Compare and contrast Acceptance and Commitment Therapy
Compare and contrast Acceptance and Commitment Therapy
The current essay focuses on two different therapeutic techniques, Acceptance and Commitment Therapy and Solution Focused Brief Therapy. The initial component of the essay outlines the therapeutic orientations of both approaches; then, the different approaches are related to a case study of a young lady called Linda who is seeking counseling due to feelings of hopelessness. The essay is then finished with some of the author’s personal opinions on the two therapeutic approaches.
Acceptance and Commitment Therapy
While Acceptance and Commitment Therapy (ACT) has been in development since the 1980’s, it has only recently risen to prominence and is sometimes described as a ‘new wave’ therapeutic technique. ACT is a modern behaviour therapy that uses acceptance and mindfulness interventions alongside commitment and behaviour change strategies to enhance psychological flexibility (Sonja, 2011). ACT differs from many modern therapies, in particular its approach to dealing with distressing emotions, thoughts and behaviours. Unlike many modern psychotherapies, ACT does not look to reduce the severity or frequency of unwanted thoughts and emotions; however, it instead focuses on helping people to live more rewarding lives even in the presence of undesirable thoughts, emotions and sensations.
ACT is underpinned by a program of research on the nature of human language and cognitions know as Rational Frame Theory (RFT). RFT describes how normal human language processes dramatically change the human experience by resulting in the ability to readily and frequently evaluate virtually all of its experiences negatively (Flaxman and Blackledge, 2010). This verbal capacity allows humans to compare their ‘ideal’ to their ‘flaws’. Any discrepancies can be interpreted as unworthiness, and this can be a cause of psychological distress. RFT has led to the development of an empirically based model of human functioning that comprises six interrelated therapeutic processes. These are: acceptance, defusion, contact with the present moment, self as context, values, and committed action. While detailed descriptions of these processes are beyond the scope of the current essay, a few elements can be explored.
Cognitive fusion is a core process, which can lead to psychological distress. Cognitive fusion refers to when words themselves take on the properties of the things to which they refer (Flaxman and Blackledge, 2010). For example, if someone has gone through a violent attack, that individual may have thoughts about the attack, which can bring up in the present, all the thoughts, emotions and memories associated with that event, even if it was many years ago. In this example the individual may start to think that all people are dangerous, and therefore not go out. Thus the process of ‘fusion’, by which verbal processes come to excessively or inappropriately influence behavior, which may lead one to behave in ways that are guided by inflexible verbal networks. ACT would look at assisting the individual to not be governed rigidly by the thoughts in their head, working instead to find ways to more effectively interact with the directly experienced world, rather than the verbally constructed one in their mind (Sonja, 2011).
Acceptance and commitment
While the word acceptance may have associations for some such as “grin and bear it” or ‘soldiering on’, the word is used differently in ACT. In ACT the word acceptance refers to the willingness to experience distressing emotions and experiences that are encountered in the process of behaving in a way which is consistent with one’s values (Flaxman and Blackledge, 2010).
Commitment refers to a public commitment to a specific value or value-consistent behavior, where the individual acts in accordance with their values. For example, a person whose value is to be ‘a caring partner’ may commit to taking their partner out for a meal each week.
Solution-focused brief therapy
Solution-focused brief therapy (SFBT) was developed by Steve De Shazer and Insoo Kim Berg in 1986. SFBT believes that change can come from two primary sources, firstly by getting clients to discuss their preferred future, for example what their lives might look like should therapy be successful and, secondly, by detailing their skills and resources that clients have at their disposal (Macdonald, 2011). SFBT holds that language and words are very important, and that helping clients talk about their lives in more useful language can lead to positive change. One of the major differences between SFBT and other psychotherapies is that while SFBT acknowledged that clients tend to come to therapy to talk about their problems, the SFBT will not encourage them to talk about their problems, but rather to talk about solutions (Rafter, Evans and Iveson, 2012).
One of the central assumptions of SFBT is that the client will choose the goals for therapy and that the client themselves have resources which they will use in making changes (Macdonald, 2011). The therapeutic conversation aims at restoring hope and self-esteem, while reducing anxiety to a point where people become able to think more widely and creatively about solutions. SFBT holds that high anxiety can restrict cognition and attention to the surrounding environment and that, by reducing anxiety, it would allow for wider thinking about possible approaches to problems, as well as mobilizing their existing strengths and resources to address their desired goals (Rafter et al, 2012).
Therapeutic relationship and goals
The therapist adopts a non-expert or ‘not-knowing’ stance, in which the individual selects the goals and the means to get to the goals. Unrealistic goals may be negotiated with the therapist. Unlike other therapies no homework is given and no advice is given as to what should be done next. As Insoo Kim Berg said: ‘leave no footprints in the clients life’. The word ‘brief’ in SFBT means that therapy should not last ‘one more session than is necessary’. Research shows that the average client utilizes 3 to 6 and a half sessions (Macdonald, 2011).
The therapist seeks to maintain respectful curiosity about the client’s situation. The therapist assumes that change is possible or even inevitable, given the nature of the human existence, this philosophical stand point has its basis in Buddhist teachings, that change is a continual process and stability is only an illusion (Richard, 2011).
Assumptions of SFBT
De Shazer’s 3 rules which underpin SFBT
1 If it ain’t broke don’t fix it
2 Once you know what works do more of it
3 If it doesn’t work, don’t do it again, do something different (Rafter et al, 2012).
All clients are motivated towards something. Clients do not lack motivation and it is the therapist’s job to uncover what they are motivated towards. Attempting to understand the cause of the problem is not helpful and, in some cases, can be harmful as clients get caught up in describing their situation in negative language. However fixed a problem pattern may be, the client will be engaging in some of the solution.
Linda’s presenting problem
Linda has come to counseling, as she appears unsure about the direction her life is heading. There appears to be a gap between what Linda wanted to be and what she perceives herself to be now. She has described issues with her partner, including arguments over marriage. Linda also describes some negative thoughts about herself such as feeling ‘hopeless’ and ‘not good enough’. These thoughts and feeling appears to be very distressing to Linda. Many of these thoughts appear to be related to her new job where is often feels inadequate. Linda has also stated that she has found social interaction less rewarding recently and describes it as ‘pointless’.
Linda and ACT
One of the first steps for Linda would be discussing with the ACT therapist her chosen life values, that is the things that are most important in Linda’s life. For example, Linda might decide that being very successful in her work is an important value for her. Once the goal is established the therapist and Linda would look to commit to a pattern of behavior that is in line with the goal of ‘being successful at work’. Often avoidance and cognitive fusion issues can act as a barrier for clients in achieving their goals.
Experiential Avoidance, Cognitive Fusions and Linda
Within ACT, the case formulation is that affective disorders are the result of unsuccessful attempts to escape from challenging private events that the individual is unwilling to experience (Zettle, 2004). This is also known as experiential avoidance, which can be defined as the process by which individuals engage in strategies designed to alter the frequency or experience of private events, such as thoughts and feelings, memories or bodily sensations (Sonja, 2011). For example, Linda describes herself as ‘conservative’ and not much of a ‘risk taker’; up to this point in her life Linda has taken jobs that are well within her comfort zone.
As such, Linda may have avoided challenging work environments and avoided the pressure and criticism that comes along with these positions. The ACT therapist would focus on a course of work with Linda encouraging her to experience the full spectrum of thoughts, feelings and emotions so she does not feel the need to avoid or escape (Sonja, 2011). In this case asking Linda to experience the thought/feeling that ‘she is sometimes not good enough’. By facing this thought Linda may become more comfortable with it, and be able to function even in the presence of these distressing thoughts.
As experiential avoidance is seen as the underlying cause to psychological distress it stands to reason that the solution would lie in engaging clients in the situations they find difficult. If we accept that life will inevitably have psychologically distressful events and that often these events cannot be avoided, then therapy should help clients accept the distress that arises during life. At the core of RFT’s account of language and cognitions is the assumption that the kind of abstract, evaluative words we struggle with that claim to capture reality, in fact cannot. Thus, the acceptance part of ACT is not an acceptance of how an individually literally perceives it, but rather the acceptance of his experience as it is, and not how his mind says it is.
In this instance ACT would look to reduce the hold of language on the situation. Linda may make the statement ‘I’m hopeless’, ACT would look to reframe this to ‘I’m having thoughts that I’m hopeless’ rather than ‘I’m hopeless’. Reframing the statement in this way would move Linda away from defining herself as being ‘hopeless’ to defining herself as a person who sometimes feels hopeless; this would hopefully lessen the psychological distress and help Linda be more able to move towards her chosen goals.
Linda and SFBT
SFBT holds that there are two powerful tools to assisting recovery. The first, that positive talk about an individual’s preferred future will result in positive change; and secondly, identifying and highlighting the resources an individual already has at their disposal will better allow the individuals to use those resources. The SFBT therapist may ask Linda ‘What are your best hopes for therapy?’ thus encouraging problem free talk which is used to enhance the therapeutic alliance (Rafter et al, 2012). Problem free talk can often reduce anxiety and guilt if the therapist enquires about their success and interest as well as the problem. For example Linda has stated that there is a gap between how she is and how she wants to be, the SFBT therapist may ask ‘Can you tell me about a time when your actual self and ideal self were closer together?’
Perhaps one of the most famous elements of SFBT is the ‘miracle question’; as such it is worth looking at the miracle question in relation to Linda. The miracle question is designed to bring a sense of optimism and play, allowing creative thinking to emerge and confirming the goals already identified at the outset (Richard, 2011). The miracle question is designed to encourage the client to talk about the potential positive results of successful treatment. The miracle question is as follows:
‘I’m going to ask you a kind of strange question now. Suppose [pause] you go to bed and to sleep tonight as usual [pause] and while you are asleep a miracle happens [pause] and the problem that bought you here today [look round all present] is solved [pause]. But you are asleep and don’t know that it has been solved [pause]. What will be the first small sign that this miracle has happened and that the problem is solved?’
When asked the miracle question Linda would be prompted to describe feelings, thoughts or emotions which she wants to have in the future. She may answer ‘Well I guess I might feel more confident in my abilities, I may be more comfortable with who I am and I wouldn’t feel so anxious’. The SFBT therapist would then seek to expand on this answer by asking ‘what else?’ while always focusing on the positive elements of the answers. In the above example we see that Linda says ‘I wouldn’t feel so anxious’ the SFBT therapist may respond ‘Well you say you wouldn’t feel anxious, so what would you feel?’ to which Linda would hopefully respond with something positive ‘I’d feel calm and satisfied’.
ACT vs. SFBT
The power of language
Both ACT and SFBT hold language as a powerful influence on human distress. ACT argues that as human language has become more complex it has also presented humans with new challenges. Specifically how we use language to relate our own self to other people/stimuli. People learn arbitrary ways of evaluating themselves and their experiences in culturally agreed upon ways, for example ‘having no partner means that you are undesirable, being inadequate is bad’ and people hold these statements as rules or absolute truths (Sonja, 2011). Take, for example, the statement ‘being inadequate is bad’ this could lead an individual who has been inadequate to conclude that they themselves are bad, the individual may arrive at this conclusion without acknowledging the subjective and incomplete nature of the statement ‘being inadequate is bad’. Humans, according to ACT, come to place too much value in the accuracy of language. Indeed language holds so much power that what is verbally believed is consumed as solid fact (Sonja, 2011).
SFBT focuses on a different effect of language on the human condition. While ACT states that it’s how we relate language to ambiguous stimuli which is the cause of psychological distress, SFBT focus on the use of ‘problem free talk’ to improve an individuals psychological distress. SFBT holds that talking about solutions rather than the problem will in itself allow for positive change in an individuals life. The idea being that time is spent talking about individual’s strengths, rather than their problems, will reduce stress. When stress is reduced SFBT holds that clients are more able to access solutions for their problems, as when clients are anxious they have restricted cognitions.
The therapeutic relationship
Studies have indicated that the therapeutic alliance has a significant impact on the outcome of treatment (Lambert and Barley, 2002). ACT and SFBT share some similar ideas around what the therapeutic relationship should look like. Both approaches believe that the therapist should take a ‘not-knowing’ position which puts the therapist ‘in the same boat’ as the client. In ACT the therapist acknowledges that they themselves are human and struggle as well and thus they should be able to apply ACT principals to their own experiences in order to respond consistently and coherently with the model and to form an authentic relationship. If the therapist does not apply the principal to their life in and out of the session they may come across as disingenuous (Sonja, 2011).
While ACT requires the therapist to buy into the principles they are preaching, SFBT requires the therapist to assume that change is possible and even inevitable, given the nature of human existence. The therapist needs to hold genuine optimism about the possibility of recovery. An SFBT Therapist also uses language matching or language tracking as a means to building a solid therapeutic relationship. Language matching refers to when the therapist uses the client’s word for events and situations. If possible the therapist should use words or phrases the client uses in every statement. It is argued that renaming something amounts to contradicting the clients, which may not be helpful in building relationships.
Both ACT and SFBT have strong and affective therapeutic intervention styles. In my opinion, it is ACT’s unique approach to psychological distress that stands out as the most powerful. The idea that part of being human involves times of psychological distress resonates strongly with my own set of ideas. Indeed trying to restrict unpleasant psychological experiences seems in some ways to be unnatural, and against what it is to be human. Helping people to live and function in the presence of distressing emotions seems a more worthwhile pursuit than attempting to eliminate or restrict unpleasant experiences. In modern society there is an obsession with the idea that people should be happy all the time and this creates a situation whereby people who do not feel happy feel bad about not being happy and thus compound their misery.
The central idea of SFBT, that the therapeutic session should be centered on solutions rather than the problems is a clever tweak on the traditional approach to therapy. In my opinion, it makes sense to spend more time talking about what resources an individual might have and engaging in positive speak rather than talking at length about what is going wrong. Psychodynamic therapists have long said if you name an emotion in a session, then soon that emotion will appear, often accompanied by memories and experiences connected to it, therefore it stands to reason that if the problem is discussed at length this will be accompanied by the negative thoughts and emotions experienced with it, equally if the solution is discussed the thoughts and emotions may be more positive and foster hope. I feel that this technique could be easily amalgamated into other therapeutic frameworks. It would also be personally more enjoyable to the therapist to be discussing positive solutions, rather than spending all the time listening to problems.
Both ACT and SFBT offer a unique take of traditional psychotherapies. ACT helps individuals in achieving their chosen life goals even in the face of psychological distress and difficulties, while SFBT approaches psychological distress in a unique way by focusing less on the distress itself but rather the solutions and resources the individual has available to themselves. For Linda, ACT would entail some exposure of her fears of criticism, in order for her to achieve her goal of professional success, ACT would help her deal with the inevitable professional criticism which occurs in high pressure jobs. While SFBT would lessen Linda’s anxieties with solution focused talk, which in turn would mean that Linda could more affectively assess her personal resources and apply them to achieving her goals.
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