mindfulness – Dr Farhan Shahzad

Acceptance and Commitment Therapy is also known as ACT and is an approach to counselling that was originally developed in the early 1980s by Steven C. Hayes. It rose to prominence in the early 2000s when Hayes collaborated with Kelly G. Wilson and Kirk Strosahl.

ACT seeks to help clients transform their relationship with difficult thoughts and emotions through the acceptance of these and emotions. ACT sees these thoughts and emotions as being a normal part of life for much of the time, and, rather than avoiding them, clients should show compassion and allow the thoughts to pass freely. It is avoidance of these thoughts and feelings that is the problem, not the thoughts and feelings themself. Clients present to counselling with issues because they are avoiding the difficult thoughts and emotions, and by suppressing difficult thoughts and emotions, they only make them worse.

Have you ever tried not to think of a pink elephant? What do you see? A pink elephant!

ACT is based on this premise. The more we try to NOT think of something, the more powerful it can become in our minds. ACT practitioners do not seek to eliminate or change a client’s thoughts or emotions, but instead seek to help the client view these thoughts and emotions for what they are – pieces of language and transient psychological events, not external “truths”.

“Unlike more traditional cognitive-behavioural therapy (CBT) approaches, ACT does not seek to change the form or frequency of people’s unwanted thoughts and emotions. Rather, the principal goal of ACT is to cultivate psychological flexibility, which refers to the ability to contact the present moment, and based on what the situation affords, to change or persist with behaviour in accordance with one’s personal values. To put it another way, ACT focuses on helping people to live more rewarding lives even in the presence of undesirable thoughts, emotions, and sensations.”-(Flaxman, Blackledge & Bond, 2011, p. vii).

ACT practitioners encourage clients to approach problematic thoughts and beliefs and to be psychologically flexible, mindful and open. They use a range of mindfulness and acceptance-based strategies that also borrow from both cognitive and behavioural therapy approaches, and focus on a two-pronged approach: 1) helping clients develop acceptance of any unwanted thoughts and emotions and 2) committing to taking action towards living a valued life.

The basic principles of ACT

There are a number of causes of psychological distress, as suggested by the ACT model. Cognitive fusion is a term used in ACT that refers to when an individual allows their thought processes to have an excessive influence over their behaviour. The individual becomes so caught up that they become disconnected from the present moment.

During a state of cognitive fusion, a thought can seem like it is a fact and that you must obey it. Some people feel that they need to get rid of these thoughts or emotions straight away and that they command their immediate attention. Cognitive fusion is problematic because it prevents the individual living in the here and now and experiencing the present moment.

The term, experiential avoidance is used to refer to the process of engaging in strategies of avoidance and, while these strategies are effective in the short-term, they restrict an individual’s choices and usually lead to reinforcement of these problematic thoughts in the long-term. The more a person focuses on avoiding their thoughts and feelings, the more restricted their life becomes. Similarly, when a person focuses on avoiding these negative thoughts, they remove their focus from enjoying the present moment. The more energy being used on getting rid of these negative thoughts, the less energy they have for focusing on personal inner experiences and the world around them. The more energy spent on being fused, the less they have for being psychologically present. When individuals are psychologically fused, they focus too much on the past (ruminating) or the future (worrying). The goal of ACT is therefore to help clients improve their psychological flexibility so that they can be psychologically present and enjoy the moment.

The Six Core Therapeutic Processes According to ACT

The six core psychological processes that help people increase their flexibility are known as the ACT Helaflex and include the following:

Cognitive Defusion.
Acceptance
Contact with the present moment
Values
Committed Action
Self as Concept

Cognitive Defusion

Cognitive Defusion is also simply known as defusion and is the process of learning to detach ourselves from our thought processes. We simply observe them for what they are- transient private events that stream through our consciousness and are ever-changing. When an individual is defused from their thought processes, they are no longer controlled by them and do not get caught up in trying to change or control them.

Acceptance

This is the process of opening oneself up and also allowing room for unpleasant feelings, sensations and urges. This means the individual does not struggle with these unpleasant private events, but, instead, begins to accept them as a normal part of life. By releasing oneself from battling these unhelpful thoughts, the individual goes on to free themselves to enjoy the present moment.

Contact with the present moment

In this process, the individual becomes “psychologically present” and brings their full attention to the here and now. Because we have the ability to think about the past and the future, this can sometimes make it difficult to stay present in the current moment. Staying present in the moment is imperative to enjoying life.

Values

Therapists help clients identify their values, for instance, what is important to them. This is a central component of ACT and it assists the client to highlights things that are important and meaningful to them. It focuses on helping a client live out a truly authentic life.

Committed action

Once the client has identified what is important to them (i.e. through identifying their values), they can then make steps towards living out these values, even in the face of unpleasant thoughts and emotions. Behavioural interventions such as goal setting, exposure, behavioural activation and skills training are used to help the clients take positive steps.

Self-as-context

This is also known as pure awareness or the observing self, and creates a distinction between the observing self and the thinking self. The thinking self refers to the self that generates thoughts, beliefs, memories and judgements, whereas the observing self is the self that is aware of what we think, feel, sense and do. When we are aware of the observing self, we are able to step back and be mindful, thus separating ourselves from the thoughts, beliefs and memories that we have.

Each of these processes contribute to psychological flexibility.

The aim of ACT is to increase our psychological flexibility by using the above processes. The greater our ability to be full conscious and mindful, the better we are at tackling life’s problems and challenges. By embracing life, we become filled with vitality, which is a sense of being fully alive and embracing the present moment.

The six core components of the Helaflex are split into three types of functions. Both acceptance and defusion focus on separating thoughts and feelings, seeing them for what they are- just thoughts and feelings, and allowing them to come and go on their own accord. Values and committed action involve facilitating growth and directing the individual towards living out their authentic goals. While, self-as-context, and contacting the present moment are focused on making contact with the verbal and non-verbal aspects of the here and now. The psychological flexibility can be summed up as “be present, open up, and do what matters” and the ACT acronym is very useful for helping clients do this.

A- Accept your thoughts and feelings
C- Choose a valued direction
T- Take action

Essentially, we must encourage clients to accept what is out of our personal control and take action to make positive changes that align with the client’s values. “ACT is not about trying to reduce, avoid, eliminate, or control these thoughts and feelings. It’s about reducing their impact and influence over behaviour in order to facilitate valued living” (Harris, 2009, p. 61).

ACT in a Nutshell

The ACT in a nutshell exercise is a metaphor used to demonstrate the psychological processes underlying a client’s suffering and how ACT works. The therapist’s role here is to understand the psychological fusion that affects the client’s ability to be present and in the moment. When using any of the hexaflexercise techniques or metaphors, it is important to take the time to master them and also practise reading them allowed. Sharing these techniques often requires a slow, soothing voice. Recording and listening back can be very helpful here.

Jon Kabat Zinn is said to be the forefather of modern mindfulness. He is the man responsible for bringing this Eastern practice to the West. He defines mindfulness as:

“paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally. It’s about knowing what is on your mind.”

One of the first studies that Kabat-Zinn performed was in 1979 where he recruited chronically ill patients who were not responding to mainstream treatments for mental ill health. Kabat-Zinn’s study allowed for participants to participate in his eight-week stress reduction program, which he called the Mindfulness-Based Stress Reduction (MBSR). This proved successful and has since seen a substantial body of research providing more evidence of its efficacy. The research shows that mindfulness can improve mental and physical health comparably to other psychological interventions. Furthermore, mindfulness offers clients the ability to self-teach and use the tools anytime anywhere.

Everyone will experience restless nights and lack of sleep on occasion. However, if sleep is disrupted for weeks or months, insomnia can become a nightmare. Sleep disorders such as sleep apnea require medical attention as they can really reduce the quality of life of the individual suffering, but for those suffering from insomnia, anxiety can be the root cause.

There are different types of insomnia. Chronic insomnia is where there is disturbed sleep for at least 3 days a week for more than 3 months and it affects around 7-13% of the population. Genetics, environmental issues, and long-term stress can be the cause of chronic insomnia. Primarily older people, “worriers”, and females, tend to be more at risk. Also, those with health complications such as obesity can be at further risk. The above factors, plus a stressful situation may be enough to cause a good sleeper to develop insomnia. Similarly, adrenaline pumping events can also influence sleep.

Once a sleep problem has begun, a person may worry about being unable to fall asleep which can cause the cycle to continue. The more a person is worrying about not sleeping, the worse their problem gets. Rather than counting sheep, mindfulness can help with insomnia by breeding an awareness of what comes into mind from paying attention to the present moment and being nonjudgemental of thoughts.

Mindfulness can help us let go of the past and stop worrying about the future. It is essentially embracing the thought, showing compassion to it, and letting it go. Jon Kabat-Zinn noticed a marked improvement in sleep quality for those that participated in mindfulness-based interventions. Mindfulness can improve sleep by breaking the cycle of rumination- unhelpful worrying-and worrying about not sleeping or having enough sleep. By letting go, clients can embrace the fact that sleep will come at its own time.

Practising relaxation in bed through mindfulness-based interventions can also be very beneficial, promoting both sleep, and energy for the following day. Mindfulness also reduces stress and anxiety and can break the vicious cycle whereby clients read electronic devices or watch TV before bed. This blue light interferes with the sleep-awake cycle by affecting the hormone, melatonin, and keeps people awake longer than they should be. Mindfulness and Chronic Pain and Depression Kabat-Zinn’s work also focused on how mindfulness can help those with chronic pain and depression.

Alongside his colleagues, Segal and others, Kabat-Zinn wrote the book The Mindful Way Through Depression, and states that by not focusing on the pain, worrying about it, or trying to eliminate it, chronic pain sufferers open up space to enjoy other happier and joyous life moments. Those with chronic pain will often agonise and worry about their health and suffering, often to the point that the stress and worry exacerbates symptoms. By opening up room where the patient does not focus solely on their pain and suffering, clients can then begin to enjoy small moments within the day and gradually more as they work their way through practising mindfulness.

In those that suffer from depression, Kabat-Zinn argues to start small and focus on breathing. They can eventually work their way up to tackling their negative emotions. What the focus is on is for clients to anchor themselves and so when a negative emotion comes to the surface it doesn’t automatically trigger a whole heap of associations for the person. These can render a person helpless and ruminate in their trauma. When the person is anchored and negative thoughts can leave easily, the person can mindfully choose a response to deal with the thoughts. They move from reactive to responsive and are in a much more controlled state.

Segal, a colleague of Kabat-Zinn, argues that when a person has received mindfulness training, their responses to sadness change. When someone without mindfulness training experiences sadness, a part of the brain that seeks to diagnose is activated. This causes the person to become overwhelmed because they feel far more than just allowing themselves to feel the feeling. In those that have received mindfulness training, the two parts of the brain are able to balance each other out and the person can respond in a more responsive, controlled manner. Research into the effectiveness of MBCT for those with chronic or potentially recurring depression have shown that MBCT is 43% effective in reducing relapse in sufferers of depression and is seen to be as effective as antidepressants. Furthermore, those that have done mindfulness training begin to see if as a way of life as opposed to a treatment.

Posts

Acceptance and Commitment Therapy: An Overview

Mindfulness for Depression and Anxiety

Acknowledgement Of Country