by Jill A. Stoddard, Ph.D.
This article has appeared, in part, in Dr. Stoddard’s book, The Big Book of ACT Metaphors
Life is hard. It is painful. We want, we desire, we envy. We compare ourselves to others and see what they have that we don’t. We assume they are doing better, that they are happier. With these assumptions and social comparisons often comes anxiety, self doubt, despair, longing, or dissatisfaction. We assume these negative emotions are the problem to be fixed. We believe we are supposed to be more happy (like everyone else) and we consume books and blogs and videos to figure out how to fix sadness and be more happy (like everyone else).But sadness may not be the problem. After all, pain, whether physical or emotional, is universal; it is part of being human. Perhaps all the effort we expend trying to avoid, suppress, or “fix” pain is what really leads us to suffer. This premise lies at the heart of acceptance and commitment therapy (Hayes, Strosahl, & Wilson, 1999).
Perhaps all the effort we expend trying to avoid, suppress, or “fix” pain is what really leads us to suffer.
What Is Acceptance and Commitment Therapy?
Acceptance and commitment therapy, or ACT (pronounced as the word “act,” not the letters a-c-t) is a behavioral therapy that focuses on “psychological flexibility” or the ability to contact the present moment more fully (including all thoughts and feelings, no matter how difficult) and choose actions that are in line with personal values. The goal of ACT is not to feel better, but to do better and to live better.
ACT centers on identifying the thoughts and feelings that may be obstacles to valued living, and aims to change our relationship to those internal experiences, rather than changing the experiences themselves
Through six core processes—acceptance and willingness, cognitive defusion, present-moment awareness, self-as-context, values, and committed action—ACT participants are guided to open up and invite in all thoughts and feelings. ACT advocates opening to internal experiences not because there is some glory in feeling pain for pain’s sake, but because efforts to avoid painful feelings—for example by using drugs, socially isolating, or procrastinating—create suffering insofar as those efforts pull us away from things that are important to us and that contribute meaning and vitality to our lives. ACT centers on identifying the thoughts and feelings that may be obstacles to valued living, and aims to change our relationship to those internal experiences (through acceptance and mindfulness processes), rather than changing the experiences themselves.
Language and Suffering
Theoretically, ACT is grounded in the experimental work of Relational Frame Theory (RFT), which asserts that much of human suffering is attributable to the bidirectional and generally evaluative nature of human language (Hayes, Barnes-Holmes, & Roche, 2001). RFT suggests that the unique capability of humans to respond to derived relationships is exactly what traps us in emotional suffering. Specifically, our abilities to plan, predict, evaluate, verbally communicate, and relate events and stimuli to one another both help and hurt us (Hayes et al., 1999).
Clearly, our higher cognitive abilities allow us to solve problems. For example, if you get a terrible haircut, you can go back to your stylist (or perhaps decide to see a new stylist) and get a different haircut. If you don’t like the color you just painted your walls, you can choose a new color and repaint them. At the same time, we often wrongfully try to apply these same skills to our inner experiences. We believe we should be able to control the way we think and feel in the same way we can control our hair and our houses. However, mounting research has demonstrated that the more we attempt to suppress thoughts and feelings, the more present they become (Abramowitz, Tolin, & Street, 2001; Campbell-Sills, Barlow, Brown, & Hofmann, 2006). In addition, although these attempts to avoid our internal experiences (i.e., experiential avoidance) may appear to work in the short term, they ultimately lead to a more restricted existence. For example, a person who feels anxiety every time he enters a social situation may temporarily reduce his anxiety by avoiding interpersonal encounters; however, his ability to live life freely will become greatly limited, and his fear of social interactions will persist. Thus, the verbal rules we successfully use to solve many problems in the external world typically cause suffering when we attempt to use them to “solve” painful thoughts and feelings.
ACT stipulates that overidentification with literal language (taking the mind’s messages at face value and becoming fused with their content, rather than being guided by direct, present-focused experience) leads to psychological inflexibility and suffering. Through the six core therapeutic processes, clients learn to mitigate the impact of literal language, creating the wiggle room needed to take actions that are guided by personal values, rather than being driven by internal private events.
Thus, the verbal rules we successfully use to solve many problems in the external world typically cause suffering when we attempt to use them to “solve” painful thoughts and feelings.
Experiential Practice in ACT
If, however, language is at the core of human suffering, how can we use psychotherapy to alleviate suffering, given that the foundation of therapy is verbal dialogue? Of course there is no getting around the need to use oral communication. However, ACT attempts to circumvent some of the problems inherent in literal language by shifting away from traditional didactics and dialogue and moving toward a more experiential encounter. Through mindfulness exercises, clients are encouraged to observe and make contact with their thoughts and emotions as they occur, both in and out of session. In addition, the use of a wide variety of metaphors and experiential exercises is central to helping clients understand the approach in an experienced way, rather than intellectually.
Examples of Experiential Practice
Each of the six core therapeutic processes in ACT can be demonstrated through active practices designed to experientially teach that specific concept. What follows are selected scripts for metaphors and experiential exercises from The Big Book of ACT Metaphors: A Practitioner’s Guide to Experiential Exercises and Metaphors in Acceptance and Commitment Therapy (Stoddard and Afari, 2014).
Acceptance: Yes and No exercise (Walser & Afari, 2012, adapted from Brach, 2003)
“In this exercise, I’m going to ask you to avoid experiencing the sensations you have of your back against the chair you’re sitting in. For the next two to three minutes, whenever you notice a sensation of your back against the chair, I want you to say no to those sensations.” You can expand on this exercise by having the client first say no to the physical sensations of her back against the chair, and then say no to any thoughts and emotions that show up about the sensations or even the exercise more generally.
Once you’ve allowed enough time, refocus the client’s attention to the room. Ask her what sensations came up and what it was like to say no to these sensations. Help her distinguish between the physical sensations and the thoughts and feelings that accompanied resistance.
“Okay, now I’d like to do the same exercise, except now rather than avoiding the sensations of your back against the chair, I’d like you to be willing to feel those sensations, simply as sensations, whatever they may be, positive or negative: pain, discomfort, tingling, warmth, coolness, and so on. Whatever those sensations are, I’d like you to say yes to them.”
Again, ask her to describe the physical sensations and the thoughts and feelings that came up. Help her reflect on the difference in her experiences with saying yes and no as it may relate to willingness and control strategies.
Defusion: Fly Fishing metaphor (Whitney, 2013)
“Have you heard of fly fishing? A good fly fisher knows exactly what the trout are feeding on and ties up flies that imitate those insects. They are so good at this that the trout can’t tell the difference. They cast the fly into the stream right in front of the trout, and the trout sees it floating by, buys that the fly is real, bites it, and gets hooked.
Our minds can be like really skilled fly fishers. Our thoughts and feelings are like highly specific flies the mind designs—just the ones we’ll bite on. The mind casts them out on the stream in front of us, and they seem so real that we buy them, bite, and get hooked. Once we’re hooked, the more we struggle, the more we behave in ways that drive the hook in deeper and keep us on the line.
As we swim in the stream of life, there are flies floating by on the surface all the time. As we get better at spotting flies and recognizing that we don’t have to bite them, we get hooked less often and have more flexibility to swim in the direction of our values.”
Values: Heroes exercise (Archer, 2013)
“Think about your heroes. Consider people who have played a direct role in your life: family members, friends, teachers, coaches, teammates, and so on. Now think about people who have inspired you indirectly: authors, artists, celebrities, or even fictional characters. Who would you most like to be like? Pick one person you really admire.” (Give the client time to think about this.) “Now think about all the qualities you really admire in this person—not the person’s circumstances, but personal qualities—and write them down. Once you’ve done this, I’d like you to look this over and think about how these might translate into your own personal values.”
Discuss the specific qualities that come up. Clients might write things like “ambitious,” “selfless,” “generous,” “thoughtful,” “kind,” “compassionate,” “creative,” and so on. Ask clients how they think they are like this person or unlike this person, and in what ways they might like to move toward being more like this person. Help them identify the life domains (friendships, family, career, and so on) in which they might be willing to work on building these qualities. This can lead to a discussion of obstacles and how clients might use other ACT processes, such as acceptance, present-moment awareness, defusion, and self-as-context, to handle those obstacles in the service of moving forward in a values-consistent way.
ACT aims to increase psychological flexibility, or the ability to be present to all internal experiences and choose values-driven behavior. Getting “hooked” by thoughts and literal language threatens psychological flexibility and is at the core of human suffering. To bypass the traps of language, ACT relies on the use of exercises and metaphors to facilitate learning that is experiential rather than didactic. Therapists must take care to not over use experiential practice, and to tailor the exercises to each individual client. Applying these practices flexibly to address areas where clients are stuck and disconnected from personal values can provide a powerful therapeutic experience.
Abramowitz, J. S., Tolin, D. F., & Street, G. P. (2001). Paradoxical effects of thought suppression: A meta-analysis of controlled studies. Clinical Psychology Review, 21, 683–703. doi:10.1016/S0272-7358(00)00057-X.
Campbell-Sills, L., Barlow, D. H., Brown, T. A., & Hofmann, S. G. (2006). Effects of suppression and acceptance on emotional responses of individuals with anxiety and mood disorders. Behaviour Research and Therapy, 44, 1251–1263. doi:10.1016/j.brat.2005.10.001.
Hayes, S. C., Barnes-Holmes, D., & Roche, B. (2001). Relational frame theory: A post-Skinnerian account of human language and cognition. New York: Plenum.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press.
Stoddard, J. A., & Afari, N. (2014). The big book of ACT metaphors: A practitioner’s guide to experiential exercises and metaphors in acceptance and commitment therapy. Oakland: New Harbinger Publications
Dr. Stoddard is the founder and director of The Center for Stress and Anxiety Management, an outpatient clinic with three locations throughout San Diego county, specializing in evidence based treatments for anxiety and related problems. She is also an Associate Professor at Alliant International University. Dr. Stoddard specializes in the treatment of anxiety and related disorders and has expertise in Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT).
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