Understanding Clinical Psychology and Acceptance and Commitment Therapy (ACT) with Diana Hill, PhD

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Understanding Clinical Psychology and Acceptance and Commitment Therapy (ACT) with Diana Hill, PhD

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Photo by @notquitemax, Unsplash

Photo by @notquitemax, Unsplash

The COVID-19 pandemic has brought a wide array of complications into our lives. Anxiety, uncertainty, and social isolation have presented immense challenges to our mental health and psychological well-being. In addressing these needs, approaches vary widely. How can we make sense of the different schools of thought within clinical psychology? And how do these relate to underlying psychological phenomena such as mental flexibility, mindfulness, and impulse control?

In order to better understand these questions, we recently spoke with Dr. Diana Hill. Diana Hill, PhD, is a clinical psychologist in private practice in Santa Barbara, CA, where she provides therapy, high-performance coaching, and training to mental health professionals in acceptance and commitment therapy (ACT). She is a co-host of the popular psychology podcast Psychologists Off The Clock, and the author of ACT Daily Journal: Get Unstuck and Live Fully with Acceptance and Commitment Therapy.

It seems that one of the core aspects of the ACT framework is psychological flexibility. How do you define psychological flexibility?

Psychological flexibility is your capacity to stay present, open up to your full experience, orient towards what matters to you, and then take steps in the direction of your values, even in the face of obstacles. 

Research on psychological flexibility and ACT has skyrocketed in the last decade and is showing that being psychologically flexible is helpful not only for your mental health but also for being an effective partner, parent, athlete, or leader. And, during COVID, those who were more psychologically flexible had less spillover effects of stress onto their families and showed lower levels of depression and anxiety. Psychological flexibility helps you be able to adapt to challenging circumstances while staying aligned with your values.

How does ACT relate to psychological flexibility?

ACT teaches skills to help you develop your psychological flexibility. There are 6 core processes that work together to help you respond more effectively to life’s challenges. The 6 core processes of psychological flexibility include:

  1. Cognitive Defusion: Your ability to step back from your thoughts as opposed to being entangled in them.

  2. Acceptance: Your ability to open up, be willing, and allow for difficult emotions, sensations, and other inner experiences.

  3. Values: Knowing what you care about and acting in a way that is consistent with the type of person you want to be in the important domains of your life.

  4. Perspective Taking: The ability to open your mind beyond the stories it has about yourself; placing you on a grander more flexible vantage point.

  5. Being Present: Becoming aware of the present moment and staying present during the times that matter most to you.

  6. Committed Action: Taking deliberate action toward your values.

How do you see the relationship between ACT and traditional cognitive behavioral therapy?

Unlike traditional cognitive behavioral therapies, ACT does not try to change thoughts or get rid of bad feelings, rather it helps you relate to them differently. There’s a good amount of evidence on thought and emotion suppression that the more you try and get rid of a thought or feeling, the more it tends to rebound. Anyone who’s been on a diet has had this experience. The more you try and not think about the cookies in your cabinet, the bigger they become in your mind. This is called the paradox of thought control. The core processes of ACT work together so that you can have your thoughts and feelings without getting caught up in them or spending your time trying to get rid of them. In ACT, you hold your inner experiences with awareness, but also lightly so that you can move freely toward what you care about.

How have you come to think about ACT in relation to mental health more generally?

The idea of acceptance is closely related to a lot of the mental health problems that we have. Consider for example a mental health concern like Obsessive-Compulsive Disorder (OCD), which is typified by having obsessive thoughts. But when we look deeper, we all have unusual thoughts like this from time to time. Things that pop into our heads that are inappropriate for the context, or that violate a social norm. And you think to yourself, “Oh, I shouldn’t have had that right now”. This happens to all of us.

But with OCD, what happens is the individual comes to be really hooked on them, actively trying to get rid of them. And then they start to do all sorts of things. Like if I count to seven or I wash my hands five times, or I, you know, do this other thing, that’ll get rid of my thoughts. And then you get into the compulsions. So the compulsions in OCD are about trying to neutralize or control the impulsive thoughts or imagery and you end up in a roundabout of suffering.

There’s something similar at play with depression, and negative thoughts. You have negative thoughts about yourself and you get entangled in it and you believe it to be true. Or you try and get rid of the thoughts about yourself by climbing back in the bed or not going out into the world. So you can see with a lot of our mental health concerns, how actually it’s our attempts to get rid of our thoughts or emotions that lead to the suffering. Sadly, it is often the things that matter most to us that also bring us the greatest pain in life. And, when you attempt to avoid or suppress pain, you end up avoiding and suppressing what you care about. Your life becomes narrowed and you move away from fulfillment.

This is a key difference with ACT: It’s less about trying to get rid of those symptoms and more about how you want to live more fully in your life. Living fully, even in the face of discomfort maps on to better work performance, athletic performance, parenting, even prosocial action. ACT is not just about mental health conditions, but it’s really about human flourishing.

It seems that ACT bears many similarities to mindfulness practices. How do you see mindfulness coming into the picture here?

Mindfulness or Being Present is one of the six core processes of psychological flexibility. Mindfulness is being able to be present, aware, and awake. Being able to observe in the present moment is very important for us to be able to respond to what’s happening effectively without being caught up in judgment or a story. ACT is like a Russian doll, in that there are more layers to this. It’s not just about being present. ACT’s also knowing your values, knowing what’s important to you, personal and chosen by you in terms of what you care about and how you want to be in the world. It takes being present to know your values. And when you become more present, you start to become more aware of your values. So these two processes of psychological flexibility reflect each other.

Being present, or mindfulness can also be very helpful in another process, like committed action. Say you want to start taking action in your life – you want to shift an unhealthy habit or work toward a goal you care about. You want to start doing things with your hands and your feet that matter to you. It helps to be mindful while you’re doing that. Debbie Sorensen writes about being mindful of where it matters. Mindfulness is also helpful with the ACT process of perspective-taking. When we can notice we are caught up in a self-story we can better step out of it and take other’s perspectives and take in the big picture. Likewise, mindfulness is helpful with Cognitive Defusion, because you need to be awake and aware of your thoughts in order to get some space from them. So, ACT is not just about mindfulness but it is about using mindfulness and all of these 6 processes to build your psychological flexibility. It’s sort of like a Rubix cube. Mindfulness is one side of the cube and the other processes are the other side, and when you work your way around the cube they influence each other. Ultimately the goal is not to finish a perfect cube, because that’s no fun! Perfect Rubix cubes just sit on the counter for no one to play with. The goal is to be able to continue tweaking and tinkering with the different processes over your life span. ACT is about being in the process — the process of living fully and flexibly.  


About Diana Hill

Diana Hill, PhD, is a clinical psychologist in private practice in Santa Barbara, CA, where she provides therapy, high-performance coaching, and training to mental health professionals in acceptance and commitment therapy (ACT).

She is cohost of the Psychologists Off the Clock podcast and is passionate about integrative health, homesteading, and parenting with intention.

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