Acceptance and Commitment Therapy
Acceptance and commitment therapy has a lot to say about working with thoughts. ACT identifies thought and language as key sources of human misery. From this perspective, thought and language are the suitcase by which you can pack up your troubles and move from, say, New York to Los Angeles, yet experience the same thoughts and emotions in L.A. that you did in N.Y.
ACT identifies “cognitive fusion” as a principal problem.3 What is cognitive fusion? It’s when we give properties and characteristics to words and thoughts which only really belong to the objects those words describe.
What does that mean? Consider the example of a young child who gets scratched by the family cat. Young Susie may feel afraid of that cat for a while, might feel afraid of other cats and dogs in the neighborhood, might run from the room when a cat food commercial comes on television, and might even burst into tears or show signs of distress when someone mentions the word “cat.” She can feel fear when she hears the word, even when the cat is outside. Susie has given the word “cat” the properties of scratchiness and “biteyness” that only actually belong to the animal. In ACT terms, she has “fused” the word “cat” with those properties. As a result, she can become afraid in the absence of the cat, just from hearing the word, or maybe even thinking the word. She no longer makes a distinction between hearing the word “cat” and seeing a cat leap at her, claws outspread.
As her parents notice this, they may try to help keep Susie calm by using some code to refer to “cat” when they find it necessary to mention that word in her presence. Maybe they use pig latin (ixnay with the atcay!) or refer to it as a banana rather than a cat. They’re trying to care for Susie and protect her from upset. But they are also, unwittingly, strengthening the association Susie has formed between the sound of the word “cat” and those hurtful properties of “biteyness” and scratchiness, because they’re depriving her of opportunities to get used to hearing the word.
Defusing “Hot Button” Words
You can see the same thing in anxiety and panic support groups all around the country, many of which discourage or prohibit the use of certain words that might bother their members. For instance, some support groups for people with panic attacks ask members to refrain from using the word “breathing” because some members are sensitive to this word and will have trouble catching their “b” if someone uses the “b” word! The group has fused the word “breathing” with the sensations of hyperventilation and all the symptoms that accompany it. Just as we saw with Susie and her parents, here we see people, intending to be kind and protective, acting in ways that lead people to feel more vulnerable, rather than less, to the “b” word.
Do you have some “hot button” words that you prefer to avoid, to skim over if you see them in print, words you don’t want to say aloud because they might lead you to feel anxious?
You probably do, if you let your mind ponder it for a few moments. People with panic attacks often want to avoid words like “faint,” “cerebral hemorrhage,” “screaming insanity,” and so on. People with social anxiety aren’t so fond of words like “sweat,” “tremble,” and “blush.” People with intrusive obsessive thoughts tend to avoid the key words from those thoughts, like “murder,” “poison,” “stab,” “insecticide,” and so on. Even people with just basic, garden variety anxiety have words that carry some special, “fused” feeling for them.
Want to try an experiment?
I hope by now you can guess where I’m going with this, and what the experiment is.
The experiment is: take one of those words and repeat it, out loud if you have the privacy to do that—twenty-five times.
If young Susie does that with the word “cat,” the word will probably start to lose its claws.
By the way, if you did guess what the experiment would be, or something close, that’s great—you’re getting used to using the Rule of Opposites!
ACT seeks to help people undo this kind of cognitive fusion by fostering defusion—or as I call it, “de-fusion,” since the technique aims to break the link you may have established between a word or thought and the actual properties you have come to associate with that thought. For instance, Susie’s parents might help her to de-fuse the word “cat” from those properties of scratchiness and “biteyness” by making nonsense rhymes with the word cat, singing songs about cats, rhyming the word “cat,” making artwork based on the word “cat,” and so on. Panic support groups could help their members de-fuse the word “breathing” by similarly engaging in playful exercises that use, and overuse, the word.
De-fusion can be a powerful method by which you can reduce the misery you have come to feel in response to chronic worry. Misery often accompanies, for instance, disease, especially when it’s a serious disease. However, people who struggle with chronic worry about disease can experience the same misery they associate with disease even when they are healthy, just from having thoughts about disease. That’s why they tend to avoid watching medical shows on TV. They’re trying to avoid anything that might remind them of disease. All that is necessary is to “fuse” the thought of disease with the misery of actually being ill. De-fusion is a method by which you can greatly reduce the amount of misery you experience in response to your unwanted thoughts.
ACT also seeks to help people spend more time in taking action with the external world around them and less time trying to rearrange or change the thoughts and feelings they experience in their internal world. In this sense, ACT has at least a superficial resemblance to the Serenity Prayer:
God, grant me the serenity to accept the things I cannot change,
The courage to change the things I can,
And the wisdom to know the difference.
When I received some ACT training, one of the general principles I took away was that it’s probably more useful to help people examine how their thoughts influence their behavior than it is to spend time challenging the accuracy of the thoughts. (These characterizations of ACT and CBT are my own view and, while I think they’re reasonably accurate, they represent how I use these methods, rather than how ACT and CBT experts may teach and use them.)
This represents perhaps the sharpest contrast between a traditional CBT or cognitive restructuring approach to thoughts and an ACT approach. Let’s consider the example of a client who struggles with thoughts of being a coward. A CBT therapist would probably ask that client to define what he means by coward and then compare the client’s behavior to that definition, taking note of when the client acted like a coward and when he did not. In this way, the therapist would help the client to get a more balanced and accurate view of his behavior with the ultimate goal of helping the client to achieve more accuracy in his thoughts.
An ACT therapist, on the other hand, isn’t going to get involved in looking at the accuracy, or lack thereof, of that thought about being a coward at all. An ACT therapist is more likely to ask a question like this: “This thought you have about being a coward—is it getting in the way of you doing anything that’s important to you?”
In other words, an ACT therapist will help you look at your thoughts in terms of how they influence your behavior, rather than how accurate or inaccurate they may be. The implicit goal is to help you to behave, in the external world, more in keeping with your own hopes and aspirations for your life rather than being limited by whatever thoughts happen to crop up in your internal world.
Twists and Turns: How Thoughts Can Affect Behavior
I happened to be working with a client who was continually worrying about his retirement plan around the time I was first learning about ACT. This man wasn’t close to retirement, nor did he have any financial problems. In fact, he was relatively well off. But he was obsessively preoccupied with this worrisome thought: What if my retirement plan turns out to be insufficient by the time I retire? This worrisome thought, and his ongoing efforts to rid himself of this thought, were his near-constant companions, and he used all the anti
-worry responses we looked at in chapter 3, with little benefit.
He and I worked cognitive restructuring really hard. We looked at his thoughts about how terrible retirement might be if he had less money than anticipated. We reviewed the options he would have then to cut back his expenses and considered how those lifestyle changes might affect his mood and thoughts. We considered cutbacks he could make in his current spending patterns in order to give him a higher probability of a solid retirement income, and how he would think and feel about that set of changes. We reviewed his thoughts about working part time in retirement, should he feel that necessary, and the possibility of his spouse playing a large role in moneymaking. He found neither comfort nor reduction in worry from these efforts.
I suggested the potential benefits of getting an expert review of his plan from a financial planner, only to learn that he had already done this several times. The problem he experienced with this attempted solution was that, when you consult a financial planner, they typically want you to sign a document acknowledging that their forecasts are built on certain assumptions which might not turn out to be accurate, and promising you won’t sue them for that. “Not accurate?” he said. “That was why I went there in the first place, to get an accurate prediction!”
We were getting nowhere slowly! One day it occurred to me that an ACT therapist wouldn’t be doing all this work of looking at how true or false his worries about retirement were. I remembered the ACT question, “Is having this thought getting in the way of you doing anything important?” And so I asked him that question.
It turned out it was getting in the way of him doing something important, and when I heard what it was, I realized immediately that I had misunderstood the problem. You can try to guess what it was before I tell you, but I doubt anyone will guess it correctly.
It wasn’t preventing him from working, or retiring, or saving money. It was preventing him from doing something else, something that made me realize I had been approaching the wrong problem.
What was it? When you belong to a retirement plan, either on your own or through an employer, you get a periodic report about how your plan is doing. It shows the contributions you’ve made; the contributions your employer’s made, if any; and the change in the market value of your stock and bond holdings in the plan. This is the information people use to monitor and change their investment strategy as needed.
This man’s worrisome thoughts prevented him from opening the retirement report when it came in the mail. He would put it in a filing cabinet unopened.
I realized then that I had misdiagnosed the problem. I had been proceeding as if this man needed to feel more secure in his financial planning. But now I could see that he was so intolerant of worry and uncertainty that he was willing to give up control of his finances, if only that would relieve his worry!
He didn’t need to become more confident and sure—he needed to become more willing to feel unsure, and live with that set of thoughts and feelings. He needed to do more work with the worry, and less against.
Thinking It Over
Thinking about your worries, in an effort to evaluate and correct them, has some limitations, and these limitations may hamper your effort to calm worrisome thoughts with cognitive restructuring.
For one thing, thinking objectively about your thoughts is quite difficult, maybe impossible, because the tool you use to evaluate your thoughts—your brain—is the same tool that created them in the first place. For another, your efforts to evaluate and correct your worrisome thoughts will often produce a kind of internal arguing with your thoughts, rather than the calm resolution that you originally hoped for.
If you find that these limitations hamper your efforts to reduce chronic worry with cognitive restructuring, you might find more relief with the techniques of cognitive de-fusion. Working with (rather than against) the key words and thoughts of your chronic worry, particularly in a playful, humorous manner, may well give you better results than efforts to rationalize and correct the content of your worries.
Chapter 8
Uncle Argument and Your Relationship with Worry
How are you doing with the Tic Tacs from chapter 6? It’s often surprising to see how thoroughly this “what if” habit has infiltrated your daily thoughts. I encourage you to continue using the Tic Tacs for a few weeks, because this will help you build your ability to observe, as if from a distance, your own worry habits and invitations.
This chapter will lay out the big picture of what a good relationship with worry looks like and offer some specific steps you can take to start traveling that path. Approach this the same way you would approach any significant lifestyle change like diet or exercise—focus on taking the steps and building them into your daily life rather than looking for immediate success. It’s understandable that people look for quick results when making a change, but all too often that focus on quick results detracts from their ability to stay on path with the new habit. The key here is to build the new habits into your life and then, over time, reap the benefits.
Here’s a phrase that can help you keep this in mind: Feelings follow behavior. Be it a diet, an exercise plan, or a worry reduction program, we all want to feel good as soon as possible. But the good feelings will likely come after, not before, we make the changes in our habits and daily routine.
What’s a Good Relationship with Worry?
Let’s suppose you’re going to a family event. Maybe it’s a wedding, a graduation party, a bar mitzvah, or a fiftieth anniversary party. You’re looking forward to it and want to enjoy it. Unfortunately, you misplaced the invitation for a while. You were the last person to send in your RSVP, and so they seated you next to Uncle Argument at the banquet table.
Uncle Argument is actually an okay person, but he really, really likes to argue. That’s pretty much his entire conversational style. If you’re a Democrat, he’s a Republican. If you think American football is the greatest sport, he picks soccer. If you think breakfast is the most important meal, he says that it’s dinner, and so on. The man just loves to argue. He’s not really mean, he just loves arguing.
And you’ll be seated next to him at dinner. You don’t want to argue. You want to sit and eat, you want to enjoy the meal, you want to have some pleasant conversation if possible, but you absolutely don’t want to argue. Arguing gives you a stomachache. What can you do?
It’s Hard to Avoid Arguing
You can’t move to another table, because there aren’t any empty seats. You can’t change seats with anybody, because nobody wants to sit next to Uncle Argument. So you have to sit next to him unless you skip the meal. You don’t want to do that because that’s usually the part you enjoy the most, and going without food gives you a stomachache as well. How can you sit next to Uncle Argument for the entire meal without arguing? What would your options be?
You might try ignoring him, but that just makes him louder and more persistent. He loves it when people try to ignore him, because he takes that to mean he’s winning the argument. So that won’t help.
You might tell him you don’t want to argue, but that also makes him more persistent, and he’ll start nagging you about being afraid to voice your opinion. You could yell at him, tell him to shut up, but that’s angry arguing, which delights and encourages him. You could listen carefully for him to say something that’s clearly wrong, and then point that out to him, but that’s also arguing, and he never admits to being wrong anyway. You could try to get other people at the table to help you out, but they don’t want to mess with Uncle Argument, so they’ll look the other way. You’re on your own!
You could hit him, but you probably won’t get invited to the next family event if you start a fistfight at this one. And you don’t want to bring the police to the party. So what can you do?
The Opposite of Arguing
How about this—you can humor him. You can agree with everything he says, true or untrue, brilliant or ridiculous, whatever. “Yes, Uncle Argument, how very true. So
wise. From your mouth to God’s ears.”
Do you have any doubt that if you agree with everything he says, this man who loves arguing more than anything else will find someone else to argue with? Do you give anything up by humoring him? Would this be a reasonable way of responding to the persistent invitation to argue?
You can have an arguing, confrontational relationship with him, or you can have a humoring relationship with him. The man is so persistent that he leaves you no other choice. You wish you had other choices, but you also want to enjoy the banquet, and these are the choices you have.
Dealing with your worry is like dealing with Uncle Argument. If you take the bait and reply to the specific content of the arguments, you end up getting embroiled when you just wanted to eat. You end up exactly where you didn’t want to be—arguing, and finding that your comfort level is decreasing.
On the other hand, if you create the habit of humoring your worrisome thoughts, you can increasingly pass over the invitation to argue without becoming embroiled or upset. You can play with the thoughts, rather than work against them.
Does this sound counterintuitive? That’s good, because the problem is counterintuitive. If it’s true that the harder you try to suppress these thoughts, the worse they get, then you will probably benefit from trying something very different. Humoring the thoughts will be just what the Rule of Opposites would suggest.
Is That Okay with You?
The Worry Trick Page 12