Acceptance and commitment therapy (ACT) can be slippery to describe. It’s an approach that doesn’t aim to change thought content, but instead to help us shift the way we relate to what our mind tells us. It’s also an approach focused on workability: pragmatic and context-specific analysis of how well a strategy is working to achieve being able to do what matters. Over the next few posts I want to give some examples of how non-psychologists (remember ACT is open for anyone to use it!) can use ACT in session.
Self as context
From my experience, this process is possibly the least well understood of the ACT hexaflex processes. This is my interpretation, drawn from listening to people like Kevin Vowles, Lance McCracken, Steven Hayes and Kirk Strosahl.
Essentially this process is about stepping back from assumptions and requirements of socially constructed ideas of who we should be. It reflects the ability to see another perspective without having to take that perspective as your own. I see it has having two facets: (1) who am I being in this moment? and (2) what other perspectives might I be able to understand in this moment?
When I’m working with someone living with pain I often see a deep sense of shame and alienation from what the person views as their sense of self. I might see grief and anger about what the person must do in everyday life. Things like having to move slowly, take medications, stop doing things they love, and follow administrative processes just to get treatment and/or compensation. Initially, at least, these feel completely alien – and while for a time adopting the ‘sick role’ is socially sanctioned way, as pain lingers this becomes less OK both to the person and those around them. The sick role doesn’t fit well with the old self – but the old self is so far away, the sick role sticks.
I also see efforts to retain parts of the ‘old self’ – this might look like using the same old ‘grit your teeth and burn through it’ because the old self was a really hard worker, or a competitive athlete, or a strong person who never gives up. It might also look like seeking help from all manner of clinicians because the ‘old self’ is always successful, always finds the problems and fixes them.
As time goes on, people can take on the ‘self’ that’s imposed on them by compensation organisations, or clinicians – the ‘compliant’ patient, the ‘litigant’, the ‘victim’. These might be foreign to the person’s usual sense of self, but often build upon other long-held attitudes and beliefs and seem to coalesce into a ‘new me’. They may blame others for their predicament, they may be helpless, they may not do what they’ve agreed to – and it may stem from this sense of ‘I’m not me, I’m this [sad, sorry, angry, victim, patient, feared-self]‘.
People may find it hard to resume doing things that matter to them not because they don’t want to, but because it’s so incredibly sad to have to start at a significantly lower level than the self-concept they hold about themselves: ‘I’m an athlete’ means being able to work at a high level of physical strength, and here they are just walking around the block and that’s hard.
The second expression of self as concept, as I understand it, is being able to take another person’s perspective – to try it on for a moment to gain a new understanding of the situation, or what to do. A bit like the exercise ‘what would you say to your neighbour, if they were in your shoes?’ We can be a lot kinder to other people than we are with ourselves, right? We can also use this perspective-taking as a way to view a future self, or to understand or nurture a younger self. If the person is telling you what seems like an old story of ‘being the carer for a parent’, helping them take the perspective of their younger self, but with the wisdom of now being an older and wiser self, can help them have compassion for their younger self while also showing that they are strong and capable, even if they currently feel overwhelmed and weak.
How can we use self as concept in therapy?
Apart from the ‘what would you say to your neighbour’ exercise, or the self compassion for their younger self, there are a heap of ways we can use this process. One I like to use is time – let’s measure progress from when you were at the very beginning of your rehab, not from when you were at your very best.
We don’t need to have warm and fuzzy feelings about our current self – because that can turn into a rule ‘I must be better at loving myself, so I must work hard at feeling loving towards myself.’ Remember, ACT is about action – not feelings! If you want to show yourself (and your patient/client) how hard it is to change feelings, just try asking yourself to feel genuine, warm and compassionate feelings towards someone you just don’t like very much! Yep, it doesn’t happen.
And if we can’t manufacture loving feelings towards someone else, why would we think we can do it towards ourselves, if we don’t like ourselves very much? If the person is a parent, or even a pawrent of a pet, I like to draw parallels with the actions we take that demonstrate our love for our children (or furbabies). There are times when we just don’t feel that charitable towards our kids: I remember the horror and anger I felt when one of my children drew on, and cut into, the fabric of my sofa! And yet I still cooked tea for them, washed their clothes, got them off to school and did all those ‘parental’ things – in the name of love and being a good parent.
What actions could this person take to show love for their ‘self’? Perhaps acknowledging that although it’s hard, they did the mindfulness they agreed to do. Maybe they gave themselves the gift of 5 minutes not doing anything. It could be any small act of compassion towards themselves.
Rehabilitation is also a time of reflecting on what matters in life – and this can include ‘who I want to be’. Now might be a good time to consider what rules about ‘self’ have been in place, and consider how well they’re serving the life they want. Considering and then expressing the things that really matter (values) helps begin developing a new sense of self – and as my PhD studies showed, people want to ‘re-occupy’ a sense of self that feels like them. In part, people want to still express those underlying values through the way they live their life. While the form, or how they do this might differ, what matters is that they can express those values functionally. It might look different, but it functions in the same ways the person has always valued. For example, if someone has always been an outdoors person and values being out in the wilderness but feels they can’t because they’re not the fit young buck they were, they can still go to wild places and maybe do a short walk, take some photographs, do a meditation, record the birdsong, sort through their old hunting gear and clean it up, go visit a mate and reminisce (and perhaps even plan a new trip!).
If a good part of rehabilitation is, according to people living with pain, about ‘returning to myself’ isn’t it time we considered how people live their lives before we decide to thrust unfamiliar and therapist-centred practices on them? Let’s stop judging people for failing to do their home exercise programme if they’ve never wanted to exercise before. Let’s give people kudos for all the things they now have to do that are unfamiliar – like attend appointments (on time, of course, and usually in work time); take medications (again, on time, despite side effects, and often with limited impact on pain); navigate administrative paperwork (perfectly, no mistakes, and submitted on time every time) – and fit these things into a life that was already busy before pain came on. Being a patient is hard work, clinicians we need to appreciate this, and take the perspectives of the people we seek to serve.
Some readings on self and pain…
Carrasquillo, N., Zettle, R.D. Comparing a Brief Self-as-Context Exercise to Control-Based and Attention Placebo Protocols for Coping with Induced Pain. Psychological Record, 64, 659–669 (2014). https://doi.org/10.1007/s40732-014-0074-3
Lennox Thompson, B., Gage, J., & Kirk, R. (2019). Living well with chronic pain: a classical grounded theory. Disability and Rehabilitation, 1-12. https://doi.org/10.1080/09638288.2018.1517195
Van Niekerk, L. M., Dell, B., Johnstone, L., Matthewson, M., & Quinn, M. (2023). Examining the associations between self and body compassion and health related quality of life in people diagnosed with endometriosis. Journal of Psychosomatic Research, 167, 111202. https://doi.org/10.1016/j.jpsychores.2023.111202
Yu, L., Norton, S., & McCracken, L. M. (2017). Change in “Self-as-Context” (“Perspective-Taking”) Occurs in Acceptance and Commitment Therapy for People With Chronic Pain and Is Associated With Improved Functioning. The Journal of Pain, 18(6), 664-672. https://doi.org/https://doi.org/10.1016/j.jpain.2017.01.005
Yu, L., Scott, W., Goodman, R., Driscoll, L., & McCracken, L. M. (2021). Measuring ‘self’: preliminary validation of a short form of the Self Experiences Questionnaire in people with chronic pain. British Journal of Pain, 15(4), 474-485. https://doi.org/10.1177/2049463721994863
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