One of the questions I get as a consultant concerns working with clients in crises. Therapists can struggle with being ACT- consistent in such moments, feeling at war with previous training or even requirements of their setting. ACT is well suited to work with clients in crisis, which makes sense when we consider the theory on which it is based. That is, basic learning principles and relational frame theory have taught us a great deal about how it is that humans can despair. Further, we come to under- stand that this type of suffering comes with the territory of being human. This level of understanding helps us respond to such situations in a way that is consistent with the therapy and also quite effective.
Scenario: The therapist and her female client are at the beginning of a session, and
have just completed a mindfulness exercise.
Therapist (wrapping up the exercise): “What did you notice during that exercise?”
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Therapist: “I’m not sure what you mean.”(Client remains silent, looking at the floor.)
Therapist (after waiting a bit): “What’s happening for you right now?” (Client is silent.)
Therapist (waits): “I’m not sure what to do here. It seems as though something important is going on.” (Waits, then continues.) “My mind is giving me all sorts of stuff around this, worries about what you are thinking and so on, but I don’t want to assume what’s happening for you. Would you be willing to share what you’re experiencing right now?” Client (whispers): “I don’t want to be here.”
Therapist: “So that’s a thought you’re having: ‘I don’t want to be here’?” (Client nods.)
Therapist: “Can you tell me what feelings are coming along with that?” Client: “I feel like dying.”
Therapist (very gently, compassionately): “You feel like dying.” (Pause.) “That tells me there’s a lot of despair going on right now.” (Client is silent, continues to look at the floor.)
Therapist: “And that thought about not being here… .Are there thoughts about killing yourself? About taking yourself out of all this?” (Client nods.)
Therapist (very compassionately): “I am so glad you are letting me know about this, about what you are experiencing right now.” (Long pause.) “And of course my mind is handing me stuff about it too— mostly, I’m just feeling a lot of concern for you right now.” (Client is silent, just listening.)
Therapist (another long pause, speaks slowly and gently): “There’s a struggle going on, too. On one hand, I want to somehow swoop in there and make this all okay, take away the pain and despair, the tough thoughts… .But we know it doesn’t work like that.”
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Advanced ACTLet’s take a look at this: The therapist has stayed on track, immediately working with the language she is using to create some distance between the client and the sui- cidal thoughts and feelings she is experiencing. The therapist models self- as- process by sharing her own internal experiences. She encourages client disclosure (which entails willingness) by demonstrating her own willingness to self- disclose in a vulnerable way. She has not asked why the client is feeling this way. Whys are less important in this moment than helping the client access self- as- process (and ultimately self- as- context). Her first priority is to undermine her client’s fusion with thoughts that her experience is intolerable and that killing herself is the answer.
There are numerous ways the therapist could work on defusion. For example, she could encourage her client to sit with her and simply have what’s there to be had, then eventually make the point that they were both fully capable of tolerating the pain of the moment. She could do a physicalizing exercise, asking the client to visualize her pain and put it in front of her so that they can examine it together. She could do an experiential exercise that targets self- as- process and self- as-context, such as the label parade. [Note: In this exercise the client is asked what thought or feeling she is strug- gling with, and it is then written on an index card. The therapist gives the card to the client with some tape with which she can attach it to herself, while asking what thought or feeling comes up next. They proceed until the client has covered herself in cards— a graphic demonstration of self- as-process and self- as- context. See Walser and Westrup (2007) for a more detailed description of this exercise.]
Other ways to work with this client could be to introduce the “chessboard meta- phor” (detailed in chapter 9), or to remind the client of this metaphor if they have already worked on it. She could bring in values as a way to help the client regain access to thoughts that aren’t about ending it all. First, though, it seems that just slowing down, and leaning in to the moment with great compassion, is what is called for here. It would not be ACT- consistent to respond to this situation in an alarmist way, as suicidal thoughts and feelings are a common human experience. The therapist is not fusing with the client’s thoughts, but is attending to them. While gently pointing out that these thoughts and feelings are yet another experience to be had, the therapist is treating this situation seriously. She is well placed to follow the guidelines many set- tings require in situations such as this. That is, she can complete a full risk assessment, develop a safety plan, and even move toward hospitalization, if need be.
Therapist: “One of the things I struggle with at times like this is needing to know you will be safe and also knowing this is part of being human. Life can be truly hard— it makes sense that our mind hands us stuff like ‘If this is what my life is going to be like, forget it!’” (Client nods; therapist continues.) “And we’ve also worked on the idea that thoughts and feelings aren’t actually in charge, that we don’t even have to do battle with them; they come and go, while we remain constant. In fact, there may have been other
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times in your life when these sorts of thoughts and feelings were around. Is that the case?”Client: “Yeah, a few times. But this is the worst. I’m just done.”
Therapist: “Okay. And while, on one hand, I know that this is an experience you are having, and that you are more than, larger than even thoughts and feelings this painful, I also have a value around making sure you remain safe. It’s time to talk about what we need to do, right now, to make sure you are safe.”
I wanted to include an example like this because it illustrates how therapists don’t have to choose between what their clinical judgment is telling them (this person is at risk) and being ACT- consistent. Again, it’s not about choosing between ACT and something else, or fitting ACT into something elso, so much as looking at what is unfolding through an ACT lens.
SUMMARY
In this chapter I have focused on two broad strategies for optimizing ACT. One is to start in a way that clearly marks the therapy as being about ACT. The other is to consistently approach session content by staying clear about where the therapy is in respect to the core processes of ACT. I am aware that I have been quite repeti- tious with that refrain. That is because nearly every ACT therapist with whom I have worked frequently moves off of process and into content despite their best intentions. This tendency simply speaks to the strength of languaging. Fortunately, with time and practice we build our ability to recognize and work with the processes in play.
I have stressed preparation as a way to keep the ACT lens before us. This lens helps us determine what processes are key for this client generally, where in the six processes the client is working and developing competencies, when to stay or move on, and how (such as which exercises and metaphors might serve skill development). I’ve suggested practicing delivering metaphors and exercises to increase effectiveness in the therapy room. Finally, I pointed out that looking through that ACT lens can keep therapists from being consumed by the content of a client crisis. Rather than try to fix the client’s experience, the therapist uses ACT processes to highlight what is happen- ing for the client and move forward to a safe resolution. Next, we move to a topic area that can make all the difference in how effective these strategies are: therapist style.