Embracing Your Demons: an Overview of Acceptance and Commitment Therapy
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Embracing Your Demons:
an Overview of Acceptance
and Commitment Therapy
RUSSELL HARRIS
Acceptance and Commitment Therapy is one of the recent mindfulness-based
behaviour therapies shown to be effective with a diverse range of clinical conditions. In
contrast to the assumption of ‘healthy normality’ of Western psychology, ACT assumes
that the psychological processes of a normal human mind are often destructive and
create psychological suffering. Symptom reduction is not a goal of ACT, based on the
view that ongoing attempts to get rid of ‘symptoms’ can create clinical disorders in
the first place. RUSSELL HARRIS provides an overview of ACT against a background
of the suffering generated by experiential avoidance and emotional control. A
case study illustrates the six core principles of developing psychological flexibility;
defusion, acceptance, contact with the present moment, the observing self, values,
and committed action.
I magine a therapy that makes no
attempt to reduce symptoms,
but gets symptom reduction as a by-
pain, the stress of terminal cancer,
anxiety, PTSD, anorexia, heroin
abuse, marijuana abuse, and even
of barriers, in the form of unpleasant
and unwanted ‘private experiences’
(thoughts, images, feelings, sensations,
product. A therapy firmly based in the schizophrenia. (Zettle & Raines, 1989; urges, and memories). ACT teaches
tradition of empirical science, yet has a Twohig, Hayes & Masuda, 2006; mindfulness skills as an effective way
major emphasis on values, forgiveness, Bond & Bunce, 2000; Dahl, Wilson to handle these private experiences.
acceptance, compassion, living in & Nilsson, 2004; Branstetter, Wilson,
What is mindfulness?
the present moment, and accessing a Hildebrandt & Mutch, 2004). A study
transcendent sense of self. A therapy by Bach & Hayes (2002) showed that When I discuss mindfulness with
so hard to classify that it has been with only four hours of ACT, hospital clients, I define it as: ‘Consciously
described as an ‘existential humanistic re-admission rates for schizophrenic bringing awareness to your here-and-now
cognitive behavioural therapy’. patients dropped by 50% over the next experience with openness, interest and
Acceptance and Commitment six months. receptiveness.’ There are many facets
Therapy, known as ‘ACT’ (pronounced to mindfulness, including living in
The goal of ACT
as the word ‘act’) is a mindfulness- the present moment; engaging fully
based behavioural therapy that The goal of ACT is to create a rich in what you are doing rather than
challenges the ground rules of most and meaningful life, while accepting ‘getting lost’ in your thoughts; and
Western psychology. It utilizes an the pain that inevitably goes with it. allowing your feelings to be as they
eclectic mix of metaphor, paradox, ‘ACT’ is a good abbreviation, because are, letting them come and go rather
and mindfulness skills, along with a this therapy is about taking effective than trying to control them. When
wide range of experiential exercises action guided by our deepest values we observe our private experiences
and values-guided behavioural and in which we are fully present and with openness and receptiveness, even
interventions. ACT has proven engaged. It is only through mindful the most painful thoughts, feelings,
effective with a diverse range of action that we can create a meaningful sensations and memories can seem less
clinical conditions; depression, life. Of course, as we attempt to create threatening or unbearable. In this way
OCD, workplace stress, chronic such a life, we will encounter all sorts mindfulness can help us to transform
PSYCHOTHERAPY IN AUSTRALIA • VOL 12 NO 4 • AUGUST 2006our relationship with painful thoughts rather than following a manualised feelings, so that we no longer perceive
and feelings, in a way that reduces their protocol, ACT allows the therapist them as ‘symptoms’. Instead, we learn
impact and influence over our life. to create and individualise their own to perceive them as harmless, even if
mindfulness techniques, or even to co- uncomfortable, transient psychological
How does ACT differ from other
create them with clients. events. Ironically, it is through this
mindfulness-based approaches?
Another primary difference is process that ACT actually achieves
ACT is one of the so-called ‘third that ACT sees formal mindfulness symptom reduction—but as a by-
wave’ of behavioural therapies—along meditation as only one way of many to product and not the goal.
with Dialectical Behaviour Therapy teach mindfulness skills. Mindfulness Another way in which ACT is
(DBT), Mindfulness-Based Cognitive skills are ‘divided’ into four subsets: unique, is that it doesn’t rest on the
Therapy (MBCT) and Mindfulness- • acceptance; assumption of ‘healthy normality’.
Based Stress Reduction (MBSR)—all • cognitive defusion;
Healthy normality
of which place a major emphasis on • contact with the present moment;
the development of mindfulness skills. • the observing self. Western psychology is founded on
the assumption of healthy normality:
that by their nature, humans are
In stark contrast to most Western psychologically healthy, and given a
healthy environment, lifestyle, and
psychotherapy, ACT does not have social context (with opportunities
for ‘self-actualisation’), humans will
symptom reduction as a goal. This is based naturally be happy and content.
From this perspective, psychological
on the view that the ongoing attempt suffering is seen as abnormal; a
to get rid of ‘symptoms’ actually creates disease or syndrome driven by unusual
pathological processes.
a clinical disorder in the first place. Why does ACT suspect this
assumption to be false? If we
examine the statistics we find that
Created in 1986 by Steve Hayes, ACT The range of ACT interventions in any year almost 30 percent of the
was the first of these ‘third wave’ to develop these skills is vast and adult population will suffer from
therapies, and currently has a large continues to grow ranging from a recognised psychiatric disorder
body of empirical data to support its traditional meditations on the (Kessler et al, 1994). The World Health
effectiveness. breath through to cognitive defusion Organization estimates that depression
The ‘first wave’ of behavioural techniques. is currently the fourth biggest, most
therapies, in the fifties and sixties, costly, and most debilitating disease in
What is unique to ACT?
focused on overt behavioural change the world, and by the year 2020 it will
and utilized techniques linked to ACT is the only Western
operant and classical conditioning psychotherapy developed in
principles. The ‘second wave’ in conjunction with its own basic research
the seventies included cognitive program into human language and
interventions as a key strategy. cognition—Relational Frame Theory
Cognitive-behaviour therapy (CBT) (RFT). It is beyond the scope of
eventually came to dominate this this article to go into RFT in detail,
‘second wave’. however, for more information see
ACT differs from DBT, MBCT, www.contextualpsychology.org/rtf.
and MBSR in many ways. For a start, In stark contrast to most Western
MBSR and MBCT are essentially psychotherapy, ACT does not have
manualised treatment protocols, symptom reduction as a goal. This is
designed for use with groups for based on the view that the ongoing
treatment of stress and depression. attempt to get rid of ‘symptoms’
DBT is typically a combination of actually creates a clinical disorder in
group skills training and individual the first place. As soon as a private
therapy, designed primarily for group experience is labeled a ‘symptom’, it
treatment of Borderline Personality immediately sets up a struggle with it
Disorder. In contrast, ACT can be because a ‘symptom’ is by definition
used with individuals, couples and something ‘pathological’; something
groups, both as brief therapy or long we should try to get rid of. In ACT,
term therapy, in a wide range of the aim is to transform our relationship
clinical populations. Furthermore, with our difficult thoughts and Illustration: Savina Hopkins
PSYCHOTHERAPY IN AUSTRALIA • VOL 12 NO 4 • AUGUST 2006 be the second biggest. In any week, and all of these processes rely on are therefore highly adaptive for us as
one-tenth of the adult population is human language. Thus in ACT, the humans (and indeed, teaching such
suffering from clinical depression, and word ‘mind’ is used as a metaphor for skills has proven to be effective in the
one in five people will suffer from it at human language itself. treatment of depression). Given this
some point in their lifetime (Davies, Unfortunately, human language is a problem solving approach works well
1997). Furthermore, one in four adults, double-edged sword. On the positive it in the outside world, it’s only natural
at some stage in their lifetime, will helps us make maps and models of the that we would tend to apply it to
suffer from drug or alcohol addiction. world; predict and plan for the future; our interior world; the psychological
There are now over twenty million share knowledge; learn from the past; world of thoughts, feelings, memories,
alcoholics in the United States alone imagine things that have never existed, sensations, and urges. Unfortunately,
(Kessler et al, 1994). and go on to create them; develop rules all too often when we try to avoid
More startling and sobering is the that guide our behaviour effectively, or get rid of unwanted private
finding that almost one in two people and help us to thrive as a community; experiences, we simply create extra
will go through a stage in life when communicate with people who are far suffering for ourselves. For example,
they consider suicide seriously, and away; and learn from people who are virtually every addiction known to
will struggle with it for a period of two no longer alive. mankind begins as an attempt to avoid
weeks or more. Scarier still, one in ten The dark side of language is that we or get rid of unwanted thoughts and
people at some point attempt to kill use it to lie, manipulate and deceive; to feelings, such as boredom, loneliness,
themselves (Chiles and Strosahl, 1995). spread libel, slander and ignorance; to anxiety, depression and so on. The
In addition, consider the many incite hatred, prejudice and violence; to addictive behaviour then becomes self-
forms of psychological suffering that make weapons of mass destruction, and sustaining, because it provides a quick
do not constitute ‘clinical disorders’— industries of mass pollution; to dwell and easy way to get rid of cravings or
loneliness, boredom, alienation, on and ‘relive’ painful events from the withdrawal symptoms.
meaninglessness, low self-esteem, past; to scare ourselves by imagining The more time and energy we spend
existential angst, and pain associated unpleasant futures; to compare, judge, trying to avoid or get rid of unwanted
with issues such as racism, bullying, criticise and condemn both ourselves private experiences the more we are
sexism, domestic violence, and divorce. and others; and to create rules for likely to suffer psychologically in the
Clearly, even though our standard ourselves that can often be life- long term. Anxiety disorders provide a
of living is higher than ever before constricting or destructive. good example. It is not the presence of
in recorded history, psychological anxiety that comprises the essence of
Experiential avoidance
suffering is all around us. an anxiety disorder. After all, anxiety
ACT rests on the assumption that is a normal human emotion that we all
Destructive normality
human language naturally creates experience. At the core of any anxiety
ACT assumes that the psychological psychological suffering for us all. One disorder lies a major preoccupation
processes of a normal human mind way it does this is through setting us up with trying to avoid or get rid of
are often destructive, and create for a struggle with our own thoughts anxiety. OCD provides a florid
psychological suffering for us all, and feelings, through a process called example; I never cease to be amazed
sooner or later. experiential avoidance. by the elaborate rituals that OCD
Furthermore, ACT postulates that Probably the single biggest sufferers devise, in vain attempts to get
the root of this suffering is human evolutionary advantage of human rid of anxiety-provoking thoughts and
language itself. Human language is language was the ability to anticipate images. Sadly, the more importance
a highly complex system of symbols, and solve problems. This has enabled we place on avoiding anxiety, the
which includes words, images, sounds, us not only to change the face of the more we develop anxiety about our
facial expressions and physical gestures. planet, but to travel outside it. The anxiety—thereby exacerbating it. It’s
We use this language in two domains: essence of problem-solving is this: a vicious cycle, found at the centre of
public and private. The public use of Problem = something we don’t want. any anxiety disorder. (What is a panic
language includes speaking, talking, Solution = figure out how to get rid attack, if not anxiety about anxiety?)
miming, gesturing, writing, painting, of it, or avoid it. A large body of research shows
singing, dancing and so on. The private This approach obviously works well that higher experiential avoidance
use of language includes thinking, in the material world. A wolf outside is associated with anxiety disorders,
imagining, daydreaming, planning, your door? Get rid of it. Throw rocks depression, poorer work performance,
visualising and so on. A more technical at it, or spears, or shoot it. Snow, rain, higher levels of substance abuse,
term for the private use of language is hail? Well, you can’t get rid of those lower quality of life, high risk sexual
‘cognition’. things, but you can avoid them, by behaviour, borderline personality
Now clearly the mind is not a ‘thing’ hiding in a cave, or building a shelter. disorder, greater severity of PTSD,
or an ‘object’. Rather, it is a complex Dry, arid ground? You can get rid of long term disability and alexithymia.
set of cognitive processes—such as it, by irrigation and fertilisation, or Of course, not all forms of
analysing, comparing, evaluating, you can avoid it, by moving to a better experiential avoidance are unhealthy.
planning, remembering, visualising— location. Problem solving strategies For example, drinking a glass of wine
PSYCHOTHERAPY IN AUSTRALIA • VOL 12 NO 4 • AUGUST 2006to unwind at night is experiential make room for them, and allow them a process similar to motivational
avoidance, but it’s not likely to be to come and go without a struggle. interviewing. Clients identify the ways
harmful. However, drinking an entire The time, energy, and money that they they have tried to get rid of or avoid
bottle of wine a night is likely to be wasted previously on trying to control unwanted private experiences. They are
extremely harmful, in the long term. how they feel is then invested in taking then asked to assess for each method:
ACT targets experiential avoidance effective action (guided by their values) ‘Did this reduce your symptoms in the long
strategies only when clients use them to change their life for the better. term? What did this strategy cost you, in
terms of time, energy, health, vitality,
relationships? Did it bring you closer to the
ACT assumes that the psychological life you want?’
‘Michael’ was a 35 year old
processes of a normal human mind are accountant who suffered from
significant social anxiety, and had seen a
often destructive, and create psychological number of therapists to no avail. On the
first session we ran through the many
suffering for us all, sooner or later. strategies he had used to avoid or get
rid of his social anxiety. They included:
drinking alcohol, taking Valium, being
to such a degree that they become Thus ACT interventions focus a ‘good listener’ (asking lots of questions,
costly, life-distorting, or harmful. around two main processes: but sharing little of himself), arriving
ACT calls these ‘emotional control 1) developing acceptance of late, leaving early, avoiding social events
strategies’, because they are attempts unwanted private experiences altogether, deep breathing, relaxation
to directly control how we feel. Many which are out of personal control, techniques, using positive affirmations,
of the emotional control strategies that 2) commitment and action towards disputing negative thoughts, analysing
clients use to try to feel good (or to living a valued life. his childhood, blaming his parents (who
feel ‘less bad’) may work in the short What follows is a brief summary were both socially avoidant), telling
term, but frequently they are costly of some core ACT interventions, himself to ‘get over it’, self-hypnosis and
and self-destructive in the long term. illustrated with vignettes of clinical so on. Michael realised that none of
For example, depressed clients often work with a client called ‘Michael’. these strategies had reduced his anxiety
withdraw from socialising in order to in the long term. Although strategies
Confronting the agenda
avoid uncomfortable thoughts—‘I’m such as taking Valium, drinking
a burden’, ‘I have nothing to say’, ‘I In this step, the client’s agenda alcohol, and avoiding social events had
won’t enjoy myself ’—and unpleasant of emotional control is gently and reduced his anxiety in the short term,
feelings such as anxiety, fatigue, fear of respectfully undermined, through they had created significant costs to his
rejection. In the short term, canceling
a social engagement may give rise to
a short-lived sense of relief, but in
the long term, the increasing social
isolation makes them more depressed.
ACT offers clients an alternative
to experiential avoidance through a
variety of therapeutic interventions.
Therapeutic interventions
In general, clients come to
therapy with an agenda of emotional
control. They want to get rid of their
depression, anxiety, urges to drink,
traumatic memories, low self-esteem,
fear of rejection, anger, grief and so
on. In ACT, there is no attempt to
try to reduce, change, avoid, suppress,
or control these private experiences.
Instead, clients learn to reduce the
impact and influence of unwanted
thoughts and feelings, through the
effective use of mindfulness. Clients
learn to stop fighting with their private
experiences—to open up to them,
PSYCHOTHERAPY IN AUSTRALIA • VOL 12 NO 4 • AUGUST 2006 quality of life. His ‘homework’ was to it’s not a problem. Sure, it’s unpleasant. • acceptance;
notice and write down other emotional We don’t like it, or want it, but at the • contact with the present moment;
control strategies, and to assess their same time, it’s nothing terrible. With • the Observing Self;
long-term effectiveness and costs to his the struggle switch OFF, our anxiety • values, and;
quality of life. levels are free to rise and fall as the • committed action.
situation dictates. Sometimes they’ll Each principle has its own specific
Control is the problem,
be high, sometimes low and sometimes methodology, exercises, homework and
not the solution
there will be no anxiety at all. Far more metaphors. Take defusion, for example.
In this phase, we increase clients’ importantly, we’re not wasting our time In a state of cognitive fusion we are
awareness that emotional control and energy struggling with it. caught up in language. Our thoughts
strategies are largely responsible for Without struggle, we get a natural seem to be the literal truth, or rules
their problems; that as long as they’re level of physical and emotional that must be obeyed, or important
fixated on trying to control how they discomfort, depending on who we are events that require our full attention,
feel, they’re trapped in a vicious cycle of and the situation we’re in. In ACT, we or threatening events that we must get
increasing suffering. Useful metaphors call this ‘clean discomfort’. There’s no rid of. In other words, when we fuse
here include ‘quicksand’, ‘the struggle avoiding ‘clean discomfort’. Life serves with our thoughts, they have enormous
switch’, and the concepts of ‘clean it up to all of us in one way or another. influence over our behaviour.
discomfort’ and ‘ dirty discomfort’. We However, once we start struggling Cognitive defusion means we are able
might deliver these metaphors like this: with it, our discomfort levels increase to ‘step back’ and observe language,
Remember those old movies rapidly. This additional suffering, we without being caught up in it. We
where the bad guy falls into a pool of call ‘ dirty discomfort’. Our struggle can recognise that our thoughts are
quicksand, and the more he struggles, switch is like an emotional amplifier— nothing more or less than transient
the faster it sucks him under? In switch it on, and we can have anger private events—an ever-changing
quicksand, struggling is the worst thing about our anxiety, anxiety about our stream of words, sounds and pictures.
you can possibly do. The way to survive anger, depression about our depression, As we defuse our thoughts, they have
is to lie back, spread out your arms, and or guilt about our guilt. much less impact and influence.
float on the surface. It’s tricky, because Obviously, these metaphors are If you look through the wide variety
every instinct tells you to struggle; but tailored to the particular feelings of writings on ACT, you will find over
if you do so, you’ll drown. the client struggles with. With the a hundred different cognitive defusion
The same principle applies to struggle switch ON, not only do we techniques. For example, to deal with
difficult feelings: the more we try to get emotionally distressed by our own an unpleasant thought, we might
fight them, the more they overwhelm feelings, we also do whatever we can to simply observe it with detachment;
us. Imagine that at the back of our avoid or get rid of them, regardless of or repeat it over and over, out aloud,
mind is a ‘struggle switch’. When it’s the long term costs. We draw clients’ until it just becomes a meaningless
switched on, it means we’re going attention to the many ways they’ve sound; or imagine it in the voice of a
to struggle against any physical or tried to do this—through more obvious cartoon character; or sing it to the tune
emotional pain that comes our way; strategies such as drugs, alcohol, food, of ‘Happy Birthday’; or silently say
whatever discomfort experienced, we’ll TV, gambling, smoking, sex, surfing ‘Thanks, mind’ in gratitude for such an
try our best to get rid of it or avoid it. the net—to less obvious emotional interesting thought. There is endless
Suppose the emotion that shows control strategies, such as ruminating, room for creativity. In contrast to CBT,
up is anxiety. If our struggle switch is chastising themselves, blaming others not one of these cognitive defusion
ON, then that feeling is completely and so on. (As mentioned earlier, many techniques involves evaluating or
unacceptable. This means we could control strategies are not an issue, as disputing unwanted thoughts.
end up with anger about our anxiety: long as they are used in moderation.) Here’s a simple exercise in cognitive
‘How dare they make me feel like this?’ Michael was able to connect with defusion for yourself:
Or sadness about our anxiety: ‘Not these metaphors readily, especially the Step 1: Bring to mind an upsetting
again. Why do I always feel like this?’ idea of the struggle switch. We were and recurring negative self-judgment
Or anxiety about our anxiety: ‘What’s able to refer back to this in subsequent that takes the form ‘I am X’ such as ‘I
wrong with me? What’s this doing to sessions whenever he experienced am incompetent’, or ‘I’m stupid.’ Hold
my body?’ Or a mixture of all these anxiety. ‘Okay, right now, you’re feeling that thought in your mind for several
feelings. These secondary emotions are anxious. Is the struggle switch on or off?’ seconds and believe it as much as you
useless, unpleasant, and unhelpful, and Once the emotional control agenda can. Now notice how it affects you?
a drain upon our vitality. In response is undermined, we then introduce the Step 2: Now take the thought ‘I am
we get angry, anxious or guilty. Spot six core principles of ACT. X’ and insert this phrase in front of it:
the vicious cycle? ‘I’m having the thought that . . .’ Now
Six core principles of ACT
But what if our struggle switch is run that thought again, this time with
OFF? Whatever emotion shows up, ACT uses six core principles to help the new phrase. Notice what happens.
no matter how unpleasant, we don’t clients develop psychological flexibility: In Step 2, most people notice a
struggle with it. So if anxiety shows up, • defusion; ‘distance’ from the thought, such
PSYCHOTHERAPY IN AUSTRALIA • VOL 12 NO 4 • AUGUST 2006that it has much less impact. Notice party. When I asked him to scan his conversations; i.e. keeping his attention
there has been no effort to get rid of body and notice where he felt the on the other person, rather than on his
the thought, nor to change it. Instead anxiety most intensely he reported a own thoughts and feelings.
the relationship with the thought has ‘huge knot’ in his stomach. I asked 4. The Observing Self: accessing a
changed—it can be seen as just words. him to observe this sensation as if transcendent sense of self; a continuity
There now follows a brief description he was a curious scientist who had of consciousness that is unchanging,
of the six core principles, with reference never seen anything like it before; to ever-present, and impervious to harm.
to the case of Michael. notice the edges of it, the shape of it, From this perspective, it is possible to
1. Cognitive Defusion: learning to the vibration, weight, temperature, experience directly that you are not
perceive thoughts, images, memories pulsation, and the myriad of other your thoughts, feelings, memories,
and other cognitions as what they sensations within the sensation. I had urges, sensations, images, roles, or
are—nothing more than bits of him breathe into the sensation, and physical body. These phenomena
language, words and pictures—as ‘make room for it’; to allow it to be change constantly and are peripheral
opposed to what they can appear to there, even though he did not like it or aspects of you, but they are not the
be—threatening events, rules that must want it. Michael soon reported a sense essence of who you are.
be obeyed, objective truths and facts. of calmness; a sense of being at ease In session five, I took Michael
In session two, Michael, said he with his anxiety, even though he didn’t through a mindfulness exercise
experienced frequent distress from like it. ‘Homework’ included practising designed to have him access this
thoughts such as ‘I’m boring’, ‘I have this technique with his recurrent transcendent self. First, I asked him to
nothing to say’, ‘No one likes me’, and ‘I’m feelings of anxiety—not to get rid of close his eyes and observe his thoughts:
a loser’. As the session continued, I had them, but simply to learn how to let the form they took, their apparent
Michael interact with these thoughts them come and go without a struggle. location in space, the speed with which
in a number of different ways, until 3. Contact with the present moment: they were moving. Then I asked him:
they began to lose their impact. For bringing full awareness to your here- ‘Be aware of what you are noticing.
example, I had him bring to mind and-now experience, with openness, There are your thoughts, and there is you
the thought ‘I’m a loser’, then close his interest, and receptiveness; focusing on, noticing them. So there are two processes
eyes and notice where it seemed to be and engaging fully in whatever you are going on—a process of thinking, and a
located in space. He sensed it was in doing. process of observing that thinking.’ Again
front of him. I asked him to observe In session four, I took Michael and again, I drew his attention to
the thought as if he was a curious through a simple mindfulness exercise, the distinction between the thoughts
scientist, and to notice the form of it: focused on the experience of eating. that arise, and the self who observes
whether it was more like something he I gave him a sultana, and asked him those thoughts. From the perspective
could see, or something he could hear. to eat it ‘in slow motion’, with a total of this Observing Self, no thought is
He said it was like words that he could focus on the taste and texture of the dangerous, threatening, or controlling.
see, and he noticed that as he ‘looked’ fruit, and the sounds, sensations and 5. Values: clarifying what is most
at it, it became less distressing. I asked movements inside his mouth. I told important, deep in your heart; what
him to imagine the thought as words him, ‘While you’re doing this, all sorts sort of person you want to be; what is
on a Karaoke screen; then change the of distracting thoughts and feelings significant and meaningful to you; and
font; then change the colour; then may arise. The aim is simply to let what you want to stand for in this life.
imagine a bouncing ball jumping from your thoughts come and go, and allow In session six, Michael identified
word to word. By this stage, Michael your feelings to be there, and keep your important values around connecting
was chuckling at the very same thought attention focused on eating the sultana.’ with others, building meaningful
that only a few minutes earlier had Afterwards, Michael said he was friendships, developing intimacy,
brought him to tears. ‘Homework’ amazed that there was so much flavour and being authentic and genuine. We
included practising several different in one single sultana. I was then able discussed the concept of willingness.
defusion techniques with distressing to use this experience to draw an The willingness to feel anxiety doesn’t
thoughts—not to get rid of them, but analogy with social situations, where mean you like or want it. Instead
simply to learn how to step back and Michael would be so caught up in his it means you allow it to be there in
see them for what they are—just ‘bits thoughts and feelings that he wasn’t order to do something you value. I
of language’ passing through. able to engage fully in conversation, asked Michael, ‘If taking your life in the
2. Acceptance: making room for and missed out on the ‘richness’. direction of these values means you need to
unpleasant feelings, sensations, ‘Homework’ included practising make room for feelings of anxiety, are you
urges, and other private experiences; full engagement with all the five willing to do that?’ His reply was ‘Yes.’
allowing them to come and go without senses in a number of daily routines 6. Committed Action: setting goals,
struggling with them, running from (having a shower, brushing his teeth, guided by your values, and taking
them, or giving them undue attention. and washing the dishes) as well as effective action to achieve them.
In session three, I asked Michael to continuing to practise his defusion and Continuing session six, we moved
make himself anxious by imagining acceptance techniques. He agreed also to setting goals in line with Michael’s
himself at a forthcoming office to practice mindful engagement in values. Initially, he set the goal of
PSYCHOTHERAPY IN AUSTRALIA • VOL 12 NO 4 • AUGUST 2006 going for lunch with a work colleague like: ‘I don’t want you to think I’ve got Dahl, J., Wilson, K. G., & Nilsson, A.
every day, and sharing some personal my life completely in order. It’s more as if (2004). Acceptance and commitment
therapy and the treatment of persons at
information on each occasion. In you’re climbing your mountain over there
risk for long-term disability resulting from
subsequent sessions, he set increasingly and I’m climbing my mountain over here. stress and pain symptoms: A preliminary
challenging social goals, and continued It’s not as if I’ve reached the top and I’m randomized trial. Behavior Therapy, 35,
to practice mindfulness skills to handle having a rest. It’s just that from where I 785–802.
the anxious thoughts and feelings am on my mountain, I can see obstacles on Davies, T. (1997), ABC of Mental Health,
that inevitably arose. At the end of your mountain that you can’t see. So I can British Medical Journal, 314, 27.5.97:
ten sessions, Michael reported that point those out to you, and maybe show 1536–39.
he was socialising a lot more, and you some alternative routes around them.’ Hayes, S. C., Bissett, R., Roget, N.,
more importantly, he was enjoying it. Padilla, M., Kohlenberg, B. S., Fisher, G.,
Conclusion
Thoughts of being ‘a loser’ or ‘boring’ or et al. (2004). The impact of acceptance
‘unlikeable’ still occurred, but usually The experience of doing therapy and commitment training on stigmatizing
attitudes and professional burnout of
he did not take them seriously or pay becomes vastly different with ACT. It
substance abuse counselors. Behavior
them any attention. Likewise, feelings is no longer about getting rid of bad Therapy, 35, 821–836.
of anxiety still occurred in many social feelings or getting over old trauma.
Kessler, R.C., McGonagle, K.A., Zhao,
situations, but no longer bothered him Instead it is about creating a rich, full S., Nelson, C.B., Hughes, M., Eshleman,
or distracted him. Overall, his anxiety and meaningful life. This is confirmed S., Wittchen, H.U., and Kendler, K.S.
levels had diminished considerably. by the findings of Strosahl, Hayes, (1994), Lifetime and 12-month Prevalence
This reduction in anxiety was not the Bergan and Romano (1998) who of DSM-III-R Psychiatric Disorders in
goal of therapy, but was a pleasant showed that ACT increases therapist the United States, Archives of General
Psychiatry, 51 (Jan 1994): 8–19.
by-product. This illustrates how ACT effectiveness and Hayes et al (2004)
can result in good symptom reduction who showed that it reduces burnout. If Strosahl, K. D., Hayes, S. C., Bergan, J.,
without ever aiming for it. First, a lot I had to summarise ACT on a t-shirt, & Romano, P. (1998). Does field based
training in behavior therapy improve
of exposure took place, as Michael it would read: ‘Embrace your demons, clinical effectiveness? Evidence from the
engaged in increasingly challenging and follow your heart.’ Acceptance and Commitment Therapy
social situations. It is well known that training project. Behavior Therapy, 29,
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Paper presented at the Association for
midst of strong emotions. Furthermore, Advancement of Behavior Therapy, New
ACT teaches therapists that, thanks Orleans.
to human language, they are in the
Chiles J., and Strosahl, K. (1995),
same boat as their clients—so they The Suicidal Patient: Principles Of
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AUTHOR NOTES
RUSSELL HARRIS M.D. is a medical practitioner and psychotherapist in private practice in Melbourne.
He provides training in ACT and is the author of ‘The Happiness Trap’, due for release in March 2007.
Comments: russharris@actmindfully.com.au
PSYCHOTHERAPY IN AUSTRALIA • VOL 12 NO 4 • AUGUST 2006You can also read
