Sometimes psychotherapy is spoken of as a process in which the psychologist simply eliminates the specific symptom, without taking into account the discomfort responsible for the appearance of this phenomenon.
However, this criticism does not correspond well to reality. In fact, there is a set of psychotherapeutic approaches designed precisely to put the overall well-being of patients first: are the contextual therapies, also called third generation therapies .
Third generation therapies go beyond the symptom and target the overall well-being of the person.
However, this explanation is still a simplification, and in fact there are many more interesting characteristics that make this psychotherapeutic approach a very important option to take into account when seeking psychological assistance. Therefore, it is best to have an expert’s point of view.
Interview with Adrián Muñoz Pozo, expert psychologist in contextual therapies
To learn more about the details of third generation therapies we talked to Adrián Muñoz Pozo, a psychologist who offers psychological assistance in Malaga and Fuengirola, so that he can explain this area of work in mental health.
If you had to sum up what third generation therapies are in one sentence, how would you do it?
A complicated task, that of summarizing a whole paradigm shift in a single sentence. But here we go.
In a sentence: to understand human behavior (verbal or non-verbal) within the context in which it is generated, analyzing the functions that maintain the behaviors in order to employ intervention strategies aimed at creating a more flexible behavioral repertoire that allows people to reach a horizon full of vital purposes.
What are the differences between this new proposal of psychological intervention and the classic cognitive-behavioral therapy? Do you think they totally break with the pillars on which the latter is based?
Yeah, totally. Third generation therapies constitute a contextual rethinking of clinical psychology, a new way of understanding psychological problems and their approach.
Second generation or cognitive-behavioral therapies understand that the cause of ‘mental disorders’ is found in the alterations of cognitions (thoughts, beliefs, attributes, expectations). And, therefore, the treatment of these problems will consist of the development of specific techniques to reverse this situation.
Therefore, we are facing a model based on the Input-Output (I-O) scheme of cognitivism that is internalistic, nosological, nomothetic, biomedical and focused on the elimination of the symptom as a clinical purpose.
Instead, third generation therapies are based on an ideographic, holistic and contextualist model to understand the origin and maintenance of psychological problems, based on Skinner’s radical behaviorism and the return to the use of functional behavior analysis.
From this perspective, the symptomatology is not understood as something dysfunctional and that must be eliminated, but rather all emphasis is placed on the construction of treatments that go in the direction of abandoning the fight against the elimination of the symptoms and the construction of fuller personal lives.
Among all the third generation therapies, you specialize in one called Acceptance and Commitment Therapy. What is it?
In Acceptance and Commitment Therapy, ACT, psychological distress is seen as part of life. Suffering is intrinsic to living. However, people try to avoid being in contact with all those internal events (thoughts, emotions, sensations) that produce discomfort. These attempts to eliminate, reduce, or modify “negative” private events is what is known as “Experiential Avoidance Disorder.
In ACT, the goal is for clients to learn to become aware of their control agenda (avoidance behaviors) and to give up these behaviors that have not helped them get rid of their discomfort.
At the same time, clients are trained to generate a state of acceptance of private events that cause them discomfort as an alternative to avoidance through exercises and metaphors that aim to make people generate a state of cognitive de-fusion. In other words, learning to observe private events as they are: mere thoughts and emotions that we have at a given time because of the circumstances and history that surround us. That is, learning to see private events with perspectives and not through them.
But ACT is not about exposing the client to suffering for the sake of it. Exposing yourself to their annoying private events is a means to a greater end: to lead the life you want, in accordance with your values, understanding values as all those things we do that give meaning to our lives.
Usually, people think that we can only lead the life we want if we eliminate the discomfort and we are in an ideal state of well-being. However, as many of you, the readers, will have seen that we do not have much control in selecting what thoughts or feelings we want to have or not have at a given time to perform any type of activity.
Therefore, in ACT we teach our clients that they do not have to eliminate or modify their discomfort as a premise to lead the life they want. We teach them to focus and put their time and effort on what really matters to them (to be a better parent, to be a better employee, to have better health, to be closer to friends, etc.) and to take committed actions to achieve this, regardless of the private events we have.
Working on focusing on your values, learning to accept and distance yourself from the private events that make you unhappy and are interpreted as disabling is what promotes psychological flexibility and with it the subsequent fruit of leading a life which, despite your private events, you qualify as satisfying and full of meaning, since you are devoting your time, your life, to the things that really matter to you, and not trying to control something that is uncontrollable.
One of the keys to this type of psychological intervention is that it helps you not to create additional problems for yourself by feeling responsible for your discomfort. How is this achieved?
Right. Many of my clients, and especially after performing the creative despair exercise, tend to think that they are the ones to blame for feeling the way they do. To which I always allude to the metaphor of digging:
“Imagine that you have fallen into a hole, a very, very deep hole, and you want to get out of it to continue on your way. Then you reach into your backpack and pull out the tool that you are carrying: a shovel. And you start digging and digging…after a while, you realize that you are still in the hole. In fact, you’re even deeper now.
The problem is not that you have fallen (how you feel), nor the person who has fallen, but the only problem is that a tool has been used that is not indicated, that is ineffective, to solve the problem of getting out of a hole.
This shovel is a tool that we all carry as standard in our backpack and the only mistake has been to use it where it is not effective. That said, we have no choice but to drop the shovel, later we will discover what to do to get out. But now, the main thing, is to stop using something that does not help us solve the problem.
With this metaphor we help our clients not to generate those feelings of guilt towards themselves. Instead, they take responsibility for the actions they have been taking to eliminate their discomfort. How these actions have not been fruitful and thus propel them to take further action in the direction of values.
In what type of patients do you think the advantages of Acceptance and Commitment Therapy are most noticeable?
In general, all patients who end up contacting ACT notice a great improvement in the quality of their lives.
But particularly those people whose problem is chronic, or who have been struggling for many years to resolve their discomfort, are best seen to make rapid improvements. Contrary to what one might think.
Clients who have been immersed in their discomfort for a long time are those who have developed the most avoidance behaviors with the purpose of eliminating, reducing or modifying their discomfort.
This makes it easier for them to give up the struggle to control their internal events, as their experience tells them that it has been impossible to get rid of their discomfort because of many things they have tried throughout their history. This is what is known in ACT as generating a state of creative despair.
How do psychotherapy sessions based on this paradigm tend to develop?
In general, in the contextual therapies and in particular in ACT, the sessions are usually developed in a relaxed and warm atmosphere, where psychotherapist and client are seated one in front of the other, in condition of equality, from person to person.
From this position the psychotherapist shows his client that, like him, we too are exposed to human suffering and therefore understand them and share the same experience.
When addressing the reason for consultation, this is done from the functional analysis of behavior. In other words, we analyze, together with the client, the behavioral repertoire that he displays when faced with his discomfort so that he himself can see his own control agenda and see the ineffectiveness of his avoidance behavior.
In addition, the sessions in ACT are dynamic sessions, in which many experiential exercises are practiced to expose the client to their feared private events; as well as the use of metaphors, adapted to the client, with the purpose of generating acceptance and de-fusion with the mental content. And we must also take into account the use of activities aimed at clarifying values and commitment to action directed towards them.
Finally… could you explain a case of improvement of a patient that you feel especially satisfied and proud of?
Of course. I remember one of my cases that best exemplifies the change that ACT produces in the lives of clients who demand help, and in turn one of those cases that makes you learn.
I still remember this client, a woman, about 38 years old, with a degree in chemistry, with a stable partner, although she lived with her parents in the family home. We’ll call her Ana.
He came to the office demanding assistance because he was going through a stage in his life where he was experiencing symptoms of anxiety and uncontrolled stress.
Exploring his background, we could see how he had grown up in a very protective family environment where achievements were not reinforced. Moreover, throughout her life, whenever she was exposed to a feared situation, she would leave it. She was afraid to look for work outside her city because of her distance from her parents. She was afraid of becoming independent and unable to support herself financially. Fear of leaving and losing the friends and hobbies she had around her, etc.
We started working along the lines of the ACT guidelines that I explained in the previous question, and very soon we started exploring problems, since she was very focused on trying to eliminate her private events that caused her discomfort. Even so, we continued with a lot of effort, dynamics and diverse exercises.
I remember that the sessions went by, that we worked on making this type of behaviour more flexible and on her values, but she kept insisting on the condition of eliminating her private events as a condition for leading the life she wanted to lead. In spite of this complaint, I insisted on her opening up to her experience, and we worked on many exercises of acceptance and cognitive de-fusion linked to actions in the direction of her values.
Anna had a career as a teacher, and it was her true vocation. However, she had only worked as a teacher on a few occasions, covering the summer holidays at her local school.
Throughout the sessions, Ana realized that the work she was doing was not to her liking (it was not linked to education) and took a very brave step. Which, until then, was unthinkable. She left her job, despite the uncertainty and fear that this new situation created for her. We were beginning to see changes in her: she was more open to change, to her discomfort, and above all, she was taking more action in the direction of her values.
Once this step was taken, we set out to find new work objectives in the direction of her vocation as a teacher. She began to prepare for the competitive examinations and began to register for the job bank. After a few weeks, she received a call from an exchange in Melilla to fill a position. And she accepted it.
He packed his bags and went off on this new adventure in Melilla with his partner. I remember that I was living it with a lot of fear and that we had to work a lot to live the present moment, since I had a lot of anguish and anxiety before the fear of failure. Even so, he persisted.
Today, a year and a half has passed since Ana set foot in Melilla. She still works there, lives with her partner, plays sports and has created a circle of friends with whom she goes on trips. Everything she wanted and which, in her opinion, her fears prevented her from achieving. And best of all, she has achieved it without having to stop her life to eliminate her fear and anxiety.
When I ask him how he is, he always reminds me that there are days when he feels anxiety, when fear returns, when he gets entangled with his mind… but I always remind him the same thing: “Look at yourself where you are, is this the life you want to lead?” Yes. “So make room for that discomfort and keep building a rich and satisfying life.
However, when I ask her how satisfied she is with her life, she answers something like, “It’s the best I could do. She may feel fear and anxiety but she is comfortable with what she does and feels that she is a real teacher, something she has always dreamed of.
This is a case that I like very much because it exemplifies very well how one works from ACT. From ACT we pursue that people build valuable lives, lives that want to be lived. And for that, we use techniques that help people to stop controlling their emotions or thoughts, developing a spectator’s attitude towards them.
Instead, we encourage and strengthen all those actions that are in the direction of achieving a fuller life, a life oriented towards their values.