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 can use ACT in session (remember ACT is open for anyone to use it!).
Cognitive defusion
I’m guessing that for psychologists and those who primarily work with thoughts, it feels natural to begin here, but maybe all humans jump to talking rather than doing because this is the biggest distinction between us and other animals.
Cognitive defusion refers to making some space between a thought or belief, and what we do next. It’s not just about actions we take, but also how seriously we hold on to the opinions of our mind.
The language theory underpinning ACT is relational frame theory. This theory explains how humans rapidly acquire an understanding of relationships between concepts, and why these learned relationships become so ‘sticky.’
For a full description of RFT, this is a great place to begin [Youtube playlist]. If you’re a reader, not a video watcher, I love the paper by Beeckman and colleagues (2019) (listed below).
The topic is pretty technical, so I’ll simplify it and just say that humans learn to relate to one concept (stimulus) based on how it is related to another stimulus (concept). We do this directly through our personal experiences, but we also do this by arbitrarily relating concepts (stimuli) to other concepts using language, and from these relationships we develop relationships between those associations to even more associations that have never been experienced or been talked about!
Some of these verbal rules make sense – in some contexts. For example we know that Geoff, going for knee surgery might be told ‘walking is not as painful as cycling, and cycling is not as painful than climbing a ladder.’ Geoff has surgery, and the knee is painful during initial mobilising. Because Geoff has also been told that cycling will be more painful than walking, and that climbing a ladder is even more painful than that, during his recovery he will avoid both cycling and walking. Why? Because he’s combined the ideas of ‘walking=ouch‘ with ‘cycling=OUCH‘ and ‘ladder climbing=OUCH.’ Even though cycling and ladder climbing don’t look like walking, and even though he hasn’t ever personally experienced pain while either cycling or climbing a ladder since his surgery. AND it makes sense not to go nuts and cycle or climb ladders in the early days of recovery.
Some of the verbal rules hang around longer than helpful. If Geoff follows the rule of not cycling or climbing ladders – it’s initially helpful, but if he’s later advised it’s OK to now go cycling and climbing ladders but his wife is worried and instead keeps telling him not to do these things, he may not try them out and continue avoiding. Following the rules that were relevant early after surgery helped, but the negative consequences of annoying Geoff’s partner stops him from ‘disobeying.’ And Geoff never experiences what really happens if he tries cycling or climbing a ladder: the verbal rules win!
What can we do about these really sticky verbal rules?
One of the most popular approaches to getting people on board with pain rehabilitation is explaining pain neurobiology and the poor relationships between pain intensity and what’s going on in the tissues. Information, like ‘explaining pain’ or drawing a network diagram showing links between thoughts, emotions, physiological arousal, pain and activity can help give people a bit of distance between their immediate thoughts (based on initially useful rules), and being OK to begin therapy. It’s pretty helpful, has been part of pain management and rehabilitation ever since Fordyce and Main and the early pain psychology researchers. It doesn’t change pain very much, but then it wasn’t intended to! It’s meant to help people feel more confident about doing their movement-based therapy.
So that’s one thing we can offer. But what do we do if the person just does not believe us? If the rules the person’s learned are really sticky – like ‘I have a disc prolapse and that jelly stuff is oozing out of my disc’, or ‘I have a weak core and if I don’t hold it in my vertebrae will go out of alignment’? What do we do then?
Doing beats talking
This is where therapists can draw on strengths the person has in other processes of the hexaflex. For example, I often use values (and I’ll bet many of you do!). We might say ‘Geoff, if you want to recover, we’ll have to do these exercises first – they’ll be in the ‘orange zone’ where they’re a bit uncomfortable, but you’ll be safe.’ We’re drawing on the value Geoff places on recovery to help him be willing to something that goes against the ‘rule’ he’s learned, and making the initial actions relatively easy to do so he achieves success and the anxiety isn’t too high, using ‘behaviour under appetitive control.’
We might use mindfulness, as I suggested in the first article in this series. We might say ‘Geoff, would it be OK to mess about with attention for a bit while we start experimenting with some little movements – can you bring your mind to your breathing? And can you step up on this wee box? What do you notice in your breath right now?’ In doing this, we’re bringing his attention away from the rule he’s learned and towards his own sensory experience. This helps anchor him to the here and now, and with our guidance, helps him to use his own experience to guide both his actions and how closely he follows the rules he’s learned.
We can also draw on self as context by reminding him that during the early days of his recovery, he was a patient, and now he is becoming himself again: see how far he has come from the early days after surgery!
The cool thing about using the other parts of the hexaflex is that we’re not arguing with them and instead we’re helping them develop a different relationship to those thoughts. So it can be fun to give the thoughts names: ‘ooh that’s my mind being my dictator!’ , ‘the devil on my shoulder’ or ‘the parrot’. Some people think of what their mind tells them as a lot like an off-station radio, or the passengers in a car all having an opinion but the driver gets to make the decision about whether their conversations are worth listening to.
Literally hundreds of metaphors and ways of developing a different relationship with thoughts have been written about in ACT. Some great resources include the Big Book of ACT Metaphors (Stoddard and Afari, New Harbinger Press, 2014); examples from Radical Relief by Joe Tatta , and content on the ACBS website .
But I have two wishes: 1) that we stop reverting to talking just because it’s easy and doesn’t make us feel too uncomfortable and instead 2) we draw on experiential learning and use the other processes in the hexaflex. Doing is so much more potent than talking, and from my experience, transfers to life outside the clinic much more readily. And that, folks, is where life is lived.
Beeckman, M., Hughes, S., Kissi, A., Simons, L. E., & Goubert, L. (2019). How an Understanding of Our Ability to Adhere to Verbal Rules Can Increase Insight Into (Mal)adaptive Functioning in Chronic Pain. Journal of Pain, 20(10), 1141-1154. https://doi.org/10.1016/j.jpain.2019.02.013
Fordyce, W. E. (1984). Behavioural science and chronic pain. Postgraduate Medical Journal, 60(710), 865. https://doi.org/10.1136/pgmj.60.710.865
Kendall, N. A., Linton, S. J., Main, C. J. (1997). Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk Factors for Long-Term Disability and Work Loss. Wellington, NZ
Waddell, G., Main, C. J., Morris, E. W., Paola, M. D. I., & Gray, I. C. (1984). Chronic Low-Back Pain, Psychologic Distress, and Illness Behavior. Spine, 9(2), 209-213.
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