3 day workshop with Russ Harris in Copenhagen: Interview with Russ Harris on the 15th of May 2012
Interview by Maria Krøl and Ole Taggaard Nielsen
I: What was it that brought you to ACT?
R: I thought it was a very realistic look at the human condition. It starts with the premise that life involves lots of pain. No matter how good your life gets there’s going to be plenty of pain that goes with it. I found that to be very realistic. We’re all gonna have lots of painful feelings, we’re all gonna have lots of negative thoughts. So how do we learn to live with that? How can we still live a rich, full and meaningful life, even with the pain? So it was very realistic, and it really resonated with my experience. And I liked that there was a lightness and playfulness about the model; it had a sense of humor. I also love the creativity of it; the way that it frees you up to design your own metaphors and your own interventions. It gave me a lot of freedom as a therapist; there are just so many different ways I can do it. I love that I can be creative and playful. And I love the compassion and the self-compassion that’s built into the model. And I think more than anything, I loved the training: how it was about working with my own issues, and applying the approach to my own stuck-points in life; to help with my own pain and suffering. It just really resonated with me.
I: You mentionend that you used to do traditional CBT. When did you move in the ACT direction?
R: I started working as a GP (family doctor) in 1991 and I became increasingly interested in the psychology of health and wellbeing. And as I started spending more and more of my time looking at the role of stress in the lives of my patients. My consultations would average to 20-30 minutes, which was unusually long for a GP. 5 minutes at the end of the session would be about the medical problem, and 25 minutes would be about what’s happening in your life: the stresses and difficulties. And I started to realize that I was really in the wrong profession.
So I wanted to train in therapy and the first model I trained in was traditional CBT. And I liked it. It’s a very effective model. I think I started formally doing sessions of therapy as opposed to GP counselling, in about 1994. And from that point, until 2003, I mainly did traditional CBT. However, at the same time that I was doing CBT, I kept training in other models, I was always looking for other things because even though CBT had some really good stuff, it didn’t, for example, have much to say about finding meaning and purpose in life. Also, I was very interested in mindfulness. There’s a whole branch of medicine called Psychoneuroimmunology, which is about the connection between the mind and the body, and there was some very interesting research coming out, about the benefits of mindfulness meditation for the immune system. So I was very interested in mindfulness, but it was very hard to get my clients to meditate.
As for traditional CBT, I really liked the behavioral elements: the skills-training, exosure, scheduling, and goal-setting etc, and I also liked the distancing components, where you become more aware of your thinking processes; but I didn’t like the components that were about challenging thoughts, because it didn’t actually work for me. I could challenge my thoughts all day long, but they’d just keep coming back, again and again. And I liked the mindfulness stuff, but I wasn’t overly keen on meditating. And I wanted to explore meaning and purpose with my clients, but I wasn’t quite sure how to do it. So I was trying for many years to bring these elements together: behavioural activation, mindfulness, cognitive distancing, meaning and purpose. I didn’t know anything about ACT, but it’s what I was intuitively trying to do. So when I finally discovered ACT in 2003, it was like ”WOW, this is fantastic!” A friend told me about it, I went to the book store, I looked at the book and it was love at first sight. ”Oh My God, this is fantastic.” I just fell head over heels in love with it. I became obsessed with it, and I instantly moved all my clients from traditional CBT to ACT. It was a bit confusing for them initially. I would say, ”No, no we don’t need to challenge those thoughts anymore”. They would say, ”Really?”
I: What is the goal of ACT, and how is it different from traditional CBT?
R: The aim of ACT is to create a rich, full and meaningful life while accepting the pain that inevitably goes with it. You might get some CBT people to say that’s the aim of CBT too - but words like ”rich, full, meaningful”, well, I didn’t encounter that emphasis in my own CBT training. More technically the aim of ACT is to increase psychological flexibility. And that’s definitely not the aim of CBT. Psychological flexibility is your capacity to be in the present moment, open fully to your experience and act in line with your values: to ”Be present, open up and do what matters”. That’s the outcome we’re looking for.
I: Could you tell me a little bit about the therapeutic stance in ACT?
R: The therapeutic stance is that ”We’re both in the same boat”. There’s no real difference between client and therapist; it’s just who’s sitting in that chair on that day. This metaphor that we like to share on the first session is the ”two mountains metaphor”. I say to clients: you come along to therapy, and it’s easy to get the idea that therapists have their life sorted out, that they don’t have any issues, no major problems. And I don’t want you to leave this room buying into that illusion. I want to shatter that myth right now. What’s it like is, you’re climbing your mountain over there and I am climbing my mountain over here. From where I am on my mountain I can see stuff on your mountain that you can’t see. For example, I might be able to see an alternative pathway that’s easier, or you’re using your pickaxe incorrectly, or there’s an avalanche about to happen. But I’d hate you to think that I’m sitting on the top of my mountain, no problems, no issues, just sitting back and enjoying life. I’m climbing my own mountain, over here. And we’re all climbing our mountain till the day we die. But what we can learn to do here is to climb more effectively, climb more efficiently; learn how to enjoy the climbing. Learn how to take a break and have a good rest and take in the view and appreciate how far we’ve come. That’s what this is about. So it’s a stance of commonality and equality: we’re both in the same boat; we’re dealing with the human condition. It’s not like some people have got a mental illness and some don’t; this is the human condition.
I: What is ”happiness” in ACT?
R: In ACT we stay away from the word ”happiness” because most people think that happiness means ”feeling good”. So in ACT rather than using the term happiness we use the term ”vitality”: a sense of embracing this moment of life, living this moment of life to the fullest. Steve Hayes has a saying: ”There’s as much life in a moment of pain as a moment of joy”. So the question is: ”Can I embrace this moment of life, whether it’s a very painful moment or whether it’s a joyful moment?” I say to clients all the time: ”If you’re going to live a full human life you’re going to feel the full range of human emotions”. So if you pushed me hard to define happiness in terms of the ACT model I would say ”Happiness means living a rich, full and meaningful life in which we feel the full range of human emotions - both the painful ones and the pleasent ones - without a struggle.”
I: How can you as a therapist help a client to identify personal values?
R: Many different ways. You can often identify them by asking questions: What matters to you? What’s important to you? A question I ask every client on the first session is: ”If the work that we do in this room could make a difference in one relationship, which relationship would that be? How would you behave differently in that relationship as a result of the work that we do?” Other useful questions are ”What do you want to stand for in life?”; ”When you look back at your life from your deathbed, what do you want to say that life was about?”; ”If you could be the ’ideal you’, how would you treat your body, how would you treat your children, how would you treat your job, how would you treat the environment, how would you treat your loved ones?”. You can think of vaues as how you would treat your relationship with anyone or anything; what are the qualities that you would bring to it? For many people these questions are useful. However, some people just go blank when you ask them such questions; in which case, we would do experiental exercises, of which there are many. One of the best is Kelly Wilson’s ”sweet spot” exercise, where you ask someone to get in touch with a very rich sweet memory, one of life’s ”sweet spots”. So it could be a memory of a time of love, a time of creativity, a connection with nature, a moment of achievement or pride or having fun, or a simple pleasure. We help them to relive the memory, and then we ask them questions to tease values from it: What does this memory tell you about what matters to you? What qualities were you embodying in the memory? What does this tell you about the way you want to behvae or the things you want to do more of, moving forwards? In this memory what were you ”in relationship with”? Was it a relationship with nature, or with your body, or with a loved one, or with an activity? In that relationship, what personal qualities were you embodying? There are many experiemental exercises, but the sweet spot is a particularly good one.
I: What are your thoughts on medication as a treatment for depression and other psychological problems?
R: The ACT stance on medication is like the ACT stand on everything else. The ACT model rest on the concept of ”workability”: is it working to give you a rich, full and meaningful life. If it is, keep doing it. If it’s not, do something different. This would be the ACT stance for any medication; not just psychiatric medication, but also medication for diabetes or cancer. For example some people with cancer choose not to have chemotherapy. They figure ”The chemotherapy won’t cure me, it will just give me six extra months of life- and the quality of life will be so low, I’d rather not do that.” So the ACT stance on medication is neither for it, nor against it; it’s all about workability. And there are quite a few published ACT studies where clients were on medication as well as doing ACT.
I: Do you have clients that choose to be on medication?
R: Sure, and if they do, I’ll work with them. I ask clients on antidepressants: ”What difference do they make?” The most common answer I’ll get is: ”I felt a bit better initially but now I don’t know if they’re doing anything” or I’ll get: ”I’m not feeling as much pain, but I’m not feeling as much of anything”. Most therapists don’t ask, but if you ask clients on antidepressants if they have sexual problems, about 70% of clients will say ”yes”. The incidence is much higher than the drug companies acknowledge. It’s a big problem. If a client considers the costs of being on medication outweigh the benefits - as many of them do - I will work in conjunction with a psychiatrist to help them get off it. I personally don’t want to play the role of prescribing medication or monitoring medication; I’m not interested in that. Basicly since I started doing therapy, I’ve said, ”I’m here to work with you as a therapist, if you want medication, you go see a gp or a psychiatrist, they can monitor all of that.”
I: You seem to use a lot of your own experiences in your book, in presentations and in therapy; what is the purpose of that?
R: ACT is a model that is in favor of self-disclosure from the therapist. ACT doesn’t insist on self-disclosure, but it’s very much in favor of it. If you read the literature you’ll certainly find studies and papers warning you about the dangers of self-disclosure, but you’ll also find plenty about the enormous therapeutic benefits of self disclosure. ACT is in favor of self-disclosure as long as it is done mindfully and judiciously: to model ACT for the client, or validate their experience, or normalize their experience, or build therapeutic rapport in a useful way.
I: Today when you did tell your own story, I think people got very emotional and touched by it. Are you purposefully aiming to bring up emotionality in the client?
R: What we are aim to do in ACT is to model and instigate and reinforce ACT processes. So I can model the ACT processes, I can instigate them, and if I see them happening in the room, I can reinforce them. One way of modelling them is through self-disclosure. We want to have an intimate therapeutic relationship. Kelly Wilson uses the term ”values and vulnerabilities”. If you know nothing about my values and vulnerabilities, we don’t have an intimate relationship.
Now ACT doesn’t insist on this. You can do ACT and be closed off, without sharing any of your personal thoughts or feelings; but it’s very different when you open up and self-disclose. It helps to break the illusion that the therapist has their life sorted out and doesn’t struggle with this stuff. Many of our clients are fused with the idea that ”everyone else is happy and has a wonderful life except for me”. When the therapist says, ”I get anxious too” or ”My mind is saying that I’m not good enough”, the client goes, ”Oh woww, you too!”
I: What are you occupied with at the moment in ACT concerns?
R: I’m writing four books. I’m writing with Louise McHugh – co-authoring a textbook, trying to make RFT really simple and understandable, and link it to ACT. RFT is the theory of language and cognition that underlies ACT, and many people find it really hard - so we’re trying to make it really simple.
I’m also writing a self-help book with Joe Ciarrochi and Ann Bailey on the use of ACT for weight loss. There are five or six published studies now on ACT with weight loss. That book is called ”The weight escape”, and it should be out in late 2013. I’m nearing completion of an advanced-level textbook called ”Getting Unstuck in ACT” for people who already know the basics of ACT. It’s about the most common ways therapists get stuck, and how to get unstuck again. That should be out in early 2013. And I’m writing a humorous book on mindfulness called ”The Way of The Sloth”. The sloth is an animal in South America. It hangs upside down from the trees with these hugh long claws, and it’s really slow moving. It’s the slowest mammal in the world. In English, the word ”sloth” means ”laziness”. ”Sloth” is one of the ”seven deadly sins” in the bible. Everyone thinks that this animal, the sloth, is really lazy - but what we’re saying in this book is that it’s a master of mindfulness. It doesn’t waste any energy; it’s this mindful creature; the zen master of the forest. So it’s a humorous book, where everyone gathers in the forrest to ask the sloth questions about life, the universe and everything.
I: Do you still have clients?
R: Not many, these days. Just a handful. I’d like to see more but I just don’t have the time; I’m always travelling and teaching.
I: Would you like to tell us a bit about your new book ”The reality slap”? It will published in Danish soon?
R: A ”Reality Slap” is when life just slaps you in the face, knocks you around, turns your world upside down. So ”The Reality Slap” is a book for anyone who goes through a major stressful life event; in particular, it’s about loss and grief. Death of a loved one, bankruptcy, divorce, major illness, a serious accident, a disability: any of these big life events. How do we cope with these events? There are 4 basic principles.
First principle: Hold yourself kindly. This is about self-compassion: Can I be kind to myself? There’s a massive gap here between what I want and what I’ve got; there’s a huge amount of pain showing up: so can I be kind to myself? Many of us don’t know how to do that. We stuff our face with drugs or alcohol or food, or we beat ourselves up, or withdraw from life: this is not really being kind to ourselves. So what are simple ways that I can be kind and caringand supportive to myself, in the midst of my pain?
The second principle, I call ”Dropping an anchor”. All these painful emotions, thoughts, feelings: it’s like an emotional storm. And if I get swept away by the storm, there’s nothing effective I can do. So how do I drop an anchor? Basically, I use mindfulness to ground myself in the present moment, and let those thoughts and feelings flow through me, without carrying me away.
The third principle is ”Take a stand”. What do I want to stand for in the face of this? What do I want to be about in the face of this challenge, in the face of this loss, in the face of this tragedy or crisis? I don’t have to give up on life. I can still stand for something, even if what I’m going through is horrendous. Even if the person I loved most has died, I can still stand for something in the face of that. I can give up on life, or I can stand for something that makes it meaningful. So it’s really about values, and committed action.
The fourth and last principle is ”Find the treasure”. Even in the midst of great pain and suffering, there are things that we can treasure and appreciate. For example, when we’re at the funeral of a loved one, we experience great pain - but in the midst of that pain, people reach out to us with love and kindness and caring; so can we appreciate and treasure those moments?
This principle has to come last, only once the other three are in place. The danger is that many people will try to ”find the treasure” as a first line response. They’ll say things like ”Well, every cloud has a silver lining” or ”What does not kill me makes me stronger”. But if that’s the first thing that you say to someone in great pain, they will experience it as completely invalidating. So ”Find the treasure” comes after everything else. And we’re not trying to pretend that the pain is not there. There is pain here AND there are things here that I can appreciate. But principles one to three have to come first.