Being Prepared vs. Being Present in Sessions

Any practicing therapist can identify with the feeling of flying by the seat of your pants in a session—banking on your experience and foundational clinical skills to see you through. But for the majority of us, flying by the seat of our pants can land us on our behinds when it comes to acceptance and commitment therapy (ACT). In her new book, Advanced Acceptance and Commitment Therapy, Darrah Westrup, PhD, reminds us that putting time into thinking about sessions beforehand can really help maximize the therapy in the interest not in the service of being smooth, but of being able to be present to what is actually happening in the room with your client.

In ACT, the last thing a therapist should do is develop a script or protocol that could potentially steamroll over everything else in session. Rather, by orienting yourself to the objectives and principles of ACT, knowing where you client stands in terms of the core clinical processes, and familiarizing yourself with ways to introduce and talk about key abilities, you can be confident that during sessions, the present will trump all else.

Here’s an example of being too rigidly attached to protocol or delivery technique: ACT therapists rely heavily on the use of metaphors to help clients more effectively connect with their values and give them the motivation needed to make a real, conscious commitment to change. But at times we can get stuck on the technique and delivery of metaphors (that is, in which order should I deliver them, how long should I spend on each, and so forth), rather than focusing on behavioral principles first and foremost. If you are constantly checking to see which metaphor comes next in your latest ACT manual, or doing a mental checklist of the metaphors you need to be sure to cover, it may be time to tune back in to a process-based approach.

Once your client seems clear on how experiential avoidance has been functioning for him, for instance, you might ask yourself if it’s time to move into further exploring the problems that arise from misapplying control. Or, you might ask yourself the best way to introduce the idea of “control as the culprit,” determining which exercises and metaphors will best illuminate this principle for this client. The latter entails a consideration of what is actually happening in the therapy session with the particular client. The ability to move forward is not predetermined by protocol; rather, it is dictated by assessing where the client is in terms of the therapy overall. This assessment entails an ongoing consideration of where the client stands in terms of the behavioral abilities targeted in ACT—for example, say you had determined that it was time to move into values work, and your client suddenly revealed that he was still fused the idea that reasons are causes. It would not be clinically effective to continue with whatever you had planned for the session if your client subsequently gives you conflicting information.

All that said, this is not to say that planning sessions is not important. It makes sense to begin with a grasp of how the client perceives his problems and how that perception might be reframed from an ACT perspective. This involves assessing the client’s abilities in terms of the six core processes, in order to translate how he perceives his difficulties to ACT framework. In ACT, case conceptualization is important because it helps therapists to focus on the processes as the earliest stage in the therapeutic treatment process.

Sometimes we get so focused on what is currently happening that it can be hard to defuse and consider the larger picture: how is the therapy going overall? Westrup suggests that a great way to maintain perspective is to ask yourself: Where is my client stuck? And what key ACT idea, if embraced, would be the game changer for this client? 

It’s important to carefully consider where you and your client are in terms of the ACT objectives (in other words, in terms of the client’s abilities in respect to the core processes), so that you can determine where it would be fruitful to go next. Once this is clarified, you can consider which metaphors and experiential exercises you will need to have in your back pocket to help demonstrate the abilities you with to explore in the next session.

Westrup maintains the importance and utility of spending time prior to your sessions thinking about the overall picture and the next therapy session. She provides the following session summary outline to guide you in your own preparation: 

1. Case conceptualization: How does the client view the problem? How would you translate that view into an ACT framework? What core ACT abilities will likely be most key for this client?

2. Where are you? What core ACT processes have you explicitly worked on so far? Where is the client in terms of those processes (comprehension, buy-in, application, barriers)? How does the client view the problem? Does it make sense to move forward, or should you stick with the processes of the moment?

3. When moving on, what metaphor(s) will you use to further the client’s ability with the particular process(es) you anticipate targeting?

4. What two experiential exercises will bring it home?

5. Practice.

6. Get present.

Stay tuned next week for more on timing, planning, being present, and doing ACT in-sessions.