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Theory to Therapy: Acceptance and Commitment Therapy for Social Anxiety

• Dr. Linton Hutchinson, LMHC and Stacy Frost

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Do you wish to revolutionize your perception of anxiety, rather than just suppressing it? Join Dr. Linton Hutchinson and Stacy Frost as they bring to light the profound approach of Acceptance and Commitment Therapy (ACT) in dealing with social anxiety disorder. Navigate through the six core processes of ACT - being present, self-as-context, cognitive diffusion, acceptance, values, and committed action. Discover out-of-the-box strategies like mindfulness exercises, diffusion techniques, and values-based goal-setting, which go beyond textbook knowledge and equip you with practical tools for your client interactions.

Let’s walk through the journey of a client tackling social anxiety and witness the transformative power of ACT. Learn how cognitive diffusion exercises can help clients disconnect from their anxious thoughts and gain a fresh perspective on their inner experiences. Unravel the significant roles of being present, acceptance, and values in this therapeutic voyage. This episode serves as a comprehensive guide to ACT and its practicality in managing social anxiety, shedding crucial light for anyone interested or practicing in the field of mental health therapy. Let's delve into the world of ACT therapy and explore its potential to change lives.

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This podcast is not associated with the NBCC, AMFTRB, ASW, ANCC, NASP, NAADAC, CCMC, NCPG, CRCC, or any state or governmental agency responsible for licensure.

Linton:

Hello and welcome to our Theory to Therapy series here at Licensure Exams. I'm Dr Linton Hutchinson, and joining me today is my co-host, Stacy Frost. In this episode we'll explore how to use the principles of ACT to address a client's anxiety, specifically social anxiety.

Stacy:

Before we get into the details, we want to mention that ACT is not the only evidence-based intervention strategy that you can use to treat social anxiety disorder. Cbt, combined with exposure therapy, tends to be the first-line treatment for social anxiety disorder, in part because it's been researched so heavily. However, mindfulness-based approaches like acceptance and commitment therapy have also demonstrated efficacy in treating the disorder.

Linton:

Right, and as you prepare for your licensed singing exam, you'll need to know about different approaches to therapy, not just CBT. So let's talk about acceptance and commitment therapy, or ACT, the main goals you'll be working through with your client, key concepts you need to know and techniques that you can use to help clients manage anxiety.

Stacy:

All right, so let's start with the main idea behind acceptance and commitment therapy. It's a kind of mindfulness-based cognitive behavioral therapy that focuses on embracing uncomfortable thoughts and feelings instead of suppressing them or running away.

Linton:

Okay, right. So let's say your client has social anxiety disorder. With ACT, instead of trying to get rid of their anxiety, encourage them to embrace and accept their uncomfortable feelings and thoughts as being part of a normal human being.

Stacy:

Exactly so. The goal is not to eliminate anxiety, but really to change your client's relationship with anxiety so it doesn't hold them back from living the life that they want.

Linton:

Right Stacey. That's a great summary of the overall philosophy behind ACT. Now let's get into some specific key concepts. One of the main principles of ACT is helping clients develop psychological flexibility, which is the ability to be present and act effectively even when experiencing difficult thoughts and emotions.

Stacy:

And to develop psychological flexibility. Act focuses on six core processes. Number one being present. Number two, self-esquon-text. Number three cognitive diffusion. Number four acceptance. Five, values and six committed action. Can you give us some more details about these six core processes, linton?

Linton:

You got it. Being present means focusing on the here and now with openness and curiosity. It's paying attention purposely, non-judgmentally and flexibly to what is happening at the moment, to open experience, thoughts, feelings and sensations. Self as context refers to the perspective from which a person can observe their thoughts without getting caught up in believing thoughts literally or allowing them to dictate actions experiencing oneself as the observer of internal experiences rather than being defined by them. Another thing you need to know is cognitive diffusion, which involves creating distance from your thoughts. You can detach yourself instead of becoming consumed by them. Cognitive diffusion allows a client to change the relationship with their thoughts by perceiving them as transient mental events rather than reflections of unchangeable truths carved in stone.

Linton:

Acceptance means embracing internal experiences as they are. It doesn't mean you're happy about unpleasant thoughts, emotions or events. It just means that you're making room for them to exist. You stop fighting their presence in your life. Values Values refer to desired qualities of living that can guide your actions. What do you want your life to be about? What's meaningful to you? Committed action is setting goals and engaging in actions that align with your chosen values, while embracing the internal experiences, positive or negative, that may arise during the process. It is also the process of following through by engaging in value-based activities.

Stacy:

Great review of the six core processes of ACT. Some of the techniques that ACT uses include mindfulness exercises, diffusion techniques and values-based goal-setting. The therapist helps the client practice these techniques and apply them to anxiety-provoking situations.

Linton:

Right. Here's an example case study using acceptance and commitment therapy with the client struggling with social anxiety disorder. You ready?

Stacy:

I'm ready.

Linton:

Okay, clinton, an older adult, experiences intense anxiety in social situations. Due to a fear of negative evaluation and rejection, he avoids going to social events and meeting new people. He tells you I can't attend my friend's birthday party and interact with total strangers. Everyone will think I'm ridiculous and make fun of me. Based on an initial assessment, quinton appears to struggle with cognitive fusion. His thoughts that he is unlikeable, boring, awkward or unattractive dominate his mind when encountering social situations. This leads to experiential avoidance as he attempts to control anxiety by avoiding any triggers. He values connection and friendship, but because of his social anxiety, he is isolated and alone. In your treatment plan as an ACT therapist, you would focus on cognitive diffusion exercises to help Clinton create distance between himself and his thought, allowing anxious thoughts to come and go without believing them or having to act on them.

Stacy:

And some examples of cognitive diffusion exercises include repeating a thought. This is where the client repeats a distressing thought out loud over and over again until it loses meaning or power, and this helps create distance from that thought.

Linton:

That happens to me when I repeat a word over and over until it doesn't make sense like the name Omatu agroyudeki Omatu agroyudeki Omatu agroyudeki Omatu agroyudeki. What the heck is omadik.

Stacy:

Omatu agroyudeki.

Linton:

Well, I sometimes use that name, which is the name of my colleague, when a cashier asks my name when ordering food, to see what reaction that they have.

Stacy:

Do you really do that, Linton?

Linton:

What do you think? Ac? Oh right.

Stacy:

I forgot who I'm talking to here. But yes, the ACT techniques of cognitive diffusion are at play there. Singing thoughts is another diffusion exercise. The client takes the troubling thought and sings it out loud, sometimes exaggerating the singing. This adds a sense of silliness or humor to diffuse the thought. How about it there, Quinton, here to regale us with a tune?

Linton:

That's Linton.

Stacy:

Oh, oops, Freudian slip Different podcast.

Linton:

And you're really going to have me sing during the podcast. You got to be kidding.

Stacy:

Nope, it's all in the name of counseling and illustrating to our therapist how it's done. Linton.

Linton:

I don't know, Stacey.

Stacy:

Ah, finding yourself feeling the pressure of social anxiety, afraid you might look silly. Come on, quinton, I mean Linton, demonstrate that ACT technique, Okay.

Linton:

okay, I know that you know that I love you. What I want you to know is that I know that you love me.

Stacy:

Pitchy, Linton Pitchy.

Linton:

See, I just knew someone would make fun of me.

Stacy:

Of course, with ACT you would embrace and fully experience feeling foolish and embarrassed and the anxiety that's associated with it. Our diffusion exercise is labeling thoughts. The client practices seeing thoughts as just thoughts by labeling them. Let's say a client says I feel ridiculous. Have them give it a name like redonkulous or radic, and every time they have that thought have them say out loud or to themselves that word that they've chosen. This helps create separation between the person and the inner experience of feeling ridiculous.

Linton:

Sort of like radic, radic, radic. Exactly over and over and over again. Yep Okay.

Stacy:

So you continue to collaborate with Quinton to set these ACT techniques into motion, to empower psychological flexibility. This allows the client to pursue valued directions while accepting the inevitable anxiety of the situation. Again, the focus is not on fixing or fighting anxiety, but really transferring that energy toward values-based actions that enrich life. I personally withdraw from metaphors and experiential exercises during this process.

Linton:

Those are good ones. Act does use a lot of metaphors to facilitate cognitive diffusion, like leaves on a stream. This is a classic mindfulness-based diffusion exercises where clients visualize placing their thoughts on leaves and watching them just float down a stream. When you do this, it reminds the client that their thoughts just come and go.

Stacy:

That's a good one. Or how about this one? Leave it on a bus. Thoughts and feelings are like passengers on a bus that you're driving like your life. You can't kick the passengers off, though sometimes you might want to. But you can decide where to steer the bus, based on your values and your goals.

Linton:

I really love that one.

Stacy:

And if any of our dear listeners love metaphors as much as we do, there's a book called the Big Book of ACT Metaphors, and the foreword is actually written by the founder of ACT, stephen Hayes. It's a great resource.

Linton:

So what happens when you have a client that is like totally literal and metaphors are just confusing? You know the type where you say something like we all have our paths in life and they look at you blankly and say, what path? There's no actual path. I'm just living my life day by day.

Stacy:

Yes, the very concrete fingers. Well, in that case, you're right. Metaphors often fall really flat and you want to be mindful no pun intended of your client's learning style and cognitive profile. If metaphors don't resonate with the client, don't force it. Instead, focus on breaking down the ACT concepts into very simple, direct language. Like there are thoughts in your mind that make you feel anxious in social situations. During our work in therapy, you can practice exercises to create distance from those thoughts so that they have less power of real Well, I know some people that definitely could use that.

Linton:

The both of us know.

Stacy:

Oh, yes, yes we do I think? Everyone does right. There's always some very literal people out there.

Linton:

I know it just drives me nuts.

Stacy:

Exactly what time is it, linton, or do you have the time?

Linton:

Yes.

Stacy:

Exactly exactly Right. So I'd also experiment with acceptance and present moments focus exercises. Acceptance exercises use direct experience to build distress tolerance, to foster an acceptance of anxiety rather than struggling against it. And present moment focus exercises are used to anchor the client to the direct sensory experiences that are happening right now. This brings their focus to the simplicity of present moment sensory details, rather than getting tangled in anxious thoughts about the future.

Linton:

For example, you may guide your client through a brief mindfulness meditation, having them focus on their breathing, the body, sensations or external sights and sounds, bringing their attention fully to the present moment, and ground them instead of allowing them to get caught up in their anxious thoughts about the future, exactly.

Stacy:

Another one that just came to me too is I really like, as the you count five different things, that you can hear five different things, you can see five different things, you can feel, and that's really good, I think, for the real literal people too, because it gives them a very direct, practical mindfulness exercise.

Linton:

Yeah, that would also break that being anxious.

Stacy:

Exactly, exactly.

Linton:

Because you're no longer in the future. You have to be in the present to be able to do that Exactly.

Stacy:

And values. Clarification motivates clients to engage in social situations, even though it's uncomfortable. So let's say that your client with social anxiety disorder, like Quinton, identifies community service and learning as his deepest values. Well, as his therapist, you would first help him gain more clarity on what community service and learning means to him specifically. For example, you might articulate that volunteering at a homeless shelter or tutoring children in reading are manifestations of those values. So, in Quinton's situation, help him connect with his desire for intimacy and belonging. And next you would help the client set goals aligned with those values, like volunteering once a week at the shelter or signing up to tutor with a local school, which reminds me Linton.

Stacy:

I don't know if I ever told you, but my mom did that when I was in elementary school. Yeah, she was, and especially I think this is really interesting because English was the second language for her she came from Germany. So when I was in elementary school, she worked with a small group of kids who had really serious medical issues that kept them from being able to attend school regularly, and after work she'd come to school once or twice a week and she'd meet with this group of kids in the library and she'd help them with their reading assignments and at the time I had no idea what she was doing at my school, especially when it wasn't to see me. Just this mysterious thing. You know my mom is disappearing off into the library. You know the teachers really kept that information on a need to know basis.

Linton:

Yeah, I can see that.

Stacy:

And it really wasn't until I was an adult, reminiscing about my favorite second grade teacher, miss Matrosky, that I found out what my mom had actually been doing all those years ago, and I think about her acts of service sometimes when we're doing these podcasts.

Linton:

How so.

Stacy:

Well, I know this may shock you, but I was not born with a microphone in my hand.

Linton:

What.

Stacy:

I know. I know I put on a good front.

Linton:

You do.

Stacy:

But the truth is giving presentations, whether it's in person or on a podcast, it's a bit anxiety-provoking. What if I say something that sounds so totally stupid or my mind goes completely blank? Mid-sentence.

Linton:

Well, don't worry about that Stacy, because I can just edit it out. Wouldn't it be nice if you could do that with life?

Stacy:

Oh, it would. Yes, it would hit the rewind button or the fast forward.

Linton:

Yeah.

Stacy:

So here's where the ACT process of values clarification comes in handy. When you can identify meaningful values like helping others and education which is the case with me, my mom and I adventure to say you too, linton then those values act as motivation to help get you past the anxiety. Instead of acting on anxiety and avoiding situations that might make us uncomfortable, like giving a presentation, we choose to act based on our values, which is to help test takers pass their licensing exams.

Linton:

So that helps you get over that, because that's a higher order reason for you to go through the anxiety.

Stacy:

Yes, well said.

Linton:

Yeah, I see what you're saying. The anxiety really doesn't ever go away. It just isn't the star of the show. So how are values different than goals?

Stacy:

Well, that's a great question. Values represent an ideal way of behaving that you continually work toward. Unlike goals that can be definitively accomplished, values serve as a compass to steer choices and decisions in the direction of the person that you aspire to be. Values involve principles in action that you renew every day. They're not an endpoint that you reach.

Linton:

Clarifying a client's deepest values allows them to set goals and commit to patterns of behavior that align with those values Right, so the values themselves represent ongoing processes and ideologies, while the goals are concrete steps you take to live out those values that you have. For a client with social anxiety, helping them to get really clear on their values provides motivation to continually take action in valued directions, even when they're feeling anxious.

Stacy:

Exactly.

Linton:

Yes.

Stacy:

Well, linton, I think we've reached the end of this rabbit hole. In this episode, we talked about acceptance and commitment therapy, which is an approach used to treat social anxiety and other disorders. We explored the goals of ACT accepting difficult thoughts and feelings like anxiety, instead of struggling against them or trying in vain to eliminate them from our lives.

Linton:

We also covered key concepts like psychological flexibility and the six core processes of ACT. Can you tell me what those are?

Stacy:

Being present.

Linton:

Okay.

Stacy:

Self as context.

Linton:

Yes.

Stacy:

Cognitive diffusion.

Linton:

I think that one's really important.

Stacy:

I do too. Acceptance also another really important one.

Linton:

Yeah.

Stacy:

Values and committed actions Right. And we also discussed techniques like mindfulness, diffusion exercises, metaphors and values clarification to help clients relate to anxiety differently. Knowing these techniques will help you if you run into questions about ACT on your exam and truly benefit your clients. So give them a try.

Linton:

This seems like it's a really good theoretical model to use, don't you think?

Stacy:

so I think so too. I really like it. I do too.

Linton:

Well, good luck to all of you. Will you prepare for your licensing exam? And until next time, remember it's in there, it's in there.

People on this episode

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Dr. Linton Hutchinson, LMHC

Host
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Eric

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Stacy

Co-host