Acceptance and Commitment Therapy

The “Acceptance and Commitment Therapy” (ACT) presentation by Alessandra Strada, PhD, was undoubtedly helpful to pain practitioners who deal regularly with depressed or palliative care patients. But the benefits of the session didn’t end there. Much of what Strada presented was as germane to the attendees as it was to their practice.

In fact, this reporter found the discussion so thoughtful that it became difficult to take good notes from the session. There was much discussion from Strada about living in the now, in this moment. “You’re here right now,” she said. “How do you connect right now? You don’t have to be a meditative master to take a step back. You can constantly bring awareness back to the present. You can do that at any time. It’s our birthright, the natural ability of our mind.”

If this all sounds a little earthy-crunchy, it was not. Strada is not interested in hocus-pocus “inner healing,” but in tools that can help pain practitioners and palliative care professionals work with patients who may not have much hope and whose experience of cognitive dissonance is hurting their ability to heal. “This approach has been validated by patients who have chronic pain.”

One of the key goals of the ACT approach is that language and cognition interact with life circumstance, and produce what Strada calls “psychological inflexibility—inability to make necessary changes. Patients can become stuck in their own discomfort, and that prevents them from moving forward.”

ACT differs from Cognitive Behavioral Therapy (CBT), which seeks to challenge a patient’s beliefs and ask the patient to look at other ways to react to their situation or feel about their condition. For example, a person who sees a friend from afar and waves, but does not receive an acknowledgment, may think it’s because they’re unlovable or because they’ve done something wrong. Under the CBT model, a therapist might ask the patient to consider a host of other possibilities: that the person didn’t see the wave, or was too wrapped up in his or her own problems to acknowledge it.

The ACT model does not encourage the patient to do that. “That’s a lot of work to challenge the belief,” Strada says. In the case above, the CBT approach could lead the patient to become depressed about having a wrong thought, which can encourage the notion that they’re unlovable. “[With ACT], we ask the patients to observe, to notice their feelings of alienation and sadness. Instead of pushing sadness away, we should develop the ability to observe it, almost as if we’re watching a movie on the screen.” This kind of thinking can create breathing room between the patient and their experience.

Strada often returned to the concept of “mindfulness.” She says that our mind evaluates objects and categorizes them as good or bad, with very little gray. “The world is complex, so one of the ways the mind adjusts to an infinite number of variables is to say, ‘Do I like it or hate it?’ If it’s good, I like it. If it’s bad, I hate it. The natural progression is to try to hold on to the good things and push away the bad.” This uses up a lot of energy. In Buddhism, it is the beginning of suffering, according to Strada.

“Mindfulness helps you open that chain,” she says. “Patients often feel as if they’re in situations that they can’t control, which makes it very hard to have a stable, grounded sense of self.” A state of mindfulness can help patients’ mental state of awareness and focus, and allow them to get back to living their life in accordance with their own values and what is important to them. “It’s the most portable intervention you’ll ever find,” Strada said. "You can take it with you anywhere."

ACT seeks to identify the values that define a person—giving the person strength and meaning. “Who are you?” she asked. “What sustains you as a human being? What are you made of? What values guide your life and are still important to you? Often, patients put their lives on hold while going through treatment, waiting to resume it after treatment. For so long, their energy was focused on trying to achieve a cure.” The ACT model can help them reconnect, by helping them define their values and then commit to actions that help them achieve their goals.

Strada then presented six core processes to increase psychological flexibility:

1. Acceptance of present experience, without disconnecting, judging, pushing away or wanting to challenge it.
2. Cognitive diffusion, which she defined as de-identifying ourselves from our thoughts. “We are not our thoughts,” she said. Thoughts not good or bad; they are what they are. But we don’t have to be them, because we’re not”.
3. Being present in the moment—having nonjudgmental contact with psychological events as they occur.
4. Using the Self as context, by differentiating between the thinking self and observing self.
5. Defining valued directions: Looking at the big picture, finding each patient’s sources of meaning. “Life has always meaning,” Strada said. “You as a therapist can communicate that strongly, and help your patients reconnect.”
6. Committed action, which is about hope—a sense of what the patient would like to see happen. It’s key that the action is achievable. “Otherwise, it’s a fantasy that will not hold the patient for very long.”

Strada closed with a moving anecdote about an elderly cancer patient, recently diagnosed, who told her once that, “My life sucks, because I suck.” Socially awkward and not adept at picking up on cues, the patient had gone through life desperately wishing to connect, but finding that he drove people away. Though the patient only lived eight months beyond his diagnosis, ironically, the man’s cancer finally gave him a sense of purpose and the ability to connect with people.

“It’s hard to be present in the moment,” Strada said. “The only reality we have is this, this moment, you and I connecting in this room. This is all that’s real. But it’s difficult to stay focused in the present, especially for a patient dealing with chronic pain or cancer.”