Demystifying ACT: A Practical Guide for Therapists

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How to Practice Willingness and Acceptance in ACT for PTSD

By Sonja Batten, Ph.D.

This video is part of our upcoming online course about ACT for PTSD.

Highlights

  • Find experiential ways of demonstrating what the process actually is.
  • Physical metaphors, using notecards or other visual cues, can provide a useful introduction to various stances of control, avoidance, and willingness.

 

Transcript

So, you’ve introduced the concept of willingness and acceptance. But my guess is that it’s probably still not entirely clear to your client what it is that you mean when you say “being willing.” So, I might start with a metaphor with the client next.

So I understand that I’ve been talking about this term willingness and talking about acceptance, but I know it may not be entirely clear what it is I’ve been referring to, like what you’re actually supposed to do.

So you know, it’s sort of one of these things where it’s hard to describe in words—like words don’t do the action justice.

It’s like if I were trying to teach you how to hit a baseball, for example. I might say, “Stand with your body perpendicular to the ball. Square your hips, bend your knees. Hold your bat like so. Pull your arms back and keep your eye on the ball. And when it crosses your field of vision, swing and make contact with the ball.” And I could go into way more detail than that. I could give lots and lots of verbal details about how to hit a baseball.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

And you know what? How do you actually learn how to hit a baseball? By hitting a baseball and by doing it badly. And by trying to take the instruction and turning it into physical actions. But over time, really, the way that you’re going to learn how to hit a baseball is by doing it over and over.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

So, I might give that metaphor. Or in your culture or your corner of the world, there may be another activity that would be a better example to use. Maybe baseball doesn’t work. Maybe it’s learning how to ride a bicycle, or kick a soccer ball, or drive a car, or some other sort of sport or activity. It could even be cooking the perfect, you know, whatever the specific food is in your culture.

Pick an activity that can only be learned by experience and then you can create your own metaphor.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

And so as I just mentioned using the learning to hit a baseball metaphor, the application of willingness is difficult to directly instruct.
So instead, it can be useful, once you’ve suggested the importance of experiential learning, to practice what acceptance is through some exercises.
And often, this works best initially with low- to moderate-intensity private events because you’re trying to demonstrate the action without overwhelming the client and distracting them from the point of the exercise.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

So, here’s an exercise that I find can be a useful way to introduce this concept, and what it is that we’re asking somebody to do with willingness and what it isn’t. I might say something like this, “So I know that I’ve been saying that there’s an alternative to the struggle and proposing that it might be this thing I’m calling willingness. But I’m guessing it may not be entirely clear yet what I mean when I say that. So, I wonder if you’d be willing to do an exercise with me so that I can demonstrate what I’m talking about.”

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

And so if the client agrees, then you can have next to you, a stack of notecards or pieces of paper. So I’d go on. “What I’ve got here is a stack of these small notecards. And what I’d like for us to do, for a few minutes, is to write down the types of thoughts, feelings, and bodily sensations that come up when you start to feel that high anxiety.” So again, this is for a client where anxiety is the issue, but the content could be whatever is relevant to that person.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

And so the therapist and the client spend several minutes writing individual items on each notecard, like difficulty breathing or knot in my stomach or panic or “I can’t take this any longer.”

So, then you’d go on. “So now, we’ve got this stack of cards and on each of them, we’ve written something that shows up for you alongside the anxiety that you’ve generally tried to struggle against and get rid of. Is that right?” And see how the person responds to what you have written on those notecards. So then, after creating that stack of personalized cards together, the therapist asks the client if she’d be willing to try relating to the cards in some different ways, just to see what it’s like.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

And the therapist explains that maybe he’ll be gently tossing these cards in the client’s direction and suggest that the client can choose various ways of responding.

So, for example, he might first suggest that she try to fight these experiences as they show up.

So, he announces the content on each card and carefully tosses them one by one toward her.

And in response, the client uses her arms or hands to bat the cards away as they come near her. So, they go through the stack of cards that way and the client is asked how that experience was for her. And they process that for a minute.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

Then they pick up the cards again and the therapist suggests that they try the exercise again, but with a different mode of responding. So, for example, the second time through, the client might be asked to try to ignore or hide from the different experiences by holding her hands up in front of her eyes so that she can’t see the card. The therapist then initiates the same process by announcing the content on each card as he carefully tosses them in her direction. So some of the cards bounce off. Other ones may land on her lap and stay there. And the client is again asked to describe her experience and they process that for a couple of minutes.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

And finally, the therapist asks if they can do the exercise 1 more time. This time, the client sits openly with her arms and hands facing up on her lap signifying that she is welcoming whatever lands there, without having to fight it or hide from it or defend against it. And like with the second posture, some of the cards land on her lap while other ones bounce off onto the floor. And then you can process that experience with the client as well.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

And you know, tell the client that you’re curious to hear what they noticed and how are those 3 postures or ways of responding are different.

And it’s an opportunity to point out the difference between FIGHT, avoidance or control, and then openness and willingness. And you can do a lot more to elaborate on these points.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

And it’s useful to know we’ll talk about defusion in the next videos. And you can remember at that point that writing the thoughts down on cards allows some distance from the information that the mind is producing. And seeing those things written down as an external entity can allow the client to look at that content rather than through those thoughts. And the therapist can also then physically give the cards to the client at the end of the session and give homework to walk around with the cards during the week, putting them in their pocket or purse or backpack or even under a pillow at night.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

And the idea is that you’re walking around with these things all of the time. And maybe sometimes, you’re aware that they’re there. Sometimes, you forget. And then notice what happens when you contact physically, you know, you happen to touch those cards with your hand. Notice what shows up and that you can choose how to respond in that moment as you carry around that content mindfully and still continue to move forward and live life.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

And you can come up with some creative alternatives to conducting this exercise if you’re practicing therapy through video or telemental health.

So, for example, you can do that whole same process where you go through and you write down the information on cards or pieces of paper.

But then for the first option, I guess the therapist would be putting the cards up to the camera or the video equipment and you can ask the client to put their hands up to the screen to try to cover up the content they don’t want to see on their end.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

And for the second option, they could turn around from the screen, close their eyes, and cover their ears.
And for the third option, they can allow the content to come up on the screen and notice that it’s there while also looking around the room occasionally or reading something in front of them or writing down some notes.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

The idea is, whether you’re doing this in person or by video, that you want to help the client notice that when you are focused on fighting the content or focusing all of your energy on ignoring or not contacting what the content is that is there, there is very little else that you can do because you have to focus so much of your energy on not being present to what’s there.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

Instead, when you actually allow the process to unfold the way that it naturally is, then you actually have the flexibility to do other things: to have a conversation, to read something, to look around, to do some activity.
And that’s what we’re talking about when we’re talking about psychological flexibility. It’s the ability to be flexible and live your life even in the presence of that challenging content.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

So, some key points. Once the concept of willingness or acceptance has been introduced, it’s useful to find experiential ways of demonstrating what that process actually is rather than just focusing on verbal descriptions.
And physical metaphors, using notecards or other visual cues, can provide a useful introduction to various stances of control, avoidance, and willingness.

More ACT for PTSD presentations