Podcast: Acceptance & Commitment Skill-Building for Adolescents

Jenn talks to Nate Gruner about acceptance and commitment therapy (ACT) and how it can be utilized by adolescents. Nate explains the benefits of ACT principles on the mental health of young adults, discusses how these applications can lead to more meaningful and fulfilling lives, and answers audience questions about how these small, habitual practices can have a big impact. In addition, Nate shares strategies for implementing ACT in daily life and runs through exercises with Jenn to help the audience better understand how ACT works.

Nate Gruner, LICSW, is a staff behavioral therapist for McLean’s Obsessive Compulsive Disorder Institute (OCDI). He received the McLean Hospital Career Development Fellowship Grant to fund a research study examining acceptance and commitment therapy-enhanced exposure therapy for OCD.

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Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

So, hi, folks. Good morning. Good afternoon. Good evening to you.

And thank you so much for joining us, wherever you’re joining us from and whatever time you’re joining us at, to talk all about acceptance and commitment therapy and how its principles can help adolescents and young adults lead fulfilling and engaging lives.

I’m Jenn Kearney. I’m a digital communications manager, for McLean Hospital, and I’m joined today by the lovely Nate Gruner. I know some folks who have joined today have heard of acceptance and commitment therapy.

Throughout the session, we might be talking about it as ACT, but a lot of people often associate it as a treatment for obsessive compulsive disorder, but it turns out that the strategies that are used in ACT can actually be beneficial for folks with depression, anxiety, substance use, other conditions, or no conditions at all.

Regardless of your mental health status, the principles behind ACT can be applied to anybody at any age. I am really excited to have Nate with me today, because we’re going to talk about how the components of ACT can actually benefit young adults.

We’re going to talk about how we can engage kids in making positive changes in their behaviors and thoughts based on principles of ACT, and how really small habitual practices that are taught in ACT can actually have a really big impact.

So if you are unfamiliar with Nate, he is a licensed social worker and a staff behavioral therapist for McLean’s Obsessive Compulsive Disorder Institute, as well as recipient of McLean’s Career Development Fellowship Grant, which funded a research study that examined ACT-enhanced exposure therapy for OCD.

In addition to his research and clinical work, Nate also serves as a founding member on the Board of Directors for the New England Chapter of the Association for Contextual Behavioral Science.

So Nate, hello, and thank you so much for joining me today. It’s nice to put a name to a face. I want to get started just by asking, what exactly is ACT?

Nate: So I thought about how to explain this, because a lot of the things we’ll end up talking about today will be a little bit tricky to understand, even though they’re actually not once you get them.

So I’m going to start with a metaphor to explain it. You may be familiar with this, Jenn, this idea of a bus that you’re driving, and I’m going to walk you through that so you can get all the elements of ACT.

So ACT is a therapy that focuses on increasing psychological flexibility. There are six components to that, and I’m going to explain that using this bus metaphor. So imagine you’re driving a bus, Jenn, and you have passengers on it.

The passengers are your thoughts and feelings and memories and physical sensations and urges, all the stuff that happens inside of you. And you are trying to go somewhere where you want to go. And the passengers say a bunch of things to you.

So they’ll say things like, “You have to stop. You have to turn around. You’re too anxious. You’re too sad. You’re a good driver. You’re not a good driver. Get off at this exit.”

They’ll say all kinds of things to you. Some will be helpful. Some won’t be helpful. Some will be positive. Some will be negative. Some will be neutral and you won’t even notice them. This is basically what it’s like to be human, is you’re like driving this bus with passengers on it.

And in ACT, there’s six things we’re trying to help people do while they’re driving that bus. One is this idea of being present. So you’re working on focusing on what’s important in front of you, where you’re trying to go, what the road looks like in front of you and flexibly focusing your attention there. That’s being present.

Acceptance is making room for the passengers to be there, instead of fighting with them and trying to control where they are on the bus, or get them off the bus, really actually allowing them to be on the bus and move around.

Defusion is this skill where you’re learning to see the passengers as just passengers, not as real things that you have to respond to or follow, and you’re not interacting with these passengers based on how good, bad, true, false, right, wrong they seem, but instead on how useful they are for helping you drive where you want to go.

We can get more into that. Self-as-context. This is a trickier one, which we’ll end up talking about more. But to just give a brief sense of this, is seeing yourself as the bus instead of seeing yourself as the passengers.

So what I mean by that is, you’re the place where all the passengers are, but you’re not defined and controlled by the passengers. And then values is knowing where you want to go.

Just knowing which directions you want to drive this bus in, and then committed action is learning how to drive the bus flexibly towards where you want to go.

And just to give you a sense of that, like if I told you to drive north from like Boston to Canada, you can’t just go straight north. You’ll like run into stuff. So committed action is like learning how to drive flexibly towards the destination you’re trying to go in.

Jenn: Got it. So it seems like, it seems like acceptance and commitment therapy is like drastically different than what people typically assume like talk therapy or CBT is.

Can you elaborate on some of the additional differences that, or some commonalities that the two of them may have?

Nate: Yeah, I thought about this. So one of the interesting things is modern cognitive behavioral therapy. The more kind of updated versions of it are actually looking a lot more like ACT.

So if there are therapists watching this, they may watch this whole webinar and say, “I’m already doing a lot of this stuff. And I’m a CBT therapist,” which means the field is moving more in this direction already of doing these ACT components in therapy.

But the older forms of CBT focused more on trying to change the passengers that are on the bus. So what I mean is trying to get control over them, trying to get them lined up and more rational, and reducing the amount of distress that they cause. And then kind of once that stuff is more controlled, moving the bus where you want to go.

And in ACT, it’s not about getting control over the passengers, it’s about changing your relationship to the passengers so that it’s easier to drive the bus where you want to go.

Jenn: So it sounds like there’s some mindfulness that’s a part of ACT. Is ACT different from mindfulness in any sense?

Nate: Yeah. So if you think of mindfulness as three or four of the things I talked about.

So if you think about mindfulness as being present, letting things be as they are, seeing your thoughts and feelings for what they are, just thoughts and feelings, and seeing yourself as the place where thoughts and feelings happen instead of being defined and controlled by them, ACT includes all of that mindfulness stuff.

So if you think about ACT as a mindfulness based behavior therapy, it’s like blending mindfulness and acceptance ideas with behavior change ideas, all mixed together to create this thing called psychological flexibility.

Jenn: Got it. And I got to be honest, some of these concepts, like when you’re explaining them, they seem a little bit out there.

Like, I know one of the goals of ACT is aiming for a more rich and meaningful life where your behaviors, your actions, they aren’t controlled by the transient thoughts and emotions that you’re having. But it seems like the primary goal isn’t always symptom reduction.

It seems like it’s more acknowledging and overcoming symptoms as they come up. I mean, with that being said, how could you explain ACT to somebody who, like me, might feel a little bit hesitant to get on board with things that might seem a little bit like hokey and or holistic?

Nate: Yeah. So it’s a great question.

So if you think about like in your own life and a lot of people watching this may resonate with this, a lot of people in our society, I think, think about their life as, “My life will be good once I get happy, and once things start kind of going my way.”

And this isn’t just like people with mental health problems, it’s like most people actually see their life that way, that like the goal is to feel good and then live well.

And ACT actually like flips that around where it’s like the goal is to learn how to stop controlling what you’re feeling, to stop sort of defining your life based on how good you’re feeling inside.

And to start actually defining your life based on how much you’re living in a way that feels true to yourself. And what I mean by that is like, how much you’re living in a way that feels consistent with what you really care about in your life.

And the cool thing about that shift in perspective is once you start getting it, you actually can have a good life before anything happens. So what I mean by that is, once you’re being true to yourself, you’re already, like, winning the game.

Whereas that older sort of more traditional perspective people have in their life is, “I have to get everything to go my way first, inside and outside, and then I can relax and enjoy my life.”

Whereas this is like, being able to relax and enjoy your life in the presence of all the things that are stressing you out and living in a way that feels true to yourself in the presence of all the things that are stressing you out.

Jenn: Do you have any examples or practices that someone tuning in could actually apply here and now towards shifting their perspective?

Nate: Yeah. I’ll just, I’ll give you one little perspective shift and then we can do some exercises here and there as we go.

Like, if you said to me right now, I stole this little example from one of my favorite ACT people who trained me years ago. If you asked me right now, “How anxious are you, like, doing this webinar?” The funny thing is I wouldn’t be able to give you a number.

Like, I wouldn’t be able to tell you, like, “I’m here between zero and a hundred. I’m like at a 70 or something like that.” The reason why I couldn’t tell you is because the better I’ve gotten at doing ACT in my own life, the less I track what I’m feeling, meaning like, how bad I’m feeling.

But if you said like, “How important is this webinar to you?” Or like, “How much do you want to like communicate information or like, have fun with this?” Like, I can talk to you about that, but I can’t talk to you that much about like, how bad I’m feeling right now, ‘cause it’s not important to me.

So if you said, years ago, before I learned ACT, like, “What would my focus be right now when I’m doing this webinar?” It would be more on like tracking how anxious I am, but like, that’s not helpful to me, right? Like, I don’t need to know how anxious I am to, like, do this with you.

So that shift in perspective where you’re literally saying like, “I don’t know how anxious I am. I can tell you, like, what’s important to me right now.” That’s the shift we’re trying to help people make a lot when we’re talking about ACT.

Jenn: I really like that. That’s, for like a personal application, I know I’ve been running these for a couple years now and I, I remember specifically like fixating on how nervous I was originally.

And then over time as I’ve gotten more used to it, but also like, as I’ve realized that there are so many interesting things to talk about in mental health, my perspective has changed from how nervous you get on camera to how much impact do you want to make.

And I feel like that shift in perspective for me has been really helpful in terms of meaningfulness. And that, honestly, to me, that sounds like a little bit of me implementing ACT in my own life.

Nate: It’s kind of obvious when you think about it that like, if I said to you, “No, Jenn you can’t enjoy these webinars until you relax.”

That would really suck for you because then you’d be like, “Well, okay. So I guess once I get my anxiety below, like a 50, then I can really relax and enjoy these webinars.” And I’m saying, you could just shift your perspective over to, “It’s okay to be anxious and do a webinar. And what’s going on inside of me, doesn’t really matter.”

And I don’t mean, some people are going to listen to this and think, “Is he saying emotions don’t matter?” No, they do, and we’ll talk about that. But for this activity that we’re doing right now, you don’t need to know how anxious you are. It’s not going to help you.

Jenn: So I want to shift a little bit of our discussion over to young adults and adolescents, because that is ultimately what we want to talk about today.

What are the benefits of those groups of kids learning the core processes of ACT? Can you talk about some of the both short and long term benefits to them understanding and implementing ACT?

Nate: So short term, just in terms of like the research, what we know now about psychological flexibility, those six things that I outlined at the beginning, is that that stuff is actually correlated with pretty much every mental health problem that humans struggle with.

And so if you get good at psychological flexibility, a lot of the mental health problems that young adults and adolescents are struggling with start to come down.

So psychological flexibility is just super useful in mental health treatment, but then long term, it’s just a nice guide for your life to be able to sort of see your life in a way where you don’t have to, like, fix everything that’s going on inside of you before you’re happy.

So I kind of see short term and long term benefits to it. I can get more into the specifics as we go as to specific things that I think adolescents and young adults could be helped by.

Jenn: Actually, I think that would be really useful to jump into right now. Like, what components of ACT would they benefit more from implementing than others?

‘Cause it doesn’t seem like, with ACT, it doesn’t seem like you have to master all six processes in order to be like, feeling good about yourself and having some, like, mental health symptoms reduced. So you know, what’s...

Nate: Yeah. So I might actually start with one of the more complex ones, but let’s, you tell me how this lands for you and then the audience can jump in on this too.

So self-as-context usually is one of the hardest processes for people to understand, but I think it’s really helpful to adolescents.

So self-as-context, again, is basically learning to see yourself as the place where your thoughts and feelings happen instead of being defined and controlled by your thoughts and feelings. Said another way, you’re the bus, not the passengers, you’re the bus that contains the passengers. Now why is that important for adolescents?

Well, think about all of the identity problems that adolescents are struggling with as they start to like figure out who they are, how they want to live, how they want to express themselves.

Kind of the old traditional way that I think adolescents have done this is they define themselves based on, like, their friends, the sports they play, political orientations, religions, their parents, whatever.

But in modern society, there really has been this move more towards like, you sort of pick who you’re going to be. There’s much more flexibility in choosing how you’re going to live and define yourself.

And that can be super overwhelming, I think, for adolescents to sort of understand, “Who am I and what do I really want?” From an ACT perspective, you’re helping people back up and see that in some way, they’re just the observer of all of those labels that they have for themselves.

And then from that perspective, they get to grab onto and choose the ones that fit for them and go try them out in their life. And if they feel true to themselves, they feel like, “This is helpful to me. I like this label of being an athlete or being a scientist,” or whatever it is, you go with it.

And your sense of self from an ACT perspective can be flexible. You can change over time, meaning you can let go of labels and grab onto new ones. None of this stuff is fixed in place. And so I think a lot of adolescents could benefit from like, seeing themselves as the place where all this stuff happens and then grabbing onto the stuff that feels right to them.

Jenn: That seems like that would almost be something that should, I feel like it should be taught in like high school or secondary school because that’s something where you go to college, if you go to university, you move away from home.

A lot of people have no idea “Who they are,” so to speak. And a lot of people tie themselves to an identity that they had in the past or the identity that somebody else had helped establish for them.

And that’s such a formative and difficult time that you can’t help but wonder if there’s some correlation between the mental health of students struggling in that population and the difficulty with, like you keep saying, identifying themselves as the passengers in the bus versus the bus itself.

Nate: All of these skills, to be honest with you, Jenn, like, probably should be taught in schools at a pretty young age.

Like, just knowing psychological flexibility before you hit mental health problems can be super useful, almost like as a prophylactic, you know, against a lot of the things that you’re going to face in life. So yeah, I totally agree with that.

Jenn: I’m curious if there are any specific subgroups of adolescents that would benefit more from ACT than others, with the full understanding that this is something that is typically used in OCD treatment, but again, like we’ve been saying, everybody can benefit from it.

Nate: So the sort of straightforward answer to this is anyone who’s low in psychological flexibility can benefit from ACT.

So what I mean by that is, anyone who gets really caught up in their thoughts, avoids their emotions, isn’t really clear about who they are and what they care about in their life, and isn’t good at taking action on things that are important to them can benefit from ACT because ACT really is teaching psychological flexibility.

So honestly, like it doesn’t just have to be adolescents who are struggling with a mental health problem. It can be someone who’s just struggling in general with psychological flexibility.

Jenn: So because of where kids are developmentally. So I know I’ve talked to other licensed mental health professionals. They’ve all said, you know, your prefrontal cortex or your thoughts, emotions, behaviors, it’s not fully developed until your mid-twenties. Right?

So taking that into consideration, is there like a right or wrong age to start teaching ACT? Should it be something that we’re trying to implement as they’re approaching maturity? Should we try to get to them faster?

Nate: Yeah. You know, I don’t think that there’s data out on when is the right time to learn this, but I will say this. I sometimes have a harder time teaching ACT to older people.

It’s sort of like, the old dog new tricks issue is like the longer you’ve been living a certain way, the harder it is to learn new things. So I’ve actually found a lot of times with younger people, their minds are a little bit more ready to learn ACT.

I may do some exercises with you in here that will give you a good example of this. Do you want to do one now? Or should we wait on that?

Jenn: Yeah. Let’s go for it.

Nate: Okay. So this one is an exercise that is an example of one I actually see older adults struggle with more than adolescents. So it’s like a good example of where I think adolescents can quickly grab some of the key concepts in ACT.

So I’m going to do this exercise. It’s pretty straightforward. And then it gets a little weird. So, and you’re going to be my participant. So round one is, I’m just going to give you instructions. And then I want you to just follow what I say.

So can you raise your right hand and then lower it and then raise your left hand, lower it, turn your head to the right. Turn your head to the left. Awesome. You’re doing great. Round two, slightly harder.

So I’m just going to flip it around where I’m going to give you instructions and you just do the reverse of what I say. Okay? So can you look up, look up, you’re doing alright. Keep going, look up.

Jenn: Already looked in the wrong direction.

Nate: I faked you out a little bit. Look up, look down. Good. Raise your left hand. Okay. Raise your right hand. Good. Round three’s the hard one.

Jenn: Okay. I’m ready.

Nate: Round three is I’m going to give you instructions and you get to do whatever you want. So, but I want to be clear before we start this, cheating would be you just walk away.

You just go off camera and you like, go do whatever you want. I want you to actually like, stay here, which you’re going to do.

Jenn: Okay.

Nate: And, but actually, like, just do what you want to do, which means like, you can tune in to me when you want to.

Jenn: Okay.

Nate: And tune out when you want to. But like what I’m saying to you is just me talking. Okay?

Jenn: Great. Yup.

Nate: Alright. Let’s start. So can you, that sectional behind you looks super comfy.

Can you go back there and like grab one of those pillows and maybe just make yourself feel a little more comfortable, and then the door over on the side there, can you go grab the door knob, pull it open and then close it?

I don’t understand why you’re not listening to me.

Jenn: I think I was told to do whatever I wanted to do.

Nate: Right. But I’m talking so there’s, you know, I’m giving you instructions. You got to follow what I say. Jenn, can you refocus your attention and follow my instructions? So.

Jenn: Trying very hard not to not follow your instructions.

Nate: Interesting. Put your right hand up, put your right hand up. Okay. Put it up, keep it up.

Jenn: Which for folks who can’t see, I did not raise my right hand at all while he was saying, “Keep it up.” Not up at all.

Nate: Alright. Pausing the exercise. I want to point something out to you in the audience here. Round one, you did great. Round two, you did great. Round three, you did pretty well, but it’s harder.

Here’s why. I’m talking to you. And like, when I do this with patients, I’ll often do this in groups or in individual sessions. Patients will really struggle with round three because I’ll kind of mess with them a little bit and I’ll be like, “I don’t understand why you’re not following my instructions. Like I just told you to raise your hand.”

And interestingly, the older patients, a lot of like the adults that I work with, tend to struggle more with this exercise because they take things so damn literally. And so when I’m talking to them, they’re like, “I don’t understand.” And I’m like, remember the instructions where you get to do whatever you want.

Jenn: Which is why I was like, I’m openly acknowledging that I’m having a hard time not doing what you’re asking me to do.

Nate: Exactly. And what’s interesting is if you followed everything I said, I’m controlling you. If you oppose everything I say, I’m controlling you.

But the place where you actually have freedom is when you can just hear what I’m saying and decide when you tune in and when you tune out, and this really is what ACT is, is it’s like learning how to treat your mind like a thing that talks to you all the time.

And you get to decide when you’re going to like, listen and pay attention and when you’re not going to. And again, like I said, and this isn’t universally true, but I think adolescents can get this pretty quickly. Sometimes, I’ll flip it over to an analogy.

It’s like, if you’ve ever listened to a baseball game or like a sporting event that goes on for like three hours, there’s so much that the like announcer says that like you don’t actually have to listen to.

Like, they’re talking about the new car that they bought or like, what the hot dogs are like at the game or what the weather’s like or whatever. But when they say, like, something important is happening in the game, that’s when you want to tune in.

In ACT, like, we’re trying to help people tune into their minds when there’s useful stuff going on up there, that’s going to help them with their life. And when it’s not useful, being able to just notice it there, even when it seems super compelling, and be able to get back to doing what you want to do.

Jenn: And I do want to be clear that you are very useful. I’m not, I’m tuning you out for the sake of following the exercise. So just want to be clear about that, but I mean, you brought up a really interesting point in terms of being able to, like, tune things out.

A really, one thing that we all do, not necessarily young adults, but a way to just kind of tune ourselves out is devices, screen time, kind of numbing ourselves in front of the TV.

How can we encourage people to be more present when we’ve all fallen privy to being distracted and tuning ourselves out for another hit of dopamine?

Nate: So I like to, I mean, honestly, this is the way I do it in my own life. And I encourage this for a lot of the adolescents I work with. Leave your phone or your devices somewhere where you can’t use them when you actually notice that you don’t want to be using them.

So this kind of gets back to this idea of, like, “What are my values right now?” Or like, “What’s important to me right now?” So like, just to give you an example, I’m sure a lot of people can relate to this.

Sometimes I’ll be, like, on my couch trying to watch a TV show and I’m like looking at my phone and I’m like, “Why am I looking at my phone? I want to watch this show.” Or like, “Why am I looking at my phone? I want to read this book. Why am I looking at my phone? I want to talk to my friend.”

So like just choosing to put your phone somewhere else or like your devices somewhere else can be like a useful way of saying like, “This matters to me. Like, I really want to focus on this thing and not be distracted right now.”

But the way I try to explain it to people is, don’t do it just ‘cause like, you know, your parents or your therapist is saying like, “Technology’s bad” or like, “You’re overusing technology,” but more like, you want to have more flexibility in terms of how you use it, based on what actually produces wellbeing in your life.

And you getting better at tracking when you want your phone there and when you don’t. So like before you go on your next bike ride or walk or whatever, like deciding like, “Do I want technology with me or not?”

Now sometimes for safety reasons, you got to bring your phone. But I really like this idea of like, similar to the way in ACT we talk about seeing thoughts as either helpful or not, seeing technology as either helpful or not, depending on the situation you’re in.

Jenn: That’s a really good application too, for folks who, I mean adolescent, older, younger, who have a really hard time with sleeping and they’re on their phones right before bed.

It’s like, do I want to get a good night’s sleep? How much do I want technology impacting how tired I am tomorrow morning?

Nate: Definitely.

Jenn: So we had someone write in saying that the idea of a person “being the bus” seems like it’s a way of integrating the ego into the self, especially in our society where things seem a little bit more fragmented.

Do you have any comments on this or want to elaborate any further?

Nate: Yeah. So this is the part of ACT that I think is one of the hardest to grasp. And so I’m glad that question came up. The self-as-context perspective really is, it’s going to sound weird to say this. There’s no such thing as you.

So what I mean by that is like, you’re just the place where all these thoughts happen. All these feelings happen, all these ideas about who you are happen, and that can freak people out.

Like, there’s a lot of people when I explain that to them, they’re like, “Well then, who am I, if, like, all my thoughts about myself are just like these clouds floating by?”

And the second step to this is then grabbing onto the thoughts and to the identities that really feel true to you, that feel helpful to you, and, like, trying them out in your life almost like you would try out clothing, like you’re going to go try and see how it fits for you.

And, but then once you have it on and you’re using it and it feels right to you, it doesn’t mean now that’s permanently you for the rest of your life. There’s this ability to like, put on labels and take off labels depending on, like, what feels useful in the situation you’re in.

Like, I really think adolescents could benefit from knowing when they want to be more outgoing and when they want to be more shy, or when they want to nerd out, and when they want to be more cool. And I don’t mean that in like a, “You got to change yourself in every situation to fit in.”

I mean, you got to change yourself to be able to fit with what feels true to you and to have this more flexible sense of who you are that isn’t permanently fixed in place because of like, what you’ve been doing your whole life, or what your parents told you you were or what society says you are or whatever.

Jenn: So how do you think today’s conversation we’re having may relate to issues like gender dysphoria? I know that that’s a conversation that’s been popping up much more often in preteen and early adolescent groups.

Nate: Yeah. That’s actually one of the reasons I brought this self-as-context thing up is, the more patients that I work with who have this going on is kind of this question of like, “Well, how do I define myself? Just, what’s really true about me?”

And especially with all of the different options you have now for picking like, what pronouns you’re going to use and what gender you want to be and how you want to express your gender or your hair color or whatever.

I think that, this is how I like to approach it and this is where I think ACT really can help. You don’t have to figure it all out right now.

Like, you really can have this sense of like, “I don’t know who I am. I’m going to go try on different ways of expressing myself and I’m going to see what feels right to me,” not in a rebellious way or a conformity way. Neither of those are really what we’re shooting for.

It’s more like a, “What’s really true for me?” And like, those are like the conversations you can have with your therapist is like, “I’m trying out these pronouns or I’m trying out this hair color,” or, you know, “This way of just, like, being social with my friends.”

And I’m seeing like, “Does this feel true to me or not?” And I really think, like, these identity issues that adolescents struggle with don’t have to be, like, sorted out all, like, right now. Like you can actually take some time to learn through your experience who you are and what feels right to you.

Jenn: I know another thing that happens a lot with young adults is there’s a lot of fixation on feelings.

Even something that somebody says to them, that a lot of times you become more socially, you become more conscious of what’s happening socially, whatever...you get embarrassed a lot more easily.

Do you think that if all of these, this self-consciousness, this embarrassment, that sometimes, like, rumination on what someone said to you, do you think if those passengers are acknowledged, they’ll stop bothering them?

‘Cause I know sometimes, if you’re not processing the feelings, they’re just going to come back.

Nate: Yeah. So when you are having thoughts, yeah. I’ll give you an example.

So if you’re having thoughts, like, “Is this person judging me? Does this person like me? Does this person want to be my friend? Does this person like my hairstyle,” whatever it is.

One of the things I want to be clear about is the ACT approach here isn’t, “Oh, just ignore all of those thoughts. They don’t matter.” That’s not what we’re talking about. We’re actually talking about tuning into the ones that are helpful and tuning out from the ones that aren’t helpful.

So it may actually be the case that you’re dealing with a friend or a person who doesn’t like you very much, or who is judging you. And there’s really useful information to get there about like, how your behavior is impacting them.

Do you want to change it? Is this about them or is this about you? And there’s moments to really tune into your mind on that stuff and see if it has some useful things that you want to pay attention to.

But it’s being able to do it in a way that actually moves your life forward and produces wellbeing in your life and creates positive relationships in your life, and not tuning in and tuning out based on how true the thoughts feel, but more based on how helpful they are for being the person you want to be.

Jenn: That makes much more sense. You know, one thing I do want to address too, is a lot of adolescents that struggle with depression often have motivation issues.

And that ties into not how am I feeling in the moment, but like, who I want to be and how I want to get there. But when you have depression, it can impact your homework. It can impact your studying.

You might not want to go to school, so on and so forth. So is there any way that ACT could be helpful for adolescents that are depressed and feeling that impact in their education?

Nate: Yeah. So let’s just go back to some of the skills here. Is it okay to feel sad and do your work at the same time?

You know, I got to tell you, like, this is one of those things where I kind of wish I had learned that from a young age was like, it’s okay to have painful feelings and do your schoolwork at the same time, or get out and exercise at the same time.

I think a lot of people don’t know that, they think you first have to feel good and then you can go do it. So just that idea of like, “I can go do my schoolwork or exercise or see my friends, even when I’m feeling sad,” and, like, focus more on what’s important to you than on what you’re feeling inside of you.

And that’s again where the values piece comes in. So yeah, in classic CBT terms, we talk about this as, like, opposite action where you’re, like, doing the opposite behavior to what you’re feeling.

But ACT adds this piece to that, which is like, and also do the thing that matters to you even when you’re feeling sad. And so getting a lot of clarity about like, “Do I care about doing my schoolwork?

Is there something I’m shooting for in my academic life or in my career that I really want?” Going and doing that instead of just following the feelings that are happening inside of you.

Jenn: So if a teenager is fighting through depression and multiple medications haven’t worked and I want to address too, like, little seems very important to them. And they’re having a hard time with discerning what is of value.

How would ACT possibly help them? And before you jump into the response, I do want to remind folks tuning in that just because Nate is a provider does not mean anything that he is suggesting you should implement without talking to your own care team first.

Nate: So, can you remind me of your question again?

Jenn: Sure. Sorry. ‘Cause I threw the disclaimer in. If a teenager is fighting depression and multiple medications haven’t worked and that little seems important to them, how could or would ACT help them out?

Nate: Yeah. So I mean, this is just like a classic problem where you don’t know what your values are. You don’t know what you care about because you spent a lot of your life avoiding, which means you just don’t know what’s important to you.

You haven’t interacted enough with the world to know like, do you care about having friends? Do you care about dating? Do you care about school? Do you care about sports? Whatever it is.

So this really is where you kind of got to get out there and do the drive the bus part first, meaning you got to go drive the bus to some different places and see, like, what you like and what you don’t like and what feels true to you and what doesn’t.

This is more of the, like, kind of force yourself part. Once you’re out there in the world, doing things, you need to pay attention to what feels good to me. When I say good, I don’t mean what feels easy or what feels comfortable.

I mean, what feels true to me, what feels meaningful to me? What creates wellbeing in my life? And so oftentimes values clarity for adolescents doesn’t come from sitting in a therapist’s office, just talking to them.

It comes from getting out and having experiences and then going to their therapist and saying, “This is how this thing felt for me, and this is how this thing felt for me,” and getting values clarity that way.

Jenn: So for a parent who wrote in asking, “What are the first steps to implementing ACT for an older teen that struggles with OCD and has no confidence?” What advice would you have for those first steps?

Nate: Yeah, there’s a lot here. I’d start with this. I specialize in OCD so I can talk about OCD forever, but we’ll go with some of the initial stuff. Knowing the difference between an obsession and a compulsion and how these work from an ACT perspective.

I could, I’ll actually do this little exercise with you, Jenn, so you can see it. If I said to you, I want you to not think about, hmm, what you’re going to have for dinner tonight. And I just said like, “I will give you 10 bucks if you cannot think about what you’re going to have for dinner tonight for the next 30 seconds,” how would you do with that?

Jenn: Well, do I owe you $10, because I already thought about it?

Nate: Okay. What if I just up the stakes a little so I make it a hundred or a thousand. You think you could do it?

Jenn: Yeah, probably. I think so.

Nate: We’re going to go a thousand bucks. Can you go 30 seconds without thinking about what you’re going to have for dinner tonight? Try it.

Jenn: And to be clear to folks, this is purely monopoly money. This is not a real bet.

Nate: But really try, like really try to have no thoughts about what you’re going to have for dinner tonight. People are probably starting to get the point that like, no matter how much money I give you, that’s not how thoughts work.

It’s like, interestingly, the harder you try to get rid of them, the more you have them, or like the more important it is not to have them, the more you have them. But if I said to you, I’ll give you a thousand bucks if you can raise your right hand, you can do it.

And so this is the part in OCD treatment that I think a lot of people get stuck on initially, is they’re like, they’ve been trying really hard to control the obsessions. And they think like, “If I can control the obsessions, then I can go do the things I want to do in my life.”

And in ACT, we’re saying, “What about actually leaving the obsessions alone and starting to control the compulsions,” and just helping people see, not even just controlling the compulsions, controlling their behavior in general, just like putting your energy into doing the things you want to do, because that’s where control really works, is in your overt behavior.

But control doesn’t work very well in your inner stuff, when it comes to your inner stuff. And I think a lot of people starting OCD treatment just don’t know that.

Jenn: So would you recommend ACT to somebody who is overthinking or struggles with their self-esteem, or maybe even both?

Nate: Yeah, definitely. And I want to go back to something I said before on the self-esteem piece.

If you defined self-esteem as having positive thoughts about yourself, which I think is kind of like the older definition of self-esteem, the problem with that is your thoughts about yourself are always going to change.

They’re never going to stay just as positive all the time. The sort of ACT perspective on self-esteem is being able to, again, see yourself as the place where all this stuff is happening, not being defined and controlled by it, and defining your self-esteem more on how much you’re living true to yourself.

So how much you’re living in a way that feels consistent with what really matters to you. And that means before you get all the things you want in your life, meaning before you, like, graduate from high school or before you get a boyfriend or before you like, you know, get into college or whatever it is, you actually get to have self-esteem that comes from living true to yourself right now.

It’s like the journey instead of the destination, but it’s like, you get points for living true to yourself, not from having a bunch of positive thoughts about yourself, but living in a way that feels meaningful to you.

Jenn: Someone actually wrote in saying that it sounds like traditional CBT. So the cognitive behavioral therapy is more about that destination, and ACT focuses more on that journey, about how you travel flexibly. That seems like it’s pretty spot on with what you just said too.

Nate: Yeah. And again, one of the things I want to say is if there are CBT therapists watching this, really good CBT therapists are already doing a lot of this stuff, like the whole field is moving more in this direction.

So if you’re working with a patient who is spending a lot of their time just trying to accomplish goals and not focusing on their values and like sort of the long term things that matter to them in life, you are going to want to shift them more towards living in the moment and focusing on the journey instead of the destination.

But I think in a lot of ways, ACT is like, hmm, it’s sort of improved CBT in a lot of ways.

Jenn: A little bit more, like, new age CBT versus what...

Nate: Yeah. Yeah. And I want to be clear, it deals with a lot of those things that were traditionally thought of in like a Buddhist realm or like in an Eastern religion realm, but, like, brought into Western psychology behavior therapy.

Jenn: With that being said, with the acknowledgement that there is some overlapping and, you know, blending of different types of therapies, are there any connections between ACT and dialectical behavior therapy?

Nate: Yeah. So tons of, in fact, they kind of evolved out of the same treatment centers on the West Coast. So ACT and DBT are very similar.

DBT tends to be used a little bit more with a focus on, like, crisis situations or just like dealing with really high risk behaviors and coping skills that are used kind of in moments of really, really high emotion, with, kind of with a focus on getting through the moment and tolerating it.

ACT is a little bit more the, like, fully letting go and embracing. And by the way, there are elements of that in DBT as well. So there’s crossover here, but this idea of acceptance is in DBT too, radical acceptance is a huge part of DBT.

Acceptance is obviously in ACT. So there’s a lot of similarities. To be honest with you, a lot of therapists who do DBT also do ACT, and therapists who do ACT also do DBT. So I wouldn’t get too caught up in what’s what, there’s a ton of overlap.

Jenn: Do you think that ACT would be helpful if a person is tending to obsess over the worst case scenario?

So like, if someone says, “What could possibly go wrong?” It’s just, their mind immediately goes there. Especially if the person has a history of traumatic experiences.

Nate: Yeah. So one of the things the ACT is doing with this skill of defusion, is being able to see that thoughts really are just thoughts. In fact, I’ll give you, I’ll do another little exercise with you, maybe a couple, actually, just to show you this.

Like, I’ll do this exercise with patients a lot where I’ll have them say a bunch of thoughts in a row, and I will have them mix in their catastrophic thoughts with other thoughts. So for example, if someone has a catastrophic thought, like, “I’m going to get in a plane crash today when I fly from Boston to Miami.”

So you might have them say, “I’m going to drink coffee for breakfast. I’m going to have my favorite cereal. I’m going to go for a walk. I’m going to die in a plane crash. I’m going to walk my dog. I’m going to buy my favorite shirt. I’m going to die in a plane crash.”

And what you start noticing is that they’re all just thoughts. And when you kind of see that positive, negative, neutral, random thoughts, all in a row are happening, you actually start to catch that that catastrophic thought also is a thought when you sort of see it in that way.

Another thing I will do is I will say to people like, “Which one of these objects is better, water bottle, cell phone?” And, you know, most people will be like, well, it’s got to be the iPhone, ‘cause that’s worth a lot of money and you can do so many things with it.

But then if I said, “But if you were really thirsty, which object would be better?” And they’re like, well, “The water bottle.” And then I’m like, alright, so well, “Which one’s better?” And they say, “Well I guess it depends on the situation.”

From an ACT perspective, that’s how we see thoughts as like, this one’s good for making phone calls. This one’s good for when you’re thirsty, and you don’t grab onto thoughts based on like, how powerful they feel.

You grab onto them based on how useful they are in the moment. And that’s super new for a lot of people, ‘cause a lot of people are like, “I just go with whatever my mind tells me,” meaning however powerful it feels, that’s what I go with.

And what we’re trying to teach people is like, if I handed you a water bottle, you wouldn’t just start drinking from it. Or if I handed you a cell phone, you wouldn’t just start texting. You use these objects when they’re useful to you. In the same way with your thoughts, you use them when they’re useful to you.

Jenn: So based on all we’ve talked about for ACT, and you know, I think self-as-context is one that we’ve really talked about extensively. Beyond that, which of the processes in ACT do you think would be most beneficial for the whole family to try to implement?

Nate: Hmm. For the whole family. So if we’re talking about something like that, I would stay away initially from some of the harder ones.

In fact, I’ve found in some of the research we’ve done actually at the OCDI too, one of the easiest concepts in ACT for a lot of people to get initially is this idea of values. And so like if the whole family was like, working on this in therapy, like, what do we really care about as a family?

Getting clarity about that early on in treatment can be really helpful for, like, orienting where you want to go in your life or in the family or in the treatment. And I think that that concept is a little bit easier for people to grasp than defusion or self-as-context, even acceptance can be hard for people to grasp.

So I kind of like starting with values, it keeps it pretty simple early on. And then it gives you kind of a roadmap for, like, where you’re going in the family or in the treatment.

Jenn: How can parents start talking to their kids about implementing some of the components of ACT? I know values seems a little bit more low hanging fruit.

Like, what are a few things you were grateful for today? But any ways that they can start incorporating it without “therapizing” their children?

Nate: Yeah. Well you always got to be careful of that. In fact, one of the things that I guess I haven’t mentioned yet is, what we’re doing in ACT is always trying to increase psychological flexibility.

And if whenever, like therapists who are training in this asked me like, “Which technique do I use right now with this patient at this time?” I always say to them, “It depends on what moves psychological flexibility.”

So it’s not like, there’s this one thing you need to say right now, that’s going to, like, make this person more accepting. You got to try things out and see. And so as a parent, just to give you a sense of this, I might say something to your kid, like, “What’s your mind saying to you right now?”

It’s like a way of getting some distance from a thought or like, “Can you make room for that emotion to be there right now? Is it okay to have that feeling?” Those are, like, useful ways of talking about thoughts and feelings.

But again, if you’re in a way, like you said, that sounds kind of therapisty, they’re just going to be like, “Okay, like I’m not listening to you.” So you’ve got to find a way to say it that, like, lands well for your kid and the situation that they’re in.

And by the way, as a therapist, that’s what I’m always doing is trying to figure out, “What am I going to say right now that’s going to move them more towards acceptance or move them more towards defusion?”

Jenn: For any clinicians that are tuning in, any suggestions on where someone can get good training in ACT?

Nate: There is so much good training out there. So there’s this website called the Association for Contextual Behavioral Science. I think it’s acbs.org. That’s the big ACT association. If you go there, it lists everything. It has all the trainings, all the books, all the, you name it.

So there are, what do you call it? Certified ACT trainers that are listed on that website. And all of those people are good. We’ve actually got several in Boston, but all around the world, people are trained.

So I would go to that website and find people who are trained there. And that’s kind of how you know where the good training is.

Jenn: And for the general public, that’s interested in learning more about ACT, helping us explore our own values. Do you have any books, resources, apps that you’d recommend for those folks?

Nate: Yeah. There’s tons of ACT books that it’s just kind of exploded over the last decade or so. The one that I actually recommend to all of my patients is one that I’ve been recommending since 2009, I think?

It’s called “The Happiness Trap” by Russ Harris. And I actually think he just came out with the second edition. I’m not even sure if it’s out yet, but that’s cool, ‘cause I think he’s like updated it with a lot of like newer research on ACT.

There’s an illustrated version of “The Happiness Trap,” which means you can just like read cartoons about how to do this and it’s super simple. There are a ton of ACT books also that are geared towards adolescents, but I would start with “The Happiness Trap” if you want to easy book to start with.

Jenn: Amazing. And since we are winding down the hour together, any last words of wisdom about ACT, adolescents, young adults, that you’d want to share with folks?

Nate: Honestly, like you were saying before, Jenn, I think ACT is more a way of life than a therapy, and something you could have like learned in school as a kid.

Like, I look back at this and I think, “Man, if I had known this stuff when I was in school, this would’ve really helped me.” So I would just take psychological flexibility as a concept and try to start integrating that more into your day to day life, and just see what it does for you.

And like I said, books like “The Happiness Trap” can be, like, little guides to how to like, follow through on using these things or go find a therapist who specializes in this.

Jenn: Amazing. I know Nate, you and I, before we started the session, I was saying that psychological flexibility is one of my favorite things to talk about and this did not disappoint.

So I just want to say thank you for spending an hour with me to talk all things ACT and how it’s applicable to young adults, adolescents, teens, older adults, and walking us through some pretty fun exercises.

Thankfully did not embarrass myself, but appreciated nonetheless. And for anybody tuning in, this actually concludes our session about ACT for adolescents. So until next time. Be nice to one another, but most importantly, be nice to yourself.

Thanks again, Nate, and have a great day, everybody.

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