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Psychotherapy goes through fads, or phases, beginning perhaps in the western world with Freud's psychoanalysis, moving on through the object relations therapists and the Heinz Hartman Ego Autonomy therapists, through the Family Therapy movement, into Behavioral Therapy, Rational Emotive Therapy, Brief Therapy, Client Centered approaches, Directive and Problem Solving Therapy, Cognitive Therapy, Cognitive-Behavioral Therapy, Narrative therapy, lots of others, and then to the latter fashionable approaches, Acceptance and Commitment Therapy with Mindfulness which is what this book is about.
Of course, when one listens to one or the other, one hears another echoing, such as when listening to experts expounding on ACT, then one hears the ghost of Jay Haley and others, (is Haley still alive?). Carl Rogers is dead, but his reflective approaches live on, for instance in Miller and Rollnick's Motivational Interviewing. Some approaches, such as those based on Systems Theory, or Logotherapy or others, provide a blank framework for other approaches to slot in.
So Wilson slots Mindfulness into ACT, and as ACT does not draw tight divisions between client and therapist, so Wilson talks directly to the reader. To enhance this connection, Wilson provides more than 6 hours of DVD material to illustrate his concepts along the way. He is a seminal figure in the ACT field.
On the DVD, exercises are given, for instance to allow the therapist to go still, eg Sweet Spot, Client Descending, mindfulness exercises to enhance the approach to a more mindful appreciation or witnessing of concerns, etc. His voice is very much soothing in the manner therapists adopt, perhaps even the Jay Haley type, with constant invocations to be the watcher, or become the watcher. One may even discern a somewhat Eriksonian raspishness emerging. This of course is a mix of the therapist watching their own past activity, but also then the therapist observing their own work. It's all vintage relaxation with noticing and breathing and inviting and allowing and appreciating and taking a moments and sound of my voice and other key words peppering the monologue. You will have to concentrate very hard to hear the ground breaking. It is also quite tedious, with for instance an intervention into a client who may cause anxiety or concern in the therapist being 17minutes on the go before the relaxing side is complete, and one begins to engage with visions of the filing cabinet in which photographs of the client are arranged, and many more minutes, with my gaze lingering on the chosen photo, before we get into the thing. For me, life is too short, and this is why there are more than 6 hours of the stuff. Interestingly is his approach that we may long to find answers for them, while gazing at their eyes and hair, and that helping them is just beyond our reach, and we cannot stop them from tumbling down the stairs. We gaze into their face as they hurtle backward down the stairs, hand outstretched, and we cannot reach them. We linger there, as they fall away, their eyes long for help, we long to help them, we freeze frame, breathe in their longing, while restricting our grasp, we take one last long look at this face, take a long last look and let the picture drop into the drawer of the filing cabinet, and then observe our powerlessness, all the while, breathing, then we go back and get the photo that is ten years from this day, and while worried they will die, we see them alive 10 years from now, still struggling with the problems of today, and this photo we then study mindfully. We are 26mins into this now, imagining what it is like to be like that, but breathing in ten more years, during which they may have lost their wife and kids, and then I go for a cookie, a soda, and check the post, and when I come back, more than half an hour into the intervention, we are now withdrawing a photograph of them on their last legs from the cabinet, and I am seriously missing Milton Erikson's potato plant, and now they are slipping away on a very empty life voyage, their potential never realized. We are to honor them by being present in their last hour, a last hour that saturates us, so that when they pass, someone will have known, or cared to know, someone took the time, not turned away, and like a Dementer in Harry Potter, breathe in that suffering, and I have to gently let go of my nose and say yes, I will care and also be still. The last sad hour has to saturate me as a therapist, before I reverently take one last look at the photo, letting it slip gently gently into the drawer which then closes. We are now headed for 40mins. He then coaches that we should express, like pouring from a jar, to a listening partner in this exercise, and while staring into their eyes, find the concern in their eyes, and while staying with their eyes, breathe their presence, and give expression to the concern they have, gently, about the decline of the client they just witnessed. It has to pour outward. Silence follows. I wait by the DVD, wondering if there is more, and the timer on the Windows Media ticks on…past 42'22".....is he coming back, should I gently invite myself to breathe and leave? The slide bar on the player is perhaps ¾ through, at 45 mins, when he is suddenly back. And there is more pouring from my face apparently, then he is gone again, and back again five minutes later. At this stage, my daughter comes in to ask me to turn off the sound, it's annoying her.
My problems with such approaches to immersion around a client aside, the nature of human suffering, and the manner of the helping professions of psychiatry and psychology approach to human suffering has brought criticism before (see my review of Facing Human Suffering by Ronald Miller) with Wilson claiming that empirical clinical psychology has failed to see the unity of human suffering. As with Miller, Wilson sees the categories imposed on the varied and untidy nature of human suffering as being limiting. Unlike Steven Hyman's view, that the categories are too categorical, Wilson is claiming that the act of categorization changes the therapists view of the shared humanity of that suffering. This first exercise, touched on above, is an exercise to get therapists to engage with suffering at a close level. Engaging with suffering comes with aversion and ambivalence, but that is the point of getting up close and, what Wilson calls, personal with it. Poems and exercises pepper the pages. Wilson's wager is then to live in the liberation of the personal expectation of positive hope, expecting to wield choice even in something as deep as Frankl's misery in the camps.
Wilson takes time then to discuss the distinction between behavior and context such that context is seen to organize behavior. Responses are thus behaviors that respond to stimuli, namely context. The skill is in working out the patterns, with transitions in responding being transitions in context. Contexts can thus precede an event of change, or be a consequence of an event. These concepts all operate in the context of what ACT refers to as a Hexaflex model.
The model contends that there are six processes that converge: acceptance, defusion, self-as-context, values, committed action and contact with the present moment, as most of the exercises indicate. In keeping with the functional contextualism at the core of ACT, these are integrated elements, although they are described individually, as are most things in psychology. After working with these six elements, Wilson moves on to the next chapter, where Mindfulness is then integrated. It is not hard to work out why, given the elements of ACT, which are so engaged with the process of being in the moment, rather than racing on from one context or emotion to the next, the act of slowing alone is enough.
The presence of mindfulness is said to enhance ACT, the absence, to hinder the process. The therapy process should thus begin with the time taken to grab hold of the pace of the modern world, and slow it down, to relieve us of the burden of the disconnect, quoting from Death of a Salesman. If everything we want is somewhere else, and waiting for us to say we know who we are, why can we not just say this? If the core of therapy is reflective listening, then the core of that in turn is really listening, something which Wilson felt was lacking in his own therapies at times. He then sets about keeping clients in the present moment.
In essence, this means keeping the client from immersing themselves in the wholly commonsense attempt to solve their suffering, rather than becoming the watcher of it, acknowledging its presence without desperately trying to remove, alleviate or indulge it. That means that worrying, ruminating, self punishing and other usual events, although they give immediate reward, being a form of problem solving, or at least the sense that one is doing something. Worry and ruminating and the like are really a form of storytelling, and like narrative therapy and similar approaches, these can be retold, differently, or a different content can be sought in context. Mind-y are bad conversations, that go nowhere, and advice is given about spotting those.
The next advice giving is about data: both those outside and inside the skin and the therapists mind as well. Much of the training in the DVD goes to this end as well, as the therapist confronts the countertransference. Instead of the patient being disconnected, here the therapist disconnects are examined. This is the point of mindfulness for two, with both sides of the relationship examined in the moment, and avoiding the therapist Mind-y. As others such as Miller and Rollnick have pointed out, therapy that sounds Mind-y, or argumentative, is probably bad, and the resistance concept hangs on just that, that resistance within the client's change activity, called sustain-talk, is the result of the therapist's actions, not the client's. Here too, the focus shifts to the introspections of the therapist. What is termed fusion and avoidance is thus possible as an emerging issue when the history is 'hard'. Part of this section therefore is for the therapist to learn how to hover on the cusp of doing or not doing something as an intervention that is screaming out to be done, avoiding the trap of the above fusions, such as one where the therapist is wedded to a solution which he or she is certain the client needs to pursue. We called this learning to live with 'dis-ease' when I was trained. Wilson cleverly examines the various pitfalls and avoidance techniques psychotherapists use to fend off and control the relationship variables which they find uncomfortable.
Wilson carries on with a curve ball, finding a way to conceptualize cases based on his approach to this two way examination of the value of mindfulness in ACT. This would mean linking assessment, diagnosis and treatment within the hexaflex model. Wilson thus returns to the recent criticisms of the categorical nosology of the DSM, this time David Kupfer's and his colleagues in 2002. He marvels that this was from within the establishment, not outside, as for instance Thomas Szaz's was. He has to balance the two competing philosophies, one so personalized, the other not at all.
To do this, he introduces the HFDEI, or the Hexaflex Functional Dimensional Experiential Interview. As the name suggests, this format tries to avoid the categorical formulations of the DSM in favor of what Steve Hyman and others have called for, a dimensional approach. This also draws on the Valued Living Questionnaire, the VLQ-2.
In speaking about making experiential contact with mindfulness, he rightfully points out the one has to earn the results. So for instance, if one attends a seminar on resilience, one does not come out of that session more resilient: this stuff has to be earned, it's a body contact sport. This will be a different sort of conversation, one that Bradford Keeney described as akin to an art gallery: the sign on the door tells the client the conversation will be different, but what one really does is rearrange the art on the walls without changing the gallery, it's a life-changing conversation if done properly, and this takes practice.
He then introduces a Sweet Spot exercise, mentioned at the start of DVD-ROM attached, as having come before. This is a folie a deux, or more, and is then referenced to the DVD and the exercises that follow on that for couples or groups of learners to do in workshops. He does this book, as he explains, not punctuated by science, but informed by it, in his own voice. I found, as my daughter did, that his soporific therapist-type hypnotic voice and intense trance-inducing approach was not my style, but the book, even in his own voice, is not simple, and contains a lot of very valuable didactic and structured material that can seriously influence the conversations a therapist has with clients.
Criticisms of other eclectic approaches include the 'what is new doesn't work, and what works is not new' but this approach kind of beats that rap somewhat. I certainly learned the basis of all of this in my training, which was more ecosystemic and post-modernist 'decon'- cum- family therapy, so not much is a shock to me, and I have never been immersed in CBT or other narrow styles, these are just part of my toolbox. Weaponry, sort of, for the close combat of psychotherapy: his approach is much more use of self, in a mindful way, and I think very useful, if not revolutionary, but certainly of value in the day to day what to do with them world of the psychotherapist.
© 2009 Roy Sugarman
Roy Sugarman PhD: Director of Applied Neuroscience, Human Performance Institute, Sydney, Australia