ACT Questions and Answers: A Practitioner's Guide to 150 Common Sticking Points in Acceptance and Commitment Therapy

by Russ Harris

Renowned ACT expert Russ Harris presents easy-to-read Q&A sessions to uncover the most common ways clients and practitioners get stuck when using ACT, how to get unstuck, and how to transform that “stuckness” into powerful personal growth. Acceptance and commitment therapy (ACT) is a highly effective, evidence-based treatment for a number of mental health issues—from depression to addiction—that focuses on mindfulness, client values, and a commitment to change. It also provides innovative tools, techniques, and strategies for promoting psychological flexibility and profound behavioral change. However, there are several challenges and frustrations that can arise when delivering ACT in-session. In the tradition of the hugely popular professional guide ACT Made Simple , ACT Questions and Answers offers practical tools for overcoming common sticking points in-session. You’ll find effective tips and strategies for moving past misconceptions about mindfulness and acceptance, how to deal with reluctant or unmotivated clients, and how to break down communication barriers that can stand in the way of progress. You’ll also find links to free downloadable resources. If you are new to ACT—or just want to improve your delivery—this easy-to-read reference guide will help you troubleshoot common in-session challenges and help your clients achieve lasting change.

Genres: Psychology

280 pages, Paperback

Published April 1, 2018

About the author

Dr Russ Harris is a medically-qualified doctor, stress consultant, executive coach, trainer, author, and a leading authority in the powerful new paradigm of Psychological Flexibility. (This is a revolutionary new development in human psychology that enhances performance, reduces stress, and improves health and wellbeing.) Dr Russ regularly presents workshops on Psychological Flexibility at both national and international psychology conferences, and has a thriving business traveling around Australia running training seminars for psychologists, coaches and a variety of health professionals.

Dr Russ's first book, 'The Happiness Trap', was published in Australia in March 2007, and is already well on the way to becoming a bestseller. (The title reflects a key theme in the book - that popular ideas about happiness are misleading, inaccurate, and actually make us miserable in the long term.) He is currently completing his second book 'From Fear To Fulfilment' - which is also the title of his most popular talk.

Back in the early nineties, when Russ was a GP in Melbourne, he moonlighted as a stand-up comedian, and as well as appearing regularly on the Melbourne comedy circuit, he featured on TV shows such as Tonight Live with Steve Vizard, and The Mid-Day Show with Ray Martin. As a result of this experience, his talks are fast-paced, engaging and humorous - as well as being action-packed with information, tools, and techniques for reducing stress, enhancing performance, and increasing vitality.

Reviews

[Lil · Rating 5 out of 5]

This book answered all of my ACT questions even after taking Bootcamp and ACT II. Thank you!

[Jeremy · Rating 5 out of 5]

Notes:

+ 3 basics that so many therapists skip over
1. Informed consent
2. Establishing goals for therapy
3. Clarity about the purpose of exercises

+ Informed consent
- One choice is: we give up. We let your mind call the shots. A second choice is: we get into a debate. I try hard to convince your mind to stop thinking this way; I try to prove your thoughts are false and to convince you that this approach will work. The problem is, that kind of debating will eat up our valuable session time, and I can pretty much guarantee your mind will win the debate anyway. A third choice is: we can let your mind say this stuff, and we can just carry on. We just keep on working together as a team, working away here, to help you build a better life

+ Goals questions
- What will need to be different in your life in order for you to say therapy was successful?
- From zero to ten, how likely does it seem to you right now that you will actually do this?

+ 5 Creative hopelessness questions:
1. What have you tried?
2. How has that worked?
3. What has it cost?
4. What’s that like?
5. Are you open to something different?
- We only target experiential avoidance when it’s so extensive or inappropriate that it’s interfering with the client’s life and getting in the way of his therapy goals
- We don’t always advocate acceptance in ACT; we don’t want to turn into mindfulness fascists. There are times when alleviating unpleasant thoughts and feelings is workable
- The agenda of emotional control: in order to have a good life, I need to control how I feel; I need to get rid of my unwanted thoughts and feelings, and replace them with more desirable ones; I need to control how I feel before I can do what matters
- The acceptance agenda: allowing your thoughts and feelings to be as they are in this moment (whether they are pleasant or painful, wanted or unwanted), neither struggling with them nor getting swept away by them, allowing them to come and stay and go in their own good time
- “Given that what you’ve been doing until now isn’t giving you the sort of life you want, are you open to a new way of responding to anxiety? Are you willing to try something radically different? A way of handling it differently, so it has less impact and influence?”
- “ACT is an empirically supported treatment for anxiety disorders, but improvement won’t happen by going into battle against anxiety, trying to avoid it or get rid of it. The improvement will come through responding differently to it: by dropping the struggle with it.”
- Unwanted cognitions are likely to keep recurring, and there’s no known way of eliminating them. So our work together will need to be about learning how to respond to them differently—to learn how to unhook from them, so it’s easier to do more of what matters

+ Defusion
- The simplest way to defuse from feelings, emotions, and sensations is to notice and name them: “I’m noticing anxiety,” “Here is sadness,” “I’m having a feeling of anger”
- “If you let this thought push you around, where will it take you: toward or away from the life you want?”
- Imagine the thought printed on a billboard along the highway
- We target fusion selectively, when it is clearly getting in the way of the client’s goals for therapy… If a client identifies that the way she’s currently responding to these cognitions is problematic, we can ask her whether she’s open to learning a new way of responding to them, so as to reduce their impact and influence
- Defusion probably won’t help any client unless:
A. The degree of fusion with these particular thoughts is, from the client’s own perspective, significantly impacting her quality of life
B. The client is able to recognize and acknowledge the above
C. The client is open to learning a new way of responding so that when these cognitions recur, they will have much less impact or influence
- “Where Is Your Mind Taking You?” technique

+ Acceptance/Willingness
- Means acceptance of one’s private experiences (thoughts, feelings, memories, emotions). It doesn’t mean passively accepting a situation that is clearly making life worse. In such circumstances, ACT advocates committed action guided by values
- In acceptance work, we turn toward our unwanted thoughts and feelings with openness and curiosity. And we progressively move through what I like to call the three As: acknowledging them, allowing them, and accommodating them
- So this exercise is to help you learn to unhook from those anxious thoughts and feelings and refocus your attention on what is most important to you. It’s not a relaxation technique to get rid of the anxiety; it’s a way of learning how to act well in the presence of anxiety: how to let the anxiety come and stay and go in its own good time, without struggling with it—so you can focus your attention and energy on what matters most to you
- Clients will almost always interpret “letting them go” as “making them go away.” So “letting go” is a phrase I rarely use, and when I do use it, I modify it to “letting them come and stay and go in their own good time, without struggling with them and without getting swept away by them”
- Reframe the problem: it’s not the feeling itself that creates so much suffering; it’s getting hooked by the feeling that causes all the problems

+ Observer self/self-as-context (SAC)
- 5 main indications for making SAC explicit:
1. Facilitate defusion—especially from the conceptualized self
2. Facilitate acceptance
3. Facilitate flexible contact with the present moment
4. Access a stable sense of self
5. Access a transcendent sense of self
- 4 instructions to make self-as-context explicit
1. As you notice X, be aware you’re noticing
2. There’s X and there’s a part of you noticing X
3. X changes all the time, coming and going, but the part of you that notices X is always there
4. X is a part of you, but it’s nowhere near the whole of you; there’s so much more to you than X
- Client: I don’t get it.
Therapist: You’re confused?
Client: Yeah.
Therapist: Can you notice your confusion?
Client: Yeah.
Therapist: Can you notice your mind trying to make sense of this?
Client: Yeah.
Therapist: Can you notice yourself saying “yeah”?
Client: Yeah (smiles).
Therapist: Can you notice me asking all these annoying questions?
Client: Yeah.
Therapist: Can you notice your irritation as I keep asking these questions?
Client: Yeah (smiles).
Therapist: Can you notice yourself nodding your head?
Client: Yeah.
Therapist: Can you notice your feet on the floor?
Client: Yeah.
Therapist: So there’s a part of you noticing everything.

+ Values
- Flavor and savor exercise: When you wake up each morning, pick one or two of your most important values and aim to “flavor” your day with them. See if you can find little ways to “sprinkle” these flavors into whatever you’re doing. Whenever you do this, take a moment to “savor” it. Notice what it’s like to be living those values, and whether it’s more like the person you want to be, or less.

+ 7 R’s for maintaining new behaviors and habits
- Reminders, Records, Rewards, Routines, Relationships, Reflecting, and Restructuring

+ Dropping anchor exercises are based on two strands of instruction:
1. Expand your awareness of what is here in the present moment [This is not to distract from pain, but to notice that in addition to pain there is a lot happening here in the present moment; there is so much more present than these difficult thoughts and feelings that are currently dominating awareness]
2. Exert self-control over your physical actions [The aim here is to regain a sense of self-control by focusing on what you have most control over when struggling with difficult thoughts and feelings: your physical actions. Move, stretch, change posture, sit upright, stand up, walk, alter your breathing, push your feet into the floor, push your hands into the chair, push your fingertips together, drink water, hug yourself, massage a tense spot, do a yoga or tai chi movement, or make any other physical action. “Notice that as well as this pain, there’s also a body around that pain—a body that you can move and control”]
- “The anchor doesn’t make the storm go away; the anchor holds you steady until the storm passes. The storm may pass quickly, or it may pass slowly. It may get worse before it gets better. The anchor holds you steady during this time, so the storm doesn’t sweep you away.”

+ 6 elements of self-compassion,
1. Acknowledging pain
2. Defusion from self-judgment
3. Responding with kindness
4. Acceptance
5. Validation
6. Connectedness
- The two friends metaphor: “what kind of friend are you being to yourself, as you go through this?”

+ 5 Choice Point Questions:
1. Are you hooked by this thought or feeling? (If no, go to 3.)
2. If yes, what effect is it having on you right now?
3. How do you usually behave when you get hooked by this thought or feeling?
4. What towards moves would you do if you weren’t hooked?
5. What unhooking skills can you use right now, if necessary?
- Running through the first four questions often helps the client to rapidly unhook. However, if the client remains hooked, question 5 prompts him to use additional unhooking skills, such as grounding techniques, acceptance and self-compassion exercises, or other defusion techniques

+ Alternative layman’s terms
- unhook, expand around, open up, make room for it, carry it with you, flow with it, let it be, notice it, expansion skills, opening up skills, unhooking skills, flow skills, making space, allowing, dropping the struggle, sitting with it, holding it gently or lightly, breathing into it, “allowing these thoughts and feelings to freely flow through you, to come and go in their own good time, neither struggling against them, nor being swept away by them”
- If I’m lost in my thoughts in a way that is life-enhancing, we’d call that absorption rather than fusion. The term fusion indicates a problematic narrowing of behavioral repertoire in response to one’s thoughts and feelings
- If it’s exposure to the inner world, I’d use words such as unhooking, noticing, being present, opening up, or making room. And if it’s exposure to the outer world, I’d talk about away moves, or taking action, or pursuing goals, or living values, or doing what matters

+ Free will and choice vs. determinism
- “Yes, that’s the way it’s been for you for a long time. Without unhooking skills we effectively have no choice; we get hooked and we do away moves. It’s automatic. So a big aim of our work here is to help you to have some choice, and that will involve learning new skills. Without these new unhooking skills, you’ll keep on doing the same things, over and over.”
- “Yes, right now, that’s exactly the way it is. Right now, you can’t control it, you have no choice, it just happens before you realize it. Would you like to change that? If so, it’s going to require learning some new skills.”

+ Payoffs (functional analysis)
1. We get away from something we don’t want
2. We get something that we do want
3. We get to escape unwanted feelings
4. We get to feel good
- Often our payoffs are a mixture of all these things
- It’s often very useful to highlight the payoffs of fusion with clients, and then gently and kindly contrast those with the costs by looking at them in terms of workability



Quotes:

Don’t immediately give up on an exercise because the client says it’s weird or uncomfortable or strange or makes her feel nervous. Validate and normalize those reactions. Reframe them as “good signs.” For example, you could say, “The fact that you’re feeling this way is a good sign. It means you’re doing something new, something different—stepping out of your comfort zone. If you felt totally comfortable, that would mean we are just doing the same old stuff that you’re familiar and comfortable with, even though we know that’s not helping you build a better life.”

We’re always dancing between two questions: “What valued direction does the client want to move in?” and “What’s getting in the way?” If clients can’t or won’t answer the first question, we focus on the second. But often, just taking the time to establish behavioral goals for therapy develops readiness to change.

In neuroanatomical terms, the cerebral cortex is involved in the formation of all emotions. There are no emotions that arise from the limbic system without input from the cerebral cortex. So I like to talk of fusion with (and defusion from) “thoughts and feelings” to help us remember this; to help us let go of the often artificial distinction between them… Suppose someone is feeling anxiety or dread. Just recognizing the experience as “anxiety” or “dread” is cognition. Now, as we explore this emotion, we may encounter all sorts of thoughts, such as worrying or catastrophizing. We may also find memories of similar events from the past, and mental images about what we fear might happen in the future. And if we explore concurrent physical sensations in the body, we may encounter a racing heart. But notice the cognition implicit even in a sensation like this: the client identifies it’s her “heart” (cognition) and it’s “racing” (cognition) and it’s in her “chest” (cognition). Judging the sensation as “bad” or “unpleasant” is cognition.

Our modern mind reacts to difficult thoughts, feelings, and memories the same way a Stone Age mind reacted to dangerous beasts: fight or flight!

There is no chemical, hormone, gene, or part of the brain called discipline or willpower. These words are merely descriptive labels; they are ways of describing a pattern of committed action. When we say someone has discipline or willpower, all we mean is this: this person consistently commits to acting on his values and doing what is required to achieve his goals—even when he doesn’t feel like doing it.

A wealth of research (e.g., Craske et al., 2008) shows there is no correlation between the drop in anxiety levels or SUDS during in-session exposure and the long-term behavioral outcomes of exposure.

[Ittai Glick · Rating 5 out of 5]

Wonderful, very helpful for psychotherapists

Especially if you practice ACT or integrate it into your work this book is very helpful. Easily read, it focuses on many misunderstandings and frequent pitfalls, and explains the Do's and Dont's with clarity and humor.