This post was written by one of our contributors, Principle Clinical Psychologist – Dr Joanne Skeldon
ACT is a type of psychotherapy which at its core is about identifying values – the things that are really important in your life – and using these values to guide and motivate behavioural changes (1). There is a growing evidence base for the use of ACT with adults to address mental health difficulties including anxiety and depression as well difficulties such as chronic pain (2). Research into the effects of ACT with children and young people is less extensive, however emerging evidence suggests that, as with adults, ACT can be used to address depression (3), anxiety (4) and chronic pain (5).
Emotions such as anxiety, sadness or anger are often labelled as bad or negative for both adults and children. They are uncomfortable feelings, and in some cases distressing and painful so we often try to avoid experiencing them. When we have a distressing thought, we can find ourselves ruminating on that thought. Before we know it, one distressing thought has spiralled into lots more thoughts, leaving us feeling sad, anxious or completely overwhelmed by emotions. Not only do these painful thoughts cause painful emotions, they have an impact on us physically. Anxiety triggers the sympathetic response (a.k.a the fight or flight response) including a racing heart, butterflies in the stomach, sweating and rapid breathing. We can also experience physical symptoms when depressed
including; tiredness, low energy, poor concentration and difficulties with attention. Not only can these physical symptoms feel horrible they can also contribute to our understanding that these feelings are bad or harmful and therefore should be avoided or stopped.
How does ACT work?
ACT aims to support people to live the life they want in line with their values, despite experiencing difficult feelings. Although these emotions feel bad, it doesn’t mean they are bad. In fact it’s normal to experience a whole range of emotions and different moods are part of being human. For example, sadness can help children to develop empathy and fear has a role in keeping us safe at any age in our life. Instead of teaching how to challenge or avoid unwanted thoughts and difficult feelings, ACT focuses on living life to the full, alongside them. At times in our lives we will all experience difficult thoughts, unpleasant memories and unwanted emotions and sometimes we can get stuck on them. We start to dread having them, worry about them and resent them when they prevent us from doing things we want to do. ACT can help people to change how they experience these thoughts and feelings and shift the way they respond to them and in turn cope with difficulties (6).
For example, let’s think about the experience of a psychological disorder such as anxiety or depression using the metaphor of a tug or war. The psychological disorder is holding onto the other end of the rope. The tug of war isn’t going well and you’re getting pulled closer and closer. You’re starting to lose the battle so you start to put all your energy into pulling on that rope and fighting harder to pull back. The thought of losing to the anxiety or depression makes living the life you want feel impossible, so you continue to pull and pull, eventually becoming exhausted. However, there is another option. You could drop the rope. This doesn’t mean the anxiety or depression goes away, but the outcome of the tug of war is no longer important. The tug of war doesn’t have to be won to prevent anxiety or depression from stopping you live the life you want to.
A key element of ACT involves using mindfulness techniques to help us to change our perspective of difficult thoughts and feelings and respond to them in a way which has less impact on our emotional wellbeing and our life in general.
What is mindfulness?
Mindfulness has become increasingly popular and for good reason. There is a growing evidence base that mindfulness can reduce the severity of symptoms of depression (7) and anxiety (8). Similarly mindfulness can reduce anxiety in children (9) and improve emotional regulation (10). Mindfulness is about attending to what is happening in the here and now and living in the present moment. Mindfulness can be described as being the opposite of our minds taking flight and ruminating on things which have happened in the past or fretting about something which may happen in the future. Mindfulness can help us to notice and identify difficult thoughts and feelings and in turn build resilience and confidence that emotions fluctuate and can come and go. When being mindful, no attempt is made to evaluate experiences as good or bad, wrong or right and instead you are encouraged to observe the experience without judgement.
ACT and mindfulness exercises don’t have to follow traditional styles of meditation and can tap into your creative and playful side. Mindfulness exercises can involve movement and activity whether that’s yoga, running, gardening or being creative.
Noticing and identifying physical feelings
A body scan exercise is a great way of starting to notice physical feelings related to stress or anxiety such as tightness or tension in the shoulders. Get in a comfortable position, either on your back or sitting and start to bring your awareness to your breath, followed by bringing the attention to the body. This includes an awareness of things like the texture of clothing on the skin and the surfaces the body is connecting to. Next the focus is drawn to particular parts of the body and awareness is brought to areas which may feel heavy or light or where there are sensations such as tingling or tightness. A body scan can be done by itself or can be incorporated into a cool down at the gym or stretches after exercise.
Noticing and identifying thoughts and feelings
The ‘leaves on a stream’ mindfulness exercise starts to help you to notice your thoughts and feelings; it doesn’t matter if they are pleasurable, upsetting or neutral. As you start to notice them, imagine the thoughts as a leaf floating by on a stream. The stream flows at its own pace. Sometime the stream is fast flowing with lots of leaves and other times it will be calmer and slower. We can’t control the stream and we don’t try and rush the leaves along to get rid of thoughts and feelings, we notice them and allow them to pass in their own time. From time to time, it’s normal for your thoughts to wander and distract you from being fully present in this exercise. Once you notice this happening, gently bring your attention back to the exercise.
Being in the here and now
Mindfulness activities aim to train the mind to remain anchored in the present moment and engaging with your senses can be an effective way of staying present. Getting creative with activities like painting, pottery making, gardening, baking or sewing can be a great way of focussing on your senses and disconnecting from everyday stresses. Think about how the textures feel in your hands, focus on colours of the paints or patterns of the material or notice the smell of the baking. The sky’s the limit when it comes to being creative but any activity which requires attention and focus can done in a mindful way.
(1) Harris R. ACT made Simple. Oakland CA; New Harbinger Publications, 2009.
(2) A-Tjak JGL, Davis ML, Morina N, Powers MB, Smiths JAJ, Emmelkamp PMG. A Meta-Analysis of the efficacy of Acceptance and Commitment Therapy for Clinically Relevant Mental and Physical Health Problems. Psychotherapy and Psychosomatics. 2015;84;30-36.
(3) Hayes L, Boyd CP, Sewell J. Acceptance and commitment therapy for the treatment of adolescent depression: a pilot study in a psychiatric outpatient setting. Mindfulness. 2011;2:86–94.
(4) Swain J, Hancock, K, Dixon A, Koo S, Bowman J. Acceptance and Commitment Therapy for anxious children and adolescents: Study protocol for a randomized controlled trail. Trials. 2013;14:140:2-12
(5) Pielech M, Voeles KE, Wicksell R. Acceptance and Commitment Therapy for Paediatric Chronic Pain: Theory and Application. Children (Basel).2017;4(2):1-12
(6) Hayes, S.C. Get out of your mind and into your life. The New Acceptance and Commitment Therapy. Oakland CA; New Harbinger Publications, 2005.
(7) Strauss C, Cavanagh K, Oliver A, Pettman D. Mindfulness-based Interventions for People Diagnosed with a Current Episode of an Anxiety or Depressive Disorder: A Meta- Analysis of Randomised Controlled Trials. Plos One. 2014; 9(4):e96110.
(8) Singh SK, Gory KM. Relative effectives of mindfulness and cognitive behavioural interventions for anxiety disorders: Meta-analytic review. Social Work in Mental Health. 2018;16(2):238-251
(9) Borquist-Conlon D, Maynard BR, Brendel KE, Farina ASJ. Mindfulness Based Interventions for Youth with Anxiety: A systematic Review and Meta-Analysis. Research on Social Work Practice. 2017;29(2):195-205.
(10) Mendelson T, Greenburg MT, Dariotis JK, Gould LF, Rhoades BL, Leaf PJ. Feasibility and preliminary outcomes of a school based mindfulness intervention for urban youth. Journal of Abnormal Child Psychology. 2010;38(7):985-994.