Author: Lou Lasprugato, MFT
Over the years, I’ve amassed quite a collection of handheld percussion instruments. While all of these instruments are designed to produce a beat when struck, or rhythm when played in a pattern, each of them emit different tones, and thus are suited for different purposes.
Some instruments lend themselves well to large drum circles while others are more pleasing to play alone; some provide more bass while others are more melodic in nature. And depending upon the context at hand, I will choose the instrument(s) that will most likely fulfill the desired effect, or function.
I’ve come to view psychotherapy in very much the same way – the instruments, or therapeutic interventions, I choose are dependent upon the client and context. If there’s one thing consistent about providing acceptance and commitment therapy (ACT), it’s that it looks different with every client. In other words, the topography varies greatly while the primary functions of the approach remain the same (when applied competently).
With some clients, I’ll make use of classic ACT exercises and metaphors; whereas with other clients, exercises and metaphors arise out of the moment in a collaborative manner; and finally, with most clients these days, my interventions occur more naturally in the form of questions, reflections, observations, and invitations – that is, invitations to relate to and interact with private and public events (i.e. thoughts, feelings, overt behaviors, experiences, etc.) in novel ways.
However, if one were to look under the hood (i.e. analyze the function of these different topographies), common themes would emerge: contacting the present moment, flexible perspective-taking, defusing from thoughts, accepting feelings, valuing and committing values to action; these six processes of psychological flexibility, combined with creative hopelessness (compassionately undermining unworkable behavior), function to alleviate suffering and advance well-being across many diagnostic categories and intervention targets (Gloster, et al. 2020). And yet, when not following a particular protocol, ACT can appear dramatically different from one therapeutic exchange to the next, as well as among adults, adolescents, children, couples, and groups.
So, how does a clinician know if they are delivering ACT in a consistent and effective manner? Well, it may start and end with a therapeutic stance that is flexible, respectful, genuine, curious, and compassionate.
At any given time with any given client, we can ask ourselves the following question: “Am I willingly making room for feelings that show up (including those of my own and my client), and unhooking from unhelpful thoughts (e.g. judgments and criticisms of self or other), while consciously aware of ‘us’ (being and working together) in the here-and-now committing to actions that support our respectively chosen values?” If so, that’s psychological flexibility, which represents the primary component of the therapeutic stance. On the days when I’m feeling particularly spent with little to give, as has been the case on more than one occasion this past year, I return to that question to anchor me in the therapeutic relationship. Even if that’s all I’m able to provide, at least there’s a chance that such modeling will naturally transfer skills of psychological flexibility to the client, as has been shown in preliminary research (Walser, et al. 2013).
Respectful and Genuine
Drawing from a Rogerian (person-centered) approach, ACT also asks the clinician to be respectful and genuine. Referencing this approach in the book, The Therapeutic Relationship, C.H. Patterson states, “The client is regarded as a person of worth…the counselor’s attitude is non-evaluative, nonjudgmental, without criticism, ridicule, depreciation, or reservations.” Patterson goes on to say, “Clients are accepted for what they are, as they are. There is no demand or requirement that they change or be different in order to be accepted.” For me, this means welcoming clients, with all of their history and all of their vulnerabilities, just as they are, and enlisting their willingness be in charge from the outset of therapy; that is to unconditionally respect what they’re willing to disclose, experience, and do to live the life they long to live. Therapeutic genuineness, formerly known as congruence and sometimes referred to as authenticity, means to be freely and deeply oneself, to be transparent, especially when it serves the therapeutic relationship. Therapists “are involved in the relationship and not simply mirrors, sounding boards, or blank screens. They are real people in real encounters” (Patterson, 1985). At times, this may involve me sharing in the client’s excitement or pride over a values-based action, or disclosing thoughts and feelings related to a lack of progress in therapy or my own stuckness. And, if it can function to either normalize the client’s experiences or enhance therapeutic rapport, genuineness may come in the form of my own self-disclosure of personal challenges and triumphs.
When inviting clients to observe their private events in ACT, we often ask that they adopt an attitude of open, or receptive, curiosity. And, as therapists, we aim to have that same attitude towards them, curiously attending to and inquiring about their experiences with what the Zen Buddhist tradition refers to as ‘beginner’s mind’. Our mind naturally yearns for coherence – to make sense of what we experience and observe – however, if we fail to remain openly curious, we develop a confirmation bias that attracts information that fits, or coheres, with existing hypotheses and rejects what doesn’t, possibly missing out on subtle shifts in psychological flexibility and opportunities to reinforce small improvements in behavior. Being curiously receptive allows us to enter each moment anew, with a fresh perspective, continually renewing our commitment to the here-and-now and the humanness of the person sitting across from us. Consider the effect that a listener’s curious receptivity may have on you as you express your heart’s deepest desires or unburden your most painful vulnerabilities. When that person demonstrates, through verbal prompts and body language, an interest to know more of you, the whole of you, how do you feel in response?
Paul Gilbert, founder of Compassion-Focused Therapy (a close cousin of ACT), espouses a view of compassion supported by research, as “a sensitivity to suffering in self and others with a commitment to try to alleviate and prevent it.” To bring a compassionate stance into the therapy room requires us to become empathically attuned to the inner world of our clients in a way that we can sense their suffering, not based upon content but rather context – the way in which a client relates and responds to aversive stimuli (i.e. unpleasant private and public events). Sometimes, the contextual cues will be more obvious – overt expressions, such as crying – and other times more elusive and hidden under the armour of experiential avoidance (i.e. attempts to control, avoid, or escape from painful thoughts and feelings). Either way, ACT asks us to courageously be with, as opposed to turn away from, and explore the contingencies of, suffering with our clients so that any efforts in behavioral change are grounded in a mutual understanding of the patterns that give rise to suffering, which often once had useful, even life-preserving, functions. Then, we can commit to discovering more flexible and compassionate ways of relating to painful stimuli to transform their function, or effect, and thus, transcend suffering.
When we combine a psychologically flexible therapeutic stance with respect, authenticity, curiosity and compassion, we are setting a tone for ACT and for meaningful work to commence. Regardless of the specific interventions we employ, there is a co-created rhythm through the therapeutic stance and alliance that can provide healing and growth in itself. If interested in learning more about this stance and the entire ACT model, register now for ACT I Online starting April 9th.
Gloster, A. T., Walder, N., Levin, M., Twohig, M., & Karekla, M. (2020). The empirical status of acceptance and commitment therapy: A review of meta-analyses. Journal of Contextual Behavioral Science, 18, 181-192.
Walser, R. D., Karlin, B. E., Trockel, M., Mazina, B., & Taylor, C. B. (2013). Training in and implementation of Acceptance and Commitment Therapy for depression in the Veterans Health Administration: Therapist and patient outcomes. Behaviour Research and Therapy, 51(9), 555-563.
Patterson, C. H. (1985). The therapeutic relationship: Foundations for an eclectic psychotherapy. Thomson Brooks/Cole Publishing Co.