ACT: Acceptance/Willingness

1. ‘When suffering knocks at your door and you say there is no seat for him, he tells you not to worry because he has brought his own stool’ • Chinua Achebe, from Arrow of God

2. ACT: Acceptance/Willingness

3. Key targets for willingness • Help clients let go of the agenda of control as applied to internal experience • Help clients to see experiential willingness as an alternative to experiential control • Help clients come into contact with willingness as choice, not a desire • Help clients to understand willingness as a process, not an outcome

4. Control • A great deal of suffering and struggle is found in the denial of the inevitability of human pain. • When we feel a whole range of negative emotions, we generally try our best to undo these experiences • These attempts at controlling our private experience (via suppression, avoidance, distraction, re-structuring etc.) can often back fire • Despite being a perfectly natural coping strategy, and despite sometimes working very hard to avoid painful events, the positive effects of avoidance are short-lived • For example, imagine a social phobic who values relationships with people. Initially avoiding people may provide relief, but the long term implication for this action is isolation

5. Attempts at controlling unwanted, unpleasant experiences can cost us in two major ways • Firstly, often when we try to reduce or remove pain it returns stronger to haunt and distress us. It also leads to the development of a vicious circle where pain is something to be feared. Therefore we feel pain about having pain, or anxiety about feeling anxious or depression about being depressed! ACT calls this dirty pain! In contrast ‘clean pain’ refers to the discomfort that is natural and the automatic consequence of living life! • Second, attempts at avoiding painful experiences comes from our huge need to ‘feel good’. However, often a life lived in pursuit of feeling good is not lived in the service of our most deeply held values. Often, doing what is important or matters is painful and creates that sense of vulnerability. Ironically, often trying to feel good via avoidance will only lead to feeling bad!

6. What is willingness? • ACT specifically targets letting go of the control agenda, which aims to get rid of experiences that cannot be gotten rid of • ACT offers willingness as this alternative • If a client is unwilling then he or she makes choices based on the avoidance of internal experiences, rather than his or her core values • Willingness can be defined as ‘being open to one’s whole experience while also actively and intentionally choosing to move in a valued life direction’

7. Willingness is an action and has an all or nothing quality to it, it is a choice • Clients sometimes confuse willingness for a feeling. But one does not have to feel willing to be willing • Clients can often mistake willingness for tolerance. Tolerance implies that negative experience is to be withstood until something better comes along. • Willingness on the other hand involves openness and allowing, not as waiting or needing for something to change to a better thing if we are tolerant enough • Finally willingness is not loss or resignation, as the word acceptance can sometimes imply. It is life affirming, empowering and vitalizing

8. Willingness is a skill to be learned, not just a concept that provides miraculous results • It therefore takes time and practise • The job of the therapist is to manufacture situations where clients can choose to experience difficult thoughts or feelings • But there are steps the therapist employs in order to manufacture willingness in the client

9. The Method • The process of fostering willingness usually involves two steps; • Firstly, the therapist must undermine control as the dominant way of relating to one self and ones world. With the aim of creating an initial openness, this is a good precursor for introducing willingness • Secondly, willingness is introduced and the therapist will try to create situations that allow the client to practice these skills

10. Undermining control • Attempts to control are so second nature that managing and controlling unwanted events is not a choice, but ‘the way it is’. • Indeed the idea that clients might be able to willingly accept anxiety is a bit like suggesting they could live without breathing! • Therefore substantial work is done at the beginning of therapy, introducing the client to this new way of thinking.

11. The therapist will focus on a few issues when trying to undermine control attempts; • Help the client to become aware of his or her attempts at control based on their own experience. This is called ‘drawing out the system’ • Examining the workability of these strategies relative to larger life goals • Guiding the client to a place where he or she can let go of these strategies • The outcome of the process of undermining control is often a loosened attachment to and confidence in the control agenda

12. Draw out the system • Start with asking the client the nature of the issue i.e. why are you here? • Almost always clients will report a struggle with some emotion, memory or self evaluation (pain, anxiety, self doubt, worthlessness) • Next we move on to the strategies that the client has used to ‘solve’ the problem • Be careful some of these problem solving strategies may seem helpful (talking to friends) as well as unhelpful (getting really drunk!) • Importantly, the client probably isn't aware of the ways that they struggle to control their private experience. It is the therapists job to slowly ‘draw these out of the system’ • For example a depressed client may not immediately see how oversleeping and over eating are intended to modulate a mood state

13. Examine workability • At the same time as drawing out the possible ways that the client has attempted to solve their problems, the therapist must also examine the workability of these strategies • The basic question here is ‘have these strategies worked out as your mind said they would?’ • There are spheres to explore here • Firstly - has what the client did to reduce or eliminate anxiety actually eliminated anxiety • Your are in a win-win here, because the fact they have come to see you in therapy means that every other attempt at solving their problem hasn’t worked • Secondly, in what ways has the client constricted or limited their lives to deal with the problem? • ‘What would you be doing with your time if you were not busy managing your anxiety’

14. The reason the therapist explores these two avenues is because the two are linked in the experiential control agenda • Namely, control strategies often promise us not only that we will feel good, but that we will be living well also. The therapist in ACT attempts to undermine these two promises • Its ironic that most clients/people believe that if they feel good first, then living well is easy. And some spend their whole lives trying to achieve the first, at the expense of actually living

15. Therapeutic stance and pitfalls • The therapist should view whatever attempts at control the client has tried as perfectly reasonable and understandable • It is also important to focus on workability. This is not about being right, or proving that the therapist has a better way. Its about helping the client to apply the criterion of workability to their lives • Don’t get caught up in the content of what the client is saying i.e. don’t get side-tracked into discussing the clients problems in too much detail, we just want to know if the strategies worked • Remember that the client would have verbally rehearsed his or her stories many times, and may feel threatened and begin to defend themselves and their strategies, at this point come back to the issue of workability

16. The next step • Discussion is likely to show that past strategies have not worked too well. • In order to move the clients forward to a place where they can let go of these attempts, the therapist tries to foster a state of creative hopelessness, where the therapist suggests that perhaps those attempts ‘cant work’. • The idea of creative hopelessness is to ask the client to recognise that their attempts have not been working, and to suggest that a place of not having a solution is where we want to be. Because it’s a place where new possibilities are born • Importantly, at this point the therapist shouldn’t come up with a solution. Just let the client sit with their not knowing.

17. The importance of metaphor • Throughout the entirety of ACT metaphors are used to demonstrate the principles the therapist talks about. • With creative hopelessness the therapist will want to convey that usually, the more effort we make with something the more reward we receive. Yet in this case the client has made a lot of effort to no avail. The following metaphors may help • Struggling with quicksand • A person who has fallen into a hole with only a shovel to get out • Feeding a hungry tiger so that he will leave • Running on a hamster exercise wheel that goes nowhere

18. Lets look at some transcripts to see if we can spot what the therapist is doing

19. Important point 1 • Be respectful and humble even when being confrontational, otherwise it can seem like your playing a game • The idea is to let the client know that the strategies reinforced by the social community are not working, not that he or she is incorrect • the agenda is hopeless, not the client • The idea of leaving the client ‘hopeless’ comes from the fact that when were not busy engaging in avoidance we can see our lives more clearly • Remember that each client will need different amounts of time on this. Some are steeped in their avoidance, others not so much

20. Important point 2 • Here the therapist moves on from workability to suggesting that ‘control might be the problem’ rather that the solution to the clients problems • The problem is that our history tells us that if we have a problem, then we get rid of it and all will be well, but this may not be the case with psychology. • In all of these examples, clients think that getting their internal experiences under control will enable them to live (just like with physical problems). But what if it was all a lie! • When I get my anxiety under control, I’ll get a job • When the pain stops I’ll find another relationship • When I don’t feel guilty anymore, I’ll reconnect with my children

21. At this point a number of metaphors are available to the therapist to help out • Chinese handcuff • Tug of war with a monster • The polygraph metaphor • And many more • These all convey the same message – if you're not willing to have it, you’ve got it!

22. Fostering acceptance/willingness • Once the client recognises unworkable strategies and realizes that control might be the problem, therapy turns to willingness. • In this phase, attention is turned towards building new behaviours that are about embracing, holding and compassionately accepting one’s experience • Clients often enter therapy to feel better (be happier), acceptance aims to let clients feelbetter (get better at feeling) in the service of living better • The therapist guides the client to practise willingness so that they can apply it broadly to their lives

23. Remember that the client is taking a big step into the unknown here. • Not many people allow themselves to come into contact with their emotions/issues. • The therapist is there to gently guide the client to take these steps. They will do this in two ways; • Teaching the client what willingness is • Actively practising willingness in the present moment

24. Willingness involves embracing the moment, in the here and now, as it unfolds, fully and without defence • What we mean by fully is broad and inclusive, all emotions and mind content are there to be experienced, not just the parts we like. • Willingness is a choice – making a selection because we can • Many clients might provide many reasons why they do not have a choice, it is your job to allow the client to defuse from their reasons and take action

25. There is a quick way you can do this • Tea or coffee? • List the reasons why you would not choose one over the other • And now ask if the client could still drink that option despite all the reasons not to • It is not the reason that chooses, but the person • Would you be willing to choose willingness if it meant you got to live your life? • Lets look at a classic willingness metaphor

26. Willingness is an action • Just like teaching someone to ride a bike, it is difficult to instruct and must instead be experienced and practised • Willingness tends to be practised throughout the therapeutic process. The therapist will do this by continually giving clients the choice to do a difficult exercise or discuss a difficult topic • Popular exercises; • Eyes on exercise • Tin can monster exercise • Looking for Mr discomfort exercise

27. Important points • Willingness is often decided by the context i.e. a social phobic could be willing in a bookstore, but not a shopping centre, he or she could be willing or five seconds or one hour • Therapists would usually start by asking the client to be willing in a small way, then increase the steps with time. • Willingness is on-going – we can never achieve it, simply continue to choose willingly in each situation • Willingness is heavily integrated into the other parts of the ACT model • We will therefore come across many willingness exercises in the next few weeks • Now lets do some examples!!!!