Reading G

One of the most common questions I get asked in ACT workshops is “Russ, where do you get your amazing shirts from?” To which I reply, “I’m sorry, but that’s a trade secret.” However, two other questions I get asked a lot are “Where do I start?” and “What process do I focus on first?” And my answer to both of those questions is “It depends.” Remember, ACT is a nonlinear model, and you can work with any core process at any point in any session. So there’s no fixed sequence; where you start will vary from client to client. However, I can give you some pointers around (a) the first steps in active therapy and (b) where to go in subsequent sessions. (And as usual, remember to modify and adapt everything; what follows are just tips and suggestions, not the Ten Commandments.)

Ideally, you will start off your first ACT session(s) by doing all the stuff we covered in the previous two chapters:

• establishing rapport
• taking a history
• obtaining informed consent
• establishing behavioral goals

If you’ve managed to do all that in your first session (or two) and you still have a bit of time left, then ideally you will (1) do a brief experiential exercise and (2) set a simple homework task. Let’s take a quick look at these two interventions.

A Brief Experiential Exercise

Throughout this book, you’ll find a wide range of brief experiential exercises, many of which take less than five minutes to do. One of the simplest is dropping anchor, which we cover in chapter 10. Another is the defusion technique “I’m having the thought that,” described in chapter 12. There are many others covered in other chapters, and you can pare back any mindfulness technique (e.g., observing the breath or a body scan) to a simple three or four-minute version.

Keep in mind, however, if you’re going to introduce an experiential exercise, you need to ensure that you have time not only to complete the exercise, but also to debrief it afterward, to make sure the client understands the purpose and sees how it’s relevant to her therapy goals.

Also keep in mind what we discussed in the last chapter: if your client is only interested in feeling good and getting rid of pain, and resists your efforts to establish behavioral goals, your first experiential work will need to be creative hopelessness (chapter 8).

A Simple Homework Task

It’s a good idea to ask your clients to do a bit of homework between sessions. For example, if you took your client through a mindfulness exercise in session, then for homework, you could ask her to practice it. Alternatively, you might ask her to keep a diary or fill in a worksheet, such as those mentioned at the end of this chapter.

If you’ve introduced the choice point, it readily lends itself to simple homework tasks. Here’s my favorite:

Noticing Towards and Away Moves

There are many ways to modify this homework. For example, you might ask the client to write his observations down in a diary. Or you might give the client a blank choice point to put in a prominent place as a reminder. Or you might ask him to fill in a choice point between sessions, focused on a specific issue (e.g., a “bad habit” he is trying to break, such as smoking or drinking too much, or a recurring situation he struggles with, such as looking after his three young children) and bring it back completed to the next session. This deceptively simple choice point homework serves a number of different purposes:

• It increases client self-awareness.
• It provides useful information for the next session, which helps with setting an agenda and deciding what to target first.
• It’s a good first step in getting the client to notice his thoughts and feelings and become more aware of his behavior.
• The information gathered on towards moves is usually very useful for exploring values, goals, and committed action.

Client Worksheets

Worksheets are often helpful because they act as a reminder of the session, increase the chance that your client will follow through, and provide good material for the next session. However, if clients are not keen on filling in forms (or if you as a therapist dislike them), then you don’t have to use them. They are simply aids to ACT, not essentials.

At the end of the first session, if you didn’t get much information about values, and you didn’t get the client to fill out a Bull’s Eye worksheet (chapter 6), you could now ask her to do so for homework. For example, you might say, “We’ve talked quite a lot about your problems today— the thoughts and feelings you struggle with, and the things you do that make your life worse— but we haven’t talked much about what sort of life you want to live, what really matters to you in the big picture. So I’m wondering, between now and next session, would you be willing to fill in this worksheet, which asks you to think about these things?”

Other worksheets you might give out are the Vitality vs. Suffering Diary or the Problems and Values worksheet (see Extra Bits). You can explain that these worksheets help gather more information to guide therapy.

Hopefully this chapter and the previous one have given you a reasonably clear idea about what to do in your first session (or two). And the burning question now is “What next?” And again the answer is “It depends.” That’s right: there is no “correct” answer to this question, no such thing as the “right” or “wrong” next step. All six core processes are interconnected and overlapping, and you can use any of them at any point during therapy. What follows are some ideas as to where you could go next, but this will vary depending on your assessment of the client’s needs. So make sure to hold these pointers loosely— and feel free to make different choices, tailored to suit your unique client.

• When clients are overwhelmed by their feelings, extremely fused, dissociated, emotionally dysregulated, or highly impulsive: begin with mindful grounding exercises such as dropping anchor (chapter 10).
• When clients are experiencing major grief or loss: begin with self-compassion (chapter 18) and/ or dropping anchor (chapter 10).
• For the poorly motivated or those fused with hopelessness: begin with values (chapter 19) and defusion from hopelessness (chapter 14).
• For clients fixated on feeling good and getting rid of painful feelings: begin with creative hopelessness (chapter 8).

(Clients who are mandated or coerced to get counseling are beyond the scope of this book, but I cover this in my advanced level textbook, Getting Unstuck in ACT [Harris, 2013].)

Choosing Which Path to Follow Broadly speaking, after the first session, ACT protocols tend to follow one of two paths, which flow from these two questions:

1. What valued direction does the client want to move in?

   If this is the path chosen, the steps followed (not necessarily in this order) are typically:

   • Values clarification
   • Goal setting
   • Action planning
   • Problem solving
   • Skills training
   • Exposure

   Speaking in terms of the choice point, when we take this path, we focus on clarifying and planning towards moves.

2. What’s getting in the client’s way?

   If this is the path chosen, the steps followed (often in this order, but not necessarily) are typically:

   • Target inflexible attention with contacting the present moment.
   • Target fusion with defusion.
   • Target experiential avoidance with acceptance.
   • Target self-criticism, self-hatred, and self-neglect with self-compassion.

In the language of the choice point, all of the above are unhooking skills, chosen to match the client’s specific away moves.

Whichever path you start on, sooner or later it’s going to cross over with the other path. Remember, all core processes are interconnected. But don’t concern yourself about this for now; as you progress through the book, we’ll look at how to jump from path to path.

Recall that the aim of ACT is to cultivate psychological flexibility: the ability to be fully conscious and open to your experience while acting on your values— or, said more simply, the ability to “be present, open up, and do what matters.” The outcome we’re looking for is mindful, values-based living: doing what is meaningful while embracing each moment of life.

ACT practitioners need to learn how to do three things really well:

1. develop a client’s openness to her own thoughts and feelings;
2. help the client be fully present— engaging in life and focusing on what’s important; and
3. help the client do what matters, acting effectively, guided by her values.

The ACT triflex, which we first saw in Chapter 1, shows how these tasks relate to each other and to the core processes:

In any session, if we do any intervention— no matter how brief or long, how simple or complex— that helps the client with being present, opening up, or doing what matters, it’s useful; it helps develop psychological flexibility.

The triflex serves as a useful visual map of what we tend to do in each session, based on our assessment of what the client needs at the time:

• If the client is overwhelmed, dissociated, or extremely fused, we start up top with being present: grounding and dropping anchor.
• If we want to help the client get moving, we shift to the right side of the triflex: doing what matters (values and committed action). We clarify values, set goals, create action plans, and teach skills.
• If the client is deeply stuck, going nowhere, paralyzed by fusion and experiential avoidance, we shift to the left side: opening up (defusion and acceptance).
• If we run into barriers at either the left or right side (or both), we come back to center: being present (grounding, dropping anchor).
• If the client is successfully doing what matters, we return to being present: we help the client to engage fully in her experience and focus on what she’s doing. And if she’s doing something potentially enjoyable, we help her learn how to appreciate and savor it.

The more stuck, directionless, or overwhelmed your client is, the more important it is to establish an agenda for the session. This is doubly so when your client keeps “problem-hopping”: rapidly moving from problem to problem without focusing on any one of them long enough to come up with an effective action plan or strategy to address it. You could ask, “Can we pick one important problem or area of life that we can make the main focus of the session, in order to improve it?

It’s often good to give a rationale for this, such as “The reason for this is it makes our work much more efficient. If we are trying to deal with several different problems at once, it’s very hard to deal effectively with any of them.”

Alternatively, you could ask the client to nominate a single problem, goal, relationship, or other aspect of life to focus on for today’s session. Then agree to work on a specific unhooking skill or an action plan to deal with the chosen issue.

You can of course use the choice point to set an agenda. You could present it to the client and say, “So we have two main options for today’s session. We can focus on the towards moves— have a look at what you want to do differently to take your life in the direction you want. Or we can focus more on building those unhooking skills, to help you handle those difficult thoughts and feelings. Which would you prefer?”

If your client is fixated on feeling good or getting rid of her pain, and that’s all she wants from therapy, then go to creative hopelessness.

If the client chooses towards moves, then start with either clarifying values or setting goals:

• If she already knows her values, set goals.
• If she doesn’t know her values, clarify them. Then use those values to set goals.
• Once the client has values-based goals, turn them into action plans.

If the client chooses unhooking skills, start with the easiest ones first: dropping anchor and simple defusion.

When we teach unhooking skills, there is no particular sequence we have to follow. However, when I created my own ACT protocol for the general public (“The Happiness Trap Online Program”; to find out more about it, go to https://thehappinesstrap.com), this is the sequence I used:

1. Dropping anchor/mindful grounding (chapter 10)
2. Simple defusion (e.g., noticing and naming) (chapter 11)
3. Meditative defusion (e.g., Leaves on a Stream) (chapter 15)
4. Attention-training and focusing skills (e.g., mindful breathing) (chapter 17)
5. Engaging and savoring skills (e.g., mindful eating, drinking, walking, listening) (chapter 17)
6. Self-compassion (chapter 18)
7. Acceptance of pain (chapter 22)
8. The noticing self (chapter 25)

You can use this sequence as a general guideline, likely to work well with most of your clients. However, please don’t regard it as something you have to follow. Vary it as needed. We always want to be flexible in how we work and adapt what we do to the unique client in front of us.

Here’s a good general structure (again, hold it loosely and adapt it as needed) for your sessions:

1. Mindfulness exercise
2. Review of previous session
3. Agenda
4. Main interventions
5. Homework

Let’s take a quick look at each of these now.

Mindfulness exercise. It’s often helpful to start each session with a brief mindfulness exercise such as dropping anchor or mindful breathing. This is not essential, but it gets both client and therapist into a mindful state and sets an expectation for experiential work.

Review of previous session. Review the previous session, including key content covered, exercises practiced, and any thoughts or reactions the client has had since. If your client followed through on his homework, what happened, and what difference did it make? And if not, what got in the way?

Agenda. Agree on an agenda for the session, as outlined above.

Main interventions. If you’re following a protocol, you’ll have a good idea in advance of what you wish to cover in session. It’s important, though, to be flexible— to respond to what’s happening in session. Be willing to let go of everything you had planned, if need be. (You can always come back to it later.) If you’re not following a protocol, you will either pick up from wherever you left off in the previous session or you will address a new issue based on the agenda you have just set.

Homework. It’s important to repeatedly emphasize to clients that what they do in between sessions is what will really make all the difference in their lives. New skills require practice. Valued action requires effort. Before the end of each session, you need to collaboratively agree on what the client is going to practice, do, or experiment with between sessions. (But be careful— don’t get too pushy or use values coercively.)