Treating Trauma with ACT
New Harbinger Publications
New Harbinger Publications: You say early in your book that “the goal of acceptance and commitment therapy, or ACT is to bring vitality and valued living back to the traumatized individual who has been unable to recover.” This is a real departure from what most people would expect to get from therapy—symptom relief. Why is this the goal instead of relief from trauma symptoms?
Darrah Westrup: We don’t want to think of it this way, but in fact, traumatic events are a fairly common aspect of human experience. To be horrified, terrified, or otherwise in pain about such events is natural and appropriate! Who would we have to be to not be thus affected? It’s interesting that we call such reactions “symptoms”; we interpret them as “not okay” and pit ourselves against experiencing them. It’s that effort which is problematic and which fuels PTSD. Valued living becomes possible when clients are freed up to make value-based, rather than avoidance-based choices.
Robyn D. Walser: In fact, for many trauma survivors with PTSD, their lives have become unlivable. That is, they’ve stopped doing things they used to do, including the enjoyable things. In many ways their lives have become “small” as their symptoms have come to rule their existence. For example, the assault survivor who stays in his bedroom to avoid anxiety, the rape victim who stops having relationships because “all men are dangerous”, the car accident survivor who never drives again, or the war veteran who cuts himself off from his family as he has returned home “different”. These kinds of life-shrinking problems are consistently seen in PTSD and are largely done in efforts to control symptoms—in efforts to not think, feel and experience. However, these very efforts can actually increase symptoms and problems. The price of avoidance is the loss of a vital life. When these same people come to therapy, their request is often to help them “forget” the trauma so that they can get their life back. The work in ACT is to help clients live now, along with these experiences.
NHP: What is experiential avoidance, and why do you say it that its impact on a trauma sufferer is usually negative?
RDW: All humans experience—we feel, we think, we sense, we remember. These experiences are what make up our lives, and they provide richness, enjoyment, and relationship as well as pain and sadness. Experiential avoidance occurs when humans make any effort to escape these experiences. Trauma survivors, like many humans, work to avoid painful experiences. This in and of itself is not necessarily bad. However, when that avoidance leads to diminished engagement in life, suffering and pain can increase. What happens is a paradox: not only do trauma survivors not want these experiences, but they begin to fear them—they have a fear of fear or anxiety about their anxiety—and their suffering increases as they battle to get away from their own senses, emotions, and minds.
DW: Experiential avoidance is a human problem, and we all try to avoid pain. This costs us if we end up tiptoeing through life, trying to pick and choose the emotions we will have. It’s not possible to live a full and vital life in this way—we’re either in life or we’re not.
NHP: You say that “verbal knowledge, or our ability to create and grow our languages, is our miracle and our misfortune.” What do you mean by this, and how does this relate to the experience of those with post-traumatic stress disorder or trauma-related symptoms?
RDW: Verbal knowledge is our miracle because it has brought us and continues to bring us many wonderful things in life—ideas, transfer of knowledge, intimacy in relationships, communication, travel, technology, and so forth. But this same ability has also brought great struggle. Through language we can compare ourselves to an imagined ideal or imagine a future that would be filled with happiness—if only our histories weren’t filled with pain. We can think about what it would be like if things were better or different. This is problematic for trauma survivors when they think about (“language” about) their histories and how life would be better if they could eliminate the trauma and the painful experiences that often accompany trauma. History however, moves in one direction—a trauma cannot be undone. Misfortune arises when survivors imagine (again, “language” about) their life as a better or more whole human being if the trauma and its pain could be eliminated.
NHP: Mindfulness is an ancient Buddhist practice that entails being aware of and experiencing the present moment to the greatest degree possible. Yet it comes up again and again in this very contemporary and even revolutionary way of treating trauma. Why?
DW: The art of mindfulness has been around for a long time, but it certainly isn’t widely practiced in our society. In fact, our culture tends to be anything but mindful; we have ever increasing ways—like cell phones, videos, blackberries, iPods—to take ourselves out of the present moment. We also believe that if we “put our minds to it” or do the right things, we can make ourselves happy. This sort of belief system comes crashing down when a trauma occurs because none of the rules or strategies seem to apply, and we don’t have a skill set for dealing with the traumatic event. So what’s really revolutionary with the mindfulness component of ACT isn’t so much that the ideas are new, but rather that they’re novel to our culture. The mental health profession also has a long history of trying to help people feel better—read “happier”—so explicitly disavowing that as a goal of therapy is both revolutionary and bold. On the other hand, trauma is not a new experience for humans. It has been around as long as we have. It’s not really surprising that a technique arising from an ancient wisdom ultimately proves most helpful when it comes to human suffering.
NHP: For many therapists, applying an ACT-based program for PTSD is new territory, a radical departure from what the traditional behavior therapist is used to. Throughout your book you talk about “sticking points” for both clients and therapists. Can you tell us an example of a sticking point for clients and one for therapists? How are they resolved?
RDW: A common sticking point for clients happens when they hold themselves out to be broken or damaged as a result of their trauma and associated experience. This happens when clients lose contact with themselves as an experiencing being and fuse with their mind—holding the things that the mind has to offer as literally true. The resolution lies in recognition of self-as-context, in recognition that the client is a whole and experiencing being—larger than the mind and what it has to say.
DW: A common sticking point for therapists, particularly those new to ACT, is to prioritize completing a particular agenda for the session, say to introduce and discuss all the points regarding “Control is the Problem,” over being present to what is happening in the room. A therapist whose attention is on getting certain things accomplished runs the risk of missing important moments that are occurring in the here and now, and can also inadvertently support an avoidance agenda—for example, by moving ahead per the protocol rather than sitting with discomfort in the room. The resolution is to prioritize being present over completing the protocol in a certain way. That way the therapist can attend to what is actually happening and can address it in an ACT-consistent manner. This is ultimately far more powerful than marching through an agenda.
NHP: What is creative hopelessness?
RDW: Many trauma survivors with PTSD have tried numerous things to rid themselves of their symptoms only to find that many of these efforts have failed. They’ve used alcohol to control anxiety or isolation to control fear, for instance. These efforts are most often about trying to have some other experience than the current one that is happening in the here and now. These efforts can be fundamentally flawed, however, in that it is a “first you lose then you play” game. First there is something wrong with you that you need to fix, and then you need to go and try to live your life. The survivor starts from a place where what they feel isn’t okay—whole parts of their experience must be eliminated. It seems to the trauma survivor that he or she must change his or her thoughts and feelings in order to be whole and live fully. This is a change agenda—change your thoughts and feelings and you will be better, more acceptable, and so forth. This agenda is about being something other than what you are. Creative hopelessness tackles this agenda. The idea is to give up the agenda of change of internal experience by pointing to how misapplied and rigid control of internal experience hasn’t worked in any long-term or satisfying way or has been costly to the survivor. It is important to remember that the agenda is hopeless, not that the person is hopeless. Finally, stripping away misapplied control efforts is creative as it allows the possibility of something new to happen.
NHP: One of the original concepts of ACT is “self-as-context.” What does this mean and what issues does this concept bring up when applied to a trauma survivor?
DW: Self-as-context refers to the idea that we are more than the thoughts, feelings, or physical sensations we are experiencing at any given moment. Each one of us is an entity with all sorts of phenomena going on at all times. That is, we are inhaling and exhaling, our sensory receptors are picking up information, and our thoughts and feelings are also part of this constant and dynamic process occurring within us. As such we are the context for these phenomena, the “whole being greater than the sum of its parts.” This may sound deceptively simple; the ramifications are quite profound, particularly for trauma survivors. For example, a woman who is struggling with the memory of being raped might be experiencing thoughts such as “It’s my fault,” “I’m dirty,” or “I’m ruined”; she may have feelings of guilt and shame along with sensations of nausea, shortness of breath, and so forth. Because they are salient, she focuses on these internal experiences, and they become her reality. Understanding herself as context as opposed to content helps her make the distinction between these internal experiences and her actual self. This concept helps trauma survivors get out of the bind of having to erase their internal experiences in order to be okay. In addition, if the self is distinct from these internal experiences, then it follows that the self cannot be broken or ruined by trauma. This realization is huge for our clients.
NHP: The notion of “committed action” is central to ACT. What is this, and how do you apply it with trauma survivors?
RDW: Committed action is key in this therapy. It is the very thing that enhances and brings vitality to life. Committed action is about regularly taking very specific steps that are values driven. One component of the ACT intervention is to have people define their values to help them rediscover their own sense of personal direction. In ACT we ask, “How would you like spend your time here on earth? What will you stand for each day?” What we learn with trauma survivors, just as with most people, is that they want to stand for loving relationships, connection, being present to what is happening, and engagement. Many trauma survivors, however, have bought into the idea that they have to be free of the pain of their trauma before they can do these things. Yet history only moves in one direction, and the trauma will never be undone, although the pain of it will come and go. Vitality is found in the actions taken that are consistent with being loving, connected, engaged. It happens when we are present while compassionately showing up to the human experience of feeling, rather than waiting for “good” feelings (no more symptoms) to show up before living our lives.
DW: The concept of committed action is both a burden and a blessing. A key moment in ACT occurs when the client realizes that he or she is on the hook for the life they are living. Committed action holds the key to a meaningful life and also takes away reasons for not living fully. It’s very important to help trauma survivors find genuine compassion for themselves and their suffering while also holding themselves responsible for the choices they make.
NHP: Do survivors of different kinds of trauma—a war veteran as opposed to someone who has survived abuse, for example—present different symptoms?
DW: We have observed that the experience of trauma, the pain of it, is common across traumas. In other words, pain is pain. At the same time, clients’ stories are unique to them. Their experiences are as individual as they are. Traumas occur within a context, and that context also contributes to someone’s experience. For example, one of the greatest risk factors for PTSD is sexual assault, which along with the initial violation carries the burden of social taboo. It is therefore the case that certain traumas lead to particularly distressing thoughts, but ultimately even such thoughts are just that, thoughts.
NHP: In chapter 10 you discuss how a therapist can decide whether or not ACT is right for his or her practice. What are a few things a therapist should know about how ACT will change his or her understanding and practice of psychotherapy when thinking about adopting an ACT program?
RDW: ACT specifically targets experiential avoidance and is largely focused on changing one’s life rather than changing one’s insides. ACT targets the function of behavior (including cognitions), not the form. No effort is made to change the form of cognitions, in fact, it is nearly the opposite: The goal of ACT therapy is to help clients observe thoughts for what they are…thoughts. Acceptance of internal experience is key in this process. The client is asked to be willing to feel what she feels, notice what she thinks, be aware and mindful, and make and keep commitments that are consistent with her personal values. The same request is made of the ACT therapist: He or she should be willing to experience, notice, and choose a direction in life and in therapy that is values- based. If a therapist holds the notion that thoughts and feelings must be “good” or better in order for a life to be well-lived, then this therapy probably wouldn’t be for them.
DW: This is an active and disclosing form of therapy—the therapist is right in there with the client. If the therapist is uncomfortable with the idea of being on the same level with the client—experientially, not just conceptually—then ACT is probably not a fit for him or her.
New Harbinger Publications has been publishing psychology and self-help books since 1973. Their website includes author interviews, a mental health blog, and a listing of bestsellers and new releases.
New Harbinger Publications
The following is an interview with Robyn Walser, Ph.D., and Darrah Westrup, Ph.D., authors of Acceptance and Commitment Therapy for the Treatment of Post-Traumatic Stress Disorder and Trauma-Related Problems: A Practitioner’s Guide to Using Mindfulness and Acceptance Strategies
New Harbinger Publications: You say early in your book that “the goal of acceptance and commitment therapy, or ACT is to bring vitality and valued living back to the traumatized individual who has been unable to recover.” This is a real departure from what most people would expect to get from therapy—symptom relief. Why is this the goal instead of relief from trauma symptoms?
Darrah Westrup: We don’t want to think of it this way, but in fact, traumatic events are a fairly common aspect of human experience. To be horrified, terrified, or otherwise in pain about such events is natural and appropriate! Who would we have to be to not be thus affected? It’s interesting that we call such reactions “symptoms”; we interpret them as “not okay” and pit ourselves against experiencing them. It’s that effort which is problematic and which fuels PTSD. Valued living becomes possible when clients are freed up to make value-based, rather than avoidance-based choices.
Robyn D. Walser: In fact, for many trauma survivors with PTSD, their lives have become unlivable. That is, they’ve stopped doing things they used to do, including the enjoyable things. In many ways their lives have become “small” as their symptoms have come to rule their existence. For example, the assault survivor who stays in his bedroom to avoid anxiety, the rape victim who stops having relationships because “all men are dangerous”, the car accident survivor who never drives again, or the war veteran who cuts himself off from his family as he has returned home “different”. These kinds of life-shrinking problems are consistently seen in PTSD and are largely done in efforts to control symptoms—in efforts to not think, feel and experience. However, these very efforts can actually increase symptoms and problems. The price of avoidance is the loss of a vital life. When these same people come to therapy, their request is often to help them “forget” the trauma so that they can get their life back. The work in ACT is to help clients live now, along with these experiences.
NHP: What is experiential avoidance, and why do you say it that its impact on a trauma sufferer is usually negative?
RDW: All humans experience—we feel, we think, we sense, we remember. These experiences are what make up our lives, and they provide richness, enjoyment, and relationship as well as pain and sadness. Experiential avoidance occurs when humans make any effort to escape these experiences. Trauma survivors, like many humans, work to avoid painful experiences. This in and of itself is not necessarily bad. However, when that avoidance leads to diminished engagement in life, suffering and pain can increase. What happens is a paradox: not only do trauma survivors not want these experiences, but they begin to fear them—they have a fear of fear or anxiety about their anxiety—and their suffering increases as they battle to get away from their own senses, emotions, and minds.
DW: Experiential avoidance is a human problem, and we all try to avoid pain. This costs us if we end up tiptoeing through life, trying to pick and choose the emotions we will have. It’s not possible to live a full and vital life in this way—we’re either in life or we’re not.
NHP: You say that “verbal knowledge, or our ability to create and grow our languages, is our miracle and our misfortune.” What do you mean by this, and how does this relate to the experience of those with post-traumatic stress disorder or trauma-related symptoms?
RDW: Verbal knowledge is our miracle because it has brought us and continues to bring us many wonderful things in life—ideas, transfer of knowledge, intimacy in relationships, communication, travel, technology, and so forth. But this same ability has also brought great struggle. Through language we can compare ourselves to an imagined ideal or imagine a future that would be filled with happiness—if only our histories weren’t filled with pain. We can think about what it would be like if things were better or different. This is problematic for trauma survivors when they think about (“language” about) their histories and how life would be better if they could eliminate the trauma and the painful experiences that often accompany trauma. History however, moves in one direction—a trauma cannot be undone. Misfortune arises when survivors imagine (again, “language” about) their life as a better or more whole human being if the trauma and its pain could be eliminated.
NHP: Mindfulness is an ancient Buddhist practice that entails being aware of and experiencing the present moment to the greatest degree possible. Yet it comes up again and again in this very contemporary and even revolutionary way of treating trauma. Why?
DW: The art of mindfulness has been around for a long time, but it certainly isn’t widely practiced in our society. In fact, our culture tends to be anything but mindful; we have ever increasing ways—like cell phones, videos, blackberries, iPods—to take ourselves out of the present moment. We also believe that if we “put our minds to it” or do the right things, we can make ourselves happy. This sort of belief system comes crashing down when a trauma occurs because none of the rules or strategies seem to apply, and we don’t have a skill set for dealing with the traumatic event. So what’s really revolutionary with the mindfulness component of ACT isn’t so much that the ideas are new, but rather that they’re novel to our culture. The mental health profession also has a long history of trying to help people feel better—read “happier”—so explicitly disavowing that as a goal of therapy is both revolutionary and bold. On the other hand, trauma is not a new experience for humans. It has been around as long as we have. It’s not really surprising that a technique arising from an ancient wisdom ultimately proves most helpful when it comes to human suffering.
NHP: For many therapists, applying an ACT-based program for PTSD is new territory, a radical departure from what the traditional behavior therapist is used to. Throughout your book you talk about “sticking points” for both clients and therapists. Can you tell us an example of a sticking point for clients and one for therapists? How are they resolved?
RDW: A common sticking point for clients happens when they hold themselves out to be broken or damaged as a result of their trauma and associated experience. This happens when clients lose contact with themselves as an experiencing being and fuse with their mind—holding the things that the mind has to offer as literally true. The resolution lies in recognition of self-as-context, in recognition that the client is a whole and experiencing being—larger than the mind and what it has to say.
DW: A common sticking point for therapists, particularly those new to ACT, is to prioritize completing a particular agenda for the session, say to introduce and discuss all the points regarding “Control is the Problem,” over being present to what is happening in the room. A therapist whose attention is on getting certain things accomplished runs the risk of missing important moments that are occurring in the here and now, and can also inadvertently support an avoidance agenda—for example, by moving ahead per the protocol rather than sitting with discomfort in the room. The resolution is to prioritize being present over completing the protocol in a certain way. That way the therapist can attend to what is actually happening and can address it in an ACT-consistent manner. This is ultimately far more powerful than marching through an agenda.
NHP: What is creative hopelessness?
RDW: Many trauma survivors with PTSD have tried numerous things to rid themselves of their symptoms only to find that many of these efforts have failed. They’ve used alcohol to control anxiety or isolation to control fear, for instance. These efforts are most often about trying to have some other experience than the current one that is happening in the here and now. These efforts can be fundamentally flawed, however, in that it is a “first you lose then you play” game. First there is something wrong with you that you need to fix, and then you need to go and try to live your life. The survivor starts from a place where what they feel isn’t okay—whole parts of their experience must be eliminated. It seems to the trauma survivor that he or she must change his or her thoughts and feelings in order to be whole and live fully. This is a change agenda—change your thoughts and feelings and you will be better, more acceptable, and so forth. This agenda is about being something other than what you are. Creative hopelessness tackles this agenda. The idea is to give up the agenda of change of internal experience by pointing to how misapplied and rigid control of internal experience hasn’t worked in any long-term or satisfying way or has been costly to the survivor. It is important to remember that the agenda is hopeless, not that the person is hopeless. Finally, stripping away misapplied control efforts is creative as it allows the possibility of something new to happen.
NHP: One of the original concepts of ACT is “self-as-context.” What does this mean and what issues does this concept bring up when applied to a trauma survivor?
DW: Self-as-context refers to the idea that we are more than the thoughts, feelings, or physical sensations we are experiencing at any given moment. Each one of us is an entity with all sorts of phenomena going on at all times. That is, we are inhaling and exhaling, our sensory receptors are picking up information, and our thoughts and feelings are also part of this constant and dynamic process occurring within us. As such we are the context for these phenomena, the “whole being greater than the sum of its parts.” This may sound deceptively simple; the ramifications are quite profound, particularly for trauma survivors. For example, a woman who is struggling with the memory of being raped might be experiencing thoughts such as “It’s my fault,” “I’m dirty,” or “I’m ruined”; she may have feelings of guilt and shame along with sensations of nausea, shortness of breath, and so forth. Because they are salient, she focuses on these internal experiences, and they become her reality. Understanding herself as context as opposed to content helps her make the distinction between these internal experiences and her actual self. This concept helps trauma survivors get out of the bind of having to erase their internal experiences in order to be okay. In addition, if the self is distinct from these internal experiences, then it follows that the self cannot be broken or ruined by trauma. This realization is huge for our clients.
NHP: The notion of “committed action” is central to ACT. What is this, and how do you apply it with trauma survivors?
RDW: Committed action is key in this therapy. It is the very thing that enhances and brings vitality to life. Committed action is about regularly taking very specific steps that are values driven. One component of the ACT intervention is to have people define their values to help them rediscover their own sense of personal direction. In ACT we ask, “How would you like spend your time here on earth? What will you stand for each day?” What we learn with trauma survivors, just as with most people, is that they want to stand for loving relationships, connection, being present to what is happening, and engagement. Many trauma survivors, however, have bought into the idea that they have to be free of the pain of their trauma before they can do these things. Yet history only moves in one direction, and the trauma will never be undone, although the pain of it will come and go. Vitality is found in the actions taken that are consistent with being loving, connected, engaged. It happens when we are present while compassionately showing up to the human experience of feeling, rather than waiting for “good” feelings (no more symptoms) to show up before living our lives.
DW: The concept of committed action is both a burden and a blessing. A key moment in ACT occurs when the client realizes that he or she is on the hook for the life they are living. Committed action holds the key to a meaningful life and also takes away reasons for not living fully. It’s very important to help trauma survivors find genuine compassion for themselves and their suffering while also holding themselves responsible for the choices they make.
NHP: Do survivors of different kinds of trauma—a war veteran as opposed to someone who has survived abuse, for example—present different symptoms?
DW: We have observed that the experience of trauma, the pain of it, is common across traumas. In other words, pain is pain. At the same time, clients’ stories are unique to them. Their experiences are as individual as they are. Traumas occur within a context, and that context also contributes to someone’s experience. For example, one of the greatest risk factors for PTSD is sexual assault, which along with the initial violation carries the burden of social taboo. It is therefore the case that certain traumas lead to particularly distressing thoughts, but ultimately even such thoughts are just that, thoughts.
NHP: In chapter 10 you discuss how a therapist can decide whether or not ACT is right for his or her practice. What are a few things a therapist should know about how ACT will change his or her understanding and practice of psychotherapy when thinking about adopting an ACT program?
RDW: ACT specifically targets experiential avoidance and is largely focused on changing one’s life rather than changing one’s insides. ACT targets the function of behavior (including cognitions), not the form. No effort is made to change the form of cognitions, in fact, it is nearly the opposite: The goal of ACT therapy is to help clients observe thoughts for what they are…thoughts. Acceptance of internal experience is key in this process. The client is asked to be willing to feel what she feels, notice what she thinks, be aware and mindful, and make and keep commitments that are consistent with her personal values. The same request is made of the ACT therapist: He or she should be willing to experience, notice, and choose a direction in life and in therapy that is values- based. If a therapist holds the notion that thoughts and feelings must be “good” or better in order for a life to be well-lived, then this therapy probably wouldn’t be for them.
DW: This is an active and disclosing form of therapy—the therapist is right in there with the client. If the therapist is uncomfortable with the idea of being on the same level with the client—experientially, not just conceptually—then ACT is probably not a fit for him or her.
New Harbinger Publications has been publishing psychology and self-help books since 1973. Their website includes author interviews, a mental health blog, and a listing of bestsellers and new releases.
