Essay

kt1990

Paper.pdf

Chapter 2

ACT’s Six Core Processes

A number of things make ACT unique among therapies and approaches. One of ACT’s differences stands out: It is based on a scientific program that does not simply theorize what helps; rather, each component of ACT is analyzed and presented separately to explicitly detail how it helps people live a richer, more vital life. ACT is composed of six such components that we refer to as the six core processes. Each of the processes is individual but not mutually exclusive. This means that each one of the processes works with the others. When combined, the six core processes form a circular model that represents psychological flexibility.

The six core processes of ACT can be viewed separately and defined individually. In this chapter, we look at each process in detail, which will be helpful to you in learning ACT as you will see how each process makes ACT work. Furthermore, each process is individually mediated to be a valid mechanism of change. That means if you successfully focus on any one of these processes in your clinical work, you should see an improvement in psychological flexibility. This last term, psychological flexibility, represents the whole ACT model of health. All six processes seek to increase psychological flexibility or coming in full contact with painful experiences and with uniquely chosen values, while consciously choosing the actions to engage in a meaningful life. Notice from this description that psychological flexibility does not prescribe one’s attempts to escape or avoid painful experiences but instead invites experiencing them. To work with our pain where painful experiences do not exclusively govern our behavior. That is what ACT’s six processes are about. The six processes include acceptance, defusion, present moment, self-as-context, values, and commitment.

ACCEPTANCE

Acceptance is practicing openness to private events (thoughts, feelings, sensations, memories). We often focus on our clients’ most difficult private events (e.g., anxiety, sadness, physical pain, etc.) as targets for therapy. In ACT, individuals are encouraged to be accepting of their experience, rather than avoiding private events such as anxiety, sadness, or physical pain. Because the term acceptance can have different meanings to others, it is important to note that in ACT, acceptance means a willingness to come into contact with a person’s whole experience, including the unpleasant internal stuff that shows up. Acceptance is not liking or wanting these experiences, is not begrudgingly or angrily saying they exist, and is not giving up and not doing anything; rather we encourage a willingness to notice those difficult private events, to allow them to be there as part of your experience.

Now, because unpleasant private events can be painful, we do not encourage this contact with private experiences without a function. The function of acceptance is to further the goal of working toward a meaningful life. Often when we experience unpleasant internal events we tend to work hard to escape or avoid those private events and anything that may evoke those experiences. The problem with this is that the things that cause us pain often point us in the direction of what is important to us. We would not have the thoughts, “everyone will hate this book, we have nothing original to say,” if doing a good job, helping others, and furthering professional development were not important to us. If we exert all our effort trying to distract, ignore, or avoid unpleasant internal experiences, we are not moving toward who or what matter most to us. We

Gordon, T., & Borushok, J. (2017). The act approach : a comprehensive guide for acceptance and commitment therapy. Retrieved from http://ebookcentral.proquest.com Created from uneedu on 2018-09-24 16:08:56.

C op

yr ig

ht ©

2 01

7. P

E S

I P ub

lis hi

ng &

M ed

ia . A

ll rig

ht s

re se

rv ed

12 The ACT Approach

will talk more in this book about how a control or eliminative agenda is not a functional or workable solution and actually can lead to greater distress over time. Note that acceptance is not an end in itself; it is one part of the larger whole, increasing psychological flexibility.

A C C E P T A N C E I N P R A C T I C E

Take a moment to pause and notice the thoughts and feelings that show up while reading this book. Maybe you have sounds or other people in your environment distracting you from reading; maybe you are feeling rushed or frustrated and thinking, “I don’t have time for this.” Maybe your mind keeps wandering off to all of the things you have to do today or trying to make connections between what you are reading and the therapy session you had last week. As you notice these private events, rather than trying to avoid or escape or ignore them, instead try to allow yourself to experience and notice them.

Begin to practice opening up to these experiences and develop a willingness to sit with frustration or difficult thoughts as you turn your attention back to the book. Would you be willing to have these thoughts and feelings if it meant staying committed to learning or professional growth?

DEFUSION

Defusion is a made-up word that places focus on a cognitive component encouraging awareness of private experiences (thoughts, feelings, sensations, memories), the response to them, and the consequence (what happens as a result) of that response. Defusing creates space to pause and notice the effectiveness of a response to a private experience and an awareness that we have the flexibility to choose how we respond to private experiences rather than being reactive or automatically trying to eliminate or avoid them with poor results. For example, imagine that every time you are presented with the opportunity to go to a party and meet new people you have the thought, “I’m going to make a fool of myself and everyone will laugh at me,” the feeling of anxiety, the sensation of your heart pounding and palms sweating, and the memory of saying or doing something embarrassing at a party. Now imagine that you were so caught up in those sensations, as if you wrapped that feeling of anxiety around you like a blanket and you began to believe that those thoughts were the only option, were inevitable. If you believed those thoughts were the truth, would you go to the party? The answer, we’re guessing, is no. If we buy into our thoughts and private experiences to the point where we believe they are literally true, it is likely we will react automatically and attempt to avoid or escape a situation.

Now, imagine that same scenario, but instead of being caught up in those private events, like standing in the inside of a tornado, we are on the outside seeing the swirling cone and feeling the wind whipping by, but also able to see the whole scene in front of us. Defusion is similar—still experiencing our private events, but having the ability to pause, take a step back, and notice that, for example, the thought, “I’m going to make a fool of myself and everyone will laugh at me,” is just that: a thought. Creating space allows us to recognize that escaping that anxiety and not attending the party might provide relief in the short-term, but it is only increasing our anxiety of interacting with others and working against our goal of having meaningful relationships in the long-term. When we take a step back to see the whole picture, we are able to see that an alternative is to acknowledge that going to the party means that we will likely feel an increase in anxiety and be bombarded with many similar thoughts, but we will also be taking steps to work closer to the life we want to live. Defusion creates choice.

C op

yr ig

ht ©

2 01

7. P

E S

I P ub

lis hi

ng &

M ed

ia . A

ll rig

ht s

re se

rv ed

ACT’s Six Core Processes 13

D E F U S I O N I N P R A C T I C E

Pause and notice any thoughts that you’re having about reading this book right now. Maybe you are having the thought “this doesn’t make any sense to me, maybe I just can’t learn this” or “there are so many technical terms that I don’t understand, maybe ACT isn’t for me” or “I don’t remember struggling so much when I was learning [different therapy], maybe I’m not as sharp as I used to be.”

Notice any urges following that thought to close the book and stay within your comfort zone or any conversations your mind is having trying to rationalize why it would be a good idea to stick with what you already know. Notice also how those behaviors are not working toward your goal of learning ACT. Notice what your options are when those thoughts pop up and choose what is more helpful for you—to continue reading?

PRESENT MOMENT

ACT orients people to the present moment, encouraging their awareness of their experience here and now. Inside us exists a rich and complex private world, and although it can be helpful to get caught up in that world, ACT encourages awareness of private experiences (thoughts, feelings, sensations, memories) and an acknowledgment of how in this moment these private experiences influence you. One of us, Jessica, is a daydreamer. She has spent many hours caught up in the imaginary world in her mind. She is creative and enjoys coming up with stories, characters and faraway places, and taking the time every once in a while to spend an evening caught up in those worlds helps feed her creativity. It serves a function. But sometimes getting caught up in her mind and not paying attention to the world around her can become problematic: crossing a busy street, sitting across from a client in therapy, writing an ACT book. Most activities that are meaningful for life require some degree of present-moment awareness, but staying in the present moment when there is no immediate threat or crisis can be difficult because our minds can come up with endless “pay attention to me!” “look out!” “danger ahead!” situations.

Take a client with generalized anxiety disorder who spends all of their time planning their life to avoid danger, catastrophes, or simply messing up. While on the surface it may not seem like it, planning requires taking ourselves out of the present so that we can think about a future potential experience. Although planning is an excellent skill to have, when we look at the function of the behavior, rather than the observable movement of the behavior, we can begin to notice situations in which a lack of present-moment awareness can work against us. This client may benefit from sitting down to write out a five-year plan for saving up for a down payment on a house, or a plan for how to complete the degree or certificate needed to begin their dream job. However, when they are spending all of their time planning, it can be helpful to pause and notice the cost. Clients may actively avoid being in the present moment for fear of unpleasant internal experiences popping up or to ignore unpleasant situations in their environment.

Working with clients to clarify what is important to them and whether spending time in their minds focused on the past or future “what if ” alternative realities is helping them move closer to what is important. Also, creating a greater awareness of their experience here and now may help them identify problematic patterns of behaviors or responses to internal stimuli that they were otherwise blind to. We cannot work to modify our behavior if we are not aware of how behaviors are problematic or unworkable. Building a practice of present-moment awareness into every session can be a good way to model the importance of noticing. We like to begin every session after the initial session with a brief present-moment activity. In Chapter 6 we offer a few examples of what these exercises may look like.

C op

yr ig

ht ©

2 01

7. P

E S

I P ub

lis hi

ng &

M ed

ia . A

ll rig

ht s

re se

rv ed

14 The ACT Approach

P R E S E N T M O M E N T I N P R A C T I C E

Take a moment to notice your experience here and now. Notice the feel of the book in your hands, the texture of the pages or the coolness of the device it is displayed on. Pause to notice where you are right now as you read this sentence. Is the environment quiet or noisy? Are you cold or warm or just right? Notice the places where your body meets the chair or couch where you are sitting, or the places where your feet touch the ground if you are standing. See if you notice anything in your environment or inside your mind that surprises you, that you didn’t realize was there.

SELF-AS-CONTEXT

Self-as-context is a way of experiencing oneself. It invites people to see themselves as separate from their private experiences (the opposite would be seeing oneself as their content or self-as-content). This is a unique way of viewing our experience. It is in this way that self-as-context allows a person to see themselves as a stable entity and the experienced content (private and public behaviors, contextual stimuli, etc.) as changing. From this perspective, a person is seen as the observer of their own experience, rather than saying they are their experience. From this perspective in any given context it is the experiences that change, not the self who is observing. The observing self is constant and is the same self that existed in the past and the same self who will exist in the future. The part that changes is what the self is observing in any given moment. This concept can be a difficult one for clients, and for clinicians, to grasp, but it need not be complicated or involve any spiritual view of the self. It is simply the idea that our selves are the observer of our experiences and not the content we notice and interact with; the self interacts with experiences both private and observable, but is separate from them.

S E L F - A S - C O N T E X T I N P R A C T I C E

Pause and notice you, the person behind your eyes, observing the words on the page and noticing the thoughts your mind generates. Notice that this you, this observer self, is the same you that first purchased this book and the same you that sits across from your clients. Regardless of the roles you don or the time that passes, the you looking out of your eyes noticing is the same you that has always been there.

VALUES

Values are the who and what that personally matter to an individual and are uniquely chosen principles or standards. For example, being a loving partner may matter to one person who also states that their partner is important to them. Another person may state that athleticism is important to them, that taking care of their body and increasing their skill level are what they value. In both examples, the value of who or what is important has been clarified. Values go beyond goals, not simply professing love to your partner or performing well at an athletic event; you can’t check a value off a list and call it done. Values are a sort of beacon that guides how we live our lives based on what creates a meaningful life to us. In that sense, there are no right or wrong values, only who and what is important to us now with the understanding that as we grow and change, so too may our values. In the therapy room, it is important to be aware of both what the client’s values are as well as what your values as a therapist are. Values will be the guiding force of therapy, helping to outline what success looks like for this client. We can evaluate the function of clients’ behaviors in terms of whether the behaviors work to take them closer to or further from their values.

C op

yr ig

ht ©

2 01

7. P

E S

I P ub

lis hi

ng &

M ed

ia . A

ll rig

ht s

re se

rv ed

ACT’s Six Core Processes 15

V A L U E S I N P R A C T I C E

Take a moment and explore what is it that’s important to you about reading this book? What do you hope to get out of reading this book? What qualities do you want to be about in reading this book? Are you hoping to challenge yourself to learn about a different therapy, looking to harvest new techniques for your clients, wanting to develop a new perspective, or creating a context for professional and personal growth? What about this moment and this behavior is meaningful to you?

COMMITMENT

Commitment is about doing the observable behaviors or engaging in activities in the service of one’s values (the who and what that are important). Examples of committed actions will look topographically different for all people: taking time out of the day to have a nap or go to bed early may be a committed action for one person, pursuant to values such as sleep management, sleep hygiene, or taking care of oneself, whereas for another person, sleeping may be functionally about avoiding unpleasant private experiences: “I’m feeling down and hate this feeling. I’m going to go to bed and just sleep the day away.” As with private experiences, observable behaviors are neither good nor bad, but rather are dependent on their function: does the behavior move me closer to whom and what matters most to me (committed action)? If values are true north, then commitment can be viewed as the mile markers along the way. They are observable behaviors that can be checked off as complete.

There is often the misconception that engaging in committed actions leads to happiness. However, depending on where the client is in their own journey, sometimes engaging in behaviors consistent with their values can cause an increase in unpleasant internal experiences. Take for example a client who values having a family and being a loving father, but is in a marriage with a woman he is not close to and who refuses to have children. A committed action for this client may be getting divorced and dating again or even adopting on his own. Even though these behaviors certainly function to take him closer to his values and the life he wants to live, they are in no way easy or even pleasant. Again, the focus is on the function of behavior rather than the removal or elimination of unpleasant internal experiences.

C O M M I T M E N T I N P R A C T I C E

Building on the activity for values, what is something you can commit to today that will bring you closer to the qualities you want to be about? Can you make a commitment to devote time to reading this book and developing your practice? What would that look like? Picture yourself doing those behaviors, engaging in each of the small tasks that make up this larger commitment.

ACT IS A CIRCULAR MODEL

The following illustration depicts the six core processes as a circular model in which the processes are connected. Although we began the list of six core processes with acceptance, and acceptance is also the first word in the acronym of ACT, we wish to be explicit that the circular model means you can begin with or target any process at any time in any order in your work; you do not have to begin with acceptance or touch on only one process at a time. You are free to weave different processes into a single session or begin with any process you please while being consistent with the model. Whichever process you focus on depends largely on what your client presents with and what would be most beneficial for that client in that moment.

C op

yr ig

ht ©

2 01

7. P

E S

I P ub

lis hi

ng &

M ed

ia . A

ll rig

ht s

re se

rv ed

16 The ACT Approach

Bringing the Six Core Processes Together To give you a sense of how these six core processes interact with one another and how they can all be used effectively in a single session with a client, we are including this transcript of a typical interaction between a therapist and client using the six core processes with explanatory notes. Please note that this is not the only way to do ACT, this is simply an example. The way you introduce the six processes into your practice may sound different and that is okay. In our experience teaching and supervising others in ACT, having your own flexible approach to ACT works best.

Therapist: I know this is an incredibly painful topic, but let me make sure I’m getting this right, what makes this sadness so hard for you isn’t just the self-doubt that shows up when you’re at work and criticizing yourself but the absence of something?

Client: Yeah, I want a relationship. My little sister is getting married. It’s like she has everything figured out; she’s got a great career, she’s successful, she’s great at her job, has an awesome guy, her fiancé loves her so much and I’m just at home, alone, with no one.

Therapist: [Pauses and takes a breath.] That sounds hard to compare yourself to her like that.

Client: It is, I hate it. I love her but it’s hard for me to see her doing so well.

Therapist: And that’s what you do when this hurt shows up is reach for an answer, like criticize yourself.

This is an early attempt to assess why this hurt is showing up in this client’s life. What does the client value that causes this pain?

The therapist attempts to role model slowing down with this action of taking a breath and being in the present moment.

The therapist attempts to expose the function of this behavior, demonstrating how fusion works practically to this client: when certain feelings and thoughts show up that are painful for you, you begin to criticize yourself—a behavior the client has reported as problematic.

Present Moment

Values

Commitment

Self-as-Context

Defusion

Acceptance

C op

yr ig

ht ©

2 01

7. P

E S

I P ub

lis hi

ng &

M ed

ia . A

ll rig

ht s

re se

rv ed

ACT’s Six Core Processes 17

Client: Well that’s what I usually do, yes.

Therapist: Bear with me, can you tell me what this hurt is exactly, like what thoughts and feelings occur to you in those painful moments?

Client: That I’m not as smart or good looking as my sister and this is why I’m single, lonely, and not successful at my job.

Therapist: Pause right there with me if you will. Could we both just take a breath and feel that right now?

Client: [Tearfully] Yes.

Therapist: [Slowly] And what is it like to be here in this moment?

Client: Sad. Hard. I just want to shut down.

Therapist: I know. Try not to turn away from that hurt. It’s natural to want to shut it down but stay with me for a moment and let’s not fight this.

Client: [Pauses] Okay.

Therapist: And what does your mind tell you about this now?

Client: That this is a bad idea.

Therapist: Yes, and what do you typically do with this hurt?

The therapist again purposefully slows down, drawing more attention to the here-and-now, asking this client to not shy away from the experience but more closely identify it. This could also be seen as preparation for defusion work, bringing the client’s potentially out-of-awareness experience into awareness.

The therapist again draws on present- moment process combined with an early priming for self-as-context work— experiencing the moment, observing it. Notice how the therapist is gently inviting the client to come into contact with the experience.

This is an example of acceptance in action where the therapist invites the client to not engage in experiential avoidance.

The therapist uses the present moment to enact defusion, separating the content of the mind, what it may be telling this client, from what the client may do next.

Again, the therapist uses defusion to draw on what might happen in this instance if the content of the mind was taken literally or acted upon.

This is an example of the present moment process enacted.

C op

yr ig

ht ©

2 01

7. P

E S

I P ub

lis hi

ng &

M ed

ia . A

ll rig

ht s

re se

rv ed

18 The ACT Approach

Client: Just sleep or stay in my room, eat, watch TV.

Therapist: And right now, what does this hurt tell you to do?

Client: I just want to feel better so I would change the subject.

Therapist: Even here, right now with me, your mind wants you to turn and run away?

Client: Yes. I hate it, it’s embarrassing.

Therapist: What’s important about that? Why does this hurt matter?

Client: I’m alone. I want a relationship and not just a romantic one. I don’t even feel connected to my family, and I live with them.

Therapist: It’s like a flip side of a coin: you value relationships, a romantic relationship but also a relationship with your family and that’s beautiful, but the flip side of the coin is when that comes into conflict and that sounds like it brings a lot of pain. And yet, they’re flip sides of the same coin, they’re indivisible, it’s almost as if you don’t get one without the other. You can’t have relationships matter to you without feeling alone when there’s an absence of them.

Client: [Making eye contact] You’re so right.

Therapist: So what if that is what our work could be about, not focusing on us getting better at eliminating your self-doubt, criticisms, the comparisons you make between yourself and your sister. Instead we focus on the life you most want for yourself, looking at ways to bring yourself closer to the relationships you want with your family, and explore ways you can pursue the romantic relationship you want.

Client: I’d like that, it makes sense to me and feels concrete.

Therapist: Could I take this one step further?

Based on the client’s ease of self-reporting, the therapist enacts another intervention with present-moment process work focusing on the interpersonal relationship between the client and therapist in the here-and-now.

The therapist again brings the focus to the client’s behavior and experience in the room with the therapist.

The therapist asks a values-driven question, clarifying what is it about this painful experience that uniquely matters to this client.

The therapist describes what the client values and parallels values with pain using the metaphor of a coin. The therapist then also outlines the perils of experiential avoidance by explaining that walking away from this hurt is akin to walking away from values.

The therapist promotes a noneliminative agenda, encouraging acceptance and commitment over avoidance and fusion.

Giving options, creating the context of choice in the therapeutic environment, is important and respectful from our perspective.

C op

yr ig

ht ©

2 01

7. P

E S

I P ub

lis hi

ng &

M ed

ia . A

ll rig

ht s

re se

rv ed

ACT’s Six Core Processes 19

This interaction may not have looked like any particular exercise, but it is ACT and did touch on all of the six core processes. In this book we want to teach you how to approach all interactions with your clients through this perspective and have the foundational understanding of ACT so that no matter what shows up in the room you can flexibly respond in an ACT-consistent way whether you touch on one, two, or all six of the core processes. We have similar therapist-client scripts throughout this book with explanatory notes to help broaden your own relational frame when it comes to doing ACT.

ACT Informed Consent Practicing ACT means you are creating an entirely different kind of therapeutic contract. Introducing ACT to your clinical practice is not merely about using a set of ACT methods or techniques, like introducing mindfulness and sprinkling in metaphors that involve acceptance and connection with values. ACT offers a unique approach to the informed consent that breaks the commonsense eliminative agenda that clients largely visit therapists for: to reduce or fix painful private experiences and feel better. Instead, the ACT informed consent encourages engagement with painful private experiences because research shows we cannot escape that pain and that attempts to rid ourselves of painful private experiences get in the way of living a rich and meaningful life that improves quality of life in the long-term.

The ACT therapeutic contract as demonstrated in the previous therapist-client dialogue acknowledges the short- term relief of attempts to control, avoid, and escape painful private experiences yet parallels how those attempts can serve to limit one’s life and may have a reinforcing effect on those painful experiences. This realization can be incredibly validating to clients suffering with chronic or persistent problems from medical health issues such as diabetes, chronic pain, or even severe mental health issues like a diagnoses of schizophrenia or borderline personality disorder. Clients suffering with these chronic or severe problems can become frustrated by their own lack of control over private experiences and feel demoralized by former therapies that may have also failed in curing or fixing their painful private experiences. This statement is not meant as a critique of other therapies or previous attempts to eliminate painful experiences; rather, it is meant to bring a modern behavior analytic understanding, informed by evidence of how therapists can create validating therapeutic contracts free from the pitfall of a promise to eliminate or control a human experience that research demonstrates is out of our control.

Client: Yes, please.

Therapist: Let’s both of us take a step back for a moment. What is it like to see your self-doubt, criticisms, and the comparisons you make? To bring them alive here, to not shy away from them, and for us to just talk about them and go on being here, working together?

Client: I don’t know, I’ve never thought about it this way. It’s different and helpful.

Therapist: [Smiles] I’m really happy to hear you say that because we just did something unconventional, we broke a social convention. I asked you to do something hard and you courageously did it, you brought your most painful thoughts and feelings here. Then I asked you not to turn away and you didn’t. You stayed in this moment with me and we were able to loosen the shackles of what your pain was telling you and now we’re here, connecting despite your mind telling you to shut it down.

This is a present-moment activity leading into defusion and perhaps also promoting self-as-context in this client.

The therapist reinforces the client’s accepting and present-moment committed behaviors in the session with the goal of increasing the occurrence of these behaviors in future sessions and outside of the sessions as well.

C op

yr ig

ht ©

2 01

7. P

E S

I P ub

lis hi

ng &

M ed

ia . A

ll rig

ht s

re se

rv ed

20 The ACT Approach

We have included a sample of what we have written in our own informed consent. How it appears below is verbatim in the introduction to treatment letter that all of our clients receive at the beginning of individual and group treatments. Note that this excerpt is brief; we have left out the limits to confidentiality, billing information, and other administrative details because that information will look different based on your region and legislation/laws.

I N F O R M E D C O N S E N T E X C E R P T

Our work is very important to me and it may focus on helping you struggle less with the thoughts, emotions, sensations, and memories you don’t want so as to help you better move toward what’s important to you in life. Sometimes our own personal histories can make things more difficult for us. In this work together, we will always be focusing on your hopes, goals, or possible outcomes important for you in life. Through our work, I hope that you will gradually learn a new way to relate with the things you’ve long struggled against.

Bringing this language into your informed consent ensures that clients are aware not only of confidentiality and other legal considerations, but also of what to expect from you and your time together. Creating an ACT- based informed consent can help to facilitate the initial conversation in that it outlines directly in the therapy agreement what therapy with you will focus on, allowing them the opportunity to ask questions and collaborate in their care and set the stage for increasing connection with what matters rather than reducing or eliminating unwanted symptoms. An ACT-based informed consent highlights three main points.

1. Your work together will help them struggle less with the thoughts, emotions, and memories that they don’t want to experience so as to help them better move toward what’s important to them in life. This point provides an excellent opportunity to discuss their prior efforts and the central idea that you will not be removing or reducing their symptoms because truthfully you can’t (and now you know you have science on your side to back you up).

2. Valued living is the focus rather than symptom reduction, which means you will always focus on their hopes, goals, or possible outcomes that are important to them in life. Clients, particularly those who may come from a different background from you—whether that be race, gender, religion, culture, disability, or anything they judge to be different from you—may have concerns that you will project your own values or goals on them, prescribing how they ought to live their lives. Highlighting that the focus will be on what they want for themselves, who and what are important in their lives, can help to alleviate some of these concerns. A direct conversation about this can also be a powerful therapeutic relationship builder as can acknowledging to yourself that at times your desires for their life and their desires for their life may differ and bring you back to your governing goal to help them live the life that they want. In our experience that can take a lot of pressure off of therapists to “fix.”

3. Sharing your own hope that they will gradually learn new ways to relate with the things they’ve long struggled against and learn to move forward in their lives means that even though you cannot get rid of their painful experiences, you can show them a new way to connect with that pain, perhaps how to create space for their pain, validating it and moving forward with the life they want to live, doing the actions that bring them closer to an increased quality of living.

Subscribing to an ACT therapeutic contract with relevant informed consent also energizes the work of therapy in our experience. By creating this new type of therapeutic contract, you expose the cultural forces of “feeling good” as a rigged game. The point of therapy becomes not how do we get better at escaping pain and feeling

C op

yr ig

ht ©

2 01

7. P

E S

I P ub

lis hi

ng &

M ed

ia . A

ll rig

ht s

re se

rv ed

ACT’s Six Core Processes 21

good but instead how do we build a meaningful life and get good at feeling. It also means that nothing a client says is inherently wrong or problematic. Their most painful experiences can be validated with empathy and when appropriate, the therapist can skillfully ask where energy could be redirected in order to grow toward values and a richness of living.

The Hexagon Model We would be remiss if we did not show you the most common way to present the six processes as a hexagon model, it is often colloquially referred to as the hexaflex (Hayes, Strosahl, & Wilson, 2011). Now, you may look at the next diagram with puzzlement and wonder to yourself, “ACT is a circular model and that hexagon is not a circle?” And you would be completely correct. We use a hexagon to depict the model and the six processes because a hexagon has six points and each process can be overlaid with each point on the hexagon and connected to all of the other points. We can then use the hexagon to depict how each process is separate, on its own point, but each connects with one another to make up a larger whole: psychological flexibility. The term hexaflex is meant to be a play on words: combining hexagon with psychological flexibility. We have adapted the hexagon model of psychological flexibility and presented it here demonstrating how the whole model is psychological flexibility and how the model is made up of six smaller, independent parts that are interconnected.

Using the hexagon to depict a greater whole in the ACT model, psychological flexibility, is important. In Chapters 5, 6, and 7, we demonstrate process-based interventions with specific presenting problems, but the goal is not to simply target acceptance alone or defusion exclusively. Instead, we focus on growing a measure of psychological health: psychological flexibility.

PSYCHOLOGICAL FLEXIBILITY

By now you should have a sense that ACT is based on a philosophy of science called functional contextualism that looks at what works in a given situation. ACT’s theory, relational frame theory, is based on functional contextualism and looks at a person’s private behavior. Here is where we get the psychological portion of psychological flexibility. If we did not apply ACT to thoughts, feelings, memories, and sensations, we would simply have a model of behavioral flexibility. ACT’s six processes combine to target behavior but not just publicly observable behavior such as walking, talking, hugging, kissing, fighting, and arguing. ACT’s six processes also target private behavior that includes thinking, feeling, remembering, and sensing.

Present Moment

Values

Commitment

Self-as-Context

Defusion

Acceptance

PSYCHOLOGICAL

FLEXIBILIT Y

C op

yr ig

ht ©

2 01

7. P

E S

I P ub

lis hi

ng &

M ed

ia . A

ll rig

ht s

re se

rv ed

22 The ACT Approach

In ACT, we seek to increase flexibility both publicly and privately through broadening behavioral repertoires. Adding flexibility to a repertoire of behavior, either public or private, is especially pertinent when someone is suffering or coming in direct contact with something painful, because people often narrow their lives in unproductive ways when faced with painful events. For example, a person with agoraphobia may create rigid rules around what is considered safe, reacting to feelings of fear when exposed to anything outside of these rules. Over time that person may be limited by rules or thoughts or feelings never leaving their house or even a specific room in their house. They have trapped themselves with their own mind.

Now, this isn’t to say psychological inflexibility or the narrowing of behavioral repertoires is “bad.” Again it is dependent on the function of the behavior. For example, typically people need to add flexibility not in their happiest most joyous moments but in their darkest and most painful moments. It can be helpful at times to be completely focused or immersed in what you are doing, say, when you are at home watching a movie or streaming an interesting show. You want your behavior to be pretty inflexible there, affixed to the screen, immersed in the story and the characters when a major moment occurs that makes you jump from your seat—these are all examples of psychological inflexibility. Or imagine a basketball player taking a foul shot. The player tends to have restricted, almost ritualistic behaviors in that situation; the rhythm and consistency is what helps the player perfect the shot and maintain focus when thousands of opposing fans are screaming at them. The bottom line is that psychological inflexibility can also be good! When in doubt, always stop and ask WTF: What the function?

Let’s look at how we break psychological flexibility down to understand it more closely. Picture a person arguing with someone they care about. Maybe this is a repeated behavior: a conversation begins that they do not want to have and the person feels frustrated. By continuing to focus solely on their frustration, memories pop up replaying old arguments, and the frustration builds until the person says something hurtful, ends the argument, and later creates feelings of regret. What the function? In this context, the person has both private and public restricted behavioral repertoires: when a fight begins they narrowly focus on the frustration, and act in a way to escape an unpleasant conversation.

These behaviors later lead to feelings of regret, likely because this person does not want to hurt someone they love; therein lays his values: to be loving and kind. Is psychological inflexibility functional in this context? No. Rather than becoming rigidly fixed on their frustration, replaying past arguments, the person could learn to become more open to all of their experiences and aware of their restricted pattern of responding. They could notice the urge to react and instead focus on slowing down, noticing the other person’s face, listening to what the other person is saying, acknowledging their own frustration, and connecting with why it is important they have a productive conversation with this person they care about. Then, in the face of frustration they can choose a more workable behavior, perhaps a different action, one that brings them closer to the loving and kind relationship they want to have with this person. With those actions they are broadening their behavioral repertoire and becoming more psychologically flexible because in that moment of frustration they now have two options for how to behave: argue or slow down.

Most clients do not come to our offices because what they are doing is working for them or because they are too psychologically flexible. Generally, they come because their lives are not what they want them to be and they feel stuck or trapped by their minds or private behaviors. Working to increase psychological flexibility may sound abstract at times, but it has real world implications and promotes tangible behavioral outcomes. We have a helpful way of tying all the processes together in a single sentence that highlights what we are working toward: “In this moment, I’m holding my pain so that I can choose to do the things I care about.” We feel that sums up the whole model succinctly and exposes what psychological flexibility is about: being present with our experience, even pain, and choosing to make a life that is about living what we value.

C op

yr ig

ht ©

2 01

7. P

E S

I P ub

lis hi

ng &

M ed

ia . A

ll rig

ht s

re se

rv ed