Association for Contextual Behavioral Science

Dear Kimpfrey,

Following I provide you with some unorthodox advice, which I hope it is useful at least while you become more confident in your ACT skills. What I propose is a "workable solution," one through which you could shape your CBT skills into ACT skills (presuming you do CBT). This was my own chosen road--while working on an elevator phobia--to become ACT competent as well as to satisfy my supervisor at the time, who did not know that "commitment therapy thing." And I am sharing with you because (reason-giving) it did work.

Here's what I did--and she got rid of her 40+ years old phobia (of course, "getting rid" of the phobia is not ACT, but CBT, the goal is committed action, that is, action in spite of what shows up in the experience. Still, she did get rid of her phobia altogether as the experience was transformed by her willing exposure. This might not happen, of course, and an ACT therapist works as if this is NOT going to happen.)

1. After assessment (mostly CBT, although also used AAQ to establish baseline) and informed consent, and some "ACT-friendly psychoed" about phobias (really ACT non-kosher), I also used the tug of war and Chinese trap metaphors (experiential exercises). (You'll find what you need in Chapter 8 of "ACT for Anxiety Disorders" by Eifert and Forsyth, New Harbinger, 2005). (In Chapter 4 of "ACT" by Hayes, Strosahl and Wilson, Guilford, 1999, you can learn about creative hopelessness, an extraordinary intervention which may require significant skill and tends to be, to put it mildly, disliked by non-ACT supervisors--and for the not yet licensed crowd: this is not just a thought!)

2. This was followed by ACT values work, to help the client generate willingness (and committed action) to experience whatever there was to be experienced in the presence of elevators. Initially, she was quite unaware of what values she was sacrificing by avoiding her experience, so this was quite "valuable" to her. I used the "monsters in the bus" metaphor/exercise, as well as write your own epitaph, attend your own funeral. You'll need to be very clear about what values versus goals are--as your clients will likely confuse them. I like to speak of values as rainbows--they set a lively, vital course, and they can never be reached--the "pot of gold" contains a very different kind of money! Let your client figure out what this means. (Re values, you might find what you need in Chapter 9 of "ACT for Anxiety Disorders" by Eifert and Forsyth; and in Chapter 11, 12 and 13 "Getting out of your mind" by Hayes and Smith, New Harbinger, 2005--you can also use Chapter 7 of this book if the person has identified with her phobia, e.g., by believing "there must be something wrong with me").

3. I then taught my client diaphragmatic breathing (CBT heresy!) and special place visualization (both ACT no-no's)--the latter in preparation for imaginal exposure--as well as mindful acceptance of the present moment. Of course, the latter is not about relaxation (therefore is ACT-certified) AND (don't forget to use the by now classic "getting of your buts" metaphor) my mind is thinking it may likely produce calming effects (as it does with my clients) perhaps through: (a) defusion/reduced believability, (b) emotional exposure, (c) emotion "surfing" (DBT's riding the wave), etc. (Please beware of the dog: the latter "calming effects" comment is nor ACT- neither Sanga-approved and likley just a fidget of my overactive mind.)

4. Following, we carried out "cognitive defusion" interventions in preparation for exposure. This was instead of cognitive restructuring, that is, my client learned to observe without judgment and de-identify with the literal contents of her mind (put your thoughts on a leaf or on toy soldiers carrying signs; thank your mind for your thoughts; I am having the thought that...; etc), instead of "restructuring" them. (Warning: I am having the thought that "if you 'restructure thoughts' you risk being expelled from the ACT planet into the way more mundane CBT world, in a galaxy far, far away..." "Definitely not worth the risk," my mind says.) Also, don't miss the opportunity to have your client give a name to her phobic mind--these names are usually really fun and creative and high-octane fuel for de-fusion as well as for humour, in my experience a powerful defusing tool in its own right, which on top makes one laugh a bunch while being paid--it also makes the client laugh, even though she/he is not being paid.) (For defusion check Chapters 6 & 7 of "ACT" by Hayes, Strosahl and Wilson, Guilford, 1999.)

5. Then, we did semi-brief imaginal exposure to develop some simple mindfulness and defusion skills (and techniques) to be used during exposure (and likely the client's life in general) as well as to perhaps begin desensitization (horrible word, ACT-pariah). This work provided the opportunity also to have the client experience the power of her newly gained contact with her valued directions and a new experiencing of her elevator phobia as a barrier to a valued life (instead of her old "minding").

6. Finally, we did prolonged, in vivo, almost fully ACT exposure, as my client was willing at that point to go all the way the acceptance road. Since the goal of act is psychological flexibility, exposure included a lot of goofing around while in the elevator--telling jokes to people coming in, playing cards on the elevator floor, dancing, following the cracks on the walls, etc, etc. We both had a ball. (We trained a goofy partner to accompany her for out of session exposure.) Now, in vivo exposure in an elevator is one thing, AND a different one is exposure in an aeoplane. The latter, for one, is expensive, although I presume your client needs to fly. However, I presume the ACT approach, with it's emphasis on willingness and altogether dropping "the control agenda" (so typical of anxiety disorders) may be particularly helpful to a flying phobia, where short of flight simulation, the only viable choice might be to jump into a jumbo plane. (Chapter 10 of "ACT for Anxiety Disorders" by Eifert & Forsyth, New Harbinger, 2005, is really useful for exposure.)

I hope this is useful. If you choose to go the 'watered down' way, as I did, to begin shoring up my ACT pedigree, Part I of the 2005 Eifert & Forsyth book aptly contrasts CBT and ACT and it might be useful. The "A Practical Guide to ACT" by Hayes and Strosahl, Springer, 2004, contains several goodies you might benefit from: (a) Ch. 2 is an ACT primer presenting of its many, many interventions (with page reference to the 1999 Hayes, Strosahl and Wilson book, where many interventions are explained in detail; although the Eifert & Forsyth book, in my mind's view--so it's not really my own and so please nobody take it personally--does a better job at describing interventions and it is focused on anxiety); (b) Ch. 3 describes how to carry out an ACT case formulation, less important for the 'watered down' way; and (c) Ch 5 describes ACT for anxiety disorders (and still I really recommend Eifert & Forsyth, 2005). (There are a bunch of new ACT books being published, mostly by New Harbinger, including ACT for PTSD, chronic pain, for anger, for children, etc, etc.)

Finally, the groundbreaking 1999 Hayes, Strosahl and Wilson book is considered the "ACT-bible" (funny term, isn't it?); and their first three theoretical chapters are presumably a must that, at times, drove me into temporary despair--if you survive these three chapters, you may have passed the first step (and most painful one) towards official ACT legitimacy. The other step is participation in at least one two-day ACT workshop--if lacking an ACT supervisor this might not be enough, at least it was not for me. Again, the 'watered down' way is workable for beginning ACT therapists and at the same time works for clients, at least for elevator phobias!

By the way, beware, beware, there may be a subversive subtext to my message: If ACT wants to "influence the culture", then it may have to allow each person to take what she or he wants from it, even if it means blending and mixing and bending and deforming. An either or cultural proposition, my mind tells me, perhaps wrongly, limits its ability to influence society broadly. Will ACT be like the air that gives us all life and we are rarely aware of it, or like a construction company, which comes with trucks and stones, and tears down and pushes away before building its new stuff? I am having the thought that it may be that if ACT wants to be "air," the creative, open and hetherodox spirit that resonates throughout everything ACT(when contrasted to a lot of our cultural practices), may have to also be preserved within the ACT community, where--my imprudent mind tells me--a chosen few (ACT nomenklatura?) may be working too hard to preserve some paradoxical ACT orthodoxy. I was also hoping the humour in my unorthodox, proposed ACT for Flying "protocol" for beginners would help difuse some of that. I thank my mind for all of these thoughts.

And it is terrific that you are considering ACT, an effective therapy that is also humanistic! Welcome.

Your fellow ACT traveller,

Koke Saavedra
Berkeley, CA