By Rachel Eddins, M.Ed., LPC-S, CGP
This is the second article in a series to feature different models of therapy and how they can be incorporated into a group context. This article and the series of articles do not necessarily reflect the beliefs of Houston Group Psychotherapy Society. To submit an article highlighting a model of therapy in group context, please contact the publications committee chair at [email protected].
What is Acceptance and Commitment Therapy?
Acceptance and Commitment Therapy or “ACT” (pronounced as the word “act”, not the letters a-c-t) is a mindfulness-based behavioral therapy that focuses on psychological flexibility and valued engagement in life. ACT in a nutshell can be summarized as be present, open up, and do what matters. ACT gets its name from its two core messages: accept what is out of your personal control, and commit to action that improves and enriches your life. Psychological acceptance, mindfulness processes and values based living help clients overcome obstacles to living well. The goal of therapy is not to eliminate certain parts of one’s experience of life, but rather to learn how to experience life more fully, without as much struggle, and with vitality and commitment.
ACT is concerned about identifying thoughts, feelings, sensations, and urges that act as obstacles to valued living and then change the function of and our relationship to those experiences vs. changing the experiences themselves (i.e., getting “rid of”). This is the acceptance skill – bringing an open and willing attitude towards all internal experiences. It does not mean resigning yourself to your circumstances or giving in to where pain usually leads you. It simply means instead of struggling to get rid of or reduce thoughts and feelings, they’re accepted. Why? Because to not think about something is to think about the very thing you did not want to think about. (Try it now: don’t think about chocolate cake). To resist a feeling is to have the feeling all the more.
Opening up to internal experiences is important because efforts to avoid or control them lead to long-term suffering. These strategies are referred to as experiential avoidance. For example, an addictive behavior may serve to “get rid of” loneliness or boredom, but leads to greater struggling. Likewise, attempts to get rid of or avoid anxiety or anxiety-provoking thoughts create more anxiety. Just as attempts to avoid future rejection lead to an amplification of the role of rejection in our lives and so on. Another way to think of this is that ACT helps people learn to feel better instead of learning to feel better.
The goal of ACT is to create psychological flexibility, which includes 1) the ability to be psychologically present (i.e., aware and engaged in your experience), and 2) the ability to direct your behavior to serve meaningful life values. This is accomplished through six core processes:
- Contact with the present moment: a mindfulness skill about being fully engaged and present in your here and now experience vs. getting lost in thoughts or trying to control feelings.
- Acceptance: a mindfulness skill of making room for unpleasant feelings, sensations, urges and other private experiences without defense.
- Cognitive Defusion: a mindfulness skill of stepping back from thoughts (that we are ‘fused’ with) and observing them for what they are, bits of language, without being caught up in them.
- Perspective taking/observing self: a mindfulness skill involvingcontact with self as an observer to facilitate a healthy distance from fused thinking and a sense of space to experience what is.
- 5. Values: clarifying what is most important, the sort of person you want to be and the things you want to do in your time on this planet. Values provide motivation, guidance, meaning and abundance.
- 6. Committed action: overt behavior in the service of values.
At any particular time we can be moving towards something important to us or away from some unwanted thought, feeling, urge or bodily sensation. The goal with ACT is to move towards a meaningful life, even if that means allowing room for uncomfortable or unpleasant sensations, emotions, thoughts, and urges. This is not willpower, but mindful intention.
ACT has proven effective with a diverse range of clinical conditions in both individual and group context. ACT is an effective treatment for eating disorders, anxiety disorders, psychosis, chronic pain, diabetes management, substance use problems, depression and others. There is also a range of flexibility in the delivery of ACT. In my own group practice, I incorporate elements of ACT with concepts appropriate to the population I work with. All components of the ACT model are appropriate for group application. Clients learn ACT concepts in an experienced way, rather than intellectually, through metaphors and experiential exercises. This experiential focus is also what lends ACT to be an effective and impactful treatment in the group setting.
ACT in Group Context
ACT can be quite effective when applied in the group context. A group is fertile ground where experiential avoidance, fusion, and disconnection from values – the targets of ACT – are likely to occur. The group setting can provide opportunities for willingness and “showing up”, being present to emotional experience, and vulnerability through support of others. A client in a recent group stated she was willing to be present with uncomfortable feelings in the group because of the safety and support. Learning from others’ experiences and reactions to an experiential exercise can be very powerful and helpful for group members who are struggling with a particular concept, emotion, or need. It can also provide the validation and courage for those experiencing shame and emotional pain. Committed action is a key component of ACT. The group context can be helpful in fostering the motivation to carry out one’s commitment. Commitments made in public are more likely to be followed.
Application of ACT in a Group Context
Group Rules
Many of the group norms typically outlined in an initial group session apply. Encourage clients in the beginning to intend for this to work. The commitment to showing up to the group is reiterated. It can be difficult to recap a powerful experiential experience that the group may have shared together. One additional rule is that of “no rescuing”. No rescuing means allowing fellow members to have their feelings without trying to solve them. Setting this up as a group norm ahead of time will allow members to be mindful of the goal of psychological flexibility vs. experiential avoidance or “don’t feel what you’re feeling.” It also helps prevent sending the message that someone is too fragile for his or her emotional experience.
Format and Structure of Group
Groups can be focused on one specific topic such as anxiety or heterogeneous. A common way to structure group is to start with a mindfulness exercise. The goal is not relaxation, but rather skill building. I may also do a mindful movement or mindful eating exercise as the starting exercise. While I use mindful eating with emotional overeaters to help them slow down and become present with food and body, it also serves the function of learning to engage with all five senses vs. internal thoughts and feelings. Mindfulness skills can also be used in group process when getting off topic for example. The therapist might ask participants to slow down, guide them back into the present moment through a body scan and then notice what shows up.
Check in can be kept to the here and now sensory experience and prior commitments made. In a new group there is typically a brief didactic component to introduce core concepts, group discussion and an experiential exercise. Once the basic concepts have been introduced, the didactic component is not necessary. The remainder of an ACT group looks much like traditional group therapy. Through the process and discussion group leaders are encouraged to incorporate the interpersonal group process into conversations about acceptance, mindfulness, and values.
Experiential exercises can also be introduced or included in a traditional psychotherapy process group. When processing centers around a particular ACT component or group members engage in “moving away” behaviors, an experiential exercise might be helpful. Similar to here and now processing, experiential exercises bring alive core patterns and allow group members to get in touch with and experience that which they may often be in their heads about. After each exercise, process the experience (i.e., “what did you notice?” or “what parts were difficult/easy?”). Watch out for analysis such as like/didn’t like or explanation. Experiential exercises can be found in all of the ACT texts. Clinicians are also encouraged to utilize and develop their own ACT-consistent exercises. ACT is not a manualized approach.
Traditional group process and working in the here and now is important in ACT groups just as in traditional groups. Excessive attachment to one’s thoughts, staying in the past or in the future and clinging to stories about who one is work together with experiential avoidance and disconnection from values to create suffering. This calls for group members to look beyond content to discover what is happening within and between them. They might notice what their minds are saying about the discussion, observe what feelings are stirred up in response to their fellow group members, and consider what interpersonal behaviors might best serve their values. For example, you might suggest, “if you find yourself overly focused on evaluating other group members, gently ask yourself this question, what is this in the service of for me?” “Processing” can also at times be a function of experiential avoidance vs. just acknowledging and allowing the client to “show up” to the immediate experience.
When conflict occurs in the group it can be helpful to direct the member back to their inner experience first. In A Practical Guide to Acceptance and Commitment Therapy, contributors Walser and Pistorello suggest asking clients, “what is showing up for you right now, any emotions, thoughts, evaluations, or urges?” “Is there something about this situation that seems very familiar to you, as if you’ve been here before?” “How does this interfere with your life?” “What has this kind of interaction gained or lost you in the past?”
ACT groups are evocative and bring up emotional experiences. Both facilitator and client sit with a number of difficult emotions without “rescuing” from pain. This can be uncomfortable for both therapists and clients, but witnessing the vulnerability, bravery and courage to change is also tremendously touching emotionally and rewarding. I personally feel very present and alive in this process. As this model of therapy is primarily an experiential one, a therapist should attend one or more intensive ACT training workshops before incorporating the model into their own groups. It also helps the therapist to experience what they are asking group members to do as well as connecting exercises to theory.
As facilitator, the therapist helps the client get into contact with direct experience. The therapist stance is not a distant observer, but willing to be present and “show up” in the group. I operate from the stance of “we” vs. “you,” to help further illustrate that we, humans that is, are all in the same boat together. The therapist speaks to the client from an equal, vulnerable, sharing point of view and respects the client’s inherent ability to move from unworkable to effective responses. The therapist can also make a commitment to the group at the beginning, which helps to model the values and commitment process. For example, “My commitment is to be fully present in this group for the full time that I am here, to stand with you, to help you make a difference in your own life.”
An example exercise is listed below to help give you a flavor for an ACT experiential exercise. Again, it’s important to have completed your own ACT experiential workshop prior to using exercises with clients to help you facilitate effectively. Resources for learning more about ACT have been listed below. This exercise is adapted from a version provided by ACT Trainer, Jason Luoma. It has also been printed in several ACT texts.
Experiential Practice with Acceptance: Eyes On
This is an example of a traditional ACT exercise designed to facilitate the skill of acceptance though it has elements of all ACT processes. Prior to facilitating an exercise such as this one, it would be important to be aware of any client factors that might make this exercise inappropriate or too difficult. This is also an exercise that is conducted after members have established safety and trust with one another.
Step 1 — Tell participants you are going to ask them to break up into pairs, but not to do this until you tell them to. This exercise will be more of a challenge for some than others. Let clients know that what we are trying to do is not about being comfortable, but it’s about being comfortable with our discomfort. Superficially the purpose of this exercise is to look at another person. At a deeper level, this is about noticing the things that come up and stand between you and another person. You’re going to have thoughts, feelings, bodily sensations, and it’s your job to let them come up and let them go. Just simply look at the person in front of you, without communication, without talk. This is one where the no rescuing rule applies. If you think the other person isn’t doing it right and you are. Just do your work, and they will do theirs. You’ll be in silence together through this process for about five minutes.
b) Step 2 — Ask participants not to start until everyone is organized. Put them in pairs, facing each other, with one person’s knees between the others, touching their chair. Mention that it is likely to make some participants uncomfortable, as it is closer than our usual social distance.
c) Step 3 — When everyone is seated and quiet, ask them to just look into the other person’s eyes. Say: “When you look at each other’s eyes, just notice your own mind and what it is doing. Let go of what your mind is doing, and see if you can just be present with this other human being across from you for a few minutes.”
d) Step 4 — After about a minute has gone by, say: “As you look at this person, also notice that there is a person who is looking at you.” This person has struggles, ways in which they judge themselves and find themselves lacking. See if you can let yourself be with this fact. Is there anything this person needs to do to be a whole, valid human being in your eyes?
See if you can take this as an opportunity to let go, even if it’s for just a second, the barriers that stand between you and other people. See if this isn’t a safe place where you can experience that.
Can you let this person see you, simply, witness you?
e) Step 5 – After about another two or so minutes, ask the participants to stop the exercise, and come back to the circle.
f) Step 6 – Debrief – Possible questions include:
- How many people had an urge to talk, or reassure?
- Did something come up that you started struggling with? What did you do? What happened? Did the person in front of you disappear?
- This exercise illustrates the benefit of letting go of experiential avoidance in the service of our values, of caring about connecting with people. The thing that dignified this exercise is that it is beyond something more than a simple exercise. It was about human connection.
For more information on learning Acceptance and Commitment Therapy:
Attend a two-day experiential ACT workshop.
This is the best way to learn the ACT core processes and experience the approach. For more information, visit http://contextualscience.org/act_training.
There is an upcoming ACT training in Houston from November 6-7. More information can be found here: https://www.praxiscet.com/events/act-i-houston-texas.
Read on your own.
Read Get Out of Your Mind, an ACT self-help workbook, and do all the exercises to get an experiential sense for the work. This is no substitute for the experiential workshop, but a great start.
Read ACT Made Simple: An Easy-to-Read Primer on Acceptance and Commitment
Therapy (2009) by Russ Harris.
Read Acceptance and Commitment Therapy, Second Edition: The Process and
Practice of Mindful Change (2011) by Steven Hayes, Kirk Strosahl, and Kelly Wilson.
Read A Practical Guide to Acceptance and Commitment Therapy for many different chapters with applications to particular settings and disorders.
Read Acceptance and Commitment Therapy for Anxiety Disorders for perhaps the most accessible ACT work, particularly for people with a CBT background, which shows how to mix ACT processes into a brief therapy for anxiety disorders.
Read The ACT Matrix for a simplified and practical version of using the ACT model with clients. The ACT Matrix boils down ACT principles into an easy to apply approach.
Check out the continually evolving list of clinical resources, including treatment manuals, measures, audio recordings, at http://www.contextualpsychology.org.
About the Author:
Rachel helps men and women make peace with food, mind, and body to live a purposeful, satisfying life. Her practice is driven by compassion and concern for her clients’ core values. She and her colleagues regularly offer a Make Peace with Food group program as well as career, self-care, perfectionism and women’s groups. Visit http://eddinscounseling.com to learn more.