The Six ACT Processes
It’s useful to go through the ACT processes and how they relate to the goals for this client, because each gives us a path to a way to intervene. As you’re working with a client, you’re looking at each process as well as places where the person may be stuck.
You don’t have to do these in any order. You choose what would be most beneficial in the moment, just as you don’t have to work on one side of a Rubik’s Cube before another. They’re interconnected, so you may work on one process, then another, and go back and forth. They’re presented here in a more orderly way so they’re accessible and understandable.
Being Present
Having said that there’s no particular order, the ACT process often used first is being present, also called mindfulness. In this case, it was clear that when the client was binge eating he was not present. He was eating rapidly, he wasn’t in his body, he was using eating to escape, and also wasn’t present in his studying. It’s difficult to learn if you’re distracted.
Many of his struggles had to do with fears about the future. Sometimes, when he was studying, he would get into a worry loop about how he was going to do and what would happen if he failed the MCAT again. Then he’d imagine his family and how they would react, if he told his physician father and psychiatric nurse mother that he wasn’t going to medical school. He would time travel well into the future.
He would also time travel into the past, where he would get caught and ruminate on other times when he hadn’t done well on tests, the feelings of anxiety and overwhelm he’d had in past experiences with testing. The future and past would prevent him from being present.
Mindfulness Technique
A simple technique was to ask the client to identify in which direction their mind went when it went into the future, and imagine it going there. They held their hand up in that direction. Then they imagined where their mind went when it went into the past, and held their hand out that way. But where was the studying happening? Here. So they would bring their hand and mind back over and over again to the present moment.
If you take a puppy out on a leash, it’s going to be easily distracted. Our minds get like that. But we can have a practice of catching ourselves. I’m in the past, or the future, then bringing yourself back. The more you practice that skill, the more it will be strengthened. ACT uses a lot of metaphors. Being present practices are like playing an instrument or learning a sport.
That being present process was then brought into the client’s eating. People who struggle with binge eating or restricted eating are often anywhere but in the present moment when they engage in those. This client had a value of enjoying food, it’s very much part of his family and culture. But when he was binge eating, he really wasn’t enjoying it.
Mindful Eating and Appetite Awareness
The client was started in a practice of checking in with his body before eating, asking himself how hungry he was, and paying attention to the first three bites, or first three minutes of eating. He held an awareness of what it was like to eat without distractions, noticing the chewing, the enjoyment, what he liked or didn’t like, and hunger and fullness levels.
This included a practice of one eye in and one eye out. With one eye out, you pay attention to the food and one eye in, you pay attention to your body. Again, the mind can go off into the future: oh no, what if I lose control over my eating. Or to the past: I shouldn’t be eating because I overate last night. The skill was to keep bringing himself back to mindful eating.
He made a commitment to practice mindful eating during at least one meal a day. This was helpful for building on the concept of appetite awareness, which is discussed further below.
Mindfulness in ACT
So that’s the process of being present, which you may already use in terms of working with mindfulness in your practice. It’s widely used in many different therapies.
One difference in ACT from other therapies is a focus on being present where it matters most, because there may be things we can multitask on or don’t need to be fully present for. No one can be fully present all of the time.
But there are certain areas of life, particularly where we experience meaning or pleasure, that it’s really helpful to be present for. There are areas where we have impulsivity or a tendency to move quickly through things. Helping clients slow down in those areas can be very useful.