Trouble with ACT: Is Defusion Alone Always Enough?

So, a lot of people (including ACT practitioners themselves) make the mistake of thinking defusion is about transcending thought, or having a para-cognitive (outside of thought) experience. This gives the impression that we don't concern ourselves with the content of thoughts at all in ACT. In fact, defusion itself can only happen at the level of thought. It's not stepping "out of the mind." It's simply mentally "re-tracking" to another cognition. Imagine a train track that bifurcates into two separate tracks. The initial thought is the track we are currently on. In defusion, we essentially are creating a secondary "mental track" (one that moves us towards values-based actions) and practicing how to flick the railroad switch to redirect ourselves from our default track to the newer one.

This is actually how traditional CBT works as well. What ACT takes issue with is the idea of "cognitive restructuring" or "cognitive revision", which posits that thoughts are these latent, static entities that can be reshaped or revised. In reality, thoughts occur in time: thinking is a continuous process. So, rather than treating the contents of the mind as solid "things", we treat thinking itself as an ongoing event. Trying to "revise" cognition is akin to trying to go back in time and "un-think" a thought. It just doesn't work that way.

Anyway, to answer your question: No. Defusion alone is not enough. We are verbal creatures, and human life is highly verbal. To navigate human existence, we engage in ongoing languaging (cognition). In ACT, we are just learning to forge a new behavioral repertoire around that languaging. There needs to be ongoing thinking to propel one forward towards behavior change and a life of value. What happens with more functional clients is that the whole ACT apparatus itself serves to model more helpful thinking. This can be summarized by the ACT question:

Given a distinction between you and the stuff you are struggling with and trying to change, are you willing to have that stuff, fully and without defense, as it is and not as it says it is, and do what takes you in the direction of your chosen values at this time, and in this situation?

That one run-on sentence encapsulates all six processes of ACT. But, for some patients, that apparatus doesn't kick in. The whole of the ACT apparatus is enlisted in the creation of a new behavioral repertoire (in which language is deeply embedded). We're not trying to transcend thought. Simply learning to use it in a more flexible way that gives us more room to move behaviorally.

Now, for whatever reason, this process doesn't happen for some clients, IME. For example, if a person has lived in an utter poverty of kindness, empathy, compassion, affirmation of their right to take up space in this world and pursue happiness -- whether through neglect, trauma, or abuse -- they will have a lot of trouble accessing some of the prerequisites for ACT-work. In such cases, you may need to spend some time modelling compassion, interest in the person's inner world, and advocacy/encouragement before he/she can actually have some glimmer of their own values. A Rogerian or attachment-based approach is often helpful here. Jason Luoma has been doing some great work integrating compassion with ACT. I recommend his Case Conceptualization Frameworks for working with highly self-critical and shame prone clients.

Another Where there's pain, there's valuing. Your client wouldn't be in so much pain and wouldn't be motivated to come to therapy if they didn't hold some values. As /u/beakfullofdeath suggested, ask them to go into the nature of their pain, and their values will become self-apparent. I can tell you one right now without even meeting this person: love. They wouldn't be suffering if they didn't have some secret expectation of compassion for themselves in the world. This is Freud's great insight into ambivalence: self-hatred is, paradoxically, given its painful valence by unconscious expectation for self-love.

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