How do you teach Acceptance in Acceptance and Commitment Therapy?
We are talking about acceptance in Acceptance and Commitment Therapy (ACT). It’s often tricky for clinicians because we can fall into the trap of talking about acceptance instead of showing a client how to do it.
When this happens, we say things like, “you can’t get rid of your thoughts and feelings, but you can accept them.” Your client might be like, well, I don’t want to accept them; I want to get rid of them. I don’t particularly appreciate feeling this way, which is entirely understandable.
Has that ever happened to you?
What do you tend to do when that happens?
An excellent place to start is with creative hopelessness. It’s the process of helping a client recognise the futility of experiential avoidance. It’s a good idea to carry out some creative hopelessness work in the first or second session because it sets the course of your work.
However, just because you do it once doesn’t mean your client will automatically and permanently give up trying to control, push away, or eliminate their anxiety, guilt, shame, fear, anger, or sadness.
Clients might understand that acceptance makes sense, but often they don’t connect fully at an experiential level.
Why is that a problem?
Think about the last time you felt angry or guilty.
- What happened?
- When you felt this way, what went through your mind?
- What did you say to yourself?
- What did you do?
Did you shout or stay silent? Did you walk away, argue or sink into self-pity? Did you rationalise or reassure yourself?
Take a moment to notice your reaction. Have you been there before? Have you reacted in this way before? How many times would you estimate that it’s happened?
It’s natural to react to uncomfortable emotions. These reactions turn into loops that you repeat. It happens because you’re using your head to solve the problem instead of being aware of and open to your experience.
Let me give you an example from my experience.
Sometimes I can come out of a therapy session wishing I’d said or done something different. I might be thinking, “ah, I wish I’d said that or done that, or not said that or done that.” It gives me a feeling of regret. My mind will be saying to me: “Jim, you shouldn’t have done that. It was a silly mistake, and you should know better.”
One reaction I might have is to move away from this experience by distracting myself, keeping busy, or seeking reassurance in supervision. It would be a clear example of how I’d be trying to avoid something uncomfortable, like the feeling of uncertainty, if I were to do that.
Similarly, I might also do a toward move. Now, I don’t want to confuse what I am about to say with moving towards a value. If you’re used to using an ACT Matrix or Choice Point, then you might be accustomed to thinking about towards and away moves as being towards or away from values.
The kind of move I will describe is one whereby I try to create certainty to avoid being unsure how my client was affected. I might think I’ll ask for feedback about the session and what I said or did.
On the surface, this response might look helpful. However, below are feelings of regret and uncertainty that I’m avoiding.
If we are not mindful, we can rush into behaviours or solutions that seem helpful but deny you the chance to be more flexible with your emotions. And that can have negative consequences for your well-being and professional development.
How do you teach acceptance?
In my view, you do this best when you do two things:
- You practice being aware of and open to your experiences.
- You help clients contact or feel their experiences fully.
An important point to make here is that not all avoidance is terrible. The purpose of acceptance interventions is to target problematic avoidance. It’s not a case that all acceptance is good and all avoidance is awful. You want to teach contextual sensitivity as well as variability. In other words, you want to look at the situation with curiosity so you can choose whether it helps to be open or not. It’s the same thing with your clients.
Specifically, acceptance exercises focus on undermining excessive control of emotions. You begin by identifying which emotions the client tries to push away. When talking to your client, you want to look for statements that suggest they don’t like or want certain feelings. They might tell that they can’t cope with that emotion, that it’s unbearable or too much. Statements or language that convey a sense of being unwilling to experience confirms that an area of inflexibility.
Add Awareness First
The helpful starting point is to add awareness first. For example, saying something like, “I notice you’ve got a feeling there that’s just too much to hold.” Rather than rushing in with an acceptance or defusing exercise, you take your time while training awareness skills simultaneously.
How do they respond?
Because the client tells you that they don’t like or want that feeling, it means that they’ll move somewhere else. A second helpful step is to clarify where they go instead. For example, you could ask: Where do you go when that painful experience shows up? What do you do with it?
What are the costs?
This question sets up your next piece to explore the costs of engaging those experientially avoidant moves. Again, you could easily skip over this by doing a cost-benefit analysis, which gets the client to think. In ACT, we invite the client to feel the costs by connecting at an emotional level. You bring the context into the here and now rather than leaving it over there and then. You ask the client to be in that space, noticing and describing what they feel when they make that move over and over again.
For example, for the depressed client who stays at home playing video games, you could take them to the moment they switch it off after many hours of being in another world. You ask them to show you what they feel at that moment.
Or for the anxious client who always wakes up in a panic. They pick up their phone, try to go back to sleep or quickly get up and go out. You invite them to remember the moment they wake up as if it were happening here and now. With warmth and curiosity, you ask them to describe what it is like always to do something to get away from their anxiety. What does it cost you?
When you enter this space with your clients, you can expect some pain to show up. That’s good; it means you’re working somewhere useful. It’s not a case that you’re trying to make your client cry, but more like you’re helping them open the door to what’s there.
Once you’ve entered that space and seen that your client has connected with the pain of avoidance, you can add some reinforcing functions. For example, you can coach your client, praise them, and encourage and reward them with a more profound and closer connection with you.
Track what happens
After that, you can track the experience to help the client determine if being more open or accepting was useful. For example, you can ask, what do you notice here and now as I sit with you as you experience this pain? When you do that, you’ve introduced a new context and new functions that hopefully will motivate the client to be less avoidant in the future.
There are various tools that you can use for this task. The unwelcome party guest metaphor and the physicalising or acceptance of emotions exercises emphasise openness to experience. Be mindful that you don’t rush into these exercises. Instead, I recommend you work on the process.
Here is a quick recap of some practical steps:
- Look for emotions that the client doesn’t like or want to have.
- Add awareness to the context by sharing your observations that they don’t feel like they can go near that feeling.
- Clarify what they do to move away from that emotion, including places they go to, like certainty or control.
- Invite the client to bring the painful experience into the here and now to feel the discomfort.
- Add reinforcing functions to their openness moves so that you create a new, more appetitive context.
- Track their experience and teach them to notice the benefits of being open.
Clients will often fall back into control or avoidance. It’s natural, so expect it. Notice how much you do it too. Seeing how easily I fall into excessive control helps me appreciate my clients’ challenges.
If defusion is about taking a step back from your thoughts, acceptance brings your emotions closer. Both processes sit inside the openness pillar, so they go together. It’s about being open to both thinking and feeling.
The power of ACT rests inside its experiential methods. Instead of getting clients to think about how avoidance doesn’t work, invite them to feel the costs. People don’t often change unless they feel uncomfortable enough. If they’re not changing, there is a good chance that you need to work more in this area of acceptance.
Like with any skill, it takes practice, patience and persistence. So, keep trying and keep going.