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Essay/
Psychiatry and psychotherapy

Photo by Peter Marlow/Magnum

Sailing into the storm

Acceptance and commitment therapy teaches us how to live a values-driven life even in the face of dark emotions and trauma

Joseph Trunzo

Photo by Peter Marlow/Magnum

Joseph Trunzo

is professor of psychology at Bryant University in Smithfield, Rhode Island, and a clinical psychologist. He is the author of Living Beyond Lyme: Reclaim Your Life From Lyme Disease and Chronic Illness (2018). He lives in Rhode Island.

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Edited by Pam Weintraub

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Before she even knew what was happening, he was already on her. He punched her in the face, smashed her head against the wall, and dragged her through the corridor by her hair. The pain was searing; the fear, overwhelming. When help finally arrived, after what seemed like an eternity, the damage had already been done. The effects of the beating were both physical and psychological. The onset of trauma, at first muted by shock, would soon unfold in ways unimaginable to her. Her illusion of safety was shattered. This was her job. She was this person’s caretaker, an authority figure in a building full of authority of figures. This wasn’t supposed to happen. She was supposed to be safe here, but the young man she was caring for was severely disturbed and, for reasons that will forever remain unknown, he turned on her, and her life would never be the same.

Alice was a teacher’s aide in a small-town high school working with students who had special needs. She was good at her job and cared deeply about her students, but Alice happened to be in the wrong place at the wrong time, and suffered an astonishing trauma as a result. Moreover, this was but the most recent traumatic event in a long line of abuse going back to her early childhood, when the adults in her life were doing everything but protecting her from the horrors of the world, her neighbourhood, and her own home.

The questions regarding Alice’s situation are obvious and paralysing. How does she come back from such a horrifying incident? How can she possibly lead a fulfilling, meaningful life when she comes from such an abusive, overly critical, neglectful childhood that never allowed her to build trust or learn healthy coping skills? How does Alice, or anyone, manage life while suffering with intense pain, let alone recover from it?

These are the questions that are asked of behavioural health professionals every day. As a practising psychologist, I see variations of Alice – people with all manner of pain and fear – on a daily basis. Our profession has at its disposal a variety of tools to help bring people back from the brink and see them through the most difficult times of their lives. Early in the history of psychotherapy, Sigmund Freud’s psychoanalytic theories led the way, focusing on the conflicts of the unconscious mind as major causes of psychopathology. While Freud’s work remained a dominant theory into the mid-20th century, many were left unsatisfied by its lack of scientific support. Partly as a result of this, psychologists flocked to behaviourism, which concentrates almost exclusively on how triggers and consequences shape observable behaviour. The scientific evidence regarding behaviourism was strong, but with much of the founding father B F Skinner’s work focusing on animal models, many recognised that human beings had more complicated cognitive processes influencing their behaviours and emotions. This led to the birth of cognitive psychology, which incorporated human thought processes into our understanding of behaviour and pathology.

Over the past several decades, the dominant, mainstream model in psychotherapy has been cognitive behavioural therapy (CBT), and with good reason. Pioneered by the US psychiatrist Aaron Beck and others, CBT has been nothing short of an amazing success in changing people’s lives for the better. It centres on recognising and reining in distorted thought processes that tend to lead to emotional and behavioural dysfunction. The techniques used in CBT work well, and we have voluminous scientific evidence as to their effectiveness.

CBT is not without its critics, however. Many have criticised it for being too formulaic, too rigidly adherent to specific protocols, and lacking in an ability to help those whose suffering is not rooted in distorted thinking but due to actual, uncontrollable, deeply painful, life circumstances. Alice’s beating and the trauma resulting from it are not the result of distorted thinking, per se, so how could CBT be helpful in such a circumstance? I was raised in the CBT model, and I consider many of these criticisms to be unfair, an almost cartoonish representation of the approach, and not accurate or reflective of what the model can do in the hands of a skilled and well-trained CBT therapist. I like to think I have helped many people using CBT but, on some level, I did find it a bit lacking in certain areas. I could never quite put my finger on it, but sometimes I felt like I was hitting a wall using CBT to help people overcome their pain and suffering. Perhaps it was me and not the model but, nevertheless, I was ready for a change.

Luckily, as a therapist evolves, so does the science of psychotherapy. By the time I met Alice, I had been steeping myself in a new approach to psychotherapy and behaviour change called acceptance and commitment therapy, or ACT (pronounced as the word). ACT had been 30 years in the making, and was part of the ‘third wave’ of behavioural therapy. Along with dialectical behavioural therapy (DBT) and mindfulness-based CBT, third-wave therapies and ACT incorporate Eastern-based mindfulness and acceptance practices into Western therapy approaches that seek less to control difficult emotional processes and more to accept and move through them.

The psychologists Steven Hayes, Kirk Strosahl and Kelly Wilson (all clinicians and researchers in the US) published their seminal book on ACT two decades ago. Since then, ACT’s popularity has grown steadily, capturing the interest of therapists hungry for change in how we address human suffering. ACT trainings are offered all over the world and are typically packed, sometimes with hundreds of attendees at intensive multiday seminars. ACT’s increase in popularity and the empirical support for its effectiveness as a treatment modality have not gone unnoticed. As a result, there have been many ‘turf wars’ regarding the differences between ACT and CBT. However, I’ve always viewed the models to be more complementary than contrary.

ACT has a way of turning our reflexive human responses on their collective ear, and I have found that to be profoundly effective. ACT helps people develop psychological flexibility, which is the ability to pay very close attention to the present moment, especially in regards to feelings and bodily sensations, even if they are uncomfortable or painful. It is important to do this free of judgment, because it allows you to make decisions about your life based not on controlling or avoiding whatever discomfort or pain you are experiencing, but on moving towards your values and what is meaningfully important to you. Our common reaction to pain and discomfort is avoidance, which creates unnecessary obstacles in our lives. Imagine that you got into a car accident that caused you to fear merging onto the highway. You decide that you will simply avoid it. This might help you cope in the short-term, but it effectively sets up a permanent roadblock to getting quickly to where you want to go. ACT seeks to eliminate our self-imposed limitations by asking us to attend to our pain without judgment. When we do this, we can make decisions not hindered by fear of pain. And when we’re not controlled by our fears, we can concentrate on our values and make choices that are meaningfully important. At first blush, this can be a tough ask, but ACT focuses on core processes that help people move away from suffering and towards a more meaningful life.

After Alice’s attack, she was flooded with distressing and painful thoughts on an almost constant basis. ‘I’m not safe, I could get attacked again. I can never go back to work. I can’t even drive by the school, let alone go in. How am I ever going to work again and live a normal life? What does everyone think of me?’ Her mind, that constantly running inner voice, was not being kind to her. This is frequently the case for most of us. As humans, we are fairly egocentric in our thoughts, often automatically assuming that they are valid. In reality, however, much of what runs through our constantly chattering internal mental process is nonsensical gibberish, which can be skewed, irrational or just wrong. This is where CBT tends to target its interventions, by identifying those distorted and irrational thoughts, and then arguing against them through more rational and reality-based means.

ACT takes a slightly different approach. Alice was what ACT calls fused with her thinking. In other words, her thoughts automatically represented her reality. For Alice, some of her thinking was distorted, but not necessarily all of it. Naturally, fear is an adaptive response to trauma – it is meant to protect us from future harm – but sometimes this protective mechanism gets hypersensitive, telling us that there is danger when there really is none, or at least a very minimal amount that doesn’t warrant a full-blown fear response. Alice’s fear reactions that were rooted in her trauma would cause her to be very guarded and afraid of nearly everyone she came into contact with, especially men, even those she knew would never attempt to harm her.

While the fact that Alice was harmed by men is real and not a distorted thought, she was fused with the notion that all men are dangerous, which is not an adaptive or functional way to go through life. ACT’s approach to these kinds of thoughts is to attempt to defuse them by being more observant of one’s own thought processes. So rather than Alice thinking ‘I might get attacked again’ and simply living this as her reality, ACT asks her to notice that she is having a thought about getting attacked again. This might seem like a subtle difference, but it is actually quite powerful. By noticing her own thoughts, Alice increases her ability to make decisions about how to behave in response to them.

Here is how this works in practice. Alice thinks: ‘What if I get attacked again?’ This question sets her mind down a path. What if, indeed? When she reframes this worry according to the ACT model, Alice says: ‘I notice I’m having the thought that I might get attacked again.’ Now all her mind has to do is decide what she’ll do with the thought. Is it useful or helpful? How much attention should she pay to it? This shift gives her some room to see that her thoughts are not necessarily her reality. From there, she can decide how much, if at all, to engage with it.

Note, I did not say that Alice is in a position to control her worries, make them go away or even determine their veracity. Where CBT might make attempts to unravel the irrational nature of Alice’s momentary thoughts, ACT seeks only to identify them as either useful or not in moving her towards what she values in her current context. For example, if Alice were in a dark alley late at night and thinking that she might get attacked, then this thought is useful, and should be engaged with and responded to appropriately. If, however, she is at home with her husband or surrounded by friends and family, this thought is probably not particularly useful, so Alice can choose not to pay so much attention to it. This increases the likelihood that Alice’s behaviour will not be dictated by those thoughts. They remain uncomfortable, but not a dominant factor in how she lives her life. 

Moreover, defusing a thought avoids the trap of arguing with it, which sometimes leads to over-engagement, and prevents people from living their lives in meaningful ways. If you are debating the rational or irrational nature of a particular thought, you are not living your life. You are over-engaging with a non-useful process, caught in a fruitless battle of controlling the uncontrollable.

ACT encourages people to lean into their emotional discomfort, explore it, and move through it, rather than trying to escape

An important concept in ACT is that attempts to control thoughts or emotions usually lead to greater problems. For example, people with obsessive-compulsive disorder engage in excessive handwashing or other compulsive behaviours as a way of trying to control those difficult and uncomfortable thoughts and emotions, but these attempts at control ultimately end up becoming a bigger problem. Entire lives are spent engaging in compulsive behaviours, all in attempts to eliminate distressing thoughts and emotions. Similarly, people who use alcohol or drugs to mute emotional pain often end up with greater difficulties than if they had just allowed themselves to move through the difficult feelings in the first place. Anxiety plus addiction is not a better outcome. The need for temporary relief often fuels only greater dysfunction and suffering.

This, of course, begs the question of what we do when we are distressed, if we choose not to avoid it. If trying to control one’s depression or anxiety is not therapeutically helpful, then what is? This brings us to acceptance, a wildly misunderstood term in ACT. Where defusion focuses on letting go of thoughts that are no use in our current context, acceptance focuses on difficult, uncomfortable and painful emotional experiences. Often, when people hear the word acceptance, they think of phrases such as ‘Get over it’ or ‘There’s nothing you can do about it, so just pull yourself up by your bootstraps.’ For someone who is suffering with severe emotional or physical pain, hearing this is akin to being dismissed. ACT has often been criticised for asking people to ignore their emotions but, in reality, it encourages and helps people to do exactly the opposite, to lean into their emotional discomfort, explore it, and move through it, rather than trying to escape, avoid, extinguish or control it. 

On its face, this seems frightening and, at first, it is. Human beings are wired to run from discomfort, largely for survival reasons, so many of us tend to overcorrect or over-attend to the trigger of these emotions, especially if we’ve had an experience that reinforces the danger, as Alice did. As a matter of survival, we are fundamentally safety-seekers, and the less distressed we feel, the safer we think we are.

The problem is, much that we seek safety from is not truly harmful. While painful emotions can be excruciating, they are not dangerous – they are simply proof of being human. Moreover, they are often connected to things that are of great meaning to us. Anyone who has been in a long-term relationship knows that there are ups and downs, moments of joy and moments of pain. Each emotion needs the other in order to complete the experience of being human, of feeling the full spectrum of emotion. When we try to shut down one side of it, no matter how much sense it might make in the moment, we tend to lose out on the other side as well. Alice spent years of her life withdrawing from others, being guarded and self-protective as the result of her abusive past. The assault in her workplace only reinforced and exacerbated this dynamic for her. But the more she tried to escape and control it, the more narrow, lonely and closed-off her life became. She wasn’t feeling connected to anyone – her friends, her family, even her husband, who was a good and kind man.

Acceptance asks us to recognise this paradox, to understand that it is part of being human to experience pain, that life requires it, and to exert endless effort towards always preventing pain is more than a full-time job that will never be accomplished. If, however, we can be open to experiencing pain and fear, to recognise their connection to things that are meaningful and purposeful, to give up the never-ending battle of avoidance, then we create room for our life to happen, even if things are difficult. So, acceptance is not just ‘sucking it up’, it is remaining open to our most difficult and painful emotional experiences so that we can move through them, all the while staying as engaged in our lives in meaningful ways as much as possible.

Alice ultimately recognised that, if she was ever going to move past her trauma, she had to stop trying to avoid and control it. It was only when she reached this point of acceptance – when she allowed herself to feel her pain with purposeful, meaningful intent – that her life began to open up and change. When we are able to do this, we can then make decisions based on what is meaningful to us rather than deciding things based on managing distressing thoughts and emotions. When we commit to value-driven action, it can ease the difficulty of coping with pain and discomfort. On its surface, this is counterintuitive, but once you embrace the paradox, it can be transformative.

This sense of openness is an important aspect of developing psychological flexibility, but it’s not the only essential process in ACT. The therapy also requires one to be present, both in the moment and in one’s view of oneself.

Alice, the victim of lifelong trauma and abuse, had ideas and versions of who she was that she carried over from childhood. This is not unique. We all do this, carrying those formative experiences that contribute to developing our sense of self. For some of us, those moments are largely filled with love and support, peppered with the normal pain and awkwardness of growing up. For others, these moments are replete with abuse and neglect.

Alice had been abused physically, emotionally and sexually for as long as she could remember by the people in her life she was supposed to trust implicitly and unconditionally. Her sense of self was defined by these experiences – that she was not worth loving, that she was not safe, and that no one was to be trusted. She needed to protect herself, always, and this meant keeping distant from everyone, physically and emotionally. The recent attack had brought this version of herself raging to the surface.

Not getting dragged down by the past or weighed down by the future requires being grounded in the present

Alice was defining herself by what had happened in her life, rather than what was happening in the current context in which she was living. Always defining herself through the lens of victimhood, she was unable to embrace the fact that she had good people in her life who loved her, cared about her, nurtured her. She was hanging on to older versions and definitions of herself rather than connecting to her present life, her present self. We all fall prey to this at times. We avoid things because we tell ourselves the same old stories – that we are not good enough, not fast enough, not smart enough, not lovable enough – and we believe them effortlessly. Breaking free from this involves a certain defusion from unhelpful versions of the self, noticing the process, letting go of it, and being present with and connected to our current selves. If Alice were to overcome her trauma, she could no longer define herself by it. She could never change what had happened to her, nor could she ever guarantee herself 100 per cent safety moving forward in her life, but she could make better decisions about how to deal with her past. She could decide how much those same old stories would dictate her present, and how best to approach the inherent uncertainty of the future.

Not getting dragged down by the past or weighed down by the future requires being grounded in the present. Our minds are constantly tugging at us, pulling us towards the anxieties of the future or the regrets of the past. When we focus intensely on the present moment – on what’s happening in our bodies, our minds and all around us – we increase our ability to be psychologically flexible. This is often referred to as mindfulness, which is really nothing more than just paying exquisite attention to the present moment. Again, this is not something that comes naturally to us, especially in our current culture of fast-paced living and hyper-responsibility. 

But for people like Alice, who was stuck in the trauma of the past and fear of the future, being present is a necessary part of being more psychologically flexible. By focusing on who she is now and on her current experience of her world, Alice is better able to engage in defusion from and acceptance of difficult thoughts and emotions, recognising their transient nature, and facilitating her ability to move through them rather than trying to control them. As difficult and counterintuitive as this is for her, she realises that the more she is able to be in this space, the more she practises being present and committing to it, the better her life becomes, the more connected she feels, and the less dominated she is by her pain. For example, when Alice is with her loving husband and her worry rears its head, she focuses on the now, and enjoys her life as it is in the moment.

To be open and present requires an abdication of the control agenda. Rather than fighting or controlling pain and discomfort or past versions of ourselves, we must lean into things that are difficult and painful, with the understanding that we really do not have the ability to control our mind or our emotions, only how we react, behave and respond to them. This might make ACT feel a bit fatalistic, but there is good news ahead. Being psychologically flexible and living your most meaningful life does involve aspects over which you have complete and total control. When learning about ACT and psychological flexibility, people often recognise that they have been living their entire lives based on trying to control emotional responses. When they come to understand that this has been counterproductive at best, and positively self-destructive at worst, they have to wonder, how do I make decisions about my life now?

Alice had the same question. If she were to shed the control agenda, to lean into her pain and no longer make decisions in her life based on avoiding it, how would she know what to do? We discussed at length the things that mattered deeply to Alice, that were core to her as a person. What mattered the most? Alice came to realise that her connection with her students and the work she did to help them live better lives was deeply important to her. Her relationship with her husband, whom she loved dearly but with whom she had shared little of her past trauma, mattered to her above all else. She wanted to go back to work, and she wanted to be more connected to her husband.

Alice did a fantastic job of identifying her values, her new guideposts for decision making. Moving forward, when faced with questions about what to do or decisions she had to make about her life, all Alice had to ask was whether or not doing something – focusing on a thought, avoiding a feeling, engaging in a particular behaviour – moved her closer to or further away from those values. Did avoiding driving by the school where she was assaulted bring her closer to her value of being connected to her students – or further away? Did keeping the secrets of her childhood trauma move her closer or further from emotional intimacy with her husband?

Once Alice had the roadmap, she was better able to make choices that made her life more meaningful. She drove by the school. She parked in the parking lot. She walked the halls where she was assaulted. She wrote and talked about her childhood trauma. She spoke with her siblings and other relatives, in an authentic way that was unfettered by any need to control her fear. She shared her deepest feelings and most horrifying experiences with her husband, because doing all these things moved her towards her values, toward a meaningful life. 

None of this was easy. In fact, at times, it was excruciatingly painful, but she connected that pain to her values and, as she moved through it, she was able to walk those halls more easily and eventually, effortlessly. She returned to her job. She felt even more connected to her students, her co-workers, her friends and her family. She took on leadership roles in her work community. All of it scared her, all of it made her uncomfortable, but it was purposeful, and in service of leading a meaningful life. If there is a value-driven purpose to your pain, it becomes just a little bit easier to carry with you. When you give up the control agenda and stop pouring your energy into trying to escape, avoid or extinguish difficult feelings, you free up space to work towards your values, which leads to more meaningful living.

The ACT process helps anyone who is suffering become more psychologically flexible

Finally, at its core, ACT is a behaviourally based approach. It requires doing. The acronym is not an accident. Once values are identified and directions are determined, committed action must take place if meaningful living is to occur. This is another aspect of our lives over which we actually have control. We can control what we do, and everything we do should move us towards our values. Once we accept whatever pain or difficulty we might encounter along the way, once we defuse from unhelpful thoughts and connect with the present moment and our current selves, once we identify our values, ultimately, we must do in order to move forward. Avoidance is no way to live meaningfully. Alice recognised this, and it motivated her to live better than she had ever lived.

Even though I have laid out the core processes of developing psychological flexibility, it is important to understand that ACT is not a linear process but rather very fluid. Each process can impact and affect the other. If you are having trouble with acceptance, turn to your values to make that burden more meaningful and lighter to carry. If you can’t identify your values, look to your pain – it often serves as the shortest path to what is most meaningful to us. The entire idea behind ACT is that the therapy process will help anyone who is suffering become more psychologically flexible. Through developing the skills of defusion, acceptance, contact with the present moment, engaging with your present self, identifying values and taking committed action, the process will lead to a richer, more meaningful life. Not one that is pain-free, but free from avoidance that paralyses you and prevents you from living a value-driven life.

Make no mistake, moving through the ACT processes and finding a different way to interact with your pain is hard. People have the most difficulty embracing the paradox of acceptance. Our instinct is to run as far away from our pain as possible, to be as safe as we can be. Making a decision to step into it rather than trying to get rid of it can be excruciatingly difficult. Feeling the intensity of those difficult, painful emotions and sensations can feel very dark and very lonely. I see it in all forms of suffering. The depression that never seems to lift, the drink that has to be drunk, the highway we cannot drive on, the hands that must be washed over and over and over. The reality is that most people are willing to embrace acceptance only when they have run out of options – when what they have been doing, often for years, simply doesn’t work anymore. This is a dark place that feels like there is no light to guide you out. It can be devastating. This is exactly where Alice found herself before she decided to open up to it, to feel it, to stop trying to control it, to accept it.

Alice continues to work hard in therapy, but she is becoming less the pupil and more the teacher. She has laid herself bare to her pain and come through the other side as a person she hardly recognises from her former self, in all of the best ways possible. In a recent session, I asked her if, were she to get the opportunity to change her past – wipe away the abuse of her childhood, delete the assault from her life, make it so none of it ever happened – would she do it? Without missing a beat, her response was: ‘Seeing who I am now, who I’ve become, the life I’m living, I wouldn’t change a thing.’ To be able to connect and embrace a lifetime’s worth of suffering in service of a valued end, that – in its very essence – is acceptance.

Joseph Trunzo

is professor of psychology at Bryant University in Smithfield, Rhode Island, and a clinical psychologist. He is the author of Living Beyond Lyme: Reclaim Your Life From Lyme Disease and Chronic Illness (2018). He lives in Rhode Island.

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