‘Pain is inevitable, but suffering is optional’

Kirk Strosahl talks to Kal Kseib about acceptance and commitment therapy.

Kirk Strosahl is co-founder of acceptance and commitment therapy (ACT), a cognitive behavioural approach that has gained widespread adoption in the mental health and substance abuse communities. He is the author of numerous books including Brief Interventions for Radical Change and Inside this Moment. He has gained international recognition for his innovative approach to the integration of behavioural health and primary care services. Strosahl lives near Seattle and works as a practising psychologist at Central Washington Family Medicine, a community health centre. He also teaches health professionals on how to use the principles of mindfulness and acceptance in general practice.

Who were the psychologists that originally inspired you?
Probably two people, depending on the era of my life. One was Neil Jacobson, who was a mentor and a friend, who unfortunately passed away in 1999. He was a brilliant theorist in cognitive behavioural therapy, doing some of the first studies breaking down the different components of cognitive therapy. He developed behaviour activation just before he passed away. The second would be Steven Hayes, who I met in 1986. We’ve been friends for pretty much our entire careers. So even though we’ve written together, we’ve also had a personal relationship and shared family evolutions. Both of those guys were pretty instrumental in the mindfulness movement early on, so those were the two people that I think of fondly.

How would you describe ACT in a nutshell?
I think ACT tries to promote people who are open to their own experience and can separate themselves from the literal meaning of their experience – so that they’re not governed by thoughts or feelings or emotional reactions to things. They are in touch with their personal values so that they are geared toward living life to its fullest.

What are your most inspired actions?
I think the time I truly felt the most inspired simply in terms of output was writing my most recent book, Inside This Moment. I was in a zone for the entire time that I was writing it, it was coming from the heart. It was actually quite an amazing experience. The book zeroes in on how to use the present moment in therapy to inspire people to live their lives to the fullest, and not to run from their own demons, but rather cradle them. So that was enjoyable. Then I’ve also always been inspired to work with Patti [Dr Patricia Robinson]. We have a lot of fun and there’s intellectual growth when we write and get our arms around stuff together. So I’ve been very lucky that way.

Where are ACT and the other so-called ‘third-wave therapies’ heading now?
I think people are going to have to get their arms around what we mean by ‘mindfulness’ in a much more scientifically sound sense. Not the term, not the popular concept, but understanding exactly what goes into it. We’re still very overly general about it in our conversations, and because of that we’re losing leverage in therapy that we would otherwise gain by being more discriminating. That’s one area I think is going to see a lot of further growth. And I think we’re going to be looking at how we get our treatments briefer without losing effectiveness, because resource systems out there simply can’t afford the longer-term version of CBT or ACT for the masses – that’s another big area. How are we going to populate these concepts into public health models and work with lay people, primary care providers and teachers, for example? We’re still very therapist-centric in our profession, and because of that our population health effectiveness has been extremely limited.

I think the other area that is going to become bigger and more important is values-based behaviour change. It’s not like people haven’t been exploring it, but I think the amount of development will increase. There are measurement issues that are going to have to be dealt with, as well as creating more efficient ways of talking to people about motivating factors in their lives.

What is the greatest opportunity ACT has in today’s world?
I actually think that, if we don’t fall on our own sword, it’s going to be about bringing mindfulness concepts into the general public and Western civilisation. That’s not going to mean getting everybody in the West to put in hours of practice a day, sitting on a pillow ‘umm-ing’. Rather it’s this idea that these are actually pretty portable interventions based on neuroscience. They have a very rapid effect on brain neural pathway development and brain efficiency, and they don’t have to be these onerous, lifelong practices. There’s going to be a huge opportunity there if we can get the right message to people – that these are things you can teach yourself and your brain in small bits, and that it’s more about persistence than the amount of time you take. It’s about doing things intentionally and practising intention, as well as practising paying attention. These two things go hand in hand in mindfulness – this ability to pay attention in a particular way and then to act with intention inside of your own space. To me those things are so intricately linked to psychological health that if we could get those out into the public domain in ways which didn’t seem overwhelming to people, that would be a huge accomplishment for ACT, or for any of the mindfulness-based therapies that could get this figured out. So it isn’t just in the hands of a few people.

I once came across the ACT metaphor ‘find your cliff and jump’. What’s your favourite ACT metaphor and why?
That saying sounds a little fatalistic to me! If you ask me which I use most often, it would be the idea that the mind is the schoolyard bully who demands to take your lunch in order to let you go to school. So gradually your entire ritual of going to school is built around making contact with this bully and you forget why you’re actually at school. I think the other feature of that metaphor is that it’s about making choices – and I can build off that. ‘Who do you want making decisions for you in your life – your anxiety, depression, anger, or you?’ So it gives people the ability to pick between mind and the human being. I like those kinds of ‘choice points’. Another one I use a lot is ‘forks in the road’, and ‘right turns versus left turns’. Journey metaphors are something I use a lot.

Are ACT and CBT actually little more than saying to people ‘live with it, or change it’?
There are hidden properties of treatments, and then there are the observable properties of treatments. In ACT the observable properties are quite different, with an emphasis on values. It’s saying to people ‘don’t just tolerate your life, build your life from within’. ACT uses values as a foundation for addressing that.

Then there’s the ability to create space between you and what starts to show up in your life when you start doing things that matter. It’s an optimistic treatment that assumes people can do amazing things if they get lined up behind the right psychological processes. And it might well be that in CBT, even though ostensibly focusing on helping people change thoughts and behaviours, the act of talking about thoughts and behaviours is in a way itself a kind of a ‘defusion’ intervention. That’s what I mean by ‘hidden’ properties. You think that the mechanism is about the client becoming more logical and less irrational, but it may in fact be that by talking about thoughts you’re actually doing ‘defusion’ without even realising it.

What would you consider to be your greatest career accomplishment?
Definitely a turning point in my career was the first ACT book. We were, at that point, pretty much unknown and there was a 50/50 chance we were going to be pilloried by the cognitive community. And we did get a little along the way, but it could have been much worse. Also back then we wrote books the old-fashioned way – we didn’t have these file-sharing services, so we actually had to get together physically and have writing festivals, and that was a huge plus for me personally. Four or five days at a time with Steve [Dr Steven Hayes], locked in a room arguing about every single thing as we wrote the first book. We had five or six sessions like that which were pretty legendary… in my mind anyway.

You’re a specialist in delivering brief, or ‘focused’ ACT interventions to patients – sometimes as brief as 15 minutes. Could you give a picture of what you might focus on in a session, say for diabetes or depression?
The goal of focused ACT is to get patients to make direct contact with the unworkable results of their current life strategies. Usually, these strategies involve avoiding dealing with important life issues – such as maintaining social health, managing diet or other health risk behaviours in the case of diabetes. The counter-weight in focused ACT is to get the patient to make direct contact with what matters to them in their life, and whether their avoidance behaviours are helping them move in that direction. This discrepancy creates a ‘healthy anxiety’, which we encourage patients to accept as a ‘signal’ that some type of change in personal strategy is needed. You don’t get people to change behaviours by giving them a label, or scaring them with adverse consequences if they don’t change, or lecturing them about the necessity of change. Change comes from within, not from without. Most patients know implicitly that they are avoiding things, but they don’t want to be condescended to, criticised or cajoled about it. So focused ACT is a very humanising approach in which we readily agree that making important changes in life might likely trigger painful emotional consequences or distressing memories of past failures, et cetera. Pain is inevitable, but suffering is optional.

The therapist and patient are on the same journey in this, and they’ve just happened to run into each other. There is no difference really between us.

These briefer interventions are likely to become increasingly necessary in the NHS. Do they have downsides?
There is no convincing evidence that how much time you spend with someone in therapy directly determines the degree of clinical benefit. It is more what you educate the client in, when you do it, and how you do it. In the US we already have several large effectiveness studies showing that one-, two- and three-session interventions in general practice settings produce clinically significant, long-lasting changes in both symptoms and functional status. The effect sizes of these interventions by and large are comparable to ‘gold standard’ effect sizes seen from longer-term therapy RCTs with the same condition.

The principles of ACT and FACT are really principles of how to live an intentional, value-based life. I’m confident that if the UK NHS were to adopt a principle-based treatment – rather than technique-based ones – that can be applied across the board with all types of medical and mental health issues, or their combination, that more people in need could be served without sacrificing clinical benefits.

What are your own highest values?
Personally I think of myself as being a really honest person, I’m ‘good to my word’ as they say in America. I try to do things with integrity. I’m very persistent in my life journey. I try to stay moving in the direction I believe in, which is to help people. And related to that is compassion for people suffering, and also self-compassion for my own flaws and imperfections, which are too numerous to mention.

How would you define success?
Anything that helps clients to get their lives back. We’re far from being there yet as a profession, I think. We don’t help everybody. I think success is that we never give up searching for ways to improve how we do business and how we help people. I guess if I could ‘float over my own funeral’, I’d probably want to hear people say, among other things, that ‘he never gave up’ and that ‘he never stopped trying to improve himself’. I see life as a great teacher, and if we are willing to be students it will teach us everything we need to know to prepare us for our death. So everything along the way is part of learning. It’s not out of the flow, everything is in the flow.

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