ACT, pronounced ACT and not A-C-T, is a new form of therapy that these authors have had a meaningful relationship with, in terms of bringing it to the world. This book however is not a starter kit, but rather for those who already have a reasonable understanding of how act works. The primary view of ACT community is that bad things come and go, apart from the meanings we attach to them, and how our values play into this.  In short psychological inflexibility has as its consequence that we struggle with challenges, and the hexagon motif here has each point in correspondence with the processes ACT hypothesizes to contribute to the experience of human suffering and psychopathology, these processes combining and interacting to produce the aforementioned inflexibility.

These are: experiential avoidance, cognitive fusion, inflexible attention, attachment to conceptualized selves and conceptualized others, lack of contact or lack of clarity about values, inaction impulsivity and avoidant persistence. These inform the assessment processes in the practice of ACT.

So in essence: we attempt to control the form, frequency or situational sensitivity of internal experiences, even when we cause behavioural harm. Language and cognition thus entangle to deal with uncomfortable experiences, and an astute reader will notice the influence of Relational Frames Theory, namely the input of RFT into ACT, both bearing the fingerprints of Hayes, the second author here, but that interaction between the two inventions is not entirely clear.

Avoiding or altering internal experiences via attempts to use the same language we use for the more concrete external experiences, can create this inflexibility.  Cognitive fusion refers to the tendency to get caught up in the content of cognitive evaluations, as if they were the world itself. These then come to substitute for the real experience of the world. Inflexible attention refers to the drag of a conceptualized past or future, rather than the freedom of the here and now experience. The attachment meme above refers to the need for us to succeed by challenging our own image, conceptualized over years of experience and languaging about ourselves, and even fundamental attribution errors come into this. Values, in this case, are chosen qualities of being and doing that are reflected in patterns of behaviour that are ongoing. Experiential avoidance can thus cause us to lose contact with our values. Inaction and so on, associated with fusion, avoidance, attachment to a conceptualized self and loss of flexible attention to the present moment, results in the loss of value-based action, an inflexible approach leading to inaction or impulsivity.

In applying the reverse set of conditions to the above, there are thus six core flexibility approaches in ACT. Acceptance, Cognitive Diffusion, Being Present, self as Context and Flexible Perspective-taking, Defining Valued Directions and Committed Action.

Acceptance is a way of freeing up values-based actions, rather than attempting to change the frequency and form of private events such as anxiety. Cognitive defusion of thoughts and feelings, is somewhat unlike the CBT approach to modifying ‘stinking thinking’, as this may just focus the client even further on the negatively attributed thoughts. Thoughts are tied to actions, by this way of thinking, only in certain contexts. Thoughts can be altered by changing the context without having to change their form.  Being present is exactly what it sounds like, rather than being locked into perceptions of a conceptualized past or future. Hence, here, we can see the influence of Contextual Behavioural Sciences (CBS) along with RFT. Defining valued directions focusses on applying language where it is most effectively applied, not in the internal evaluations, and thus follows onto committed action. Larger and larger patterns of action are linked to chosen values. In essence, feeling better is tied to expanding actions taken in the environment in which change happens, and is supported, rather than waiting on the internal languaging arguments to win through. Behaviour change efforts lead to contact with psychological barriers, which are addressed using other elements of the hexagon of flexibility.

These then group into response styles, those of inflexibility being closed, mindless and disconnected, rather than the flexible styles of open, aware and engaged. Acceptance and Defusion lead to openness, being present and taking a perspective lead to awareness, and values and committed action lead to engagement. One could therefore group the inflexible ones like avoidance and fusion into closed-ness, inflexible attention and attachment to self-concept to mindlessness, and to lack of values clarity and disconnected action to disconnected-ness.

So finally the definition of ACT is that it is a psychological intervention based on modern behavioural and evolutionary principles, including RFT, that applies mindfulness and acceptance processes, and commitment and behaviour change processes, with the aim of creating psychological flexibility. In this way it is a model, not a specific set of techniques. Given it formulates a causative pathway to pathology, it is thus transdiagnostic in that it cuts across diagnostic categories, and thus can relate to Autism Spectrum as much as Major Depression.

Human pain therefore cannot be waived away by denial of its existence when it comes to visit, paraphrasing Achebe in the opening quote. The default of experiential control leads to a battle with our internal experience. This is born out of language (RFT) and amplified by culture (CBS). Short term solutions provide some relief, but not in the long term.  Attempts at avoidance and control may provide some temporary relief, as noted above, but in the long run the paradoxical outcome is that pain increases over time. The alternative approach is willingness, namely being open to the entirety of one’s experiences whilst actively working to move in valued life directions. This includes being both aware and open to experiences.

There is also a link between willingness and defusion. Unlike the external world with the possibility of neat solutions, the internal world doesn’t easily lend itself to such things, and hence attending to this discrepancy is essential. The attempts to utilise the rules of the outside world internally, can lead to increased discomfort as these attempts inevitably fail in the long run. A more-of-the-same approach to the failed attempts leads to greater, failed attempts without switching gears. So being anxious about failed attempts to avoid anxiety is paradoxical in outcome. Logic fails, namely the logical assumption that emotions, thoughts and sensations are subject to volitional control, and that failure to do so is likely. The trigger to focus on willingness is the identification of experiential avoidance in session, and can apply to the therapist too.  Two steps are required here, namely a general openness that would result from undermining experiential control as the go to control strategy, and active attempts to choose willingness via structured practice and committed action, the aim is of course to foster psychological flexibility.

The authors go on to describe how this is done in three steps, and give sample dialogues, followed by an exercise based on the dialogue.  The elements they tease out include creative hopelessness, where control does not work, even if that list is full of unworkable old agendas, with no payoff as control IS the problem, not the working solution. Teaching willingness is also part of the process here, as this is both a choice and an action. This leads then to core competency practice around these issues, 11 competencies in all, each with a modelled response.

The next chapter on undermining cognitive fusion, namely defusion, follows the same pattern. The therapist targets the context that relates to the thoughts and feelings to undesirable overt behaviour, creating greater response flexibility. Firstly they look at what should trigger working with fusion, the method, and then the exercises around core competencies, at least 20 here, and then model responses.

Moving on to getting in contact with the present moment, the next chapter follows this now established procedure, defining, triggers to work with this, the method, and so forth, included structured exercises, so to build present-moment awareness to build self-as-context and foster experiential learning. The Self-as-context concept leads to flexible perspective builds (RFT again), in the following chapter, and as it suggests, is related to the conceptualized self. Again, the formula is followed for this chapter as well, with hierarchical framing and useful metaphors as additional interventions leading to the transcendent self.

Valued directions is then dealt with, and these require definition, a key differentiator of ACT, in the pursuit of life goals and values, namely verbally constructed, global, desired and chosen life directions, which of course are disrupted by anxiety or other pathology, and the unwillingness to let this be a part of life, and not a barrier via attempts to remediate the experience.  Values offer constructive direction, consistency of trajectory, behavioural flexibility is fostered, provide motivation, and most importantly they provide a contextual purpose for behavioural change.  For instance, in my athletes who do better in training than in competition, namely they are outcomes-focussed, the process of just living has been supplanted and disrupted by the focus on the outcome. This draws attention away from the present moment, whereas values draw our attention to the valuation of whatever situation life has provided in the moment.

You will realise by now that ACT requires a great deal of skill, and many skillsets to make it viable in the face of client variability and variety. Even the following chapter on building patterns of committed action is complex, as have been the prior chapters that relate to therapist skillset and the timing and pacing of these applications. These patterns have as their goal the servicing of chosen values while making room for the pesky automatic reactions and experiences, by taking responsibility for their patterns of action, expanding them to accommodate effective, now established values-based focus on living daily life. Integrity and authenticity means being true to deeply held values around what we wish for, and long for. Persistence and change are both approaches that apply here at different stages, and thus include a range of behaviours to allow for flexibility. Actions must always be linked to comprehensive values, a kind of GPS for both grit and pivoting, which means handling slips and relapses here as well.

Given this complexity, case conceptualization can be a real issue, hence the need to know what triggers indicate where to go and what to approach in the methodology in a patient. This facilitates learning ACT theory, essential to using it fluidly and maximizing therapeutic freedom to manoeuvre.  Seeing behaviour through a functional lens supports the idea that all behaviour is meaningful. Focussed and consistent, thorough interventions are scaffolded, and guides understanding of and approach to cases across time, focussing on those patterns of behaviour which respond across time, consistently. There is of course a formal stance to ACT, and this is the fodder for the next chapter (316 pages along the journey!), and sets out the attitude of the ACT therapist vis a vis the patient and the therapy. All six of the ACT core processes should be applied if the ACT experience is to be solid for the process, and this modelled here. Considering the references to context, culture is an essential element, and so is dealt with next, adapting ACT to these cultural contexts.

As complexity has unfolded, so the authors bring it all together in Chapter 11. This is necessary as an overview to complex approaches like ACT, that require body contact practice to sharpen the overall skills required, and when to trigger each. The core processes and methods must be understood and all 6 adhered to as mentioned before, leading to flexible, process-focussed practice.

As befitting the experience and pedigrees of the authors, the book is carefully comprehensive and the outcome (excuse the phrase) of the years of using this now well-established process methodology, paying attention to core principles, RFT and CBS and providing a manual that guides the therapist as to what is meaningful in which context with the client. Given the flexibility of the approach, and really a framework in which to use the core competencies and processes, the therapist has to pay close attention and live alongside the client in the sense of dis-ease we create when we challenge the failed, core attempts by the patient to work out the discomfort and the failure to do so. For those who do know something, this is a great further training manual, and for those new to ACT and crazy about their well-established CBT skills, this would be a little beyond, but not too much so, but nevertheless, start with the more introductory ACT works as noted above at the beginning, and then move on to this one. I have done ACT courses, so this was not a stretch, but it certainly was useful in sharpening my view, with of course my being the victim of the usual process of forgetting and shortcutting that one often does when familiar with something, now back on the rails thanks to re-reading this approaches’ core tenets and triggers to use the skilled process.

It is the next gen of therapies, and so required for all therapists who need new skills for those patients stuck in failed outcomes.

 

© 2018 Roy Sugarman

 

Roy Sugarman PhD, Director, applied neuroscience, Performance Innovation Team: Team EXOS USA