Q&A

Using ACT in Session

Internationally acclaimed psychotherapist and ACT trainer, Russ Harris, answers common clinical questions about using ACT in session, including how to respond when clients hesitate, avoid, or get stuck.

Things don’t always go to plan in session. Clients may hesitate, disengage, or struggle to follow through. That’s not a sign that something has gone wrong. It usually means something important has shown up.

In these moments, the task isn’t to push harder or try to get the client to comply. Instead, we can slow things down and get curious. What thoughts are showing up? What feelings are here? What is the client trying to avoid or get away from?

As sessions unfold, these patterns often become clearer. Clients may try hard to get rid of anxiety or other difficult experiences, only to find that what works in the short term comes with longer-term costs. From there, we can begin to explore what is and isn’t in their control, and how this connects to what really matters to them.

This opens the door to a different way of working. Rather than trying to eliminate difficult thoughts and feelings, we help clients respond to them more effectively, and take small, meaningful steps in the direction of their values.

As Russ Harris highlights, ACT is not about getting techniques “right.” It’s about how we respond in the moment—staying present, open, and guided by our values as therapists. When we take this approach, the therapeutic relationship itself becomes part of the work.

This Q&A explores how to navigate these moments in session, and how to respond in a way that is practical, flexible, and consistent with ACT.

What if clients hesitate or don’t want to do an ACT exercise?

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.

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

Some clients may become dizzy, light-headed, or more anxious while doing a breath-focused exercise. 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' 🙂

What if clients react negatively to the word mindfulness?

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.”

What if clients keep changing their goals?

Not a problem. The aim is to be flexible. 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. The outcome we want is higher levels of psychological flexibility, so as long as we are always working on that, we can freely shift our focus to differing goals.

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.

What if they struggle to come up with behavioural goals and focus on emotional goals?

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.

How does ACT view the therapeutic relationship?

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.

What if anxious clients just "want to get rid of anxiety," and nothing else?

Some clients cling very tightly to the emotional control agenda. This is especially common with anxiety disorders: anxiety is the enemy, and the client's goal is to get rid of it. With any client who's strongly fixated on the goal of avoiding or getting rid of emotional or psychological pain, we'll need to do creative hopelessness to undermine the control agenda.

A brief example of creative hopelessness, exploring how attempts to get rid of anxiety can bring short-term relief but long-term costs.

What if a client's goals are focused on things that are out of their control?

In ACT, we aim to empower people. This means it's important to establish a locus of control early on. What do you have most control over? What do you have least control over? Many clients come in fused with unrealistic ideas of control-expecting or wanting to have control of things they simply can't control (especially other people); it's important that we address that early in therapy.

Initially we sit with the client's stuckness and validate their pain, but not for too long (definitely not a whole session). We want to explain, "The more we focus on things we want to change that are not in our control, the more powerless and upset we feel. This can manifest as helplessness, hopelessness, anger, anxiety, guilt, sadness, rage, despair, and so forth. So it's important that we learn to focus on what is in our control, and to channel our energy and time into that stuff. This is at the core of self-empowerment."

What if clients ask, "Why should I accept it?"

That's golden feedback for us; it means we haven't clarified the link between acceptance and values. Remember, we'd never encourage a client to accept anything in ACT, unless it were in the service of living her values, pursuing values-congruent goals. For example, we might respond, "Are you willing to make room for these difficult thoughts and feelings, in order to be the sort of partner you want to be?" or "Are you willing to have this tight chest and racing heart, these knots in your stomach, if that's what you need to allow in order to live your values of intimacy and connectedness?" If a client doesn't see how accepting painful thoughts and feelings will help her to live her values or achieve her therapy goals, confusion or resistance is likely.

What if the client's only goal is "I just want to be happy"?

My immediate response is to validate it "Of course you do. Me too. I think almost everyone wants to be happy. So I'm guessing that you don't feel happy right now? So what kind of difficult thoughts and feelings are showing up for you?... What sort of things do you do when those difficult thoughts and feelings show up?... And how does that affect your life when you do that?"

This information can then be drawn or written on a choice point if desired, and used to structure the session. From there I'd say something like, "So a big part of the work here will be learning new skills to handle those difficult thoughts and feelings more effectively, so they have less impact on you."

And then I'd segue into setting behavioral goals for therapy.

A simple illustration of the Choice Point, showing how clients can notice difficult thoughts and feelings and take small steps toward what matters.

Are everyday activities such as exercising, gardening or reading the same as mindfulness?

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.