Author: Lou Lasprugato, MFT
Nearly 14 years after the “third wave” (Hayes, 2004) landed on its shores, the field of psychotherapy is on the cusp of a new era.
Following the exile of the DSM-5 by the National Institute of Mental Health (NIMH), combined with researchers’ renewed interest in identifying and examining mediators of change, there’s a growing movement away from manualized protocols to treat syndromes and toward evidence-based transdiagnostic processes to improve people’s lives.
Several studies on experiential avoidance (Chawla & O’stafin, 2007; Kashdan, 2010), a now known key driver of psychopathology, reveal that an emphasis, whether by client or clinician, on symptom reduction (i.e. decreasing the intensity and frequency of unwanted thoughts, urges, feelings and sensations) might be perpetuating mental illness and preventing sustainable wellness. Why, because this control agenda evolved from the problem-solving mode of mind, one that often works well in the outside world (e.g. fix this ___, get away from that ___) but begets the same problems it aims to resolve in our inner world.
Due to a scientifically established paradoxical effect, what occurs within the mind is akin to intending to hit the subtraction button on a calculator that has unknowingly been replaced with a multiplication sign, amplifying the very thoughts and feelings we’re trying to reduce.
As depression becomes the most common form of disability worldwide, both consumers and healthcare organizations alike are growing desperate for a change.
Accordingly, pockets of community-based care have been revamping the language utilized for its treatment programs, replacing words such as “symptom” and “illness” with “health” and “wellness.” While this is promising, one is left to wonder if these new highways have the necessary infrastructure to support such new directions.
So, where to from here?
Cue Process-Based CBT (Hayes & Hofmann, 2017): interventions that aim to move the needle on underlying processes common to most (if not all) forms of suffering and vitality.
Acceptance and commitment therapy (ACT) is one such approach that provides clinicians with both the infrastructure and a set of directions demonstrated to improve a variety of illness and wellness indicators, from chess playing and sports performance to tinnitus and trichotillomania.
ACT’s infrastructure is comprised of Functional Contextualism, a philosophy for predicting and influencing behavior, and Relational Frame Theory, which views behavior through the lens of language and cognition, or symbolic relations. Rather than attempting to find a subtraction button that doesn’t exist, or clinically focusing only on the form (i.e. topography) of mental illness, this infrastructure provides a functional approach that targets how clients behave in (or relate to) the presence of any stimuli, regardless of specific content.
Supported by this infrastructure, ACT proposes six interrelated core processes that can be modeled, evoked, and reinforced to the betterment of what’s referred to as psychological flexibility. This skillset entails consciously and openly stepping into our here-and-now experience; noticing and unhooking from the problem-solving mode of mind when it’s ineffective; and committing to values-based action.
To this end, health and wellness are defined not by the absence of symptoms or illness, but rather by one’s range of psychological flexibility (i.e. choosing to do what matters, even in the face of difficult experiences).
As an ACT trainer, my primary objective is to bridge the conceptual, experiential, and practical aspects of these processes in a way that inspires and equips clinicians to effectively support their clients in living a meaningful and fulfilling life.
In the service of this direction, referred to as workability, a considerable amount of time and attention is paid to building a clinical infrastructure of awareness, openness, and engagement where clients can freely and flexibly experiment with new behaviors.
In this context, clients are not viewed as broken or damaged by their symptoms, but rather just stuck in unworkable ways of relating and responding to the world (both privately and publicly); and thus, as clinicians, our aim is to help them get unstuck.
Recognizing that we too exist on the same spectrum of human behavior as our clients, perhaps we can enter this new era of psychotherapy where, in the words of Kelly Wilson, co-founder of ACT, clients are approached as “sunsets to be appreciated, rather than as problems to be solved.”
Chawla, N. and Ostafin, B. (2007), Experiential avoidance as a functional dimensional approach to psychopathology: An empirical review. J. Clin. Psychol., 63: 871–890.
Hayes, S. C. (2004). Acceptance and Commitment Therapy, Relational Frame Theory, and the third wave of behavior therapy. Behavior Therapy, 35, 639-665.
Hayes, S. C., & Hofmann, S. G. (2017). The third wave of cognitive behavioral therapy and the rise of process‐based care. World Psychiatry, 16(3), 245–246.
Kashdan, T. B. (2010). Psychological Flexibility as a Fundamental Aspect of Health. Clinical Psychology Review, 30(7), 865–878.