Acceptance and Commitment Therapy - Session 1

Let's start by looking at what generally happens when you go to see a counsellor.

Someone goes to see a counsellor when they have a problem that won't go away, or a problem or an issue that is affecting the quality of their life.

During your fist visit with the counsellor, the therapist or counsellor will attempt to get some sort of history from you to better understand who you are and where this problem fits in, or even attempt to create an understanding of what created the problem.

For example, if you have depression, telling your history may help reveal that you had a very unhappy or even abusive childhood. Links can often be made with life events and family history with regard to the prevalence of depression.

Linking history to your problem can help identify the origin of the problem. The next step with traditional counselling such as cognitive behavioural therapy, is to then look at how you are dealing with the problem.

Once a behaviour, and I include depression or anxiety here, becomes entrenched or familiar, it generally becomes automatic. Many behaviours are learnt from an early age. With depression for example, a person with depression will say that when they are having a depressive episode they experience a loss of energy, they have sad thoughts, they feel worthless, they don’t socialise as much, they don’t feel like going to work or school, and a whole lot of other similar thoughts, feelings and behaviours that we generally associate with depression, using this example. Therefore the person with depression, when they experience depression, actually does depression. It’s an important concept to grasp here because when you do, you will find there actually are other ways to behave when depression hits.

The thing with behaviours such depression, anxiety, arguing a lot in relationships, always being angry, feeling guilty regularly, etc, is that they become familiar and so are more easily repeated rather than finding alternatives to these often dysfunctional behaviours.

In traditional counselling the counsellor or therapist will then look at alternatives to acting in the usual way. Counselling can also focus on trying to get you to think differently to the way you usually do. For example the angry person may be encouraged to think of the glass half full rather than half empty, or that not everyone is out to get them.

With ACT the counselling process is very different. The one major difference is not focusing on the problem and trying to change it but rather focusing on the problem and accepting it. We aren’t trying to make depression go away, or anxiety, or fear or grief or anger.  Below is how I practise ACT.

When someone comes to me for counselling I often listen as they tell me their problem. The reason I do this is that people just naturally tend to do this when they first go to counselling. It could be something like the following conversation:

“I’m feeling so sad lately. The sadness just won't go away. I find I'm not going out much anymore - I don't even want to see my friends. I've stopped exercising and I just don't enjoy work anymore..."

As with traditional counselling getting this history is good in helping me as the counsellor identify with the client what they see their problem as.

But that's about as close to following traditional counselling as I go.

The next step for me practising ACT is to then get the client to do a Suffering versus Vitality worksheet. With this, together we identify the thoughts and feelings that are associated with the problem for the client. This then introduces the concept of the observer. This can initially be achieved by getting the client to engage in a mindfulness exercise where our attention is brought back to the here and now. So I’ve introduced 2 important concepts here, that of the observer and mindfulness.

To achieve a state of mindfulness the easiest way is by focusing on our senses. Why? The reason is that we get all of our information about what is happening in our lives through our senses, particularly in the here and now. So that is what we see, hear, feel, smell, sense through touch and taste. In the exercise I do, we focus firstly on breathing and what is happening during that very basic process of breathing. Then we concentrate on what we can see, hear and feel. This process takes about 5 minutes and many clients report on how much more relaxed they feel after doing that exercise, though the aim is not to get them relaxed but rather to slow the clatter on noisy thinking in their heads. So mindfulness is about getting your focus back on right now. You can try it now if you like, look away from the screen and really focus on what you see and hear around you. Spend a bit of extra time really focusing on shapes, colours, soft sounds, background noises etc.

Already things are quite different to traditional counselling. The focus has been on taking on the role of the observer, bringing the focus back to now through the mindfulness exercise and completing the Vitality versus Suffering worksheet. Quite a lot for the first session! I find this approach so much more productive than listening to a whole lot of “this is why it’s problem stuff – he said she said – and then this happened – and then that happened etc”.  Particularly as the therapist I no longer challenge people on why they think certain ways, or ask probing questions such as “Why did you react that way”? With ACT, the belief is if you go beyond the basics of identifying the problem and associated feelings and thoughts, you invite the problem in. For example probing questions invite the client to focus on the problem and if the problem were a separate entity it would love it because it gets centre of attention. This process in fact feeds the problem.

Through the Vitality versus Suffering worksheet we look at the thoughts and feelings that happen when the problem is around. After listing some feelings associated with the problem we explore them fully. It’s important to note here that we aren’t focusing so much on the problem, but the feelings and thoughts associated with the problem. This is based on the belief that most of us try to avoid our thoughts or feelings – push them away, cover them up etc. So with the feelings I ask questions such as ... What do those feelings look like? What shape do they have? Where do you feel them? What colour are they? Are they solid or fluid? Does it spread? We thoroughly explore the feelings and thoughts. Thoughts can include belief systems and self-judgements.

Often people will avoid the full extent of their feelings and thoughts and this then can perpetuate the problem. For instance the sad person doesn't go out to see friends because their negative feelings associated with seeing friends can be increased when you are sad, so by avoiding seeing friends you perpetuate the sadness. The logic here is that the person has said when they are sad they stop seeing friends, but the very act of not seeing friends perpetuates the sadness, the very thing they are trying to get rid of – they don’t want to be sad! Remember this is when sadness has become a problem that is adversely affecting a person's life.

This has been an overview of how Acceptance and Commitment Therapy can work, and in particular, here I’ve focused on the first session.

Mark Lockyer is a Social Worker and Teacher with over 20 years of experience supporting a range of clients in a range of settings. He offers counselling and workshops in Perth, Western Australia.