Luoma, J. B., Hayes, S. C., & Walser, R. D. (2017). The ACT therapeutic stance. In Learning ACT: An acceptance and commitment therapy skills-training manual for therapists (3rd ed.) (pp. 317-319). Context Press.
Ideally, ACT therapists take an open, aware, active, and values- based stance in interactions with clients. We recognize the potential loftiness of this ideal stance, yet we encourage ACT therapists to strive for it. Speaking more technically, the function of the therapeutic relationship in ACT is to increase clients’ psychological flexibility by responding effectively to their expressions of psychological flexibility or inflexibility as they occur during therapeutic interactions. This can occur in many ways. For example, therapists can model psychological flexibility (e.g., by saying, “I’m noticing that I’m thinking, ‘I don’t know what to say.’ You don’t need to rescue me. I just thought I’d share that.”). Or they can support psychological flexibility on the part of the client (e.g., by asking, “And would you be willing to notice that anxiety and still call your dad?”). Therapists can also target psychological flexibility in relation to whatever is currently happening in session (e.g., by asking, “Instead of pushing away the tears, I invite you to open up to them. They are welcome here.”).
Achieving such flexibility is a potentially difficult task for therapists, as we all bring our own histories, quirks, and interpersonal limitations to the therapy room. Because we may misjudge whether any given instance of client behavior represents a psychologically flexible or inflexible response, it’s useful to maintain a therapeutic stance that tends to instigate and reinforce psychologically flexible responding on the part of the client. The core competencies presented below are linked to this stance and to the therapeutic relationship that flows from the ACT model.
In this chapter, rather than presenting the core competencies at the end of the chapter, in the core competency practice, we lay them out up front and discuss them at length. In some cases, we list several competencies in a row and discuss them together because they’re intricately related and the explanation addresses their interconnection.
The first core competency may sum up the ACT therapeutic stance better than any other single statement:
- The ACT therapist speaks to the client from an equal, vulnerable, compassionate, genuine, and sharing point of view and respects the client’s inherent ability to move from unworkable to workable responses.
This most basic aspect of the ACT therapeutic stance naturally arises when therapists apply the ACT model of language and human functioning to their professional and personal life. The contextual philosophy underlying ACT holds that concepts such as sick versus well, whole versus broken, weak versus strong, disordered versus ordered, and dysfunctional versus functional are not inherent in any person, but rather are all ways of speaking or thinking propagated by our culture that can be more or less useful depending upon the context. ACT therapists are encouraged to adopt a stance consistent with the phrase “there but for fortune go I,” cognizant of the possibility that, given a slightly different history, the therapist could easily be the one with problems similar to those of the client and could be sitting in the client’s chair. This competency also reflects ACT’s emphasis on context, recognizing that radical or transformational change is possible for anyone, given a shift in their verbal or social context, or even a shift in their historical context, as the person accumulates new experiences. People don’t need to rewrite their past, have different thoughts, or have better feelings before a full, deep, meaningful life is possible.
Here is the second ACT core competency related to the therapeutic stance:
- The therapist is willing to self- disclose when it serves the interest of the client.
Although inappropriate and poorly timed self- disclosure may harm the therapeutic relationship (Ackerman & Hilsenroth, 2001), well-timed, well-crafted self-disclosure that is responsive to the c lient’s behavior in session may be helpful (Safran & Muran, 2000). ACT therapists are emotionally accessible and responsive and are willing to use self- disclosure judiciously in the service of clients. If carefully done, self- disclosure tends to have an equalizing effect on the therapeutic relationship, decreasing the divide between therapist and client and bringing the therapist’s own humanity into the room. This is particularly important in ACT because it allows therapists to model an accepting stance toward their own struggles while also modeling the ability to be effective in living their values.
Here are the third and fourth ACT core competencies related to the therapeutic stance:
- The therapist avoids the use of formulaic ACT interventions, instead fitting interventions to the particular needs of particular clients.
- The therapist is ready to change course to fit those needs at any moment.
- The therapist tailors interventions and develops new metaphors, experiential exercises, and behavioral tasks to fit the client’s experience and language practices and the social, ethnic, and cultural context.
Both of these core competencies reflect the need for behavioral and psychological flexibility on the part of the ACT clinician. ACT therapists are responsive to client needs and behaviors and don’t rigidly follow protocols or rules about what should be done. The key is to see and address client complaints and the unworkability of behaviors in terms of their underlying function, which often necessitates new and creative ways of responding. Any therapeutic techniques that foster psychological flexibility are considered ACT consistent. Artful application of the ACT model allows for and encourages making up new metaphors and exercises or adapting existing techniques to fit the needs of specific clients.
When first learning the ACT approach, it’s generally helpful to follow one of the available protocols or treatment manuals and carefully practice the metaphors and exercises before applying them to a client. However, because the model is focused on implementing the six flexibility processes with contextual sensitivity, it doesn’t mandate using any particular metaphor, exercise, or method. Indeed, overreliance on prescribed metaphors, exercises, and methods can create a mechanical- feeling interaction that isn’t responsive to clients’ needs or the functions of their behaviors. And eventually, it’s usually best to leave topographical treatment protocols behind when entering the therapy room and to instead aim for functional adherence to the ACT model. If therapists are focused on the content of techniques rather than their functions and engage in rote attempts to get a metaphor or exercise correct, they can lose sight of the needs of the client. The content is important and plays a role in the learning process, but understanding the purpose of doing a particular exercise is paramount. While there are certain exercises and metaphors that are frequently presented in treatment manuals and ACT texts (including this book), and many of them are commonly used by therapists, they are not necessary ingredients of ACT. Furthermore, individual therapists will, of course, have their favorite methods— approaches that fit their personal style and seem to work better for them in terms of bringing the flexibility processes to bear in session.
Tailoring your ACT interventions to match the needs of a given client can enhance the therapeutic relationship and allow the therapy to flow in a natural manner. For instance, you might choose to spend more time on control as the problem and less time on creative hopelessness. Or you could decide, given the client’s needs, to forgo creative hopelessness as an independent exercise. You may choose to start with values, or you may bring in values later in therapy. Ongoing awareness of the client, yourself, and the function of client behaviors in session can guide you in targeting particular processes and choosing particular methods.
Tailoring the intervention to the client, including the client’s cultural context, is key to these competencies (we’ll discuss this further in chapter 11). Some metaphors or exercises may be perceived as culturally insensitive or have the potential to function as a microaggression. Additionally, some metaphors or exercises may not make sense within a given cultural or language context. Therefore, therapists may need to adapt or forgo particular metaphors or exercises depending on the client’s background. In addition, recognizing environmental, social, and community factors relevant to a client’s well- being is an important part of meeting the client’s specific needs. Stigma or discrimination related to identity or group membership must also be considered. Finally, the level or target should be considered, because ACT can also be used to work with the psychological flexibility processes at various levels, including in couples, families, groups, and organizations, and at even larger scales.
Here is the fifth ACT core competency related to the therapeutic stance:
- The therapist models acceptance of challenging content (e.g., what emerges during treatment) while also being willing to hold the client’s contradictory or difficult ideas, feelings, and memories without any need to resolve them.
It’s important for ACT therapists to directly practice willingness in session. This can pose some difficulty, as many therapists have been taught that good therapy means helping clients resolve difficult emotions or troubling thinking. For instance, when a client is confused, therapists may slip into problem solving, giving lots of information to help the client “fix” the situation, without adequately considering whether more fully experiencing confusion would be the better course in the long term. In such situations, therapists must be willing to experience their own anxiety or discomfort arising from not trying to fix what the culture or system considers to be negative content.
As noted in the introduction, beginning ACT therapists tend to be anxious about the counter intuitive nature of the model, a reaction that may change only slowly. Fortunately, beginning ACT therapists can achieve good outcomes even if their anxiety remains high (Lappalainen et al., 2007), perhaps because their own anxiety helps them model and be in touch with the flexibility processes, rather than simply transmitting theoretical material. Self- doubt is part of learning a new therapy and is common in therapists. A recent study even suggests that self- doubt may make therapists more effective, especially if they are also loving toward themselves (Nissen- Lie et al., 2015). We encourage you to embrace your self- doubt and hold it gently, as it may actually be your ally.
Here are the sixth, seventh, and eighth ACT core competencies related to the therapeutic stance:
- The therapist introduces experiential exercises, paradoxes, or metaphors as appropriate and deemphasizes literal sense making of the same.
- The therapist always brings the issue back to what the client’s experience is showing and does not substitute his or her opinions for that genuine experience.
- The therapist does not argue with, lecture, coerce, or attempt to convince the client.
These competencies focus on experiential learning, which is fundamental to ACT. The potential for growth inherent in uncertainty is prized, and adopting a nonliteral, defused, present, accepting stance is encouraged. Yet sense making exerts a powerful pull on human behavior, sometimes to the detriment of being and doing. The point of ACT exercises, metaphors, and stories is not so much to help clients understand their problems in a new light, but rather to promote their development of psychological flexibility while supporting behavior that’s inspired by their values.
Sometimes working to create greater understanding is helpful, but the function of explaining and understanding should be considered in terms of the flexibility processes. Particularly for clients who are pervasively stuck, trying to understand how they landed in a particular problem and then working to figure out how to get out of it could well be part of how they got stuck in the first place. For example, a person with chronic PTSD may believe he needs to know a lot more about PTSD in order to solve the problem of PTSD. This can result in many years in therapy pursuing understanding, rather than learning more flexible ways of living with a trauma history. In ACT, the aim is not to add to this process. If you find yourself attempting to change a client’s mind rather than trying to liberate the client’s life, stop: you aren’t doing ACT.
And finally, here is the ninth and final competency, which is perhaps the broadest:
- ACT-relevant processes are recognized in the moment and, when appropriate, are directly supported in the context of the therapeutic relationship.
The rest of this chapter focuses on how to implement this competency. To that end, we’ll examine ACT theory as it relates to the therapeutic relationship.
