On the last track we discussed implementing Behavioral Activation Therapy. When implementing Behavioral Activation Therapy, three basic steps can be followed. These are identifying alternative actions, identifying and engaging previously rewarding activities, and fostering the cognition of devaluing thoughts as distractions.
On this track we will discuss acceptance and commitment therapy. First we will examine the focus of acceptance and commitment therapy or ACT. We will then discuss the two steps in implementing ACT. These are supporting identification of value and confronting distraction. A technique for confronting distraction is presented on this track as the worry time technique.
As you listen to this track, you might consider how to apply these Cognitive Behavior Therapy techniques in your practice with a bipolar client you may be treating who experiences depressive states or hypomanic episodes.
One client, Gary, had inherited a small business from his father. Gary grew the business into a large, successful one. Gary sold the business to live out his dream of being a farmer. Some years, Gary’s farm made a few hundred dollars, but, as Gary liked to point out, it really didn’t make a difference.
Gary stated, "If I never made any money at all it didn’t matter because I was getting full value from keeping busy and keeping fit." Gary’s attitude changed, however. Gary stated, "When I got to be around 55, I think I started sliding into a depression. The farm chores seemed to become a burden and my tractor became a stationery object.
As Gary’s mood blackened, his body functions seemed to deteriorate. Gary stated, "I am constantly fatigued. I’m usually in bed by 9. But I always wake up around 2 or 3 a.m. Then I start this anxious worrying until sunrise. Mornings are the worst. The prospect of yet another damn day to get through is too much."
Gary reported feeling somewhat better in the evening, though he’d sit around working out sums on a magazine cover to see how much money they’d have if he ‘couldn’t work the farm’ and they had to live on their savings. Gary’s appetite deserted him. Although he never weighed himself, he had to buckle his belt two notches smaller than he had several months before.
To begin, I decided to approach Gary’s depressive state using acceptance and commitment therapy or ACT.
The Focus of Acceptance and Commitment Therapy (ACT)
First, let’s discuss the focus of acceptance and commitment therapy or ACT.
ACT has a broad focus that asks clients to:
Accept their reactions and be present with them.
Choose and commit to a valued direction.
Take actions that are increasingly consistent in working toward that goal.
More specifically, acceptance and commitment therapy focuses on six processes by which clients are helped to move forward. These include acceptance, contact with the now, a transcendent sense of self, defining values, committed actions, and cognitive diffusion. As you may already know, ACT is a behaviorally based therapy in which it is believed that it is not possible to influence psychological variables without changing their context.
2 Steps in Implementing ACT
Step #1 - Supporting Identification of Value
Second, let’s discuss supporting identification of value. I asked Gary what things he valued in his life. Gary stated, "Well first and foremost I value Jesus and my salvation through him. Then I’d say I value my family and the farm." As you would expect, a major component of the ACT approach is that bipolar clients in a depressive state such as Gary are supported in identifying what is meaningful in their lives and the values to which they aspire.
Clients are then supported to engage in behaviors associated with these values and goals. I responded to Gary by asking, "What can you do to protect the value that you associate with your spirituality, family, and your farm?" Gary made a list of behaviors which supported the things he valued. Gary’s list included going to church, making time to show his family how much he cared, and working hard to make his farm successful.
Step #2 - Confronting Distractions
In addition to accepting, choosing, and taking action; and supporting identification of value; a third step in acceptance and commitment therapy is confronting distraction. When distractions arise clients are asked to take note of them and gradually move on. As Gary confronted distractions in this way, he found that he began to focus more on his values rather than avoiding pain and suffering. Gary used the worry time technique to help him confront and move past distractions.
CBT Technique: Worry Time
Gary stated, "First, I go into the den so my family won’t bother me. I take 30 blank three-by-five cards and a pencil. Then, I just sit and relax. As a worrier, I don’t have to do anything and before long worries will start buzzing around. As they come, I write them down on one of the cards." I asked, "Do you ever find that worries don’t come?" Gary stated, "If you sit there for half an hour and no worries start buzzing around, that’s OK. I just look at it as though I’ve simply used the time to relax. I’m not going to worry that I might not have any worries!"
For Gary, the second step in the ‘worry time’ technique was to categorize his worries. Clearly, the purpose of this step is for the client to begin to establish order regarding the perceived chaos of the situations over which the client feels they have no control. I stated to Gary, "You might have one batch of worries about your finances, another for your relationships, and so on." Gary responded, "Yeah, I usually have about three to seven categories." Some clients I have treated classify their worries by content, others by their perceived importance of specific worries.
Would you agree that how clients classify their worries matters less than how applicable the categories are to a client’s situation?
I continued to discuss Gary’s use of the ‘worry time’ technique. Gary stated, "Once I have my worries categorized, I think about each group carefully and see what I can do with the worries in that group. At the bottom of each card, I write down what seems to be the best solution."
For example, one of Gary’s worries was that he only had $500 in his checking account, but $800 worth of bills to pay. At a later session, Drew stated, "I immediately decided which bills to pay and which ones to let go. I wrote it all down on the card, including who I needed to call to explain and make payment arrangements with."
Would you agree that combining a simple CBT technique for overcoming distraction can help clients who are in acceptance and commitment therapy?
On this track we discussed acceptance and commitment therapy. First we examined the focus of acceptance and commitment therapy or ACT. We then discussed the two steps in implementing ACT. These are supporting identification of value and confronting distraction. A technique for confronting distraction presented on this track was the worry time technique.
On the next track we will discuss self absorption. I find that when helping the loved ones of a bipolar client deal with what to them appears to be self absorption, two techniques can be combined to bring about productive results. First the client’s loved one can benefit from understanding feelings of loss. Second, he or she can benefit from dealing with change.
Peer-Reviewed Journal Article References:
Gaudiano, B. A. (2011). Evaluating acceptance and commitment therapy: An analysis of a recent critique. International Journal of Behavioral Consultation and Therapy, 7(1), 54–65.
Jacobs, A. M., & Antony, M. M. (2009). Review of A CBT-practitioner’s guide to ACT: How to bridge the gap between cognitive behavioral therapy and acceptance & commitment therapy [Review of the book A cbt-Practitioner’s guide to act: How to bridge the gap between cognitive behavioral therapy and acceptance & commitment therapy, by J. V. Ciarrochi & A. Bailey]. Canadian Psychology/Psychologie canadienne, 50(4), 295–297.
Twohig, M. P., Ong, C. W., Krafft, J., Barney, J. L., & Levin, M. E. (2019). Starting off on the right foot in acceptance and commitment therapy. Psychotherapy, 56(1), 16–20.
What are two steps regarding implementing ACT? To select and enter your answer go to .