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ACT-ing well, living well i


For some time I’ve been learning more about ACT – Acceptance and Commitment Therapy (normally pronounced ‘act’, not A – C – T).  While I have to admit that I have been flummoxed by relational frame theory, a behavioural theory of human language and cognitionthat underpins ACT (go here for a tutorial that may enlighten somewhat), there are some very simple principles that ACT employs that I’ve found useful in my own life – and in the lives of people I work with.

Over the next few days I want to outline a bit more about ACT and how I use it within pain management – I’ll be referring to journal papers that explore the use of ACT in pain management, but a lot of what I’ll cover comes more from my own experiences with moving from a CBT approach to ACT.

There are loads of resources on the internet and in books and journals for ACT – it’s one of the most generous forms of therapy I’ve found, with people readily sharing their knowledge and experience with others.  I appreciate this along with the strong adherence to an evidence-based, research-supported theory and practice, that is at the same time incredibly pragmatic.

OK, so what is ACT?  Simply put, ACT involves accepting what is out of your personal control, while committing to taking action that makes your life rich and full. Most introductions to ACT start with the concept of ‘cognitive defusion’, or recognising that our thoughts and emotions are not ‘us’.  In fact we tend to ‘observe’ our thoughts – but often remain stuck with the effects or labels our thoughts have attached to our sense of self.  So to break with tradition, and because it works well for me from my occupational therapy background, I want to start with ‘valued actions’.

Here’s an overview of the whole model, so you can see the entire thing – and see where valued action fits.

Valued action involves working with the person to identify just what they think is important in their life, then helping them do it.  Sounds like what occupational therapists have been doing since the profession’s inception!  It can be summed up as ‘Do what matters’.

There is a ‘provided that’ clause in this though, and that is to ensure that when  doing what matters the process does not help the person avoid experiences that are negative.

Three definitions here:  Values are the qualities we want from what we do, sometimes called ‘chosen life direction’. Values involve spending time thinking about what we want our lives to be about, what we want to stand for, how we want to behave over time.  ACT describes values as being like a compass because they provide direction and help keep us ‘on track’.

The second definition is ‘committed action’ which means doing what it takes to live by our values, even if it, at times, involves negative experiences. Committed action means taking action, doing things in the real world, behaviours, that need to be repeated again and again to help move you in the direction you have chosen.  It’s not just doing something once, haphazardly, or as a strategy to avoid experiencing something negative.  It may involve setting goals, working on time management, learning to persist and wait for delayed gratification, being assertive, taking care of yourself, relaxation and so on.

Experiential avoidance is about trying to avoid, get rid of, distract from, ignore or escape from unwanted thoughts or emotions – ACT calls these ‘private experiences’ or things that no-one else knows about unless you tell them.  It’s what we often do naturally to try and ‘problem solve’ how to get rid of these unwanted experiences.  What we end up doing, very often, is working so hard to avoid feeling or thinking or experiencing these unwanted experiences that we replace what we actually do want and value, and especially actions that take us along the road in the direction of our values.  An example might help:

Alex is 20, he wants to take off on his motorbike and ride the open road.  Last time he took his bike out, though, his back pain really bothered him, and he ended up coming home before going very far.

He’s now really worried that if he goes out on his bike, his back will play up again,  so he’s spent the last two years stripping and rebuilding his bike, going to the gym to ‘get strong’, seeing doctors and physiotherapists, even going in a car instead of his motorbike, but never actually taking it out on the open road just in case he has trouble with his back again. The problems are his anxiety that his back will let him down, as well as his continual search to ‘find the cause of the pain and fix it’ – and for two years he hasn’t gone out on the bike!

Now he could take off on his bike but keep on worrying that his back will let him down – how much will he enjoy his ride, do you think?  Or he could take medication, or even drink alcohol or smoke cannabis to reduce his fearof having a sore back while riding – but again, at what cost?  What do you think he learns about his fear or his pain?  My bet is that his anxiety won’t reduce if he takes either of these options, and he will actually get more anxious about having this anxious feeling (and feeling the pain) – and all the time he will be working very hard to control the problem of his anxiety AND his pain.

What if there was another way?

This is where ACT opens up another option – acceptance.  Not, you’ll note, tolerating the negative feelings, or putting up with them! Instead, actually allowing them to come along for the ride as well as the good and joyful and energising experiences we have in life.  More about acceptance later this week.

Why would an occupational therapist consider using ACT?

In the process of helping people do what is important in their lives, occupational therapists have always attempted to be ‘client centred’ and ensure the activities chosen are valued by the person.  Often, however, therapists have found strategies that increase experiential avoidance – think of the multiple gadgets that are handed out to ‘reduce pain’, or the relaxation training that is used to ‘reduce pain’, or the planning and activity pacing that is used to ‘reduce pain’.  At the same time, many of these strategies trigger negative emotions in the patient who doesn’t want to ‘leave a job half-done’, or ‘look like an idiot with that raised toilet seat’, or ‘be selfish and rest’.  Occupational therapists may use motivational interviewing techniques, or cognitive behavioural therapy to help people overcome their reluctance – but at the same time, fail to address the underlying problem of experiential avoidance.

Helping people engage in what they really want to do is a fundamental part of occupational therapy – ACT provides a very clear, evidence-based approach to enable living well.  It does mean a shift for therapists, though.  Referrals for occupational therapy may be driven by the patient/client’s desire to avoid the negative experiences of fluctutations in pain intensity, or anxiety about having pain, or frustration at having to acknowledge the limitations pain places on the pace of life.  But at least occupational therapists already have foundation skills in identifying values and actions that the person believes are important.  This gives occupational therapists a great way to begin to discover, with the client, what they want to put in place in their lives and why.

The paper below nicely describes the balance that people want to achieve – doing activities but also having pain or avoiding activities and being unable to fulfil valued actions.

Satink, T., Winding, K., & Jonsson, H. (2004). Daily Occupations With or Without Pain: Dilemmas in Occupational Performance. OTJR: Occup Particip Health, 24(4), 144-150.

8 comments

  1. Nice post, and right on. I think the values of OT fit really well with an ACT approach and the pain data are really getting strong now — it is just very clear that good can be done even with very difficult patients. (You know, while I’m on it, someone really needs to write or edit a book on OT and ACT, in pain management and elsewhere — if there is a skilled and established OT person out there who is knowledgeable about ACT and interested in doing that … I’d love to hear from you. Hayes at UNR dot edu (I wrote it that way to avoid spam spiders reading my email address from this post)

    Anyway, what moved me to respond is not that. I just wanted to mention that a lot of folks have been flummoxed by RFT … it is hard to language about language. I find that the original RFT book is almost unreadable at times … and I helped write it!

    I think it is fine for the average practitioner to put off understanding RFT for a while anyway. It is nice to know that there are basic geeks are busy in the basement but you don’t have to get on top of WHY this stuff works until you get more deeply into it. That being said I did want to mention that help is on the way for the practitioners who want to understand ACT at that deep of a level. A Swedish psychiatrist, Niklas Torneke, has written a terrific book called “Learning RFT” that will be out in a few months from New Harbinger. Really a super book. Look for it.

    I will look forward to reading the posts.

    – S

    Steve Hayes
    University of Nevada

    1. Hi Steve
      Thanks so much for taking the time to comment! I have had some excellent results with ACT in pain management, and my basic training was in occupational therapy – maybe we should get in touch (thanks for your email BTW, I understand about web bots!). I’m beginning to understand RFT a little, although yes, it is easy to get flummoxed as you put it! I think it’s the technical language (jargon maybe?) So for occupational therapists who primarily approach therapy from a ‘doing’ stance, it makes sense to work from that end first as a strategy to elicit some of the cognitive ‘fusedness’ (I’m not agin making up words!). I’m glad to hear there will be a book on learning RFT – another work from the New Harbinger stable!
      BTW, latest book for me is Russ Harris’ ‘ACT made simple’, another New Harbinger title!

  2. Did you take the photo yourself Bronnie? I really like the strong foreground focus with the flower off-center and then the more impressionistic quality of the background.

    Moving onto the actual text of the post, I certainly enjoyed reading about ACT. I especially am intrigued by the point about “experiential avoidance” and in the links the continued emphasis that ACT does not focus upon symptom management.

    “Helping people engage in what they really want to do….”

    There is a fellow here in the United States named Robert Fritz who has written several books including “Your Life As Art.” I have taken a workshop with him and his wife Rosalind at their beautiful farm in Vermont. Rather learning better problem solving strategies (how to get rid of what you don’t want) the focus is using the creative process (just like an artist goes from a blank canvas to a completed painting) to create what you do want.

    The workshops are not presented as therapy (and no change of beliefs required to create) but parallel congruent focus as some aspects of ACT.

    1. Hi Bernadette – yes the photo is one of mine, taken in the Molesworth Station in late January this year. It has a shallow depth of field and was taken one of my favourite lenses, my all manual Tamron 90.
      I’ll be using my own photographs as ‘feature’ images on here, because I have quite a few of them that I’ve never really circulated, and this new layout encourages it!

      Experiential avoidance is something I’ll be discussing a bit tomorrow – it’s one way to establish whether a coping strategy is ‘workable’ or instead gets in the way of living well and aligned with values. And thankfully ACT isn’t ‘all or nothing’, it does encourage flexible and adaptive use of different strategies at different times. I like the emphasis on creativity in ACT – and it looks like Robert Fritz has tapped into this in “Your Life As Art.” By creating more of what you DO want, and looking at what is good in your life, while accepting that all experiences flow in a never-ending pattern of waves (both negative and positive experiences) I think it’s possible for us to be living rather than simply existing.

  3. Thank you again for another brilliant post. I may, with your permission, print this one and bring it to my doctors to show them the “missing link” in my experiences with both chronic conditions and my post-surgical body. They seem to feel that if they can’t fix it, then it’s the patients job to figure out how to cope.
    I believe it is less costly and more effective for all, to help the patient learn to accept, cope with, and understand their “new” body, be it post-surgical, post diagnosis or if a chronic condition worsens or changes. Medications and PT do not address healing the mind and that is the first step, in my humble opinion. The fear/avoidance trap can send us into a hell on earth that no amount of pain medications, PT, or doctors visits can cure. Having been there, and currently revisiting, I know addressing it is key to living the best life possible. Your posts continue to inspire me and I thank you for that.
    Warm regards,
    Yvonne Henderson

    1. Hi Yvonne
      Go right ahead and print this – it’s there for you to use and share.

      I’ve heard many people say that doctors (and other clinicians) give the impression that ‘if they can’t fix it, then it’s the patients job to figure out how to cope.’ – I’ve often said ‘when the docs say ‘now you have to learn to live with it’, it’s my job to help you do this’.
      You’ve also said that ‘I believe it is less costly and more effective for all, to help the patient learn to accept, cope with, and understand their “new” body, be it post-surgical, post diagnosis or if a chronic condition worsens or changes.’ – this approach simply goes against what most health providers learn during their training. Most providers are taught to give advice, ‘fix’ or remove symptoms as a first priority, perhaps forgetting that it’s not so much the symptoms as the meaning of the symptoms, and the actions to avoid or reduce or minimise them that cause problems.
      It’s my pleasure to write these posts – and getting feedback like yours truly makes my day!

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