ACT In The Wilderness: The Making Of A Beautiful Marriage
Acceptance and Commitment Therapy (ACT) is a therapeutic model that lends itself particularly well to facilitating change in a wilderness context. In my experience, ACT and wilderness come together seamlessly, in fact, and seem to amplify each other’s potency. While the effectiveness of ACT for such things as depression, anxiety, OCD, PTSD, schizophrenia and a myriad of other clinical conditions rests on a large and growing body of empirical research, the relationship between ACT and wilderness as related to client treatment outcomes is ripe for exploration. Perhaps most informative here is to examine the interaction between ACT’s six core processes and the wilderness context in an attempt to provide a deeper understanding of the how ACT can be used most powerfully to help wilderness therapy clients.
My broad therapeutic goal is to help my clients create a more flexible relationship with their difficult thoughts and feelings (i.e., internal experiences) to increase their ability to take value-driven action in the world again. Clients often arrive seemingly paralyzed by their thoughts and feelings. It’s as though their internal experiences are holding them hostage. Supporting them in creating a more flexible relationship with their internal experiences is fundamental to the therapeutic process. From the ACT perspective, the hallmark of psychological health is psychological flexibility. The question of how best to assist my clients in being able to move freely and powerfully in the world again becomes the driving force of our work together. My intention is to help them nurture postures of openness to, and acceptance of, their internal experiences--even (and especially) the really difficult ones like anxiety, despair, loneliness, etc. As acceptance is one of the six core processes of the ACT model, this is a good place for me to jump off and more explicitly consider each of the six as they might be utilized in conjunction with the wilderness context to affect client change.
Perhaps more important than any other aspect of acceptance is the idea that it’s a skill to be learned. By nature, we don’t do a very good job with accepting difficult internal experiences for what they are. Our clients are no exception. They come to us locked in rigid, unhealthy patterns of struggle and/or avoidance of unwanted thoughts and feelings. “Can you make room for these unpleasant internal experiences without struggling with them or running from them?” becomes a question that deeply informs treatment.
I had a client with a long, complex history of abuse by his father. He’d struggled with overwhelming thoughts and feelings for as long as he could remember. Some of the acceptance work that I did with him included asking him to imagine a stressful, difficult time with his father. My intention was to elicit anxiety. I asked him to scan his body and notice where he felt anxiety most acutely. He said his upper chest felt tight, like it had a knot in it. I asked him if he would be willing to just observe this knot without trying to change it. I asked him to notice where its edges were, what its shape was, or if it had color or weight. Next, I asked him if he could breathe into it and allow room for it in spite of it being unpleasant. Over time, this client recognized that he could simply let this feeling be what it was—just a difficult feeling. Nothing more, nothing less. In the past, he would have avoided this feeling at all costs; particularly through drug and alcohol use. He found that by not engaging in the fight against his anxiety, he had an increased ability to live in the world in a way that was congruent with his most deeply held values.
The wilderness context engenders an acceptance of “what is” for clients. That is, clients can struggle against the elements (i.e., the weather, etc.) but to what end? They realize that to struggle against that which they can’t control is a waste of time and energy. Their thoughts and feelings are the internal equivalents of the external elements. Struggle and efforts to control do no good—especially in the long term. In fact, attempts to control/struggle with difficult, unpleasant internal experiences only makes them worse. Clients learn to step out of the control agenda with regards to their thoughts and feelings, just as they learn to let go of trying to control that which is beyond their control in the wilderness setting.
Defusion is the process of learning to gain space from one’s internal experience. It’s seeing thoughts, feelings, memories for what they are—just words and pictures in our heads or sensations in our bodies. That’s all. Defusion enables the client to look at the thought (for example) rather than from the thought. In ACT we often call thoughts stories, as they are made up of nothing other than words. I don’t spend much time with clients discussing or debating whether their particular thoughts or stories are true of false. Instead, I focus on whether or not it’s helpful for them to pay attention to or “believe.” That is, will believing their stories help them construct the lives that they want? Our clients often come to us in states of seeming behavioral paralysis because they believe or are “fused” with, their thoughts (i.e., stories) about who they are and what the world is. “I am worthless,” “I’m not good enough,” “I’m going to fail,” etc., are thoughts that become taken as truth and reality. Clients react to thoughts about reality as though they are reality itself. We can see how believing these thoughts could lead to behavioral paralysis and concomitant feelings of anxiety and/or depression, among many other difficult emotions.
One intervention that I like to use in the wilderness to help clients experience that they don’t have to listen to the stories in their heads, regardless of their content, is what I call the Bow Drill Back Talk. I’ll ask a client to grab his/her bow drill set and attempt to build a bow drill fire regardless of what I’m saying to them. I ask them to continue to make a fire until they hear me say, “stop.” As they begin the task of making a bow drill fire, I play the role of their minds, i.e., their stories. I may say things like “You call that a spindle? That’s the worst spindle I’ve ever seen. There’s no way that’s going to work.” I’ll criticize their stance or the pieces of their bow drill set. If they are proficient at fire building, I might say something like "You've made 20 fires before, why try now. This is dumb." There is plenty of room here for the therapist to be creative. Whether or not the client actually is able to make fire is irrelevant. Sometimes they do, sometimes they don’t. What’s important here is that they have the experience of taking action regardless of what “stories” their minds are telling them. I’m attempting to challenge the link between thoughts (i.e., stories) and actions. The experience that it’s okay to defy one’s thoughts with behavior is the goal with this intervention.
The Bow Drill Back Talk intervention points to another of the six core processes: values. The reason the client persists in making the bow drill fire is because he or she finds value (either extrinsic or intrinsic) in the activity. In this case, the value typically is the relationship to me. The client trusts that there is a good reason for what I'm asking of them--despite it seeming weird or silly. I make sure to discuss values with clients when debriefing this intervention. Values are action words—verbs and adverbs—that are instantiated through actions in the world. In fact, they do not exist independent of action. They can never be completely achieved either. For example, one never completes being a loving partner. There is always more love to give and experience. This is the difference between a value and a goal—a goal can be completed, a value can always be worked toward.
Being fused with unhealthy, dysfunctional thoughts and feelings stimulates a strong disconnection from values and value-driven living in our clients. They will often put off living their values until their “bad” thoughts and feelings can be changed or “fixed.” I call this the “If only, then…” syndrome: “If only I could make my anxiety (for example) go away, then I could live the life I want” (or some variation thereof). From the ACT perspective, it’s not a matter of making anxiety (or any other psychological difficulty) go away before living. Instead, the hope is to help clients create a more flexible relationship with their anxiety so they can experience it and still move powerfully in the world. I tell clients in my first session that I don’t attempt to take their psychological difficulties away, and I let them know that I don’t spend time taking their difficulties away for a few reasons: 1) Attempts to make difficult internal experiences go away don’t work (perhaps the subject of a future blog post); 2) one of the reasons (among others) they don’t work is that difficult internal experiences are inseparable from the human condition. I let clients know that to not feel difficult internal experiences is abnormal; 3) If I took their “bad” (i.e., difficult) internal experiences away, I would also take their good (i.e., joyous, fulfilling) internal experiences away. They are two sides of the same coin.
While values are largely culturally conditioned, it’s important that clients have the experience of choosing what it is that is valuable to their lives. Without a connection to values, clients become subject to the whims of their thoughts and stories, not to mention becoming more easily influenced by their external environments as well. When examining values with my clients, it’s careful to consider what are authentically their values versus what is they think they should value based on social conditioning, with the strongest unit of social conditioning being the family.
4) Committed Action
As mentioned above, values can only be instantiated through action. Committed action involves perseverance and change. It is the concrete behavioral manifestation of values-driven living. In Bow Drill Back Talk intervention, the client continues to take action (attempting to make fire) in service of the value found in either the act itself (intrinsic motivation) or in some other realm (perhaps, as I spoke of above, there's something in our relationship that they value).
Wilderness is an environment in which values-driven action is lived every day. It is evident for all to see. One of the most powerful therapeutic factors of the wilderness setting is the feedback that clients receive from peers and staff. It's as though a client has mirrors held in front of them so that they can experience what it’s like for others to be in relation to them in the world. Change occurs with repetition in the presence of feedback. That said, I don’t know of an environment that more aggressively invites change than wilderness. Multiple times daily clients are given feedback from peers and staff on their behavior and asked to examine whether their behavior is congruent with their values. But the feedback process does not end there. Potentially more powerful, the wilderness itself gives feedback constantly (literally), and sometimes quite dramatically.
5) Observer Self
The observer self is that “part” of the client that is able to “see” her internal experience; that part of the self that is aware of thoughts, feelings, memories, images, etc. The metaphor that I utilize regularly is that of clouds in the sky. The most furious, violent storms can roll across the sky at times, but the sky remains unharmed. The sky is the context in which the clouds happen, but it is not the clouds and not harmed by the clouds. My hope is that my client experiences that she is not her feelings, thoughts, or memories. These internal phenomena change like the weather, like clouds in the sky, but can’t in and of themselves harm her.
In the Bow Drill Back Talk intervention, the client experiences what it’s like to be the context for potentially unhealthy, self-limiting thoughts (i.e., my voice), to just observe them as they arise without getting fused with them. In this case, if the client were to become fused with her thoughts, she would stop making a bow drill fire. This might look many different ways: maybe she stops slowly and walks off silently; maybe she stops abruptly and smashes her bow into the ground. Regardless, by becoming fused with her limiting thoughts (i.e., not being able to view them from the observer-self position ), she becomes detached from the value-driven activity. She believes the story playing in her head (i.e., my voice) about how she’s inadequate, for example. She might also stop if she becomes fused with a more “positive” story about herself--maybe one of her being too good to have to engage in such a “stupid” task or some variation thereof. Without a sense of the observer-self, fusion with one's internal experience is inevitable, with the result being behavioral disengagement.
6) Contact with the Present Moment
Often, the first step in behavioral re-engagement is coming back to the present moment. Much suffering results when clients become inflexibly fused with the past or future. They get lost in their stories about the past or future and interact with these stories and though they were really happening. The result is a loss of contact with the present moment. It’s only in the present moment that learning can occur and value-driven action can be taken. Steven Hayes said it well: “One of the key targets of ACT is to help clients let go of the struggle with personal histories, feelings, thoughts, and sensations and to show up to the life that is being lived in this moment.”
I don’t know of an environment that demands contact with the present moment more compellingly than the wilderness. We’ve all been captivated by the power of a thunderstorm, a sunrise or a sunset. Moreover, removed from the technological distractions of civilized living, clients are often faced with being with themselves, in the moment, for the first time in their lives. To simply bring clients back to the present moment, over and over again, can be an extremely potent intervention. When we bring them back to the moment, we bring them back to themselves. One the more poignant moments I had recently was debriefing a solo experience that a client had in the wilderness. He talked about how scary it was for him to be present with himself, and how in the past he would avoid this at all costs. He didn’t want to sit with the difficult feelings that would flood him in moments of stillness. He described the solo as one of the most difficult times of his life, but he glowed with a confidence that I had yet to see in him when he said, “I like who I am. I have no one to run from.”
The Bow Drill Back Talk intervention is debriefed with an emphasis on the importance of the present moment. It’s only in the present moment that values-driven action can occur, and it’s only because the client stays connected to the present moment that she can continue to make fire in the face of what could be very distracting internal dialogue (i.e., my voice).
ACT is a trans-diagnostic, non-manualized modality that is highly fluid, but what makes ACT work so well with wilderness is its reliance on experience as the fulcrum for change rather than verbal activity (i.e., words and thoughts). And what better setting than wilderness to provide contact with the raw experience necessary to begin to challenge the link between a client’s stories of herself and the world and her behavior in the world? The recognition that, “Just because I tell myself a story doesn’t mean I have to believe it and act on it” by the client is immensely therapeutic. The Bow drill Back Talk in the wilderness context is one of many ACT interventions that help reveal this experience.