Whenever Richard Cory went down town,
We people on the pavement looked at him:
He was a gentleman from sole to crown,
Clean favored, and imperially slim.
And he was always quietly arrayed,
And he was always human when he talked;
But still he fluttered pulses when he said,
“Good-morning,” and he glittered when he walked.
And he was rich—yes, richer than a king—
And admirably schooled in every grace:
In fine, we thought that he was everything
To make us wish that we were in his place.
So on we worked, and waited for the light,
And went without the meat, and cursed the bread;
And Richard Cory, one calm summer night,
Went home and put a bullet through his head.
—Edwin Arlington Robinson
It is impossible to construct a human life untouched by suffering. Edwin Arlington Robinson’s well-known poem reminds us that, every day, people who seemingly have all the things a person could ever want, at least as viewed from the outside, end their existence rather than bearing up under another moment. We of the human species encounter many of the same painful events as do other species; humans and nonhuman animals alike are faced with loss, unexpected upsets, and physically painful experiences. Yet we do something with these encounters that other species do not: we think about them, analyze them, predict them, and ruminate about them, and through this process we amplify our suffering and bring it with us.
The human ability to think and reason is truly amazing. Our system of language is unlike any other; as an ongoing process, it fills our awareness with a never-ending stream of verbal connections. This ability is both a wonderful and a terrible thing. It sustains the capacity for human achievement: our ability to communicate, build, plan, and engage in problem solving. It is part of our ability to love deeply and commit to others, to dream of hoped-for futures and work toward their realization. However, the same cognitive and verbal building blocks that enable these possibilities also allow us to struggle in the midst of plenty. They allow us to be Richard Cory.
Human beings struggle in a number of ways that can be painful and life changing. When events occur that bring us into contact with difficult emotions and thoughts, we often work very hard to rid ourselves of these experiences, both by trying to avoid the event that triggered them and by attempting to remove the negatively evaluated emotions and thoughts that accompany the experience. For instance, we don’t want to feel anxiety about failure or sadness about loss, so when an event occurs that might occasion those emotions, we work to avoid the event and the resulting emotional reactions.
It isn’t surprising that we take these steps. If something is unpleasant, it makes sense to figure out how to remove what is unpleasant. The problem with this strategy lies in the paradoxical effects of language—those symbolic abilities that make up what we call in common terms the mind—as we attempt to use these abilities to avoid or subtract that which cannot be avoided or subtracted. When it becomes important that we not think or feel a certain way and we nevertheless find ourselves thinking or feeling that way, our minds can become consumed with efforts to diminish or eliminate these experiences. Often, however, in the very effort to eliminate these experiences, we propagate and grow the demons we wish to destroy.
Acceptance and commitment therapy (ACT, which is said as one word, not as A.C.T.; Hayes, Strosahl, & Wilson, 1999) offers a possible antidote to the harmful functions of this verbal capacity and its role in human suffering. ACT is an evidence-based contextual cognitive behavioral intervention designed to create greater psychological flexibility and, as a result, human liberation. ACT addresses the paradoxes inherent in human cognitive processes and works to help people live meaningful and valued lives.
ACT employs a number of strategies to alleviate people’s problems and promote their flourishing, including willingness or acceptance of experience; cognitive defusion; flexible attention to the present moment; contact with a transcendent or perspective-taking sense of self (self-as-context); clarity and ownership of values; and fostering commitment to larger patterns of values-based living. Each of these processes is applied with warmth and compassion for the client’s struggle and for the difficulties that unwanted experience can bring. ACT is a constructive approach to psychotherapy that helps people learn to compassionately embrace their internal experience for all that it is while also focusing on building repertoires of constructive behaviors that are values oriented.
ACT is informed by all of the elements of what is now known as contextual behavioral science, or CBS (Zettle, Hayes, Barnes-Holmes, & Biglan, 2016). CBS aims to recast behavioral science itself and takes a functional approach to the major elements needed for knowledge development in this domain. CBS includes functional contextualism as a philosophy of science (Biglan & Hayes, 2016), evolution science principles (Hayes, Monestès, & Wilson, in press), and behavioral principles as augmented by relational frame theory (RFT; Hayes, Barnes-Holmes, & Roche, 2001). All of these various elements come together to define ACT as a contextual behavioral method.
The relationship of ACT to this larger set of assumptions, principles, and strategies has been written about extensively in previous books, and we summarize some of this topic briefly in a more clinical way in this volume. In particular, we describe the manner in which ACT approaches how human language and cognition contribute to keeping human beings stuck. In this second edition, we also more clearly link psychological flexibility processes to evolutionary principles. But for the most part, this book centers around gaining familiarity and practice with the flexibility processes targeted by ACT, and doing so in a way that is accessible.
It is our hope that reading this book will empower clinicians to begin to apply ACT’s psychological flexibility model and methods in their practices. That is what is most unique about this volume. It is designed to go beyond the philosophy, theory, concepts, and verbal knowledge of techniques to the actual production of skills and competencies that target flexibility processes. Therefore, we have deliberately written it in an accessible style because our focus is on the practical.
This workbook:
ACT is not a cookbook approach; it is an enormously flexible model that is built from the ground up with a focus on processes of change that empower people, rather than proffering rigid protocols for syndromes. We not only want to provide practitioners with a clear sense of how ACT is conducted, but would also like to convey the vitality this therapy can bring to human experience.
We strongly encourage personal involvement with the book, including engaging in the practices we offer. We ask this for a number of reasons, most importantly so that you, as a therapist, can experience what it means to personally engage ACT, just as you will be asking your clients to do. People playing the role of therapist are not fundamentally different from people playing the role of client. As we will outline in this workbook, we human beings all tend to get stuck in the same traps. It is essential to learn about these traps from the inside out, through practice. For that reason, this therapy can be difficult to do if you are not applying the same approaches in your own life. Take, for example, your own personal experience with emotion: what do you do when confronted with what is most painful to you? If your answer includes efforts to eliminate or control your experience, we would ask, “To what end?” Perhaps for you, as for most people, that end is to feel “better.” However, if your answer is to experience the pain for what it is, learn from it, and live better by doing so, then you are ahead of the game in learning the ACT approach and more likely to be effective at it.
Many therapies focus largely on helping people feel better. The hope is that, at the end of the therapy, the client will have fewer symptoms and will feel better emotionally. The focus in ACT is explicitly on living better. Although this may involve feeling better, it also may not, especially in the short term. Sometimes living better actually calls for feeling the pain. If doing so promotes connection, choice, and living with vitality, ACT tries to provide clients with the skills needed to feel pain without needless defense. The ultimate goal of ACT is to support clients in feeling and thinking what they directly feel and think already, while also helping them move in a chosen, personally valued direction.
Learning ACT is designed to be used with other books and resources on ACT concepts and methods. We particularly recommend in the following:
Should you need an initial introduction to ACT, we especially recommend these two books:
In addition, there are scores of ACT books for specialized populations, both for therapists and for individuals. One of the authors of this book (JBL) maintains an updated list of ACT books and other resources in the e-book Learning ACT Resource Guide (available for download at http://www.learningact.com). The Association for Contextual Behavioral Science (ACBS) is the main gateway to ACT research, clinical and theoretical publications, online discussions, trainings, institutes, conferences, manuals, protocols, metaphors, and networking; ACBS also keeps a list of ACT and RFT relevant titles at https://contextualscience.org/acbs_amazon_store. Keep in mind that if you go to the ACBS website, you won’t be able to see most of the materials if you aren’t a member who is logged into the website. More information on the ACBS and other resources is available in appendix B.
ACT is an evidence-based intervention, but we want to be clear about what that means in a contextual behavioral science approach so you can understand the organization of the book. ACT is not a protocol or a set of techniques; rather, it is an approach to therapy that targets a small set of key flexibility processes. This process-based approach is a feature that distinguishes ACT from the many forms of therapy that emphasize protocols over processes.
The introduction and first chapter of this workbook provide an overview of the theory behind ACT and some tools to help you think about cases from an ACT perspective. Specifically, chapter 1 outlines the ways in which basic processes of learning and evolution science, combined with the problematic effects of language, lead to increased suffering for humans. The ACT theory of change is also outlined in chapter 1.
Chapters 2 through 7 and chapter 9 cover the knowledge and practices necessary for ACT clinicians, with chapters 2 through 7 focusing on the six flexibility processes. Each of those chapters includes a description of basic metaphors, stories, and techniques used in connection with that process, as well as vignettes demonstrating those methods, and ends with a practical writing assignment in which you’re asked to apply the principles you’ve learned to various sample client scenarios. Each of these chapters also addresses when to use the methods discussed, indicators that work with that particular process, and how to address problems that commonly arise when targeting given processes, and includes at least one experiential exercise. The goal of these chapters is to help you get what each process is about. No particular ACT technique is foundational, so the goal of these chapters is to help you abstract how to manipulate the underlying flexibility processes through reading and practice.
In chapters 2 through 7, each of the psychological flexibility processes targeted by ACT is presented largely as if it were separate. In actual sessions with clients, however, a single process is rarely the sole focus; rather, multiple processes are explored and worked on within each session. Chapter 8 focuses on how case conceptualization and treatment planning can help you begin the task of integrating the six processes into a coherent treatment and gives you an opportunity to apply the ACT model to practice cases. Chapter 9 shows you how to utilize the flexibility processes in the context of the therapy relationship, and chapter 10 offers guidance on flexibly working with cultural factors during interventions and case conceptualization. Finally, chapter 11 is designed to help you integrate your use of the various flexibility processes in sessions and to be flexible in doing so. And just as ACT attempts to build psychological flexibility in clients, we hope this workbook will increase your flexibility as a clinician in the application of ACT. To that end, chapter 11 provides various exercises to help you develop this flexibility.
We’ve also included three appendices. Appendix A presents the ACT Core Competency Rating Form, which you can use to assess your abilities in delivering ACT. In the core competency practices in chapters 2 through 7 and 9, we ask you to demonstrate these competencies. It’s only in appendix A that you can see all the competencies in one place, so you may wish to review that appendix before diving into the chapters. Appendix B offers information on additional resources for deepening your knowledge about ACT, and appendix C addresses adapting ACT to different intervention settings.
Various resources related to the book are available for download at http://www.newharbinger.com/39492. There, you’ll find the ACT Core Competency Rating Form (appendix A); a document of FAQs answering some of the most common questions of therapists new to ACT; and audio recordings of several client exercises described in the book (we’ll provide a reminder about the downloadable recordings where those exercises appear). Another downloadable resource is the document “Learning ACT in Classrooms and Peer Groups and via Peer Supervision.” Regarding the latter, experience has shown us that it’s important for ACT therapists to have a community that supports them in their ACT work. Whether it’s a group of friends or colleagues, a virtual community accessed through the Internet, a temporary course, or a relationship with a supervisor or mentor, this social/verbal community is essential in keeping you on track as a clinician, particularly as an ACT clinician. Fortunately or unfortunately, many of the ways of speaking or thinking that are part of the repertoire of an effective ACT clinician are not common outside of this context. Many of the messages of mainstream Western culture are so dominant and automatic, particularly those fostering feel-goodism (i.e., experiential control) and literal ways of interacting with thoughts, that without support from a social/verbal community versed in ACT, newer, less practiced repertoires of behaving and thinking based on ACT are less likely to be maintained over time.
In addition, we highly recommend that you visit http://www.newharbinger.com/39492 to find videos that complement the book, with experienced ACT clinicians role-playing examples of the core competencies, using trained actors to play the clients. We have created these examples to show both relatively skilled and relatively unskilled applications of the ACT methods and principles. Not all the competencies are covered in the videos, but with the exception of chapter 8 (case conceptualization), examples are provided for approaches presented in chapters 2 through 10. We recommend reading the corresponding chapter before watching its video.
The videos offer models of exercises and techniques that go beyond what we can adequately demonstrate in written form. One good way to use them is to play each clip and then pause the playback before the narrator describes what was being done. Try to determine what fit or did not fit with the ACT model in the clip, and only then resume the video to hear the narrator debrief the interaction. This start-and-stop method is especially recommended for workshops or classroom use of this book.
Although reading about ACT techniques and skills is important, to become an effective ACT clinician it is even more important to practice these skills. Having extensive mental knowledge about a therapy can clearly set the stage for implementation. However, it is not only verbal knowledge that will guide you through the therapy; experiential knowledge is also key to understanding the ACT approach and providing quality implementation. This book is structured to give you that experiential knowledge through engagement with exercises.
Learning to use ACT is like learning to play the violin. You can read a book about how to hold the bow or how musical scales are structured. However, reading about playing does not make you a violinist. Practice is essential. Although reading (verbal knowledge) can teach you how to hold the bow, the exercises in this book are designed to help you begin to play the violin (experiential knowledge). In ACT, we ask clients to engage in the process of experiential learning and to be willing to experience all that comes along with that learning, including painful failures and mistakes. We ask them to do this with the goal of learning from their own experience in the service of living a rich and valued life. We would like to ask you to do the same by engaging fully with the exercises presented in this workbook. Many of the exercises require a written response. If you’re reading an electronic version of this book or simply prefer not to write in the book, or if you need more space for your responses to any of the exercises, feel free to use a notebook or a computer or other electronic device to record your answers.
At the end of chapters 2 through 7 and 9, we’ve included a section titled Core Competency Practice, in which we provide practice exercises based on dialogues with clients. (Many of the cases presented in this book are amalgamations of actual clients but have been altered and combined so that no one, not even the clients themselves, could recognize the material.) These exercises give you the opportunity to formulate and practice responses to hypothetical clients prior to doing so with real clients. In the exercises, you are asked to generate your own responses before comparing them with the suggested ACT-consistent responses provided at the end of the chapter.
Feedback from readers of the first edition of this book indicates that they were often tempted to jump directly to the sample responses, skipping the process of generating their own responses. This is definitely the easier path and one way to engage with this workbook. However, this strategy has a major downside: it negates what is most unique about this book—the opportunity to actually practice ACT and get feedback on your responses. Here’s what some of our previous readers have said about how important it was to actually do the exercises versus just reading them:
Only you can decide whether learning ACT is worth the time and effort. If you decide that the answer is yes, we suggest that you give yourself the space to generate responses to the exercises, even if your mind thinks those responses will be wrong or of low quality. One thing that can help with sustaining motivation to do these practices is to reflect on what larger purpose this might serve. We suggest you take a minute or so to reflect on that right now. In fact, we’ll use that invitation to offer you an initial exercise.
Exercise:Identifying Your Values in Working with This Book
What honest, sincere, and heartfelt purpose would you have your engagement with this book serve? What larger patterns do you hope to feed by completing this workbook?
For me, completing this workbook is in the service of
There’s a saying we like in relation to learning something new: “If something is worth doing, it’s worth doing poorly at first.” Learning something new generally means that our performance will be poor; otherwise, it’s not really new. Doing the exercises in this workbook rather than simply reading them is not the easy way. You will make mistakes—perhaps many mistakes. However, mistakes are our teachers. And even though mistakes are an inevitable part of learning, it’s often the case that the mind will beat us up for making mistakes or for our perceived lack of knowledge, even though this makes it harder to learn. Because this is an all-too-common thing for minds to do, it’s important to be able to find ways to respond to ourselves in a supportive and kind way when we’re learning. In line with this aim, we ask that you reflect for a bit on the kind of relationship you’d like to have with yourself as you complete the exercises in this workbook. So, once again, we’ll use that invitation as a context for you to begin engaging with the exercises in this book.
Exercise:Envisioning Self-Compassion
If you were to be a caring friend to yourself as you practice, what qualities would you hope to have in your relationship with yourself? This isn’t about how you usually are with yourself around mistakes; it’s about your intentions. How do you want to treat yourself while you’re learning? In the following space, list the qualities you’d like to bring to yourself as you work with this book.
As I make mistakes and struggle with learning, I would want to have a relationship with myself that is characterized by these qualities:
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Here’s one thing I can do when I notice my mind getting down on me during these exercises:
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In addition to the core competency exercises, each chapter includes experiential exercises. By “experiential,” we mean that their purpose is to help you find the ACT space, stance, or psychological posture from which you as an ACT clinician are likely to be most effective. The nature of these exercises is both personal and deeply connected to the nature of the therapy.
While we don’t recommend that you skip these exercises, it’s okay if you do. You are the expert on your own experience and what will help you achieve your valued goals. However, if you choose not to do them during your initial reading of the book, we suggest you come back and complete them later so you can extract the full value of this volume.
We have several recommendations about beginning to use an ACT approach to therapy, set forth in the following sections.
Before you begin using ACT with clients, we recommend that you have a good sense of the entire ACT model. This includes knowing a variety of core metaphors and exercises you can use and having a working understanding of the basic theory. While this book provides a good overview of the theory, it does not provide many of the core metaphors you need or exercises you will want to use. Thus, you will need at least one other ACT book to supplement this volume and give you more specific instructions about how to sequence interventions and introduce the different processes, and to give you access to a range of metaphors and exercises. In short, this book is not meant to provide a comprehensive introduction to ACT; rather, it’s a practice guide that will allow you to apply the tools you gain during your learning process to all of the in-between moments that aren’t specific to particular exercises or metaphors.
Good books to consider for an introductory text that will give you more step-by-step instructions for using ACT with your clients include the second edition of the original ACT book, Acceptance and Commitment Therapy: The Process and Practice of Mindful Change (Hayes et al., 2012), or ACT Made Simple (Harris, 2009). We usually recommend the original ACT book, as it is the most comprehensive. However, if you would prefer a simpler introduction and step-by-step guide that focuses on tools, tricks, and techniques and is lighter on theory, ACT Made Simple is an excellent alternative. If you have a strong background in more traditional CBT methods and are branching out into ACT, A CBT Practitioner’s Guide to ACT (Ciarrochi & Bailey, 2008) is another good starting place.
To be clear, we don’t recommend Learning ACT as the first book you read on ACT. Instead, it is an excellent second book that will allow you to apply knowledge gained from more comprehensive books, like those suggested above. Then you can begin to branch out, delving into more specific ACT literature. There are now ACT books for most major categories of problems (e.g., eating disorders, anxiety, chronic pain, substance use, depression), as well as applications to particular professions (e.g., social work or pastoral counseling), settings (e.g., primary care), or types of practice (e.g., groups or couples).
Second, we recommend allowing time for a period of growth with the theory and therapy. Although, as mentioned, the flexibility processes are initially presented in this book as if they were separate, they are actually interdependent. Lacking a basic understanding of one process could lead to difficulties in implementing other processes, as well as confusion and dead ends in therapy. In addition, without an overall understanding of the approach, therapists can easily introduce inconsistencies that might undermine the overall thrust of the intervention. It takes time to learn this complex and comprehensive model. We encourage you to be compassionate with yourself as you practice, and to give yourself time to reread sections on relevant concepts and approaches as you try to apply them. Also, be forewarned that you may experience some disruptions in your practice when you begin to use these approaches, particularly if you’ve been operating from control-based theories of intervention. It is not at all uncommon for practitioners who are drawn to this work to initially feel awkward, confused, and anxious as they begin to apply ACT.
A dissertation by Douglas Long (2015) examined the use of the videos in the first edition of this book and found that clinicians being able to detect competent ACT was predicted by workshop training, knowledge about ACT, reading books about ACT, supervision in ACT, and membership in the group most responsible for the continuing development of ACT, the Association for Contextual Behavioral Science. Competency improvement following training was also predicted by therapists’ psychological flexibility. These findings make perfect sense. To be good at ACT, you need to put in some effort, give yourself time, work on your own flexibility processes, and come into community with others on the same journey.
Fortunately, we also know that feeling confident isn’t necessary for ACT competence. An effectiveness study done a few years ago with beginning therapists showed that, compared with traditional cognitive behavioral therapy, doing ACT tended to produce more anxiety in these therapists, who were new to ACT—and also led to significantly better clinical outcomes in patients (Lappalainen et al., 2007). Based on these kinds of findings, we recommend that you try to make room for whatever discomfort you may experience as you learn to implement ACT. To that end, you may find ACT self-help books helpful, allowing you to apply ACT to your discomfort in learning it. We now know that applying ACT to oneself as a therapist has broad benefits. It decreases the stress and burnout that can come from being a therapist or therapist in training (e.g., Brinkborg, Michanek, Hesser, & Berglund, 2011; Frögéli, Djordjevic, Rudman, Livheim, & Gustavsson, 2016) and helps therapists apply evidence-based therapy methods even when doing so is psychologically difficult (Varra, Hayes, Roget, & Fisher, 2008; Scherr, Herbert, & Forman, 2015).
Time and effort, combined with openness, will produce a greater sense of wholeness and empowerment. However, be aware that there is a sense of vulnerability when doing ACT that never completely disappears. ACT asks the clinician to stand with the client as another human being in a horizontal relationship, without needless defense. This brings great richness to the process, along with a rawness that can’t be avoided without undoing the work itself.
We recommend two basic ways of beginning to incorporate ACT into your practice. One is to start by implementing ACT based on one of the standardized manuals available. Many are listed under “Therapist Guides” in the e-book Learning ACT Resource Guide (available for download at http://www.learningact.com); you’ll also find a list of many therapist manuals for specific client presentations on the ACBS website https://contextualscience.org/treatment_protocols. Ideally, you would follow the manual from beginning to end with a client who presents with problems matching the specific treatment discussed in that manual. This has the advantage of pushing you into corners of the work where you may still feel awkward.
We also recommend the fairly common approach of first using ACT with a client with whom you find yourself struggling. If this client is difficult, which is often the case, this may seem like a counterintuitive place to begin; however, because your old repertoire has already been failing in an important way, if you continue with the same approaches you’ve been using, you’ll probably continue to find yourself in the same place as the client: stuck. Giving ACT a try can allow you to see whether something new can happen and free up the therapy process.
After you’ve followed a detailed ACT protocol with a few clients, we suggest that you put the protocol aside and move to tracking and targeting flexibility processes based on clients’ needs and your case conceptualizations. This book will be especially helpful to you in continuing to develop your skills during this phase.
Finally, we encourage you to attend an experiential ACT workshop. This is truly one of the best ways to learn the ACT approach. ACT is centered on living fully with all experience—both negative and positive—and on the freedom and richness that purposeful living can bring. Attending a workshop can help create these dynamics in your life, both in your personal way of being in the world and in your work with clients. It can also provide intuitive guidance about the function of flexibility processes, not just the form of these processes. ACT trainings and workshops are listed at http://www.contextualscience.org.
ACT is based on a now enormous body of scholarly and research work in the fields of philosophy of science, basic psychology, psychopathology, evolution science, and clinical intervention. As we were writing this second edition of Learning ACT, there had been almost two hundred randomized trials on ACT (for a partial list, minus some of those available only in non-English languages, see http://contextualscience.org/ACT_Randomized_Controlled_Trials). These studies have looked at almost every conceivable area of mental health, behavioral health, and social functioning. About 83 percent of that literature is less than five years old, and over the last few years, a new randomized trial has been published every ten to eleven days, on average. Across all areas of CBS relevant to ACT and its foundations, there are nearly two thousand articles currently available. In this book, we deliberately use relatively informal language because our purpose is intensely practical and focused on skills. As your skills in ACT grow, however, you may find that exploring the broader body of research deepens your understanding.
Practitioners who attend their first ACBS conference are often surprised to find workshops and sessions on RFT, behavioral principles, evolutionary extensions, and a contextualistic philosophy of science. Perhaps even more surprising, after gaining some experience clinicians themselves begin to demand such sessions and are often enthusiastic about their practical usefulness. In this book, we use clinical and commonsense terms, generally without stopping to link them to basic principles. For example, we speak easily of “mind” without delving into the work done in RFT labs to identify the component behavioral skills involved in this commonsense domain. If you’re interested in learning more about these aspects of ACT, you can start by reading more of the CBS literature.
If you connect deeply to the work, you will eventually learn that ACT is part of an attempt to restructure psychology and, indeed, behavioral science itself. Although at this point you are probably concerned with immediate practical purposes, this book will help you learn enough about ACT to care about that larger context. Most importantly, we hope that reading—or perhaps the better word would be “doing”—this book will help you learn enough about ACT to begin to use these methods with clients who can benefit from them.