Therapies

Stop Worrying and Start Living with ACT Therapy

Acceptance and Commitment Therapy — known as “ACT” — is a unique form of therapy that helps those with ADHD move past their fears and toward their goals. Here’s how it works.

A blue butterfly representing acceptance and commitment therapy
Blue butterfly on white shirt

Miguel sought therapy to understand how ADHD affected him. He had recently gone back to college after a disastrous freshman year that led him to drop out. In our first session, he said, “I tried CBT (Cognitive-Behavioral Therapy), and it did not work for me.”

Although CBT is an effective treatment for many conditions, including ADHD, it doesn’t work for everyone. So we decided to use Acceptance and Commitment Therapy (ACT) to manage Miguel’s symptoms.

ACT is an extension of the cognitive-behavioral model, but with some differences. Unlike CBT, ACT doesn’t try to change negative thoughts. It asks you to observe and accept them. ACT does not accept the idea that thoughts are easily malleable. CBT might focus on identifying a negative thought (“No one likes me”), then reframing it to something more positive (“Maybe some people don’t like me, but others do like me”).

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ACT goes beyond thoughts and feelings. At its core, ACT aims at using a person’s values as a guide for life, bringing people closer to their passions. “I never did things ‘just because,’” recalls Miguel. “I always pushed back to parents, teachers, and partners. But once I had the sense that what I was doing was connected to a deep value of mine, I knew that ACT was for me.”

Miguel always wanted to be a psychologist. But he felt that many things stood in his way, and that it was not meant to be. He was so fearful of writing a dissertation that he avoided pursuing his degree. He saw ADHD as “Intention Deficit Disorder” — knowing what to do but not doing it. Using the ACT model, we discussed the things that got in the way of his being a psychologist. We worked through the six core processes of ACT: acceptance, cognitive defusion, being present, self as context, values, and committed action.

Accept Your ADHD

This requires taking our thoughts, feelings, and bodily sensations as they are. Acceptance does not mean you are happy with your condition, only that you recognize it for what it is. In Buddhist thought, pain is inevitable and we must accept it. To deny our pain means we will not cope with it. Miguel felt that to accept his ADHD diagnosis meant that he was a weak person looking for pity. “Latino men don’t look for excuses. We’re supposed to just suck it up.”

First, we dealt with his denial, which was exacerbated by his dependence on alcohol. After some coaching on the ADHD brain and its genetic aspects, he began to see himself as someone who was simply wired in a certain way. He was not the only person in his family with the condition, but he was the only one to name it and confront it. He said, “Alcoholism is rampant in my family, and I have no doubt it is a way of coping with the frustrations of ADHD.”

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Miguel learned to accept his ADHD and his drinking problem over time. “If I knew acceptance would be such a relief, I would have accepted this years ago,” he said.

Take the Long View

This is the act of achieving a heightened awareness of your thoughts. Imagine seeing the grand canyon from the perspective of a donkey ride versus taking a helicopter tour to have an aerial view. Taking the long view gives you the ability to break your thoughts into smaller bits, so they feel less threatening.

Miguel engaged in negative self-talk: “I am a failure. I will never accomplish my goals. I am worthless.” I had him say these things repeatedly. When you say “failure” 20 times in a row, the word starts to lose its power. It becomes a bunch of letters and sounds.

I had him write these thoughts on a piece of paper and tape it to his forehead. This was a literal representation of his thoughts obstructing his view. I then instructed him to tape those thoughts to the floor, so he could see them while we were talking. He could still read his thoughts, but they were not obstructing his view. He practiced saying, “I am observing that I am having these negative thoughts.” He became separated from the thoughts, and they had less power. Miguel said, “Once I observed these thoughts, I imagined what I would feel if someone I loved felt that way about themselves. I would feel bad for them. It was a big shift in how I looked at myself.”

[Challenge Your Thoughts, Change Your Life]

Be Present

“I can’t be mindful. I don’t get how people make their minds blank and think of nothing.” People with ADHD can be mindful, even though it sounds like an impossible task. You can be mindful of the fact, say, that you are distracted. The goal of mindfulness is not to delete your thoughts and think of nothing. It is to observe what is happening. Only through mindfulness can you catch the thought or behavior that gets in your way and work to change it.

People with ADHD tend to run away from a negative mood, when they could benefit from feeling the emotion more fully. It is not a feeling that creates problems, it is the avoidance of a feeling. Miguel got anxious when he was assigned a long-term project. Being present to his feelings, not pushing them away, has kept him on course. If you are stressed about a project, and are unwilling to acknowledge the anxiety, it will paralyze you. Every time you are assigned a project, you will get anxious about getting anxious.

Self As Context

A Buddhist metaphor says that each person is the sky that holds the sun (happiness and good days) and the dark clouds (negative moods). When a thunderstorm occurs, it is in the sky, but it is not the sky. The sky (you) can observe that a storm (bad day, negative thought) is occurring and understand that it will pass. The sky will never become the thunderstorm, it merely is the canvas on which the storm happens. Miguel loved this metaphor and would say to himself, “I am the sky that is experiencing a thunderstorm right now. Thinking of myself as the sky makes me see that I’m bigger than the storm. I can deal with it and wait it out.” Miguel learned to handle tough days.

This mindset prevents a bad day from becoming a bad week for Miguel. In addition, when he is in a bad mood, it doesn’t color everything around him. “In the past, when I had a bad day, it affected everything around me. I felt nothing would work for me. No one was good around me, everything was part of that dark cloud.” Miguel learned to maintain his vision of being a therapist, despite days that knocked him down.

Embrace Your Values

Values are what matters to you, what informs your behaviors. Values are not the “shoulds” of life, which many with ADHD often recoil from; they are the healthy “wants.” The Valued Living Questionnaire (additu.de/vlq) is an assessment measure that helps people identify what is meaningful to them.

Many people’s values become clearer as they approach the end of life. No one says, “I wish I was perfect” on their deathbed. In her book, The Top Five Regrets of the Dying, hospice nurse Bonnie Ware noted the regrets people had on their deathbeds: “I wish I had the courage to live a life true to myself, not the life others expected of me,” “I wish I had the courage to express my feelings,” and “I wish I had let myself be happier.” These are all values. I asked Miguel, “what do you think you might regret at the end of your life?” I asked him to complete two sentences: “I wish I’d spent more time ____” and “I wish I’d spent less time worrying about ____.”

Our greatest insecurities and our worst negative feelings spring from the things that are most important to us. Rather than trying to push those negative thoughts away, we need to understand that the answer is not to push them aside, but to push through them. Imagine a three-foot-deep swamp that you have to walk through, since it is the only way to get to your destination. You cannot go around the swamp or jump over it. You cannot deny its existence, otherwise you won’t have the proper boots to get you through it. If you avoid it, you will go in the other direction, away from your destination.

Miguel stated his values as “being helpful to others,” “making the world a more positive place,” “helping people love themselves more,” and “creating light where there might be darkness.” Once his values became clear, every thought, belief, and feeling went through the filter of “Is this helping me achieve my values?”

Commit to Action

This is behavior linked to and motivated by your values. Goals should be SMART: Specific, Measurable, Achievable, Relevant, and Time-framed. Making goals known increases the likelihood that we will follow through in achieving them. Miguel practiced this in our work. He would send a group text to friends, saying that he was going to begin working on his school project at 7 p.m. “It is adding accountability, but on my terms. I know that one of them, at any moment, could text me asking me if I am still on track,” he said.

Procrastination results when a person doesn’t have a positive feeling about the goal or action. “I’ll do it when I feel like it” means that there may never be a time when one feels like doing it. In fact, the longer we put it off, the less likely we will be motivated to commit to action.

Miguel wanted to break the pattern of pushing things aside that seemed hard to deal with. Such avoidance in the past gave him short-term relief, but at the expense of his overall goal. We discussed how his avoidance moved him further from his values and from the things that would give him purpose. Once he understood it in those terms, he readily engaged in tasks he was unmotivated to do.

ACT was good for Miguel. Working through the six core processes let him accept his diagnosis, ask for support, apply coping strategies, not allow negative thoughts to direct his behavior, and live his values. He graduated with a bachelor’s in psychology, and is currently applying to doctoral programs in Clinical Psychology, so that he can help others with ADHD.


Why ACT Works for Those with ADHD

By William Dodson, M.D.

One of the best ACT therapy manuals is Get Out of Your Mind and Into Your Life, written by Stephen Hayes, Ph.D. The title immediately caught my eye. One of the biggest impairments reported by people with ADHD nervous systems is that they spend too much time in their heads. They are confused and hurt by the neurotypical world, which doesn’t understand or appreciate them.

Hayes’s manual works for people with ADHD because it recognizes that “importance” is not a motivator for them. Besides the burden of ADHD, many of them suffer from anxiety disorders, substance abuse, and the like. ACT therapy acknowledges that the intrinsic importance of a task and the rewards (pleasure) a person gets from accomplishing the task aren’t enough to motivate many of those with ADHD to take action.

ACT therapy solves the problem by having the patient focus on values, not the importance of a task, to spur motivation. Values are the not the same thing as importance. The things we value are things in which we have invested our emotions. We care about these things. They have meaning to us and, perhaps, only to us.

When I use Hayes’s manual, I start with Chapter 11. This chapter addresses the importance of values in moving a person forward in his or her life. I use an old therapy technique — asking the patient to write his own obituary — to focus him on his values. The obituary requires that you separate yourself from the demands of day-to-day life to reflect on the things that matter most to you. It is an opportunity to express how your life has made a difference: to yourself, your family, your community, your church, your profession, and the world in general.

The goal is to identify a person’s core values by answering the following questions:

  1. What do you care about?
  2. What have you invested the most time, energy, and emotion in?
  3. What gives meaning to your life? What gives direction and purpose?

For some people, the answer is family. For others, it might be setting a record or having fame and being remembered or admired. For others, it may be faith in God. The answer will be different for each person, and will be different at different stages of each person’s life.

The values that we hold put us back on the path when we have gone down the rabbit hole chasing a “shiny thing.” Values take the passions that would otherwise disrupt and overwhelm us and channel them into goal-directed action.

In an ACT session, I do something that may seem odd in treating highly distractible people: I regularly interrupt them. I have them set their cell phone to vibrate every 10 minutes. When it goes off, I ask them if they are engaged in something meaningful, or whether they have gone chasing a shiny thing. A person’s values tell him to get back on the path and to be engaged in something that he really cares about.

When a patient veers from his values because of distraction, I caution him to avoid getting down on himself and, instead, to inwardly smile and re-engage with something that is important to him.

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