Children seldom present for therapy on their own. They are usually assigned to work with someone because an adult in their life has identified some behavioral problem of significance. Thus motivation to participate in treatment is often limited. Most child psychologists are already sensitive to this issue and are good at managing it. The diffi- cult part for many therapists will be to understand and adopt the theoretical framework that underlies ACT. One area where people often stray from ACT is by adhering to a more traditional “control of private events” framework and then attempting to use ACT as another method within this framework. The content or form of a particular private event is not the treatment target as it is in other therapeutic approaches. For example, “urges” are not the problem for a child with ADHD, nor is “anger” for a child with oppositional problems. The problem is how the child responds to these events when they occur. The thought or feeling itself does not need to change before the overt behavior changes.
Therefore a social context needs to be created in therapy in which the child truly feels that thoughts and emotions are acceptable and do not need to be regulated simply because of their form or frequency. This is accomplished in part by creating a therapeu- tic context in which these events are normalized. Thus the therapist might express that he or she is feeling different emotions and model how to continue behaving effectively while they are there. Additionally, an ACT therapist would want to avoid talk about “causes” of disorders or other types of storytelling of how the disorder developed. Any talk that would strengthen the fusion with these thoughts would ultimately be harmful from this therapeutic stance. The client is taught to trust his or her experience rather than what his or her mind suggests.
Therapeutically, the goal of ACT is to help the client experience thoughts and feel- ings as just that, thoughts and feelings, but only as much as it helps the person move in a better direction in life. When meaningful areas of life are linked up to the work done in therapy, there will be an increase in motivation to participate in treatment and it will give meaning to participating in treatment.
Therapists who are familiar with ACT but less familiar with working with children have expressed concerns that ACT will be difficult to do with children. This could be part of the reason that there has been considerably less ACT work with children than with adults. There also seems to be confusion between understanding the theory, the model, or how to implement the therapy and what it is like to actually participate in the therapy. Functional contextualism, RFT, and the techniques, assumptions, and principles of ACT would be difficult for a child to understand, but that is very different
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than participating in ACT as a therapy. ACT relies heavily on less literal methods such as metaphors, exercises, and stories because literal discussion can inadvertently support normative language processes that give way to cognitive fusion and experiential avoid- ance. This also means that ACT methods are more similar to methods commonly used with children. Logical, straightforward discussion has its role in ACT, but it is a rather limited one because logical processes are often assumed to be problematic within this framework. Again, this means that ACT methods are less complicated and abstract than most approaches and, for these reasons, may be very well suited for children and adolescents.
Acceptance
Acceptance is a core component of ACT. It is, in a sense, what an ACT thera- pist teaches the child to do with problematic thoughts, feelings, and bodily sensations: to experience them fully and without unnecessary defense. Acceptance has multiple meanings in the field of psychology. In ACT, acceptance refers to the way in which one responds to private events. There might be some situations that require acceptance of one’s situation or the actions of others, but this is not usually what is meant by accep- tance in ACT. Acceptance is best thought of as a behavior rather than an attitude. It is a skill; it is something that the child learns to do. There are a variety of exercises or statements that could foster acceptance in a child. The following is an example of an ACT exercise that might foster acceptance over controlling a thought or a feeling. It is described as though it was being said to a child diagnosed with conduct disorder who regularly argues with his teachers.
Therapist: Tommy, you said that you argue with your teacher because she is so “dumb.”
Client: Yeah, she is always getting on my case and asking me to do such stupid things, like clean up or fix stupid things on my papers. I like to do things my way.
Therapist: Fair enough. But this arguing is getting you in trouble, right? Client: Yeah. Sometimes I have to miss recess, or I get extra homework. Therapist: I want to help you get recess and not have to do that extra homework.
There are some skills that might help you. I bet it bothers you when she asks you to do these things.
Client: Yeah, I get angry.
Therapist: Does arguing make you less angry? Client: A little.
Therapist: And it also gets you in trouble. I know you like to do things your way, but what if I taught you another way to deal with your “angry” feelings that might keep you out of trouble?
Client: Okay.
Therapist: You know how it itches when you are bitten by a mosquito or if you get into a plant that you are allergic to? You can do things to make the itch go down like scratching it, but those things only work for a couple seconds and then the itch comes back. You keep doing this and eventually your skin will turn red and become irritated. I think you are doing the same thing with your anger. You “scratch” it to make it go away each time it shows up. You yell or fight so that you feel less angry. But this ends up getting you in trouble instead of making the anger go away—a lot like scratching makes your skin red rather than making the itch go away. Sometimes the best thing to do with an itch is to let it be. It will not make it go away, but it will keep your arm from turning red and irritated. Sort of how arguing to make your anger go away leads to not getting to go out for recess. So do you think you could let your anger be there without trying to make it go away, like you would let a mosquito itch just be there?
In this situation the therapist would likely be in contact with the school and the teacher while implementing ACT individually with the child. Consistent with tradi- tional behavioral interventions, the teacher would be encouraged to use differential reinforcement with the child to help him learn greater acceptance.
It can also be helpful to be very concrete and to use experiential methods such as role play when working with children. For example, if working with a young boy who fights and teases other children because he does not feel “tough” otherwise, the follow- ing acceptance intervention could be useful. The therapist and the client can role-play situations where the boy feels “weak.” The therapist can do things better than the client, the client can purposefully fail at things he is usually good at, the therapist can pretend to tease the boy, or the boy can say nice things to the therapist instead of his usual tough things. Doing these types of exercises will likely evoke the feeling of being “weak,” which he will want to replace with feeling “tough.” The therapist can work with the child to let these feelings be there—without fighting with them. The child can describe them, or act in ways opposite to them, and just generally “open up” to them. The thera- pist needs to be careful not to tell the child that doing this is in the service of lessening or controlling the emotions; it is done so that the client can get better at having these emotions without acting on them. This type of exercise can also be done with other emotions that clients struggle with. For example, if a child struggles with sitting through a whole class because of urges to get out of her chair, the therapist and the client can make games out of who can be more accepting of boredom. They can do repetitive tasks or sit quietly while practicing acceptance of boredom.
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In addition to exercises, acceptance is one skill that is often modeled in ACT. There are many instances in which the therapist can show the client that it is fine to feel what- ever feeling or have whatever thought that shows up during the therapy session. This can be very useful for children because they generally learn from adults and may look up to their therapists. For example, when a therapist forgets what he or she was going to say or is not sure of the answer, it shows acceptance to share with the child, “Wow, I feel embarrassed; I forgot what I was going to say.” The therapist should illustrate that he or she is welcoming of these types of feelings when it is useful for the client. If it is therapeutically useful, the therapist can also model emotional acceptance by showing emotion at an appropriate instance.
Defusion
Children avoid things that are real and can harm them. If you ask a child if she needs to be afraid of a picture of a monster or a real monster, the child will likely pick the real monster. From an early age, however, children start to respond to their thoughts and feelings as though they were real things. Thoughts are useful when doing homework or taxes, but they are less helpful when constantly struggling with thoughts like “being good enough” or “being tough enough.” ACT works to alter the context under which private events are experienced and changes them from purely literal events to ongoing processes of thinking and feeling, which increases the flexibility of behavioral regula- tion. Cognitive defusion processes should increase the likelihood of acceptance behav- iors and vice versa because it is easier to accept nonliteral events. There are numerous practices or exercises that can foster seeing thoughts, feelings, and bodily sensations for what they are. The following exercise involves an active approach that may be helpful for children, as they tend to learn better from practice rather than didactic training. It is called Thoughts in Flight. This exercise also supports other ACT processes such as acceptance and self as context (described below). The exercise can be introduced by saying the following:
We are going to play a little game with the thoughts that bother you at school. Usually when the thoughts start to show up, you grab onto them and struggle with them. You really get involved with them. We are going to do something— not to make them go away—but to play with them a little differently. We are going to make paper airplanes and use the thoughts that get in your way as the names for the planes. We will write those thoughts on the side of the planes.
The therapist helps the client make a couple planes. Next, the therapist and the client determine what thoughts have been interfering with the child and write those thoughts on the side of the airplanes. Next, the child is told that it is her job to watch the airplanes as they fly by without trying to grab the thought-plane or trying to keep it in the air. The therapist and the child can play with the planes and throw them around the room. This exercise should help the child see her thoughts in a different, less
threatening way. It can also be modified to promote acceptance. For example, the planes can be thrown at the child (safely), and the child can compare fighting against them versus just letting them land in her lap. Then she can be asked which one takes more work, trying to stop the thought-planes, or just letting them land on her lap?
The following exercise, called Taking Your Mind for a Walk (Hayes et al., 1999, pp. 162–163), can be altered for use with children.
Before we start today, it is important for us to identify who all is in the room. By my count, there are four of us: Me, You, Your Mind, and My Mind. Let’s just set out to notice how our minds get in the way. To do this I want us to do a little exercise. One of us will be a Person, the other will be that person’s Mind. We are going outside for a walk, using a special set of rules: The Person may go where he or she chooses; the Mind must follow. The Mind must talk all the time about anything and everything: describe, analyze, encourage, evaluate, compare, predict, summarize, warn, and so on. The Person cannot talk with the Mind. If the Person tries to talk to the Mind, the Mind should say “not your turn.” The Person should listen to the Mind without “minding back,” or necessarily doing what the Mind says to do. Instead, the Person should go wherever he or she chooses to go no matter what the Mind says. After at least five minutes, we will switch roles. The Person becomes the Mind and the Mind becomes the Person. The same rules will apply for another five minutes.
At this point, the therapist and the client can go for a walk around the clinic or outside if possible. The therapist speaks into the client’s ear as if he or she was the client’s mind. The two switch and let the child be the mind for the therapist. This exercise should help the client experience his or her mind in a different—less literal—way.