically you respond to these the same way: ‘How long have you been trying to get rid of this stuff? How much time, energy, money, effort have you expended on it? What has it cost you, in terms of health, vitality, relationships, wasted time etc to go through life struggling with it? Just try pushing it away again: put both your hands on here, and push as hard as you can. (Once again, you get them to push against the book and you lean against it as before, and take them through that segment again.) Notice, it’s taking up all your attention and it’s sapping all your energy; you’re straining yourself; and there’s all sorts of important things you can’t do because your hands are tied up. Do you want to go through the rest of your life like this? (Then stop pushing, and take the book, and place it in their lap.) Isn’t that easier?’ 

Often at that point, you’ll get the answer you were looking for. But again, there will be the occasional exception. For example, in answer to the question ‘Isn’t that easier?’  you may get into an exchange like this:

Client: ‘Yes, but it’s still there. I can still feel it/see it.’
Therapist: ‘Sure you can. Mindfulness is not a way to stop you from feeling. It’s a way for you to feel what you feel without a struggle.'
Client: ‘So you’re saying I have to put up with it?’
Therapist: ‘Not at all. Mindfulness is not about “tolerating” or “resignation” or “giving up” or “gritting your teeth and putting up with it”. It’s about fundamentally transforming your relationship with painful thoughts and feelings – in such a way that they’re no longer a problem for you. Right now, I don’t think you can fully understand what I’m saying, because you haven’t experienced it for yourself. It’s like skiing or scuba-diving: you can’t really know what those activities feel like until you’ve actually tried them. So I can’t do justice to this in words and explanations. What I’d like to do is take you through a simple exercise, to show you what I mean. Would that be okay?'

With a response like that above, you now have an opening to lead your client through a simple mindfulness exercise – such as the ones we’ll be covering in the next email. 

You might also get a client saying, 'I don't think this will work for me.'  My response would be, 'That's a perfectly natural thought. Most people feel doubtful at first.'  If client persists, you could go on to say, 'There is no known treatment that is gauranteed to work for everyone. I can't promise this will work for you. I can tell you, it's worked for lots of other people - but of course that doesn't mean it will necessarily work for you. Are you willing to give it a go anyway, and see what happens, even though you don't believe it will help?'
Sometimes, in the bit where you’re asking the client to walk in the direction of vitality, you may get something like this: ‘You don’t understand. I can’t ever have a life like the one you’re describing. That’s bullshit.’  Comments like this require active defusion, and we’ll learn how to deal with them in a later email.
Very rarely you might even get a client saying, 'Yes, but that's just a book/clipboard/folder. I have real problems, with real feelings.'  We could reply, 'I know. It's just a metaphor. A way of conveying quickly what we intend to do here.''


Parting Note
Personally, I always prefer physical metaphors over verbal ones, because they are more interactive, tend to have more impact, and are remembered better by clients. (They're also more fun.) Clients usually have strong positive reactions to the ‘ACT In A Nutshell Metaphor’ above, and there is often some laughter in places. Hopefully the client answers ‘yes’ to the last question in section b), above: ‘Would you be willing to spend some time learning and practicing these skills, so you can take your life in the direction you want?’  Assuming they do, you can then move on to a brief mindfulness exercise, or two - which you can then ask them to practice in between sessions. We will cover several possibilities for such exercises in the next email. Until then, keep practicing!

All the best,

Cheers, Russ Harris

© Russ Harris, 2008            www.thehappinesstrap.com                  russharris@thehappinesstrap.com

 

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