This guest post is from Matthew S. Boone, LCSW. Matt teaches Acceptance and Commitment Therapy (ACT) at the School of Social Work at the University of Arkansas at Little Rock and practices ACT, dialectical behavior therapy (DBT), and other cognitive behavioral therapies with veterans in Arkansas. He is an Association of Contextual Behavioral Science (ACBS) peer-reviewed trainer in ACT, a founder of the ACBS Social Work ACT Special Interest Group, and editor of the book Mindfulness and Acceptance in Social Work.
How is ACT a good fit for social workers?
ACT is an extremely adaptable intervention model. The primary goal of ACT is to help people become more psychologically flexible. Therefore, any intervention that helps people become more mindful, more accepting, and more connected to values is consistent with ACT. Most social workers have these kinds of interventions in their repertoire already, even if they’re not thinking in terms of “psychological flexibility.”
Also, ACT is applicable across a wide variety of problems. Over 130 randomized controlled trials have been published on everything from anxiety, depression, psychosis and substance use to chronic pain, cancer, diabetes, weight loss, and tinnitus. Social workers tend to work in settings where they have to serve all comers, so a flexible intervention model that is widely applicable is essential.
Furthermore, the theory behind ACT suggests that all human beings are subject to the same processes of inflexibility. We are all prone to unnecessary efforts to avoid and escape pain. We are all capable of losing sight of what’s important to us. Therefore, in many ways, therapists and clients are no different from one another. We are all part of the same tribe. This perspective is deeply resonant with the social work perspective, which is non-hierarchical and empowering. Viewing the helper and the person being helped in this way dissolves the hierarchy that can emerge in the helping relationship. It’s very easy to put the therapist or the social worker on a pedestal, just slightly above the client, because they’re the one offering the expertise. But doing so can inadvertently reinforce oppressive circumstances that are woven into our culture, like sexism, racism, homophobia, and other forms of oppressive power imbalance.
Social workers are not always psychotherapists. How can ACT be useful for social workers in other kinds of roles, such as medical social workers, behavioral health specialists in medical settings, case managers, caseworkers, and victim advocates?
The most important thing to know about ACT is that it’s process-driven, not technique-driven. What matters most is moving your client toward psychological flexibility, not what technique or treatment protocol you use. For social workers who may only have a few brief contacts with their clients, this is a perfect fit. You don’t necessarily need a 50-minute hour or 12 weeks of therapy to get more flexible. When I do brief interventions, I ask myself, “How can I help this person move from inflexibility to flexibility in the limited time we have together?”
Here’s an example: I used to work in a college setting, and some colleagues and I held walk-in hours across campus. We called it “informal consultation,” not “therapy.” It was an effort to serve students who didn’t want to commit to therapy or who were reluctant to seek formal mental health treatment. Often these were international students, students of color, and other students who might not come from cultures or communities where mental health treatment was looked on favorably. We usually had two hours total, and we had to see everyone who showed up. So sometimes we only had 20 to 30 minutes with a student. In the brief time I had, I would try my best to offer a scaled-down, distilled version of the ACT perspective: let go of unnecessary control and let values guide your actions.
For a student struggling with anxiety, I might provide a little psycho-education about how trying to control anxiety sometimes makes anxiety worse and can prevent you from doing what matters in your life. Then I would bring in values: “In any given moment, while you’re avoiding, procrastinating, or trying to otherwise get away from your anxiety, what might you be doing instead if you were focusing on what’s important to you? What would it look like if anxiety wasn’t in charge?” We might get concrete and pin down some specific actions they could take even when feeling anxious. If we had time, I might do something experiential, like “tug-of-war with a monster” or mindfully observing and describing their feelings instead of trying to change them. The ultimate message would be, “Don’t wait to stop feeling anxious before you live your life.” I might suggest they try this out for a couple weeks and stop by again to tell me how it went. Sometimes all they needed was one or two conversations.
I recently got an email from a former student, someone I had met just once. She told me how much that conversation had made a difference in dealing with her anxiety. It made my day. I’m not going to pretend a brief intervention like this is the solution for everybody, but sometimes it gets someone started on a new path. And this kind of psychological flexibility-focused intervention can be done by any social worker in any setting.
Why do you think social workers take so readily to ACT?
In addition to everything I’ve already outlined, there’s another important point I’d like to make. Most social workers lead with their hearts, not with their heads. Why else would you work in a field with high stress and relatively low compensation? Given this, when social workers encounter the heart-felt, experiential nature of ACT trainings, they tend to sense they have arrived in a place where they belong.
I think one of the ways that the CBT tradition has failed to connect with social workers is that, historically, it has been presented as kind of cold and dry. Early on in my career I was curious about CBT because it was effective with problems like depression and anxiety. But I had a hard time engaging with the material I read. It seemed to be missing some of the key elements that drew me to social work and psychotherapy in the first place, like the possibility of making deep connections with people and really transforming lives. I’ve since learned that this is exactly what good CBT therapists do. But CBT writing and training didn’t always capture that for me.
When I got into the ACT world, I thought, “Wow, these folks are focused on science and evidence-based practice, but they haven’t thrown the heart out of psychotherapy.” Don’t get me wrong, the intellectual side of ACT offers a lot to dig your teeth into. I’m still digging my teeth into after nine years! But ACT training tends to emphasize the importance of developing deeply connected relationships with your clients and being willing to get close to their suffering. There’s nothing cold or dry about it.
Is ACT all social workers need if they want to get deeper into evidence-based practice?
If I only practiced ACT it would be far too limiting for me – as well as for my clients. I think ACT can be a “gateway drug” to the broader CBT tradition. It certainly has been for me. ACT is a part of CBT, and after getting trained in ACT and diving into the ACT literature, I became even more interested in the rest of CBT. My interest in ACT has led me to learn and practice other treatments, such as exposure therapy for anxiety, dialectical behavior therapy, and even explicitly cognitive interventions like cognitive processing therapy for PTSD. I have begun to see the commonalities among these treatment models, like a connection to basic behavioral principles, an emphasis on reducing avoidance, and a focus on building skills.
How consistent is ACT with the core values of social work?
Though ACT has historically focused on human suffering at the individual level, there’s a big movement within the ACT community to think more broadly about alleviating suffering. This aligns perfectly with social work values, which emphasize the way social, political, and physical environments contribute to the problems people face. Every year at the Association for Contextual Behavioral Science World Conference, the conference of the professional organization of ACT, there are more and more plenaries, seminars, and workshops on public health-style interventions, group level interventions, and social justice-focused interventions. I’m really pleased with where this community is going. It dovetails with the mission of social work to serve those who are most vulnerable and to think about change at the level of the community or society. When you walk into the ACBS community – even though it was originally inhabited mostly by psychologists – you immediately see social work values front and center. That’s why it has always felt like home to me. The people who developed ACT, people like Kelly Wilson, Steve Hayes, Robyn Walser and others, have always had a big picture, social-justice focus, even if the therapy itself was originally an intervention designed for individuals and small groups.
Matthew Boone, LCSW will be presenting a webinar, Defusion: From Technique to Radical Intervention on September 20, 2016. Participants will learn the role of defusion in ACT and how it can help facilitate willingness and values work, as well as techniques for facilitating defusion with clients. For more information or to sign up, click here.
If you are interested in a establishing a strong foundation in the essentials of ACT with Matt, sign up for one of his upcoming ACT I: Introduction to ACT workshops in Nashville or St. Louis, or register for ACT BootCamp – Tampa, a distillation of everything that’s so exciting about Acceptance and Commitment Therapy.
Register now for an ACT I: Introduction to ACT training event near you!