FLOW OF THERAPEUTIC CONVERSATION: In both traditional CBT (Cognitive Behavioral Therapy) & its newer incarnations ACT (Acceptance and Commitment Therapy) conversations will often have the general ebb and flow of normal conversation with an extra emphasis on both therapist and client both practicing genuine expression and active listening. Agenda setting for each session is encouraged, e.g., setting topic focus points within any given meeting. Both therapist and client are expected to contribute to setting that agenda. Conversation points will often be intentionally paused, slowed down, rewound, fast-forwarded, repeated and summarized, and/or returned to in follow-up sessions. Between session commitments (homework) are also essential to both ACT and CBT (e.g., experiential exercises, behavioral experiments, exposure, functional analysis journaling1, mindfulness exercises, etc.).
CHOOSING WISELY = ACCEPT, CHANGE OR LEAVE: Therapy is not “just talking” about problems but making choices and taking actions that improve your quality of life. Some sessions can be conversational and exploratory, and there is room for “venting” so that the therapist can reflect the possible wisdom and values hidden inside your emotions. However, if you want to optimize therapy, you will be encouraged to eventually use therapy to make hard conscious choices; to accept (acknowledge willingly, rather than avoid, deny or defend against), change (behaviorally modify a situation if it’s possible to change) or leave (if one is free to leave). If you unwisely are choosing to force one of these options where it does not fit, you will be helped to identify this as some form of old, outdated behavior and/or avoidance and expected to acknowledge that you are choosing to contribute to your own misery. This may help you to shift to another stage of readiness for change.2
COURAGE & OPENNESS: In Acceptance and Commitment Therapy (ACT), You will be encouraged to “open” (willing, accepting, vs. avoiding) to a wide range of experiences, and particularly to open to vulnerable emotions in order to adapt to what life is presenting. If you can change something into what you want it to be, you will be committing to taking steps toward that, even if it’s outside of your comfort zone. If change proves to be impossible, then accepting what is, rather than insisting on what you think it should be, may be the wiser goal. You will need to cultivate an attitude of courage and curiosity about vulnerable & difficult emotions, to slow them down, explore them, see what if any needs they are asking you to fulfill, or whether they are simply old false alarms. Generally, goals that add things to your life make for better goals than trying to subtract or remove things from your inner life, particularly when it comes to thoughts and emotions. Making too high a priority of eliminating emotions (aversive control), often ends up shrinking your life and becomes a habit of constantly escaping down dead-end alleys you never expected or planned on being in.
MINDFULNESS & COGNITIVE DEFUSION SKILLS: Modern CBT and ACT will explore intentional pauses to interrupt your history of automatic responding. While learning to pause, you will be asked to practice a variety of skills; mindful observation (neutral or detached observation, sensory and descriptive observation). You will be taught how to scientifically understand your behavior as well as that of others, this is called “functional analysis” (trigger, behavior = outcome). These cognitive and attentional tools are also central to not being a slave to the cognitions, stories, rules, and identities your brain has constructed. Compassionate mindfulness and empathic perspective-taking may also be practiced. Exploring the intention to “tend and befriend” rather than the “fight or flight” reflexes in the brain may be key to managing anxiety, depression, self-deprecation, perfectionism, and effective relationships. The compassion system in the brain is our pro-social, maternal, and affiliative brain. Paradoxically fierce self-compassion may also be about learning to allow the distress or disappointment of others to occur in the name of self-care as well as other care (not enabling them). You will be expected to commit to practicing these skills both in session and out of session.
EXPERIENTIAL & HERE/NOW PRACTICE: Experiential work is used to move beyond just talking and thinking about what happened in past or what may happen in the future. Here the emphasis is on noticing what is happening now, and how that is not identical to what your brain says has happened or will happen. This is the practice of living in the here and now, of noticing the difference between living in your senses and not your thoughts and stories. Experiential work may also accomplish this by raising awareness for here and now, and through in-session interpersonal interactions (sometimes called Functional Analytic Therapy – FAP). Here you are called on to notice behavioral patterns that work for you (are consistent with your long-term values), and those which do not. In session experiential work is also a chance to notice what “parallels” occur in session, that might also exist out of session. We will practice alternative, flexible ways of reacting in session role-plays and real-plays.
PRACTICING FLEXIBLITY and BEHAVIORAL EXPERIMENTS: Both traditional CBT & ACT are aimed at working with both thoughts and visible behaviors. One of the best ways of shifting our relationship to our thoughts and emotions is by experimenting with our behavioral patterns. If you consistently act out of character with your thoughts, one of the two must eventually shift. We all are drawn to our old familiar behavioral patterns; they are often comforting if not also outdated and unnecessarily rigid. In therapy you will be asked to experiment with your actions, both in and out of session, to cultivate “courage” (openness to difficult emotions, purposefully and intentionally leaving your comfort zone). Becoming more flexible often uses behavioral experiments to; exaggerate or minimize, delay, increase or decrease familiar behaviors. You may be encouraged to “act out of character”, to temporarily enter new roles rather than the more limited roles you may have developed in your youth or early adulthood.
VALUES: Distressing emotions are usually an indication that something is important to us. Learning to listen to our emotions to identify our needs and values and learning to separate how we may want to escape and avoid our emotions is key. Often CBT & ACT will take the time to use various emotions to get in touch with our values and needs and to committing to acting consistently to move toward those values.