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The Layers and Nuances of Acceptance and Commitment Therapy

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Therapists are all talking about ACT (Acceptance and Commitment Therapy). ACT is a ‘third wave’ behaviour therapy approach with a supposedly ‘expanded perspective on how to guide clients to skilfully self-regulate emotional distress and conflicting states of mind’, or at least, that is what all the literature suggests for this new so-called approach to the same age-old problematic experiences therapists encounter when treating their patients.

These are patients, according to the literature on ACT, who experience affective dysregulation from a new or existing anxiety, PTSD, depression diagnosis, and/or deep interpersonal conflict.

The theory behind ACT is a framework that posits through the application of traditional mindfulness exercises and intensive psychotherapy targeting specific cognitive processes, the patient will experience relief through acceptance of private experiences, active cognitive defusion, being present, and self as context.

When all of these targeted modalities are mobilised in the course of psychotherapy, patients supposedly become more flexible in their interpersonal kinship networks and other interactions in their professional work and personal lives.

Building upon the assumption that firstly, a positive increase in prosocial interactions will result in the cultivation of value-based behaviours.

ACT theoretical underpinnings go a layer deeper. The literature suggests this algorithm for conducting therapy will yield further patient insight into their own personal set of values, developing a stronger commitment to positive action and behaviour. This chain reaction yields, what ACT terms, the behavioural and cognitive activation which contributes to the success of patients experiencing therapeutic gains in the course of their treatment.

The framework of ACT builds upon basic mindfulness. While I doubt many therapists would minimise the importance of patients understanding basic mindfulness or even a nuanced deep and complex awareness of self-awareness tools, the use and validity of research confirming this existing modality is already widely accepted and utilised across the board by therapists in mental health.

So, what’s really new then? Self-acceptance? I haven’t met a social worker, psychologist, or psychiatrist that has, in the course of treating anxiety, depression, and PTSD, forgotten to teach self-acceptance strategies when the opportunity presented itself in the course of their patients’ treatment.

The next wheel I like to suggest isn’t so inventive is active cognitive defusion. Even more problematic, cognitive defusion, which has patients confront or raise problematic areas of their dysfunction or conflict without affective state escalation or agitation, isn’t even accepted as completely effective in treating the symptoms of these disorders.

I have seen first-hand, both experienced and inexperienced therapists, clumsily use this technique, and sessions collapse shortly after as their patients unravel, become irritated, and begin to flood with emotion and negative sense memory.

So, if this technique is so delicate and difficult to apply in practice, why incorporate it into this already complex and overly technical so-called ACT paradigm. I am assuming much of this has to do with the assumption that ACT-trained therapists will go through rigorous training and attend every webinar possible throughout their careers and tenure or practising ACT.

The final two underpinnings are in my opinion, the basic skills taught in social work 101. Maybe I am missing something here? Or, just maybe, contextualising the self in more meaningful and meaning-laden terms is what we are already doing as therapists. So many of these so-called new and exciting modalities we chit-chat about at the water cooler and gloat about to our colleagues should already be in our tool kit for practising psychotherapy.

Maybe I am a brilliant clinician, or just maybe, I’ve taken the time to truly be person-centred, read a diagnosis for what it is, and apply my existing and ever-broadening skill set to my patients and experience good outcomes without calling upon the buzz of a new acronym or miracle modality.

I get it, we all do it and want to talk about our skills in broad colourful strokes of positive regard, but we therapists should also be a little more humble, and learn our craft from the moment we commit to the helping process. Instead, we blame our shortcomings and inability to successfully treat our patients on our incomplete education of new terminology and the next ‘in’ therapy.

Max E. Guttman, LCSW  is a psychotherapist and owner of Recovery Now, a mental health private practice in New York City.


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