Most ACT protocols are laid out in a somewhat linear fashion. In the original ACT book (Hayes et al., 1999), the treatment begins with creative hopelessness and close experiential contact with unworkablility, and then moves on to an exploration of the control agenda as an unworkable metastrategy. From there, it proceeds to defusing language, discovering self, then finally to values and commitment.
Books are structured like that—they have a beginning, middle, and end. The pages and chapters are numbered serially. Of course, ACT can be carried out in this general order, but this ordering has caused some to imagine that it must be carried out in that order. Whether this is so or not is an entirely open empirical question.
Worse still, the structure has led some to imagine that once we’ve worked through avoidance and fusion, we’re ready to move on to values and needn’t worry too much about avoidance and fusion while doing values work. Taking this approach can be very frustrating because it often leads to great clarity about values but little movement. Homework assignments go undone. Commitments are postponed. Other troubles that are brought to therapy seem to crowd out the values work.
Very often this lack of movement, this stuckness, this inflexibility is the result of the reemergence of fusion and avoidance. There’s no value that isn’t complemented by a vulnerability. One of the easiest ways to generate fusion and avoidance is to start talking about values, especially where a person has experienced serious losses and disconnection. Even worse, begin talking about making commitments in those areas! Calling to mind a value often makes immediately present how lacking we are in that domain. For example, when a client begins valuing being a parent, the very next thing that happens is an awareness of all the ways that he has failed at that. At this point, we see behavior become narrow and inflexible, and we turn back to acceptance, defusion, and mindfulness interventions.
But if not in the order described in an ACT book, what order? I myself tend to be quite flexible in the ordering of the work. In principle, the six ACT processes described in the hexaflex are not independent. These are six lenses or facets through which we can look at one whole person and one whole life. On a theoretical level, I expect that we could, in principle, start anywhere on the hexaflex. In practice, I tend to start with a humble and gentle version of a values assessment. I like to start with a sense of the direction clients would take in their lives if they could.
This isn’t always possible. Sometimes people come in so distressed, so mired in suffering, so wrapped in a story of limitation, so fused, avoidant, and inflexible that any discussion of valued directions is impossible. In such cases, the only real way in is to settle into the room.
As I proposed in the first paragraphs of this chapter, we need to meet our clients just where they are. If that means running a hundred miles an hour, it falls to us to get up to speed. And having met them at a dead run, we begin to gently engage in pace setting and bringing them gently into the present moment.
The interventions called for in the face of very strong fusion and avoidance are present-moment focus, acceptance, defusion, and settling into a sense of self-as-context. As present-moment focused, mindfulness, acceptance, and defusion interventions alter the context, behavioral flexibility emerges and, with it, increased sensitivity to context, including that aspect of context we call consequences.
As flexibility appears, clients can be responsive to manipulations of operant contingencies and we can turn our focus back to values, behavioral activation, and committed action. These interventions give clients the opportunity to expand operant repertoires and pursue changes to behavior, the appetitive consequences of which are in the behaviors themselves.
This transition from strong antecedent aversive control to appetitive consequential control isn’t a one-way, one-time shift. Rather, behavior will move back and forth between aversive and appetitive control. You can respond to these shifts, shaping both as they occur in the moment.
There’s a dynamic quality to such work. When we begin to see the telltale signs of psychological inflexibility, we slow down and move to mindfulness and acceptance. When signs of flexibility emerge, we move into values and committed action. Even while doing values and commitment work that’s proceeding well, it’s worthwhile to stop for mindful moments. In doing so, we actively shape the capacity to move with intention, on purpose, from activity to activity.
Finally, perhaps the best place for us to look for these transitions is in our own experience in the moment during sessions. Human behavior is reciprocal, and when we feel our own behavior become narrow and inflexible, it’s likely that the client is experiencing the same restrictions. Even if it’s not the same aversive to which we’re responding, we don’t need to know what’s generating that inflexibility in the client in order to intervene appropriately.
This passage is an excerpt from Mindfulness for Two, a book by Kelly Wilson and Troy DuFrene.