Question 1

What if clients resist doing ACT exercises?

Russ Harris · Accepted Answer

First things first: have you obtained informed consent from the client to do ACT, and that the client understands and agrees to the ACT approach, including willingness to learn new skills in session and practice them between sessions? Assuming this has been done: Respond with openness and curiosity; with respect and empathy, bring the client's awareness to what's happening. For example, you might say, "I get the impression you don't want to do this ... is that right?" Explore what's triggering the behaviour: "This is a challenging exercise for many people. I'm wondering, is it bringing up some difficult thoughts and feelings for you? What's your mind saying? What are you feeling in your body?" If appropriate, work with the internal barriers you identified in step two—segue into defusion, acceptance, grounding, and so on. Clarify the purpose of the exercise: what is the aim? Link it to the client's therapy goals. "If this exercise could help you with ABC, would you be willing to do it even though it's uncomfortable?" If those four steps foster willingness, go ahead with the exercise. if not, try a different exercise or work with a different core process.

Question 2

How does ACT view the importance of the therapeutic relationship?

Russ Harris · Accepted Answer

The therapeutic relationship is of central importance in ACT. And one of the best ways we can strengthen it is to embody ACT in the therapy room. When we’re fully present with our clients, open to whatever emotional content arises, defused from our own judgments, and acting in line with our core therapeutic values of connection, compassion, caring, and helping, then we naturally facilitate a warm, kind, open, and authentic relationship. Indeed, when we give our full attention to another human being with openness, compassion, and curiosity, that is therapeutic in itself.

Question 3

What if clients keep changing their goals from session to session?

Russ Harris · Accepted Answer

Not a problem. As long as we're working with the six core processes, we're doing ACT. We can work with these on any goal. At the start of a session, agree on a goal and stick to it. However, if the client isn't following through on any goals—if they're not taking action—then we need to address the standard interventions for overcoming barriers to committed action.

Question 4

What if clients find it difficult to come up with behavioral goals and overly focus on emotional goals?

Russ Harris · Accepted Answer

Usually this indicates: a) the need for creative hopelessness to undermine the experiential avoidance/emotional control agenda b) the practitioner needs some more creative, flexible ways of eliciting behavioral goals c) the practitioner is failing to consider covert behavioral goals such as learning new skills to handle difficult thoughts and feelings d) the practitioner has skipped the informed consent process, which includes several 'catch-all' behavioral goals applicable to every client.

Question 5

Are activities such as exercising, gardening or reading the same as a state of mindfulness?

Russ Harris · Accepted Answer

No. You can do any activity mindlessly—on auto-pilot, disengaged, distracted, going through the motions, and so on. And you can do any activity mindfully—engaged in what you're doing, paying attention with openness and curiosity, focused on what is relevant and important 🙂

Question 6

What if focusing on the breath increases a client’s distress?

Russ Harris · Accepted Answer

First validate and normalise the experience; it's not uncommon. Then modify the exercise to focus on something else; after all, there are hundreds of other things here and now on which you can focus—your feet, your hands, the sounds in the room, and so on—no rule that says 'we have to focus on the breath' 🙂

Question 7

I’ve had a number of clients ask for reassurance upfront that I won’t do mindfulness with them – usually based on negative past experiences of therapy. How would you respond to this?

Russ Harris · Accepted Answer

These days, I’m increasingly advising therapists not to use the word mindfulness, as it can so easily trigger a negative reaction. So I recommend you use alternative terms, at least early on in therapy. For example, if clients are hooked by difficult thoughts, worrying, or rumination, we could talk about helping them to “unhook” or learn some “unhooking skills.” Or if making room for difficult feelings will help clients live their values and pursue their goals, we can talk about helping them “expand around” or “open up and make room for” those feelings and then refer to “expansion skills” or “opening up skills.” Another option is “flow skills,” as in learning how to let feelings flow through them. And if they’re having difficulty focusing on important tasks, engaging in life, or being present with their kids, then we can help them “focus,” “refocus,” “engage,” “train their attention,” or “be present.” But if you do use the “m” word with a client, and it does elicit a negative reaction, then you want to respectfully explore that response. Does the client see it as a religious practice? Has he heard bad things about it? What are his past experiences with mindfulness? What mindfulness practices has he already tried? What was he hoping would happen, and what actually did happen? We might say, “Thanks for being so upfront with me. I’m certainly not going to push you into anything you aren’t open to. I’m guessing you’ve had a bad experience with mindfulness in the past. That’s not uncommon. The word mindfulness is a bit like the word music; there are many different styles and variants. If you hate hip-hop but you love reggae, you wouldn’t dismiss all music; you’d just be selective about which type of music you listen to. It’s much the same with mindfulness; there are so many different types of stuff that come under that heading. When my clients have reactions like yours, it’s almost always because they’ve been through something that’s radically different from what I do. So can you tell me a bit about what you did, and what happened—so I can make sure that what you and I do is significantly different?” Having elicited that information, we can say something like, “Well given all that, I can understand your negative reaction to the word mindfulness. What we do here is so different; can we just forget I ever used the word? What I meant was learning new skills to handle difficult thoughts and feelings more effectively, and get more satisfaction out of life.”

Question 8

How can ACT be helpful for patients with eating disorders to break rigid food rules?

Russ Harris · Accepted Answer

One of the main six classes of fusion ACT targets is 'rules'. (The others are reasons, judgments, self-concept, past, and future.) We can use the same defusion techniques, exercises, and processes that we'd use with any other type of rule people are fusing with. Typically, we'd begin by noticing and naming the rules, then look at them in terms of workability.

Question 9

Any tips for engaging adolescents in face-to-face (video) online work?

Russ Harris · Accepted Answer

Take regular breaks to dance, jump, or stretch. Watch relevant YouTube videos to segue into experiential work. If using Zoom, play silly drawing games using the whiteboard, or play around with the annotation feature on the share screen. And all the usual stuff: good lighting, removal of distractions, and the largest screen possible (PC trumps iPad trumps cell phone).

Question 10

How would you explain ACT to an undergraduate medical student?

Russ Harris · Accepted Answer

I'd use the choice point. Here's a brief animation that summarises it: https://www.youtube.com/watch?v=OV15x8LvwAQ

Question 11

In session, I’m having a client write down all their negative thoughts and going through the defusion practice of lowering the paper from her eyes and resting them on her lap. Is this something that would be helpful for her to do at home when she is feeling overwhelmed?

Russ Harris · Accepted Answer

Not really. It's simply a metaphor to introduce the concepts of fusion and defusion. It would be much better to teach a defusion skill based on noticing and naming thoughts, and ask them to practice that at home.

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