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Acceptance and Commitment Therapy for Psychosis: A Highly Valuable Contribution Despite Major Flaws

09/25/2013 12:21 pm ET | Updated Nov 25, 2013

The core of Acceptance and Commitment Therapy, or ACT, is the idea of simply accepting, rather than trying to get rid of, disturbing or unwanted inner experiences like anxiety or voices, and then refocusing on a commitment to take action toward personally chosen values regardless of whether that seems to make the unwanted experiences increase or decrease.

The process of applying ACT to "psychotic" experiences is well described in the book Acceptance and Commitment Therapy and Mindfulness for Psychosis, which I recently finished reading. I found a lot to like in the book and generally in the concept of applying ACT to psychotic experiences, but I also noticed some major limitations, which I will get to below.

There is, I think, great value in the notion of shifting attention away from attempts to eliminate experiences that might be labeled "psychotic" and focusing instead on increasing a person's ability and willingness to move toward his or her values. This idea is consistent with the emphasis in the recovery movement of finding a way to live a valued life despite any ongoing problems, but ACT has value because of the unique and effective strategies it offers to help people make this shift.

It is also a virtue of ACT that it is "transdiagnostic," that is, it is not an approach designed for specific "mental disorders" but rather an approach designed to address problems in living which are understood to be universal for human beings, including for the professionals themselves. ACT appreciates that life is tricky and that we can get caught up in strategies that are unhelpful to us, like focusing too much on trying to get rid of unwanted experiences and/or getting too taken over by, or "fused," with them, but it also appreciates that we all retain the ability to turn toward more constructive, value-driven approaches.

ACT is also often fun. Inspired by the book, I recently led a group mindfulness exercise, with my co-facilitator playing the role of a voice that interrupted that exercise, saying things designed to provoke and distract the group members. Meanwhile, I was guiding people in disengaging from his remarks, and having them notice they could gently bring their attention back to their breath. People ended up laughing a lot during the exercise but also noticing they did have the option of just disengaging from whatever was said, no matter how provocative, and attending instead to a particular chosen goal such as, in this case, paying attention to the breath. (You can download a detailed guide to using ACT in groups for people with "psychotic" experiences here.)

However, as noted by one group member who has made progress in understanding the parts of herself that lie behind her "voices," such an approach of treating the voice hearing experience as simply something to accept and make nothing of, is best seen as a strategy to do only some of the time. At other times, people may be better off trying to understand what is behind their voices. That's where I see problems with ACT: it tends to suggest that disruptive experiences, whether they be emotions, impulses, thoughts or voices, are just static to be disengaged from and then basically ignored as one moves toward values. But it neglects the way such experiences, when attended to and understood, can actually contribute to the development of a more integrated sense of values and self.

A commonly used metaphor in ACT is called "passengers on the bus." The idea is to imagine yourself as a bus driver, and imagining that you have a lot of rowdy, scary looking passengers. They start telling you where to go, with the threat being that if you don't obey, they will come up front of the bus where they will be very hard to ignore. So sometimes you do what they say to keep from having to notice them, and sometimes you stop the bus and try to throw them off (but they are too strong to throw off, plus you have to stop the bus to engage with them that way). The idea the ACT practitioner would be wanting you to become aware of is that in trying to get control over the passengers and over how noticeable they are to you, you have actually ended up with less control over the direction of the bus. The ACT practitioner would suggest you try instead focusing on where you want the bus to go, without trying to get rid of the passengers or worrying about whether they come up to the front of the bus and yell at you.

I believe the problem with always trying to live by this ACT metaphor is that while it may lead to being able to carry out intentional behavior toward values identified by the conscious part of the psyche, it tends to suggest there is no way of reconciling with the angry, scary, noisy parts of the psyche which may be objecting to those actions. For a different point of view, consider the perspective of Eleanor Longden, a woman who once was seen as a "hopeless schizophrenic" but who recovered using methods promoted by the hearing voices network, which she summarizes in the following analogy:

...I want you to imagine a group of people coming into a room. Some are angry, some are hugely distressed, and some are goading and malicious. They are not easy to be around, and we can choose one of two options for dealing with them The first is to sit down and try to understand them, to comfort them, to set helpful and safe boundaries on their behavior, to ask them what has happened to make them feel this way, and to seek possible solutions. The second option is to lock them in another room and wait for them to calm down. And perhaps they will. But what if they don't? What if, instead, they begin to claw and pound at the door, to shout louder to get our attention, to grow even more frustrated and distressed? And what if we, in turn, grow more afraid and mistrustful of them and become even less inclined to open the door and begin to negotiate peace and resolution? For years I had chosen the second option as the way to deal with the voices. The first option, quite simply, was what made my recovery possible -- out of the dark room and into the light.

I suspect a wise "bus driver" would alternate between at times being firm and taking some actions despite "passengers" yelling and complaining, but also at times being flexible and seeking to understand strongly expressed complaints and to come up with reasonable solutions that resolve difficulties and make peace with the passengers. So I think that even while ACT strategies are helpful for people with difficult or psychotic experiences to know and practice at times, ACT would do better to be more aware of the limitations of those strategies, and to consider alternating them with more self-exploratory strategies such as those suggested by Eleanor, who also wrote that:

...possibly one of the greatest revelations on the journey occurred when I realized that the most hostile, aggressive voices actually represented the parts of me that had been hurt the most profoundly -- and as such, it was these voices that need to be shown the greatest compassion and care. In turn, this meant sending a loving message of compassion, acceptance, and respect toward myself. My voices seemed like the problem; they were actually the solution, an inextricable part of the healing process.

I believe, like Eleanor, that every bit of our psyche and of our experience has value if and when we put it in the right perspective. I hope to see future versions of ACT which acknowledge this and which help people find value in, rather than just tolerate, the experiences they once felt compelled to avoid at all costs.