ACT for Clergy and Pastoral Counselors: Using Acceptance and Commitment Therapy to Bridge Psychological and Spiritual Care 1626253218, 9781626253216

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“Physical and emotional suffering bring to light the spiritual in most persons, whether overtly expressed or not. Frontline care of the spiritual needs of the suffering usually falls to spiritual care providers, such as clergy and pastoral counselors, yet does not escape the responsibility of the ‘secular’ therapist. When spiritual care providers meet the patient, the encounter can vary widely across the same faith tradition, not to mention different traditions. In addition, persons suffering are both vulnerable to ill-­advised comments by these care providers, and resistant to anyone viewed as tampering with their faith. Nieuwsma, Walser, and Hayes provide a guide into and through this most important yet tenuous relationship—­the application of acceptance and commitment therapy (ACT). The central tenants of ACT—­openness, centeredness in the present, and engagement through commitment—­clarify this confusing experience for those suffering through informed and empathic intervention by the spiritual care provider. ‘If I am suffering, what am I to do with my faith?’ Recognize who you are, recognize where you are at this critical stage in your life, and recognize and engage your core values. This approach is inclusive yet does not devolve into a watered down generic spirituality. Rather it calls upon the inner values and strengths that each faith tradition brings to the healing of the body and the emotions.” —­Dan Blazer MD, MPH, PhD, J.P. Gibbons Professor Emeritus of Psychiatry at Duke University School of Medicine in Durham, NC “This superb volume is practically the ‘bible’ on how to integrate religion and spirituality into ACT. It is the first and last word on ACT in religious contexts and for professional pastoral settings. Highly recommended.” —­Jeff Levin, PhD, MPH, professor of epidemiology and population health, and director of the religion and population health program at Baylor University “Nieuwsma, Walser, and Hayes have provided valuable guidance to spiritual care providers—­congregational clergy, laypersons, chaplains, and pastoral counselors—­on how to integrate the principles of ACT into their practice. Without trying to turn spiritual care providers into therapists, they nonetheless show how ACT is consistent with some current practices, and can be used to extend spiritual interventions even further. Spiritual care providers benefit from having an evidence-­based therapeutic model to draw on. The authors and editors have held ACT like a jewel to the light, and shown how ACT can be utilized across major faith traditions and in the full diversity of settings in which spiritual care is provided.” —­Daniel H. Grossoehme, DMin, MS, BCC, associate professor of pediatrics who focuses his research on ways in which faith influences health behaviors in pediatric chronic diseases, and Staff Chaplain III serving the cystic fibrosis team at Cincinnati Children’s Hospital Medical Center

“ACT’s flexibility is marvelously on display in this adaptation for religious persons and contexts.” —­Timothy A. Sisemore, PhD, director of research, and professor of psychology and counseling at Richmont Graduate University, and author of The Clinician’s Guide to Exposure Therapies for Anxiety Spectrum Disorders “Evidence is mounting seemingly by the day supporting the relationship between meeting spiritual and religious needs and positive health outcomes in both the psychological and physical domains. However, there is a major shortage of tested interventions positioned to help deliver these outcomes effectively and efficiently. This problem is compounded by the long-­standing barriers to partnering ‘spiritual’ and ‘psychological’ interventions to the benefit of the whole human person. This book makes a major contribution to filling this gap and overcoming these barriers. In doing so, it gives both spiritual care and mental health professions a powerful new tool to help reduce suffering. Bravo!” —­The Rev. George Handzo, BCC, CSSBB, director of Health Services Research and Quality at the HealthCare Chaplaincy Network “ACT for Clergy and Pastoral Counselors is the perfect resource for clergy, pastoral educators, and mental health providers dedicated to continuing the legacy of Rev. Anton Boisen and Richard C. Cabot of bridging mental health and spiritual care. The book is excellent for clinical pastoral education (CPE) supervisors who want to introduce students to an established, evidence-­based practice that is patient centered, flexible, and values based.  Clinical staff chaplains will find it provides practical tools to help them work more effectively as a member of mental health interdisciplinary teams. It’s an outstanding text for any professional healthcare provider!” —­A. Keith Ethridge, MDiv, BCC, ACPE CPE Supervisor, former director of the VA Chaplain Service, and associate director of Mental Health Integration for Chaplain Service at the VA National Chaplain Center in Hampton, VA “This is a timely and important book, making ACT accessible to spiritually sensitive providers, not only as an evidence-­and philosophically-­based practice, but one capable of informing a range of theological perspectives to human suffering, in demonstrably practical ways. Both clinicians and spiritual care providers will find it a valuable resource.” —­John Raymond Peteet, MD, psychiatrist at Brigham and Women’s Hospital and Dana-­Farber Cancer Institute in Boston, MA, and associate professor of psychiatry at Harvard Medical School

ACT for Clergy and Pastoral Counselors Using Acceptance and Commitment Therapy to Bridge Psychological and Spiritual Care

Edited by JASON A. NIEUWSMA, PhD ROBYN D. WALSER, PhD STEVEN C. HAYES, PhD Context Press

An Imprint of New Harbinger Publications, Inc.

Publisher’s Note This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold with the understanding that the publisher is not engaged in rendering psychological, financial, legal, or other professional services. If expert assistance or counseling is needed, the services of a competent professional should be sought. Distributed in Canada by Raincoast Books Copyright © 2016 by Jason A. Nieuwsma, Robyn D. Walser, and Steven C. Hayes Context Press An imprint of New Harbinger Publications, Inc. 5674 Shattuck Avenue Oakland, CA 94609 www.newharbinger.com Cover design by Amy Shoup Acquired by Catharine Meyers Edited by Melanie Bell Indexed by James Minkin All Rights Reserved

Library of Congress Cataloging-in-Publication Data on file

Printed in the United States of America 18  17  16 10   9   8   7   6   5   4   3   2   1

First Printing

To Rev. Lee Copeland (1942–­2015), whose pastoring and counseling embodied practices of acceptance and commitment —­J.A.N. To Susan Lynn Pickett (1945–­2008), a bold and independent spirit, and my loving mother —­R.D.W. To Carlo Weber, S. J., Irving Kessler, PhD, and the other faculty at Loyola Marymount University who had faith in me and understood my explorations —­S.C.H.

Contents

Acknowledgementsix



 oreword: Integrating Religion and Spirituality F with ACT

xi



 reface: Bridging Spiritual Care and Evidence-­Based P Psychotherapy

xv

Part 1: Foundations for Integrating ACT and Spirituality 1

 mpirical Foundations for Integrating Religious and E Spiritual Practices with Psychotherapy

3

Jason A. Nieuwsma, PhD, Duke University Medical Center, VA Mental Health and Chaplaincy

2

 Theological Lens for Integrating ACT A with Conceptions of Health, Healing, and Human Flourishing

19

Joshua J. Knabb, PsyD, ABPP, California Baptist University; Keith G. Meador, MD, ThM, MPH, Vanderbilt University, VA Mental Health and Chaplaincy

3

Bridging ACT and Spiritual Care Robyn D. Walser, PhD, University of California, Berkeley, National Center for PTSD; Steven C. Hayes, PhD, University of Nevada; Jason A. Nieuwsma, PhD, Duke University Medical Center, VA Mental Health and Chaplaincy

41

ACT for Clergy and Pastoral Counselors

Part 2: Linking ACT Core Processes and Spiritual Practices 4

 eveloping Awareness: Being Present and D Self-­as-­Context

63

Robyn D. Walser, PhD, University of California, Berkeley, National Center for PTSD

5

Opening Up: Acceptance & Defusion

6

 nhancing Religious and Spiritual Values Through E Committed Action

85

Hank Robb, PhD, ABPP, Private Practice, Lake Oswego, Oregon

109

Jacob K. Farnsworth, PhD, Denver Veterans Affairs Medical Center, Eastern Colorado Health Care System

Part 3: ACT Across Different Religious Landscapes 7

ACT and Buddhism

8

ACT and Islam

9

 CT and Judaism: Suffering and the Commitment A to Valued Action

129

Hiroaki Kumano, MD, PhD, Waseda University, Japan; Phrayuki Naradevo, Wat Pa Sukato, Thailand

139

K. Fatih Yavuz, MD, Bakirkoy Mazhar Osman Mental Health and Neurological Diseases Education and Research Hospital, Istanbul, Turkey

149

Barbara S. Kohlenberg, Ph.D., University of Nevada School of Medicine

10 ACT and Christianity

163

Ingrid Ord, MSc Ingrid Ord, MSc, Private Practice, Western Cape, South Africa

vi

Contents

11 ACT and the Religiously Unaffiliated

173

Steven C. Hayes, PhD, University of Nevada; Jason A. Nieuwsma, PhD, Duke University Medical Center, VA Mental Health and Chaplaincy; Robyn D. Walser, PhD, University of California, Berkeley, National Center for PTSD

Part 4: Applying ACT in Different Spiritual Roles 12 ACT and Clergy

185

13 ACT Core Processes in Faith-­Based Counseling

203

Kent D. Drescher, MDiv, PhD, National Center for PTSD; Daniel M. Saperstein, DMin, Presbytery of Lake Huron

Mark R. McMinn, PhD; Brian C. Goff, PhD; Clinton J. Smith, MA, George Fox University

14 Using ACT in the Context of Health Care Chaplaincy 219 Jason A. Nieuwsma, PhD, Duke University Medical Center, VA Mental Health and Chaplaincy; Joe McMahan, MDiv, BCC, ACPE Supervisor, VA Southern Oregon Rehabilitation Center

15 ACT for Military Chaplains

245

William C. Cantrell, MDiv, BCC, VA Mental Health and Chaplaincy, US Navy Reserve; Jason A. Nieuwsma, PhD, Duke University Medical Center, VA Mental Health and Chaplaincy

16 ACT for Clergy and Pastoral Counselors: Addressing Spiritual Self-­Care

263

Sky Kershner, MSW, DMin, Kanawha Pastoral Counseling Center, Charleston, WV, West Virginia University, Charleston Division; Jacob K. Farnsworth, PhD, Denver Veterans Affairs Medical Center, Eastern Colorado Health Care System



Index281

vii

Acknowledgements

T

his book represents the realization of a vision that many of us have had independently as well as collectively for some time, and many people are to thank for its production. In addition to the gratefulness that we owe the chapter authors in this volume, we would also like to thank the chaplains in the Department of Veterans Affairs, the military, and civilian health care contexts who helped inform this work. The lessons that we have learned from these chaplains have been invaluable. We also want to thank the staff and leadership at New Harbinger Publications / Context Press who have maintained their support of the project throughout. Each of us also has a few specific thanks to give: J.A.N.: I want to acknowledge my indebtedness to numerous friends and colleagues in the Department of Veterans Affairs. In particular, I wish to thank: Keith Meador, for his support, thoughtfulness, and encouragement years ago to produce this book; Bill Cantrell, for many enlightening discussions on intersections between ACT and chaplaincy; and Keith Ethridge, for his unwavering support of this work. Though I am grateful to many chaplains that I have had the privilege to work with over the years, I owe a special debt of gratitude to the first cohort of 40 chaplains to participate in our Mental Health Integration for Chaplain Services (MHICS) intensive training, as I gleaned much from their trailblazing applications of ACT in pastoral care. Finally, I wish to thank my wife, Shenandoah Nieuwsma, who not only provided me the sequestered time and space that I needed to complete this book but who through innumerable conversations helped to sharpen my thinking about it as well. R.D.W.: I want to thank those who I have encountered across the years, including family, friends, and colleagues, who supported me in an ongoing spiritual journey, allowing me to explore things divine, sacred, and unseen. I am grateful to Ingrid Ord for her spiritual conviction and willingness to hold long discussions about religion and that which transcends. Finally, I would like to thank the clients who have reminded me that the mystical can still be a part of our sometimes overly secular lives.

ACT for Clergy and Pastoral Counselors

S.C.H.: I want to thank my students and my colleagues in the ACT community for their many thoughts about ACT, spirituality, and spiritual care. They are too numerous to mention but their attitude of openness and non-­defensiveness has helped me mix together Western science information and spiritual issues without having to feel as though we are doing something that violates the values and purpose of either. I also thank my wife Jacque and son Stevie both for allowing me the stolen moments to focus on these issues and for showing me sides of these issues only love can reveal.

x

FOREWORD

Integrating Religion and Spirituality with ACT

A

s the third wave of behavior therapy (see Hayes, Luoma, Bond, Masuda, & Lillis, 2006) has in recent decades emphasized mindfulness—focusing attention on one’s immediate experience in the present moment, with acceptance or an open, receptive, and curious mindset, and without censure or judgment—mindfulness-based cognitive behavior therapy has become a significant part of contemporary CBT. The three major approaches to mindfulness-based CBT are dialectical behavior therapy (DBT), mindfulness-based cognitive therapy (MBCT), and acceptance and commitment therapy (ACT)—which I have briefly reviewed, empirically and clinically, from a religious Christian perspective (Tan, 2011b; see also Tan, 2011a). Of these approaches, ACT (Hayes, Strosahl, & Wilson, 2012) in particular has grown exponentially, with many articles and books published each year. A recent and significant development is the use of ACT in religious and spiritual contexts, bridging psychological and spiritual care. This book is an excellent example of publications that are beginning to appear on the integration of religion and spirituality with ACT (see also Knabb, 2016; Ord, 2014). In contemporary CBT, explicitly religious and spiritual approaches to CBT have been developed and empirically evaluated for their efficacy or effectiveness in treating various clinical disorders, with generally favorable outcomes comparable to secular versions of CBT (see Hook et al., 2010; Worthington, Hook, Davis, & McDaniel, 2011). Such explicitly religious and spiritual approaches to CBT have been termed R/S approaches to CBT, religiously accommodative CBT, or spiritually oriented CBT (see Tan, 2007; Tan, 2013). However, ACT, though it has some roots in contemplative spirituality, whether Buddhist or Christian, has to date been considered mainly as a secular approach to mindfulness and acceptance-based CBT. As such, it has not been included thus far as part of R/S therapies, religiously accommodative CBT, or spiritually oriented CBT (Tan, 2013). This book is an important step in integrating religion and spirituality more explicitly with ACT. The six core processes of ACT can be organized into three basic

ACT for Clergy and Pastoral Counselors

response styles, each of which contains two core processes, as follows: open (acceptance, defusion); centered (present moment, self-as-context); and engaged (values, committed action) (Hayes, Strosahl, & Wilson, 2012). ACT therefore emphasizes not only acceptance and mindfulness (or being present) with cognitive defusion and psychological flexibility, but also choosing one’s values or defining valued directions, coupled with committed action in following such chosen values and directions. It does not focus on trying to change the content of one’s distorted, dysfunctional, or irrational thinking as traditional CBT does. Instead, ACT helps people to simply let thoughts come and go because they are only thoughts, and to accept feelings as they are, even if they’re painful, and not avoid them. It focuses on living a life of integrity and meaning, based on one’s values and committed action according to such values, even if that involves the suffering that is part of being human. This emphasis on values and committed action resonates well with many religious and spiritual traditions, as this book shows, and therefore integrating religion and spirituality with ACT seems natural and helpful. This is a well-written book that covers four substantial areas: foundations for integrating ACT and spirituality; linking ACT core processes and spiritual practices; ACT across different religious landscapes (such as Buddhism, Islam, Judaism, Christianity, and the religiously unaffiliated); and applying ACT in different spiritual roles (including clergy, faith-based counseling, health care chaplaincy, military chaplains, and spiritual self-care for clergy and pastoral counselors). It will help advance the integration of religion and spirituality with ACT and bridge evidence-based psychotherapy and spiritual care, although there are some areas of tension that remain between some aspects of ACT and more traditional or conservative religious faiths, as pointed out by a few authors in this book. This book will prove an important guide for the further work that is warranted in theoretical/theological, clinical, and research areas. It should serve as a particularly useful resource for pursuing empirical studies aimed at evaluating the efficacy or effectiveness of explicitly religious or spiritual approaches to ACT. And it is an excellent introduction to the integration of religion and spirituality with ACT. It will greatly benefit anyone interested in bridging psychological and spiritual care in a creative, compassionate, and ACT way! —Siang-­Yang Tan, PhD Professor of Psychology at the Graduate School of Psychology, Fuller Theological Seminary, Pasadena, California, and author of Counseling and Psychotherapy: A Christian Perspective

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References Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A. L., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes, and outcomes. Behaviour Research and Therapy, 44, 1–25. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). New York, NY: Guilford Press. Hook, J. N., Worthington, E. L., Jr., Davis, D. E., Jennings, D. J. II, Gartner, A. L., & Hook, J. P. (2010). Empirically supported religious and spiritual therapies. Journal of Clinical Psychology, 66, 46–72. Knabb, J. J. (2016). Faith-based ACT for Christian clients: An integrative treatment approach. New York, NY: Routledge. Ord, I. (2014). ACT with faith: Acceptance and commitment therapy with Christian clients: A practitioner’s guide. Great Britain: Compass Publishing. Tan, S. Y. (2007). Use of prayer and scripture in cognitive-behavioral therapy. Journal of Psychology and Christianity, 26, 101–111. Tan, S. Y. (2011a). Counseling and psychotherapy: A Christian perspective. Grand Rapids, MI: Baker Academic. Tan, S. Y. (2011b). Mindfulness and acceptance-based cognitive behavioral therapies: Empirical evidence and clinical applications from a Christian perspective. Journal of Psychology and Christianity, 30, 243-249. Tan, S. Y. (2013) Addressing religion and spirituality from a cognitive-behavioral perspective. In K. I. Pargament, A. Mahoney, & E. Shafranske (Eds.), APA handbook of psychology, religion, and spirituality: Vol. 2. An applied psychology of religion and spirituality (pp. 169–187). Washington, DC: American Psychological Association. Worthington, E. L., Jr., Hook, J. N., Davis, D. E., & McDaniel, M. A. (2011). Religion and spirituality. In J. C. Norcross (Ed.), Psychotherapy relationships that work (2nd ed., pp. 402–420). New York, NY: Oxford University Press.

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PREFACE

Bridging Spiritual Care and Evidence-­Based Psychotherapy

C

lergy, pastoral counselors, chaplains, and other types of spiritual care providers do not provide spiritual care in a vacuum isolated from the behavioral, emotional, social, and health needs of those they serve. Instead, they attend to these dynamically interrelated elements of personhood across a variety of contexts, often including contexts with very porous borders. For many religious and spiritual care providers, their care includes not only traditional counseling but also entails involvement in weddings, funerals, births, worship services, and all manner of potential crises. Indeed, they work with people in their highest highs and deepest lows. It is with an appreciation for the religious and spiritual commitments of these care providers and for the wide-­ranging and challenging manners in which spiritual care providers operate that this book is written. Our intention is to empower and further equip spiritual care providers by fostering conversation around how their work can be complemented by incorporating principles from acceptance and commitment therapy (ACT; pronounced as one word). ACT is an evidence-­based psychotherapeutic modality that we propose is especially suited for integration with religious and spiritual care. As is evident from the chapter titles, this book is not aimed at one religious tradition in particular. In fact, separate chapters are devoted to Buddhism, Islam, Judaism, Christianity, and those identifying with no religion. The motivation for this diversity is twofold. First, we believe that ACT has very relevant, important, and promising areas of interconnectivity with different religious perspectives. Second, we understand that spiritual care providers are operating in an increasingly diverse society where they need to be all the more fluent in attending to the needs of persons from various backgrounds. Still, being that the readers of this book and those they serve will come most commonly from some manner of Christian tradition, a number of chapters correspondingly lean more heavily in that direction. In specifically delving

ACT for Clergy and Pastoral Counselors

into different traditions, however, we hope the book meaningfully illustrates the potential interconnectedness of ACT with various spiritual and religious approaches. Throughout the book, we have aimed to strike a balance between depth and breadth. Depth is evident in the linkages that are made between ACT and particular spiritual traditions, as well as in different case examples that appear in the book. When providing depth in the context of a specific religious tradition, we have aimed to nonetheless make the corresponding concepts as broadly applicable as possible. Breadth can be illustrated in the range of spiritual traditions represented and in the variety of spiritual roles considered. We have encouraged the use of different tones and vernaculars to fit the different topical areas. Depending on the chapter, care recipients might be referred to as clients, patients, parishioners, and so on, and care providers might be referred to as counselors, ministers, therapists, pastors, rabbis, chaplains, and so on. The book is divided into four sections. Part 1 introduces the vision of the book by situating ACT in relation to traditions of psychotherapy, spiritual care, and theology. The chapters in this section suggest unique possibilities posed by ACT for providers concerned with delivering care that is effective, evidence-­ based, patient-­centered, spiritually sensitive, flexible, and theologically defensible. Part 2 delves into the model used in ACT to describe psychological health and suffering. The six core processes in ACT, as often depicted in the hexaflex, are here combined into three chapters that focus on the overarching ACT processes of developing awareness, opening up, and doing what matters. The themes and concepts from these first two parts of the book will be best appreciated and understood through reading all of the chapters, with there being an intentionality to the sequencing of these chapters to build on one another. The latter two parts of the book, by comparison, contain chapters that can more easily stand alone. Part 3 creatively explores ACT as it relates to different spiritual and religious traditions. Given the audience for this book, we focus primarily on the major Western religions, with the one major Eastern religion included being Buddhism (this being the Eastern religion that has been most widely adapted and disseminated in the West). Understanding that spiritual care providers also attend to the needs of an increasingly secular society, this section correspondingly includes a chapter on the nonreligious. Part 4 concludes the book by examining ACT for spiritual care providers who function in different settings and roles. Chapters in this section examine possibilities for the application of ACT by traditional clergypersons, faith-­based counselors, health care chaplains, and military chaplains, with the last chapter exploring ways that spiritual care providers can use ACT to practice self-­care. Finally, while this book targets clergy, pastoral counselors, and other spiritual care providers, it should also prove a useful reference for psychotherapists and other

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mental health care professionals who seek to provide spiritually sensitive care across a diversity of religious traditions. In bridging ACT and spiritual care practices, our aim is to provide an approach that is deeply concerned with both scientific and theological integrity. We hope that this book might help to foster further dialogue between religion, spirituality, and psychology. More importantly, we hope that this book and any dialogue it helps to foster will achieve a greater purpose: improving the lives of those we are privileged to serve. —Jason A. Nieuwsma, PhD Robyn D. Walser, PhD Steven C. Hayes, PhD

xvii

PART 1

Foundations for Integrating ACT and Spirituality

E

ver since the dawn of the scientific revolution, there have been myriad attempts by philosophers, scientists, and theologians to reconcile scientific and religious truths. These attempts continue unabated today, with our ever-­ expanding scientific and technological advances rapidly birthing new domains for religious and spiritual consideration. As with so many things, it has been the scandalous and bellicose intersections between science and religion that throughout history have grabbed the headlines: the imprisonment of Galileo, the Scopes Trial, debates over cloning, and so on. Yet while these incidents provide headings for the science and religion history books, one might easily overlook the numerous examples of successful integration between the two. For instance, religiously-­based hospitals, health care organizations, and health care providers have for centuries more quietly gone about the work of seamlessly integrating religious, spiritual, and moral convictions with scientific advances to improve the lives of millions—­in fact, probably billions—­of people worldwide. This work seldom makes the nightly news, but this is the kind of work that has the most profound, long-­lasting, and far-­reaching influence on the lives of human beings. It is in this spirit of providing compassionate, effective, patient-­centered care to those in need that we propose approaches for integrating acceptance and commitment therapy (ACT) and spirituality. In so doing, this first section does not aim to advance a single comprehensive theory for integrating science and spirituality. We do, however, aim to provide points of entry for spiritual care providers who are looking to integrate spiritual and evidence-­based approaches to care. Further, we aim to present clergy, pastoral counselors, and spiritual care providers with avenues for integration that do not necessitate thinking about spirituality and psychology as fully independent constructs. That psychology and spirituality should be thought of as distinct constructs is at least in part a creation of Western culture. Other societies and cultures, and in fact

ACT for Clergy and Pastoral Counselors

many subcultures within Western society, conceive of psychological and spiritual constructs quite differently and often do not draw sharp distinctions between the two. From an ACT perspective—­as will be further explored in the last chapter of this section—­psychological, spiritual, and other constructions have a lot to do with language. Language gives us symbols to represent various concepts and ideas, and combining words together allows us to build whole systems—­scientific, psychological, religious, and otherwise. Intriguingly, different religious traditions have pointed in their own ways to the inadequacy of language, at times, to represent spiritual matters. Ironic as it may seem to introduce a book section by emphasizing the insufficiencies of language, there are degrees of arbitrariness to the boundaries we draw around what we think of as spiritual and psychological, and appreciating that hopefully promotes the sort of epistemological humility needed to discover new possibilities for confluence. We of course are not suggesting that there is no value in using language to draw various sorts of distinctions. There would be little point, then, in reading this book. Indeed, we will be using the systems and constructions within psychology, spirituality, and religion to organize the content in these initial chapters. We will be examining the foundations for integrating spiritual and psychotherapeutic practices, first from an empirical perspective, then from a theological perspective, and finally from an ACT perspective. We will necessarily be relying heavily on those systems for thinking about God, human behavior, spirituality, and mental health that have developed over hundreds of years. We see great value in these systems and aim to show an appreciation for how these systems have formed the ways that we experience and view ourselves as well as those to whom we provide care. As already noted, it has frequently been our religious traditions that have reminded us of our own limitations—­be they in the use of language or otherwise. Operating within these confines, our desire in this first section is to provide spiritual care providers with a framework for integrating ACT into their care processes. The framework we provide has limits—­our treatment of the empirical literature in chapter 1 is necessarily selective, as is much of the theological framing in chapter 2—­but it is nonetheless intended to suggest helpful possibilities for the reader to then grapple with further within the context of his or her own spiritual tradition. We hope to capture your imagination, we aim to inspire further reflection and creativity, and we sincerely invite you to bring your own perspectives to bear in using ACT to care for those you serve. —Jason A. Nieuwsma, PhD

2

CHAPTER 1

Empirical Foundations for Integrating Religious and Spiritual Practices with Psychotherapy Jason A. Nieuwsma, PhD Duke University Medical Center VA Mental Health and Chaplaincy 1

1 Throughout this book, affiliations for chapter authors connected to government entities are listed to provide the reader an understanding of these authors’ professional contexts, even though these authors participated in this book independent of their affiliations and no positions or statements in this book should be construed to represent official viewpoints of government agencies.

ACT for Clergy and Pastoral Counselors

W

hat can we do about human suffering? How is a good life achieved? Where should we turn to find meaning and purpose? Answering such questions has long been of significant interest to theologians and scientists alike. Sometimes religious and scientific answers to these questions turn out to be quite similar. Sometimes they differ. Often, there are substantial and nuanced differences not just between but within scientific and religious traditions for how to approach and resolve such questions. Ideally, the interplay between scientific and religious perspectives produces new insights and approaches for addressing many of the important questions of human existence. As an example, consider the topic of money. Warnings about the love of money are well known from various faith traditions. Religious teachings also have a great deal to say about how to save, manage, and use money. From an economic perspective, the accepted wisdom for many years was that the accumulation of wealth beyond what met one’s basic needs did not produce any greater level of happiness—­a proposition originally advanced in 1974 by the economist Richard Easterlin. The “Easterlin Paradox,” as this proposition came to be known, seemed to complement religious teachings about money not bringing true happiness. However, subsequent empirical analyses of large data sets began to challenge Easterlin’s idea, finding that people generally report ever higher levels of happiness as their incomes increase to levels far beyond the amount required to meet basic needs (Stevenson & Wolfers, 2008). These findings could be interpreted as running counter to many religious teachings. But the story does not end there. Additional empirical findings from the economic literature present further nuance to our understandings of how money and happiness are related. Numerous studies have found that one of the best ways to achieve happiness with money is not to spend it on oneself but to spend it on others (Dunn, Aknin, & Norton, 2008). Relatedly, using money to buy material possessions tends to make us significantly less happy than we expect (Howell, Pchelin, & Iyer, 2012). In financial decisions, then, it has begun to appear that happiness is not simply a matter of accumulating more money but a matter of using that money wisely. Not all economic researchers would concur with this conclusion, and future research is likely to reveal new findings and refinements to our understanding of this topic. Nonetheless, this example serves to illustrate how questions of existential significance might be fruitfully addressed by considering findings from the scientific literature in combination with various religious, spiritual, and ethical perspectives. The combination of scientific and spiritual perspectives is explored in the present volume in relation to an acceptance and commitment therapy (ACT) model (Hayes, Strosahl, & Wilson, 2012). A pithy summary of the ACT model can be had in three words: “hold and move.” In therapeutic contexts, this summation of ACT is used to encourage clients to “hold” their experiences, whatever those may be—­ joy,

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Integrating Religious and Spiritual Practices with Psychotherapy

frustration, anxiety, pleasure, or sadness—­and to “move” forward in the direction of their values. This entails both acceptance, or a willingness to acknowledge and allow different experiences to be present without quickly trying to push them away or hold them too tightly, as well as commitment, or the decision to undertake valued activities whatever one’s experiences might be. This ACT philosophy might also be usefully applied in our approach to the dialogue between science, religion, and spirituality. In this dialogue, which too often has been characterized instead as a competition, what might it look like to “hold” contributions both from science and from our religious and spiritual traditions? How might our care provision be informed both by findings from psychological science as well as by religious and spiritual teachings? When tensions appear to exist, might we still attempt to “hold” what is of value from these different traditions without too impulsively attempting to discount one position or the other? Going back to the example of money buying happiness, might a willingness to consider the breadth of research evidence in the context of broader religious and spiritual teachings, and vice versa, help us to move beyond potential points of tension to discover meaningful interrelationships? The invitation to the reader to “hold and move” is extended in many different ways throughout this book. There is no expectation that the exercise of holding, whatever form that may take, is going to resolve all divergences between religion, spirituality, and psychotherapy. In fact, the willingness to hold and consider different ideas is very much about allowing these differences to be present. However, there is an expectation—­perhaps the better word is “hope”—­that the exercise of holding can allow care providers and care recipients to discover fuller, more enriching, more meaningful ways of flourishing in the world. In these first two chapters, you will be invited to hold findings and perspectives first from psychological science and then from theology. Later chapters will continue inviting you to hold different ideas related to the ACT model and will also focus more on the concept of moving, or ways that you can apply the ACT model to benefit those you serve as well as yourself. To begin, this chapter will broadly examine some of the foundational principles for integrating religious/spiritual approaches to care with psychotherapy, paying particular attention to the scientific underpinnings that indicate a unique role for ACT. We will first take a look at the linkages between religion/spirituality and mental health and will discuss some of the challenges inherent in this research. Next, we will turn our attention to psychotherapy. We will examine important intersections between psychotherapy and religion/spirituality, including the colorful history of cooperation and conflict between these disciplines, the evolution of psychotherapy into an evidence-­based health care intervention, and recent developments in the integration of spirituality within psychotherapy. Finally, we will conclude by

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considering scientific principles and recent empirical findings that point toward the potential promise for integrating religion/spirituality with ACT in particular.

Research on Religion, Spirituality, and Mental Health Research into the connections between religion, spirituality, and mental health has proliferated in recent decades. This can be illustrated by searching for the terms “religion” and “spirituality” in databases of the scientific literature. PsycINFO, an online database of psychological research, turns up 2,390 citations related to religion for the period spanning 1971–­1980, a number that in the following decades increases to 4,288 for the 1980s, 5,490 for the 1990s, and finally 14,686 for the first decade of the 21st century. When controlling for the fact that during this time period there has been an overall increase in all types of scientific citations catalogued by PsycINFO, these numbers still represent a 45% increase in the proportion of total studies having to do with religion. The increase is even more dramatic for spirituality, which turns up a mere 26 studies from 1971–­1980, a figure that rapidly rises to 526 in the 1980s, 2,574 in the 1990s, and 8,878 from 2001–­2010. Controlling again for the increase in overall scientific citations, this represents approximately an 80-­fold increase in studies related to spirituality. Such a massive increase attests both to the general growth in mental health research related to religion/spirituality as well as to the meteoric ascent of “spirituality” as a construct that in 30 years has evolved from obscurity to commonplace within the scientific parlance.

State of the Science What does this research regarding spirituality and health tell us? In broad terms, it suggests two things: 1) religion, spirituality, and mental health are deeply related; and 2) these relationships are complex. Studies examining the relationships between mental health and religion/spirituality have tended to focus more in some areas than others. In terms of mental health, studies have most frequently looked at mood and substance use problems. In terms of religion/spirituality, studies have most commonly considered how mental health outcomes are related to religious involvement (such as attendance at religious services). A systematic review of studies conducted from 1990–­2010 found that religious involvement was correlated with better mental health outcomes in most studies having to do with depression, substance abuse, and suicide (Bonelli & Koenig, 2013). The same relationship was found in the very small number of studies that looked at dementia or stress-­related disorders, and the review found 6

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religiosity to be inconsistently related to mental health outcomes in studies of those with the more serious mental illnesses of bipolar disorder or schizophrenia. The strongest evidence for a link between religious involvement and mental health comes from longitudinal research that has followed people over the course of their lives. The Alameda County study, which began tracking health behaviors and outcomes in a segment of this California county’s residents back in 1965, has consistently found regular church attenders to have better mental health outcomes. Those who reported weekly church attendance in 1965 were less likely three decades later to suffer from depression or to have gotten a divorce and more likely to have numerous social relationships (Strawbridge, Shema, Cohen, & Kaplan, 2001). Further, they were more likely to have quit smoking, increased exercise, avoided weight gain, and decreased drinking (Strawbridge, Cohen, Shema, & Kaplan, 1997; Strawbridge et al., 2001). Most strikingly, they were more likely to still be alive (Strawbridge et al., 1997). A separate longitudinal study that followed inner city men over 23 years found that those who regularly attended church reported higher levels of well-­being (L. B. Koenig & Vaillant, 2009). Additionally, cross-­sectional studies, of which there are many more because these only require assessing people at one time point rather than following them over the course of years, have usually found that religious involvement positively correlates with better mental health. Studies on “spirituality” have produced similar findings. Persons who score high on measures of spirituality usually also report better psychological health (H. G. Koenig, 2008). But what does this mean? Perhaps not what it seems. Much of the research in this arena has not disentangled spirituality from either religion or mental health. On the one hand, statements purporting that spirituality is related to mental health often cite research that is actually measuring individuals’ involvement in religious activities. On the other hand, attempts to measure spirituality as a distinct construct from religion have instead been accused of resulting merely in measures of psychological well-­being (H. G. Koenig, 2008), thus making a tautology of any relationships discovered between spirituality and mental health. While this ongoing challenge in the research literature makes it difficult to put forth broad empirical claims about spirituality and health, it does not negate the fact that spirituality is very important to a lot of people. Two thirds of Americans identify as spiritual, and most identify as both religious and spiritual (Stark, 2008). The fact that spirituality is so difficult to disentangle from religion and mental health may be indicating something other than researchers’ ineptitude. It may be indicating that the nosological systems we use to categorize religion, spirituality, and psychological health are in fact attempting to classify overlapping phenomena. Especially as we consider how religion, spirituality, and psychology are actually experienced in the lived lives of human beings, there are surely certain ways in which these constructs seem inseparable.

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The intricacies of the interrelationships between religion, spirituality, and mental health can be partially evidenced by the complexities and nuances that pervade this research literature. For example, while the previously mentioned Alameda County study generally found positive relationships between church attendance and health outcomes, many of these relationships were stronger for women than for men (Strawbridge et al., 1997). Additionally, religion does not appear to be universally related to lower levels of depression. A study examining data from the Epidemiological Catchment Survey found higher rates of depression among those identifying as Pentecostal (Meador, Koenig, Hughes, & Blazer, 1992). Further, the directionality of relationships is complex. For example, longitudinal evidence from the Alameda County study suggests that church attendance leads to positive health behaviors and outcomes, whereas other studies suggest that mental health conditions like depression lead to lower church attendance (Maselko, Hayward, Hanlon, Buka, & Meador, 2012). It only makes sense that these relationships would work both ways.

Research Challenges Like all research, studies in the domain of religion, spirituality, and health rest on a series of important fundamental assumptions. As any scientist knows, one of the first steps in any project is to define one’s terms. Researchers who deal with sociocultural and psychological phenomena encounter a particular challenge here, one that so-­called “basic scientists” are less encumbered by—­namely, defining terms that already carry significant connotations outside of scientific settings. The botanist naming a new plant species has the advantage of describing a phenomenon that is not already embedded with personal significance for masses of humanity. Conversely, the psychological researcher who seeks to operationally define religion or spirituality (or, for that matter, depression, anxiety, compulsivity, or other such terms) must to some extent contend with what this construct and experience means to her grandmother, best friend, next-­door neighbor, work colleague, and all sorts of other people scattered across the globe. As can be expected, definitions and corresponding measures of such constructs vary and therefore can at best strive to approximate what the construct and related experiences mean for different people. The simple question of whether religion is good or bad for mental health can be misguided for a number of reasons. First, religion is not a singular thing but comprises a host of diverse practices, experiences, and beliefs. Second, even if religion were firmly established as good for one’s mental health, it is not clear how health care providers could prescribe religious involvement or affiliation (any more than they could prescribe allegiance to certain political parties, even if being a Republican or Democrat made one happier). Third, while the relationship between religiosity and 8

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health is interesting, the notion of being religious for the purpose of reaping health benefits seems repugnant, or at least to be missing the point. Fourth, to the extent that we choose to measure the effects of religion, there are a range of outcomes that may be worth measuring beyond the typically examined mental health constructs, such as whether a person is living a life in accordance with his or her values. Much remains to be learned in the field. For now, the fact that so many studies using a variety of different measures of religion, spirituality, and mental health have found significant (though not always consistent) relationships tells us that mental health professionals and spiritual care providers probably have a lot to learn from one another.

Integrating Religion and Spirituality with Psychotherapy There have been efforts to integrate religion and spirituality with psychology likely for as long as these constructs have coexisted. New developments, perhaps particularly in scientific psychotherapy but also in approaches to religion and spirituality, invite us to learn from the past while also exploring new possibilities and intersections.

A Colorful History Often there has been something of a disconnect between evidence-­ based approaches to psychotherapy and religious/spiritual approaches to counseling, with care providers in each camp being skeptical of one another. Such skepticism is not entirely without reason. A recent survey of members of the Association for Behavioral and Cognitive Therapies (ABCT), a leading evidence-­based psychotherapy organization, found over half of survey respondents reported a strong sense of spirituality but were substantially less likely than the general population to believe in God, to practice or be affiliated with a religion, or to endorse having intrinsic religiosity (Rosmarin, Green, Pirutinsky, & McKay, 2013). Other research has demonstrated that health care providers are on average less religious than the patients they serve and that mental health care providers in particular are among the least traditionally religious (Curlin et al., 2007). Even so, it is far too simplistic to characterize the historic disconnect between evidence-­based psychotherapy and religion as simply antagonistic. Certainly, psychotherapy has historically had its figureheads with their headlining skepticisms of religion. In a 1982 survey, American and Canadian psychologists ranked the most 9

ACT for Clergy and Pastoral Counselors

influential psychotherapists as Sigmund Freud, Carl Rogers, and Albert Ellis (Smith, 1982)—­all three known for advancing variations on the idea that religion is misguided, infantile, and/or psychologically harmful. However, such sentiments have often been selectively interpreted and do not fully represent opinions of the wider mental health community. The previously mentioned survey of ABCT members found that even though 71% reported little or no training in how to assess religious and spiritual matters, approximately half reported significant interest in receiving such training (Rosmarin et al., 2013). In a qualitative study of mental health care providers and chaplains working in the Departments of Veterans Affairs and Defense, one of the most common themes identified from mental health care providers was a need to learn more about chaplains (Nieuwsma et al., 2014). While perhaps less publicized, there are many examples of prominent psychotherapists wanting to better integrate psychology and religion. Paul Meehl, a pioneer of what has grown into the modern embrace of statistically-­informed, evidence-­based psychotherapy, was a devoted Lutheran who headed a group of theologians and psychologists exploring how devout Christian orthodoxy and sound psychological science might coexist (Meehl, Klann, Schmieding, Breimeier, & Schroeder-­Slomann, 1958). A number of cognitive behavioral therapists have written texts on the integration of different cognitive behavioral therapies with religion and spirituality. Even Freud, Rogers, and Ellis have some nuance to their intersections with religion: Freud, an atheist until his death, was still motivated to explore in his final book how monotheism conferred certain historical advantages to Jews (Freud, 1939); Rogers, who quit seminary after two years to pursue psychological study, has nonetheless had a lasting impact on approaches to clinical pastoral education and health care chaplaincy (Gleason, 1998); and Ellis, despite describing himself as a probabilistic atheist, co-­authored a book with two religious psychotherapists on applications of his rational emotive behavior therapy model for religious persons (Nielsen, Johnson, & Ellis, 2001).

The Ascent of Evidence-­Based Psychotherapy Freud, Rogers, and Ellis represent three dominant paradigms of psychotherapy from the 20th century: psychoanalysis, humanistic psychotherapy, and cognitive behavioral therapy respectively. One of these, cognitive behavioral therapy, or CBT, has largely become synonymous with evidence-­based psychotherapy. The preponderance of empirical studies testing the effectiveness of psychotherapy have focused on CBT (Chambless & Ollendick, 2001), in part because this kind of a scientific approach is more enculturated in CBT therapists than in practitioners of other approaches. Most studies investigating CBT compare outcomes of people receiving 10

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CBT to those of people receiving little treatment (such as people who are biding their time on a waitlist or are receiving some form of placebo therapy). In studies that have compared CBT head-­to-­head against another psychotherapy (usually psychodynamic therapy), the evidence suggests that CBT typically performs as well as or somewhat better than other therapies (Tolin, 2010). The embrace of scientific methods for testing therapeutic effectiveness has played a major role in the proliferation of CBT throughout mental health care. The ascent of evidence-­based psychotherapy generally, and CBT in particular, can be witnessed in multiple sectors. Graduate training programs now offer didactics in CBT more commonly than in any other psychotherapy (Weissman et al., 2006). The nation’s largest health care systems have a variety of programs for disseminating training in evidence-­based psychotherapies to their mental health care providers (Karlin & Cross, 2014; McHugh & Barlow, 2010). And some predict that eventually health care insurers may selectively reimburse only for CBT and other evidence-­based psychotherapies (Thomason, 2010). Compared to excessive reliance on therapeutic anecdotes and untestable theories, a reliance on evidence to inform mental health care decisions surely represents progress. Empirically testing the efficacy of different psychotherapies has many advantages: it allows for utilitarian decision-­making about which treatments are likely to do the greatest good for the largest number of people; it challenges advocates of different therapies to prove their efficacy; it advances health care by continually raising the standard against which new treatments must be measured; it helps identify the specific attributes of a therapy that are efficacious; and it provides therapists with a “best guess” of what treatment they should use with a given individual. However, in practice, there can be disadvantages to how the reliance on empirical science manifests itself among psychotherapists: it can foster overconfidence in treatments that in fact may be only moderately efficacious; it can promote dogmatic adherence to therapy protocols; it can stifle research on novel ideas; it can lead to an underappreciating of diversity between patients and a void in knowing how to respond to patients who do not improve; and it can encourage focus on a narrow set of desirable therapy outcomes. In general, these drawbacks can become less problematic with a thoughtful and humble approach to scientific empiricism. Evidence-­based psychotherapies can also present notable challenges for clergy and pastoral counselors. Spiritually-­guided counselors and clergy need models that link to their traditions. The dynamic tension that comes from holding both empirical evidence and spiritual commitments can only lead to good outcomes if each aspect is open to the other. Psychotherapeutic traditions that do not make room for this dynamic tension, that minimize human complexity, or that undermine the importance of faith commitment are hard to integrate with spiritually-­based care.

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ACT for Clergy and Pastoral Counselors

Developments Integrating Psychotherapy and Spirituality In some respects, efforts to integrate spirituality with psychotherapy embody one way in which evidence-­based treatments might be approached with more thought and humility. Religious and spiritual worldviews provide many individuals with a lens through which to experience and interpret their joy and suffering, including psychological suffering. Many efforts to incorporate spirituality into psychotherapy seek to explicitly invite the use of religious and spiritual frameworks into the process of evaluating the etiology of a problem and charting a course for change. Such approaches need not diminish spiritual language to functioning as a mere window dressing for accomplishing psychological work. While strictly dichotomizing between things spiritual and things psychological can become a misguided endeavor given the intimately intertwined nature of these constructs, the traditions and methodologies embodied in languages of spirituality and psychology are nonetheless distinctive and can mutually inform one another. For example, forgiveness has been associated with a number of mental health benefits (Lundahl, Taylor, Stevenson, & Roberts, 2008). However, encouraging a process of forgiveness solely for the purpose of decreasing psychological suffering overlooks important moral, ethical, religious, and spiritual considerations for how to address a wrong. For many, there are sincerely held theological and existential values that cannot and should not be divorced from a forgiveness process, which in most cases is likely also all to the good with respect to ultimately fostering better mental health. Most major psychotherapies over the years have at some point been adapted to incorporate a religious worldview. Authors have written about Christian approaches to psychoanalysis, existential therapy, humanistic therapy, CBT, and many others. However, contemporary integrative efforts are unique from previous efforts. A number of past attempts have had sound theoretical reasoning but little scientific empirical backing for the therapeutic approach. Other efforts have focused on integrating spirituality with an evidence-­based psychotherapeutic approach, but the evidence base in these cases is usually embedded in a disease treatment model. In other words, the evidence for these psychotherapies primarily indicates that they can efficaciously treat and reduce the symptoms of psychological disorders. This is a good thing. Recently, though, scientifically minded psychotherapists have sought to broaden the objective of therapy beyond disease remission. They have sought to more intentionally address issues like values, life meaning, and even spirituality itself. One evidence of this is the American Psychological Association’s launch of the journal Spirituality in Clinical Practice in 2013. Another is the rise of so-­called “third wave” behavioral and cognitive therapies, which among other things are characterized by 12

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“the construction of broad, flexible, and effective repertoires over an eliminative approach to narrowly defined problems” as well as by the aim to focus on “questions, issues, and domains previously addressed primarily by other traditions,” including our spiritual and religious traditions (Hayes, 2004). ACT is one such therapy.

ACT, Spirituality, and the Refining of Evidence-­Based Paradigms ACT can be broadly understood as developing out of the cognitive behavioral tradition; accordingly, it retains a strong emphasis on empirical science. In its relatively short history, ACT has accumulated empirical support of its efficacy for a range of psychological and physical problems (Powers, Zum Vörde Sive Vörding, & Emmelkamp, 2009; Ruiz, 2010). While firmly committed to a scientific approach, as is described below, ACT introduces ways of refining the evidence-­based paradigm in a manner that presents particular opportunities for the integration of spiritual care, beginning with assumptions about our humanity.

Humans Are Not Rational Machines One of the most important findings to come out of psychological science in the past half century is that humans are not always purely rational. This has come as something of a surprise to those psychological and economic traditions inclined toward viewing people as elaborate machines. Only one psychologist, Daniel Kahneman, has ever been awarded the Nobel Prize, and it was essentially for this idea. Kahneman built a career on describing the various ways that cognitive biases and thinking shortcuts lead us astray (Kahneman, 2013), winning his 2002 Nobel in economics (there is no Nobel in psychology) for detailing the ways in which humans’ illogical, irrational thinking extends to financial decision-­making (Kahneman & Tversky, 1979). Whether it is in making decisions about money or about the myriad of other things that we are faced with on a daily basis, it turns out that we simply are not all that rational. Human thought is not machine-­like and it leads to all kinds of mistakes. Just maybe, in some way, it is also beautiful—­for all their rationality, computers cannot cherish life experiences of joy, pain, happiness, sadness, or love. Regardless, good or bad, it is a fact: we are not machines. An appreciation for this aspect of our humanness is pervasive in ACT. In fact, this is one important way in which ACT is distinct from earlier cognitive behavioral approaches. Traditional cognitive therapy approaches are heavily based on the idea that distorted thinking is at the root of psychological problems and can be fixed 13

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through realistic evaluation and modification (Beck, 1995). In keeping with this, cognitive therapy makes use of exercises such as weighing the evidence for and against dysfunctional beliefs so that these beliefs might be rationally redefined. ACT does not engage problematic thoughts and beliefs in this way. ACT is based on a contextualistic worldview that sees human action as meaningful based on history and purpose. In application, this means that ACT therapists are less concerned with the form of thoughts and feelings than they are with the role that thoughts and feelings have in one’s life. Through acceptance and mindfulness practices, ACT aims to help individuals simply be aware of and observe their thoughts in a manner that is empowering but does not lead to entanglement and argument with cognitive content. The distancing effect that this engenders helps to develop a space from which someone can more freely choose to move forward in valued life directions, bringing along for the ride whatever thoughts and feelings may exist. In this manner, ACT does not seek to fix aspects of our human nature but instead accepts these aspects of our humanness, and in so doing creates new possibilities for being fully human in intentional and meaningful ways. Grappling with what it means to be human in the face of scientific, rational enlightenment has been one of the major tasks for religions in the modern era. By embracing both our humanness and scientific empiricism, ACT presents certain new possibilities for religious and spiritual care providers undertaking this task.

Paradoxically Speaking The idea that accepting problematic thoughts and emotions somehow gives them less control over us is paradoxical. So too is there a degree of paradox in ACT’s simultaneous embrace of our irrational humanness along with rational science. Of course, paradoxes contain many important truths and are the basis of numerous religious teachings. The Christian gospels, for instance, are rife with paradoxes: the last shall be first; you must lose your life to gain it; the greatest is like a servant; blessed are the meek, mourners, and persecuted. Plenty of examples can be found in other religions as well. In psychology, recent research has uncovered some very interesting paradoxes. Take for example a study that examined patients with panic disorder (Levitt, Brown, Orsillo, & Barlow, 2004). This study invited 60 individuals with panic disorder to come into a lab and have carbon dioxide-­enriched air pumped in through a mask for them to breathe. This has the effect of inducing a panic attack—­why someone with panic disorder would volunteer for such a study is a mystery! Before breathing this air, participants were randomly divided into three groups: the first group was instructed to be willing to experience (i.e., accept) the inevitable feelings 14

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of anxiety that would arise when breathing in the air; the second group was instructed to suppress anxious feelings; and the third group was provided with no specific instructions for how to handle the anxiety. After breathing in the carbon dioxide enriched air, participants in the acceptance group (the first group) reported experiencing significantly less anxiety during the task than those in the other two groups. Other studies have reported similar paradoxical findings in cases where persons are instructed to approach discomfort with acceptance strategies (Gutiérrez, Luciano, Rodríguez, & Fink, 2004; McMullen et al., 2008). Perhaps the biggest lesson for care providers from the carbon dioxide study is indicated by the finding that those in the acceptance group were the most likely to be willing to repeat the task. Imagine what this means for people who are suffering. So much suffering is paradoxically caused by efforts to avoid pain (e.g., substance abuse to escape uncomfortable feelings; isolation to avoid social discomfort; avoidance of feared situations to prevent anxiety). If people can become willing to encounter and reencounter feelings of discomfort in the service of a larger goal, they can begin to break those problematic cycles that result in psychological and spiritual suffering.

Why Does It Matter? The Importance of Valued Living The acceptance instructions in the carbon dioxide study did not simply consist of directing panic disorder patients to be willing to experience their anxiety. Rather, participants listened to a 10-­minute ACT-­based recording that described how being willing to experience discomfort can free one up to focus on what is meaningful and valued in life (Hayes, Strosahl, & Wilson, 1999; Levitt et al., 2004). In other words, the aim of acceptance strategies is not to eliminate anxiety or other psychological problems. The aim is to open up possibilities for doing what matters in life. From a scientific perspective, this has important empirical connotations. It means that our primary outcome of interest, or our “dependent variable,” is not the presence or absence of a disorder (though this is often measured as a secondary outcome of interest). Our primary outcome of interest is valued living. Focusing on how to live life in accordance with one’s values invites interactivity with religious and spiritual approaches, in both overt and subtle ways. Overtly, many values lists and worksheets have been developed for use in ACT, and religious/spiritual values are commonly included in these. Individuals are encouraged to identify and clarify religious and spiritual values of importance to them in order for these values to guide their life choices and behaviors. More subtly, by not exclusively viewing the pains of human existence through a psychiatric diagnostic lens, ACT 15

ACT for Clergy and Pastoral Counselors

allows room for potentially finding meaning in pain. Numerous exercises in ACT use emotional pain as something that can help to uncover values and inform valued living. The ACT approach to pain challenges conventional assumptions that 1) pain is bad, 2) it can be stopped, and 3) it should be stopped. While sometimes true, these assumptions clearly are not always true. That pain cannot be entirely eliminated begs one of the largest questions in all of religion: Why do we suffer? ACT does not purport to provide the existential answer to this question, but it does allow room for this inevitable human experience. It allows space to “hold” the breadth of human experiences, including suffering, as well as the room to “move” in the direction of one’s values. In so doing, it opens wide the door for wisdom and engagement from religious and spiritual care providers.

Summary Despite instances of historical conflict between psychological and religious traditions, there is also a strong mutual interest between these disciplines that contains promising potential. Clergy, pastoral counselors, and other spiritual care providers stand to benefit by examining the evidence base in psychotherapy. Of particular promise are psychotherapeutic models that eschew mechanistic and reductionistic views of personhood, that make room not just for the rational parts of our humanness but also for our experiential and intuitive natures, and that appreciate the importance of paradox and values. ACT is such a model. For their part, psychotherapists steeped in evidence-­based modalities, including ACT, can benefit from a more intentional consideration of those issues central to human flourishing that are often thought of as spiritual—­things like love, values, commitment, forgiveness, compassion, charity, transcendence, and a sense of the divine. Psychotherapists and clergy each have unique strengths born out of their distinctive personal and professional formations as care providers, and there is rich potential in bringing together what each of these disciplines has to offer. The present volume explores this dynamic and exciting territory. We hope that the reader will find the intersections between ACT, religion, and spirituality to be as promising and intriguing as we find them to be. More importantly, we believe that these intersections hold significant and meaningful potential to benefit those entrusted to our care. As this volume unfolds, we trust that the reader will come to agree.

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References Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford Press. Bonelli, R. M., & Koenig, H. G. (2013). Mental disorders, religion and spirituality 1990 to 2010: A systematic evidence-­based review. Journal of Religion and Health, 52, 657–­673. Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685–­716. Curlin, F. A., Odell, S. V., Lawrence, R. E., Chin, M. H., Lantos, J. D., Meador, K. G., & Koenig, H. G. (2007). The relationship between psychiatry and religion among U.S. physicians. Psychiatric Services, 58, 1193–­1198. Dunn, E. W., Aknin, L. B., & Norton, M. I. (2008). Spending money on others promotes happiness. Science, 319, 1687–­1688. Easterlin, R. (1974). Does economic growth improve the human lot? Some empirical evidence. In P. A. David & M. W. Reder (Eds.), Nations and households in economic growth: Essays in honor of Moses Abramovitz. New York: Academic Press. Freud, S. (1939). Moses and monotheism. New York: Knopf. Gleason, J. J. (1998). An emerging paradigm in professional chaplaincy. Chaplaincy Today, 14, 9–­14. Gutiérrez, O., Luciano, C., Rodríguez, M., & Fink, B. C. (2004). Comparison between an acceptance-­based and a cognitive-­control-­based protocol for coping with pain. Behavior Therapy, 35, 767–­783. Hayes, S. C. (2004). Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies. Behavior Therapy, 35, 639–­665. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press. Hayes, S. C., Strosahl, K., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed). New York: Guilford Press. Howell, R. T., Pchelin, P., & Iyer, R. (2012). The preference for experiences over possessions: Measurement and construct validation of the Experiential Buying Tendency Scale. The Journal of Positive Psychology, 7, 57–­71. Kahneman, D. (2013). Thinking, fast and slow. New York: Farrar, Straus and Giroux. Kahneman, D., & Tversky, A. (1979). Prospect theory: An analysis of decision under risk. Econometrica, 47, 263–­292. Karlin, B. E., & Cross, G. (2014). From the laboratory to the therapy room: National dissemination and implementation of evidence-­based psychotherapies in the U.S. Department of Veterans Affairs Health Care System. American Psychologist, 69, 19–­33. Koenig, H. G. (2008). Concerns about measuring “spirituality” in research. Journal of Nervous and Mental Disease, 196, 349–­355. Koenig, L. B., & Vaillant, G. E. (2009). A prospective study of church attendance and health over the lifespan. Health Psychology, 28, 117–­124. Levitt, J. T., Brown, T. A., Orsillo, S. M., & Barlow, D. H. (2004). The effects of acceptance versus suppression of emotion on subjective and psychophysiological response to carbon dioxide challenge in patients with panic disorder. Behavior Therapy, 35, 747–­766. Lundahl, B. W., Taylor, M. J., Stevenson, R., & Roberts, K. D. (2008). Process-­based forgiveness interventions: A meta-­analytic review. Research on Social Work Practice, 18, 465–­478. Maselko, J., Hayward, R., Hanlon, A., Buka, S., & Meador, K. (2012). Religious services attendance and major depression: A case of reverse causality? American Journal of Epidemiology, 175, 576–­583.

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McHugh, R. K., & Barlow, D. H. (2010). The dissemination and implementation of evidence-­ based psychological treatments: A review of current efforts. American Psychologist, 65, 73–­84. McMullen, J., Barnes-­Holmes, D., Barnes-­Holmes, Y., Stewart, I., Luciano, C., & Cochrane, A. (2008). Acceptance versus distraction: Brief instructions, metaphors and exercises in increasing tolerance for self-­ delivered electric shocks. Behaviour Research and Therapy, 46, 122–­129. Meador, K. G., Koenig, H. G., Hughes, D. C., Blazer, D. G., George, L. K., & Turnbull, J. (1992). Religious affiliation and major depression. Hospital and Community Psychiatry, 43, 1204–­1208. Meehl, P. E., Klann, R., Schmieding, A., Breimeier, K., & Schroeder-­Slomann, S. (1958). What, then, is man?: A symposium of theology, psychology, and psychiatry. St. Louis, MO: Concordia Publishing House. Nielsen, S. L., Johnson, W. B., & Ellis, A. (2001). Counseling and psychotherapy with religious persons: A rational emotive behavior therapy approach. Mahwah, NJ: L. Erlbaum Associates. Nieuwsma, J. A., Jackson, G. L., DeKraai, M. B., Bulling, D. J., Cantrell, W. C., Rhodes, J. E., et al. (2014). Collaborating across the Departments of Veterans Affairs and Defense to integrate mental health and chaplaincy services. Journal of General Internal Medicine, 29, 885–­894. Powers, M. B., Zum Vörde Sive Vörding, M. B., & Emmelkamp, P. M. G. (2009). Acceptance and commitment therapy: A meta-­analytic review. Psychotherapy and Psychosomatics, 78, 73–­80. Rosmarin, D. H., Green, D., Pirutinsky, S., & McKay, D. (2013). Attitudes toward spirituality/ religion among members of the Association for Behavioral and Cognitive Therapies. Professional Psychology: Research and Practice, 44, 424–­433. Ruiz, F. J. (2010). A review of acceptance and commitment therapy (ACT) empirical evidence: Correlational, experimental psychopathology, component and outcome studies. International Journal of Psychology and Psychological Therapy, 10, 125–­162. Smith, D. (1982). Trends in counseling and psychotherapy. American Psychologist, 37, 802– ­809. Stark, R. (2008). What Americans really believe: New findings from the Baylor surveys of religion. Waco, TX: Baylor University Press. Stevenson, B., & Wolfers, J. (2008). Economic growth and subjective well-­being: Reassessing the Easterlin paradox. Brookings Papers on Economic Activity, Spring, 1–­87. Strawbridge, W. J., Cohen, R. D., Shema, S. J., & Kaplan, G. A. (1997). Frequent attendance at religious services and mortality over 28 years. American Journal of Public Health, 87, 957–­961. Strawbridge, W. J., Shema, S., Cohen, R., & Kaplan, G. (2001). Religious attendance increases survival by improving and maintaining good health behaviors, mental health, and social relationships. Annals of Behavioral Medicine, 23, 68–­74. Thomason, T. C. (2010). The trend toward evidence-­based practice and the future of psychotherapy. American Journal of Psychotherapy, 64, 29–­38. Tolin, D. F. (2010). Is cognitive-­behavioral therapy more effective than other therapies? A meta-­ analytic review. Clinical Psychology Review, 30, 710–­720. Weissman, M. M., Verdeli, H., Gameroff, M. J., Bledsoe, S. E., Betts, K., Mufson, L., et al. (2006). National survey of psychotherapy training in psychiatry, psychology, and social work. Archives of General Psychiatry, 63, 925–­934.

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CHAPTER 2

A Theological Lens for Integrating ACT with Conceptions of Health, Healing, and Human Flourishing Joshua J. Knabb, PsyD, ABPP California Baptist University

Keith G. Meador, MD, ThM, MPH Vanderbilt University, VA Mental Health and Chaplaincy

ACT for Clergy and Pastoral Counselors

“By suffering God should become our joy.” —­Dietrich Bonhoeffer

Suffering in the 21st Century Human suffering is nothing new. Attempts to understand, explain, and cope with human suffering are evident in the earliest recorded human history, certainly in many of our earliest religious manuscripts. Greek mythology is full of struggles between humans and the gods, with some form or another of human suffering as the centerpiece within most of those narratives. Many stories in the Hindu tradition could be similarly interpreted. The story of the Buddha deals centrally with how to approach suffering. And of course the book of Genesis begins with an account of how human suffering entered the world, a narrative that has been grappled with ever since in Jewish and Christian traditions. If the individuals involved in the earliest parts of these diverse religious histories across the globe could see what humanity looks like in the 21st century, they would no doubt be amazed. They would also see that, despite our many industrial and technological advances, humanity continues to suffer. They would see that we continue to wrestle with many of the same questions and challenges that have faced us for generations, and that we continue to need wisdom and guidance from faith communities as we go about this task. As we will unpack throughout this chapter, there are a number of particularities to how suffering is interpreted and understood in 21st century Western contexts. Because in Western society the dominant religious tradition is Christianity, the authors approach the topic of this chapter from an overtly Christian perspective. Even for those in Western society who may not be active participants in faith communities, it is nonetheless the case that Christian perspectives on suffering are deeply embedded in the formation of contemporary Western society and subtly pervade cultural approaches to the care of those who suffer. We critically examine aspects of these Christian perspectives and delve into the work of one particular theologian, Dietrich Bonhoeffer, in order to meaningfully flesh out how theology can connect with acceptance and commitment therapy (ACT). Our aim in so doing is to go beyond generalities of how ACT might broadly interrelate with theology so that we might concretely demonstrate actual theological linkages that have particular import for modern society. For readers from other religious traditions, or from different theological vantage points within the Christian tradition, it is our hope that much of the content of this chapter will still have resonance and might provide parallels and points of entry for further exploration. 20

A Theological Lens for Integrating ACT with Conceptions of Health

Suffering and Mental Health For many adults in the United States, mental disorders play a significant role in the etiology and maintenance of human suffering. Across the lifespan, about one in five adults (aged 18 to 64) will struggle with a mood disorder, with approximately one in three adults suffering from an anxiety disorder over the course of a lifetime (Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012). These statistics are likely the same for persons belonging to religious faiths, given that 71% of Americans in the United States indicate they belong to the Christian faith and 6% to other religious traditions (Pew Forum, 2015). Unfortunately, many depressive and anxiety disorders are chronic and recurring (Nierenberg, Petersen, & Alpert, 2003) and are among the leading factors contributing to disability in the United States workforce (Vasiliadis, Lesage, Adair, Wang, & Kessler, 2007). As these data reveal, many Americans face a daily struggle with significant psychological suffering. In response to the apparent pervasiveness of mental disorders, contemporary Western society has frequently sought “biomedical” solutions, rooted in the medical model of psychiatry. This model tends to view unpleasant inner experiences, such as low mood and worry, as symptoms to eliminate via medication or other therapies, similar to medical diseases and conditions (Hayes, Strosahl, & Wilson, 2012). Indeed, the medical disease model for psychiatric suffering has grown so entrenched that in the last several years it has been primary care physicians, rather than psychiatrists, who have prescribed most antidepressant medications (Pratt, Brody, & Gu, 2011). Moreover, even though some studies have found that antidepressant medications have comparable outcomes to a placebo for persons with mild to moderate depression (Fournier et al., 2010; Kirsch et al., 2008), about one in ten persons continue to take them in the United States (Insel, 2011). The assumption underlying this trend—­that unpleasant inner experiences are pathological and ought to be eradicated, similar to a malignant tumor—­may create at least a couple of unrealistic expectations. The first is that life should be free of pain and suffering. The second is that these wavering, impermanent states of psychic pain have no purpose in the service of psychological and spiritual growth.

Suffering and Spiritual Health Consistent with the broader culture, many faith communities in the 21st century also appear to be embracing the notion that life should be devoid of pain and suffering, especially if one is sufficiently faithful to ensure God’s protection from such experiences. The belief that God will bless a person with good health if they have sufficient faith is common among American Christians, with this view being embraced by 21

ACT for Clergy and Pastoral Counselors

roughly two-­thirds of Pentecostal and Charismatic adults and approximately half of Christians from other denominations (Pew Forum, 2006). From this perspective, a deep-­seated devotion to God seems to all but guarantee an overabundance of blessings, happiness, well-­being, and wisdom (Smith, 2014). In other words, faith is the recipe for a virtually pain-­free life. In her book Spirit and Trauma: A Theology of Remaining, Shelly Rambo (2010) describes this phenomenon by invoking familiar theological language, suggesting that there is a contemporary impulse for Christians to jump from Good Friday straight to Easter Sunday. In so doing, Christians can ignore the place of uncertainty, pain, and shrouded hope where much of life is inevitably lived: the place in the Christian story called Holy Saturday.

Suffering and Research on Religion and Health Similar in ways to some contemporary Christian approaches to suffering, research on religion and health has made little room for understanding suffering as anything other than an evil to be eliminated and avoided. Relying heavily upon correlational, cross-­sectional research, the religion and health literature has aimed to examine the relationship between religion/spirituality and mental health, well-­being, and happiness (Park & Slattery, 2013), frequently missing the theological significance of practices of caring (Shuman & Meador, 2002). As an example, in a literature review published in the American Psychologist, Hill and Pargament (2003) outlined several burgeoning areas of investigation within this field, highlighting that a range of religious and spiritual concepts seem to be positively associated with mental health. Among other lines of inquiry, a subjective feeling of closeness to God, religion as a form of motivation, and religion as a source of interpersonal support were offered as “promising areas” of research (Hill & Pargament, 2003). Yet, when considering these research domains, it appears as though many tend to focus on the role that religion and spirituality play in protecting against pain and suffering, as well as improving well-­being, often a synonym for “happiness.” Still, in their review, Hill and Pargament (2003) also underscored that religious and spiritual struggles can be important contributing factors to spiritual growth, with emerging studies revealing a more complex picture because of the association between these types of struggles and both positive and negative mental health outcomes. This area of investigation, undoubtedly, is extremely important for future researchers, given that the Judeo-­Christian tradition—­drawing from a variety of biblical authors and central figures (e.g., the Prophet Jeremiah, King David)—­emphasizes that life is filled with suffering, hardship, loss, and emotional pain. For Christians, this understanding of suffering culminated with Jesus’s violent, lonely death on a cross as the “Suffering Servant” (see Bock & Glaser, 2012), leading to a plethora of ministry 22

A Theological Lens for Integrating ACT with Conceptions of Health

efforts on the part of early Christian figures (e.g., the Apostle Peter, the Apostle Paul) who likely died martyr deaths for their faith. Clearly, faith in the early Christian tradition was not a recipe for alleviating suffering. Nonetheless, embedded within much of the contemporary research base, at least in terms of some researchers’ study hypotheses, seems to be an assumption that religion and spiritualty should reduce symptoms and improve well-­being and happiness. Surely, the expectation within many of these studies appears to be inconsistent with numerous stories and teachings throughout Judeo-­Christian scriptures indicating that pain is an unavoidable aspect of the human condition. In a similar vein, the ACT literature suggests that pain is a normal, ubiquitous part of life that should not automatically lead to a “disease” label and medical intervention. Regrettably, efforts to eliminate the inescapable pains, hurts, bumps, and bruises of life commonly distract from the pursuit of well-­defined values that emanate from embodied soulfulness. Sadly, the persistence of suffering despite sincere, religiously-­based attempts to eliminate it can leave many persons feeling additionally burdened with guilt for not being adequately faithful.

The Pursuit of Happiness: An Elusive Distraction to Values-­Based Living Interestingly, “happiness,” an emotional state that is often difficult to define, seems to be a rather elusive, fleeting experience. Recently, the United States ranked 17th out of 156 countries within the World Happiness Report (Helliwell, Layard, & Sachs, 2013). This comprehensive report, published by the United Nations, employed polling and survey data to measure the happiness and well-­being of a variety of countries across the globe (Helliwell et al., 2013). Despite widespread suggestions for pursuing and attaining happiness, and despite tremendous medical and health care advances (e.g., psychiatric medication ranked number two in 2012 for overall spending; see Bartholomew, 2013), the United States was nonetheless unable to make the “top ten” list. Maybe the pursuit of “happiness” is not the best use of Americans’ time and energy. The grasping pursuit of “prosperity” and “happiness,” an overreliance on the biomedical model, and the view of religion and spirituality as protective health factors have all likely undermined and confused efforts to discern and pursue spiritual maturity in the midst of suffering. This includes unrealistic expectations of how people of faith are to relate to unpleasant inner experiences, leading to exhausting, distracting efforts to avoid normal inner states (e.g., sadness, fear, anxiety) and a struggle to live out spiritual values. For those with a mature faith, we argue that life is not about the mere elimination of psychological pain, but foundationally involves loving God and 23

ACT for Clergy and Pastoral Counselors

others. In addition, for Christians, authentic living is about following Jesus, who modeled both endurance in the face of suffering and values-­based action. This understanding of the human condition, we believe, is firmly rooted in a well-­developed theology of suffering, servanthood, and sacrifice. In agreement with our central argument—­living faithfully is about much more than the reduction of psychiatric symptoms and the attainment of pleasure and “happiness”—­ a recent study by Knabb, Pelletier, and Grigorian-­ Routon (2014) revealed several interesting findings. Within the study, the authors elucidated a moderate correlation between distress endurance—­a part of the experiential avoidance (EA) construct—­and faith maturity among Christian adults. Defined as “effective behavior in the face of distress,” distress endurance captures the ability to suffer for life pursuits that truly matter (Gámez, Chmielewski, Kotov, Ruggero, & Watson, 2011, p. 696). In the Knabb et al. study, this variable was positively associated with self-­ sacrificial Christian behaviors. Among other characteristics, faith maturity involves helping the poor, assisting individuals who are struggling, reading the Bible, offering time and money to a local church, praying, worshipping, and following Jesus. Certainly, this study suggests that Christian living is about much more than symptom reduction. Indeed, many religious communities conceive of faith maturity as including self-­sacrificial, values-­driven behaviors that go well beyond the pursuit of happiness and pleasure.

A Theological Lens for Integrative Work: The Task at Hand Building on the above preliminary research (see also Knabb & Grigorian-­Routon, 2014), the authors of this chapter centrally argue that presuming to avoid unpleasant inner experiences by virtue of faithfulness is a basic misinterpretation of the spiritual life. On the other hand, ACT provides an opportunity to more deeply engage with the dilemma of suffering. We believe ACT offers theological integrity for those in the midst of psychological pain and a more robust regard for suffering than many contemporary therapeutic strategies and techniques. Therefore, we propose a theological lens of integration for clergy and pastoral counselors to simultaneously address psychological and spiritual problems. Stated differently, relying on psychological science and a particular religious framework, we offer an integrative model to help those from a variety of faith traditions to effectively blend acceptance of the inner world and action in the outer world for optimal functioning, rather than “happiness.” We believe that a central part of effective pastoral care involves identifying an Unterbau, or common foundation or infrastructure, for integrating psychological science with a rich theology of the human condition. While we think much of our material has 24

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broader implications for faith traditions beyond Christianity, this is the spiritual tradition within which both authors practice and the lens through which we can most credibly view this intersection. To accomplish this task, we engage ACT as a distinctive contemporary therapeutic modality through the theological lens offered in the writings of the Lutheran theologian Dietrich Bonhoeffer, who in his life and writings we believe exemplified action in the midst of suffering. For Bonhoeffer, life is about discerning and pursuing God’s will from moment to moment, seeking a deeper, more loving relationship with God and others—­rather than idolatrously attempting to be like God, relying on human knowledge of good and evil. In other words, when humans attempt to pursue abstracted self-­knowledge, fusing with a presumed autonomously derived understanding of the world, we suffer from disunion and division. When this happens, we undermine our ability to radically live faithfully, rooted in a contextualized and embodied love that emanates from God as the source of life. This “simple action”—­pressing forward, discerning God’s will, and loving God and neighbor in the context of authentic community—­has clear parallels with the ACT model, which advocates for values-­based living despite the suffering that ubiquitously emanates from the human condition. Overall, in the pages that follow, we explore the overlap between several salient concepts within the ACT model and Bonhoeffer’s theology, including: a) the inevitability of human suffering; b) the “double-­edged sword” of human knowledge, including humankind’s historic struggle with cognitive fusion; c) the problem of experiential avoidance, ultimately rooted in the experience of shame; d) the transformational movement from shame, judgment, and inaction to love, nonjudgment, and simple action, consistent with ACT’s emphasis on the merging of acceptance and values-­based living; and e) the importance of cultivating openness, centeredness, and engagement within faith communities. Of note, further reading on these intersections can be found in a previously published article by this chapter’s first author (see Knabb, Ashby, & Ziebell, 2010).

ACT and Human Suffering: A Psychological Perspective In order to begin the dialogue between ACT and a theological understanding of the human condition, we offer a basic overview of the ACT model. In particular, we highlight the ubiquity of suffering, the apparent quandary of human language, the ineffective human tendency to avoid pain, and the salience of values in day-­to-­day living as an alternative to pursuing pleasure and “happiness.” Within this section, we 25

ACT for Clergy and Pastoral Counselors

especially argue that ACT offers fertile soil upon which to grow an integrative understanding of the solution for suffering—­blending acceptance and action in the midst of psychological pain. Unless otherwise indicated, the ACT concepts in this section are drawn from Hayes, Strosahl, and Wilson (2012).

Language and Suffering: A “Double-­Edged Sword” Within the ACT model, language tends to be a “double-­edged sword,” helping humans to problem solve and navigate an uncertain outer world, while at the same time exacerbating unpleasant inner events through the use of labels and judgments. Individuals can easily assume that language and associated cognitions, whether accurate or not, constitute objective reality. This tight bonding with one’s thoughts, known in ACT as fusion, leads to an emphasis on viewing thoughts as facts, rather than mere words that have been strung together to form a sentence. When it comes to daily psychological functioning, the running commentary of the mind becomes real and indisputable, instead of being ordinary words that might or might not be true. Above all else, placing too much emphasis on language to understand intrapsychic states can leave individuals stuck, especially given that the mind is not always accurate in its assessment of both the inner and outer world. When fusion occurs, some might begin to avoid life, assuming that their mental chatter is literally true. As an example, someone with a depressive disorder might have the thought that he or she is “worthless,” and thus does not deserve God’s love or the care of a community offering support and affection. Although this verbal information is made up of mere letters in the English alphabet, the individual might allow “worthless,” a nine-­letter word, to block engagement with a substantive spiritual life.

Experiential Avoidance: Attempting to Hide from the Inevitable In addition to the human problem of language, experiential avoidance occurs when humans attempt to avoid, suppress, distract, deny, or repress unpleasant inner experiences (see Gámez et al., 2011). Within the ACT model, inner thoughts, feelings, and sensations do not determine whether or not someone is “disordered” in his or her functioning. In fact, society has increasingly and erroneously pathologized various normal states of distress, turning what would otherwise be ubiquitous human processes into “diseases” that must be eliminated. Instead, the unwillingness to accept certain ubiquitous, normal inner events can lead to a disconnection from values and a lack of committed action in living a life that truly matters. On the other hand, experiential acceptance involves relating to thoughts, feelings, and sensations 26

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with more openness, curiosity, flexibility, and tentativeness, especially in order to pursue a set of values that are deeply important and meaningful. Stated differently, inner events, including impermanent emotional states and internal verbal chatter, do not get in the way of what matters most and are not granted a primary role in navigating the roads of life.

Mindfulness: The Technology of Acceptance In order to ameliorate cognitive fusion and experiential avoidance, ACT employs the technique of mindfulness to help clients relate to inner events with more distance, openness, flexibility, and curiosity, lightly observing passing inner experience without getting swept away by a sometimes distressing stream of thoughts and feelings. Through mindfulness—­which, among other ingredients, involves being anchored to the present moment, cultivating sustained attention, and taking a nonjudgmental stance toward thoughts, feelings, and sensations—­clients are able to pivot toward pursuing a set of values to guide life. Said another way, clients can balance acceptance of the inner world with values-­driven action in the outer world. Values, which constitute verbal, meaningful, comprehensive, and freely chosen directions in life, help clients to traverse through the world with consistency, constancy, and confidence, without getting swept away by the sometimes rough, unpredictable seas of the mind. Thus, clients spend quite a bit of time in ACT getting to know their deepest longings, desires, and wishes, which emanate from the heart.

The ACT Model: Cultivating Psychological Flexibility The ACT model employs four mindfulness-­based processes—­accepting emotions, defusing from thoughts, observing inner states from a safe distance as passing events, and connecting to the present moment—­and two values-­based processes—­ values and committed action. This combination, blending acceptance and behavioral action, helps clients to move forward, guided by deeply meaningful values, despite impermanent verbal content and unpleasant emotions that might send them in a contradictory life direction. Taken as a whole, these six processes help to nurture psychological flexibility, which includes openness, centeredness, and a deeper engagement with life. To summarize, ACT helps clients to accept the inner world, choose a valued life direction, and take action in pursuing what matters most. Rather than remaining stuck due to fusion and avoidance, clients are able to live a life devoted to freely chosen, personally constructed values. We believe ACT’s core processes align quite 27

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well with the life and writings of the Lutheran theologian Dietrich Bonhoeffer. Bonhoeffer provides a theological lens through which to appropriate ACT as a therapeutic tool, while sustaining a theologically discerning and evaluative capacity within the psychologically life-­giving and embracing spirit of ACT. What follows is a review of his theology, paying particular attention to points of overlap with the central tenets of the ACT model. Unless otherwise noted, concepts within the following section are derived from Bonhoeffer (1954, 1955, 1959, 1995).

Nonjudgment, Simple Action, and Love Transitioning from psychological science to a theological understanding of the human experience, we draw parallels between the ACT model and the writings of Dietrich Bonhoeffer. In particular, we argue that Bonhoeffer’s emphasis on the human struggle with knowledge of good and evil aligns quite well with an ACT viewpoint on the dilemma of language. Furthermore, Bonhoeffer advocated for loving action, blending an awareness of possible inner barriers with a firm desire to pursue God’s will, consistent with ACT’s acceptance-­action merger. For Bonhoeffer, life is about loving others, and pushing forward in spite of the human tendency to rely on self-­derived knowledge. Overall, this unique amalgamation of ACT and the works of a highly influential theologian from the 21st century can allow individuals from a variety of faith traditions to pursue values-­based action within their respective communities. Indeed, accepting the reality of psychological pain while following the teachings of one’s sacred text(s) can help many devoted individuals to cultivate a deeply fulfilling, meaningful life.

Acceptance and Action: “Costly Grace” and “Single-­Minded Obedience” Dietrich Bonhoeffer was a German theologian in the mid-­20th century, famous for helping to found the Confessing Church, resisting the rise of Adolf Hitler in Nazi Germany, and writing a variety of popular theological works. He was hanged in 1945, charged with conspiracy to assassinate Hitler. Bonhoeffer wrote various works, some published before his death (translated to English later) and others published posthumously; these included Ethics, Creation and Fall, The Cost of Discipleship, and Living Together. All elucidated several common themes. Among other topics, he wrote on the inevitability of suffering, along with the centrality of love, nonjudgment, and total devotion to pursuing God’s will in the context of Christian teachings and authentic Christian community. Bonhoeffer frequently argued for the importance of

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simple action in the Christian life in spite of the cost or sacrifice, revealing clear parallels with an ACT model that promotes values-­based action. In The Cost of Discipleship, likely his most famous work, Bonhoeffer drew a strong distinction between “costly” and “cheap” grace. For Bonhoeffer, costly grace leads to a firm desire to discern and follow God’s will, in spite of the consequences, recognizing that self-­sacrifice is a foundational tenet of the Christian life. In fact, God’s grace—­an undeserving merit, favor, and gift offered by God to humankind—­“costs” because of its price in the death of Jesus. Quite literally, then, a fitting response to God’s compassion requires turning around and heading in a different direction when missing the mark, regardless of the challenges that may arise from this intentional pivot. Certainly, costly grace may be a difficult concept to fully comprehend in the 21st century, especially given the common American struggle with experiential avoidance. In other words, Americans are frequently preoccupied with pursing pleasure and avoiding pain, rather than practicing values-­based action in daily living. For many, suffering in order to pursue God’s will may be foreign, uncomfortable, or even antithetical to their understanding of what constitutes healthy Christianity. Still, as revealed by Bonhoeffer, the cost of following God’s will is worthy of the sacrifice because God is ultimately at the center of existence, giving true life. Therefore, although Christians are to relinquish their own will, experiencing suffering and hardship in the process of dying to self, the rewards of living a life devoted to God outweigh the costs. On the other hand, cheap grace is understood by Bonhoeffer as merely an abstract concept that need not entail a radically changed life based on faithful devotion to God. Stated differently, those who settle for a cheap version of grace overly rely on an experiential comfort that is presumed to accompany God’s gift of forgiveness, lacking a firm conviction to act in gratitude within the call to discipleship. For Bonhoeffer, cheap grace is an obstacle to a life of action, keeping Christians stuck because they have little intention of letting go of self-­interest to pursue spiritual faithfulness to God. In a similar vein, ACT helps clients to focus on behavioral action, with personally constructed values serving as a guide to life. As a result, with the ACT model employed as a proverbial vehicle, clients continue to move forward in an intentional direction, despite inner distress that would otherwise block them from embracing what truly matters. Interestingly, from an ACT perspective, pursuing deeply held convictions may actually lead to added hardship and suffering, given that values-­ based living is seldom synonymous with “happiness.” In other words, steadily walking along an unwavering path, connected to meaningful values, may produce pleasure. Yet, experiencing this fleeting, “positive” emotional reward is a secondary benefit not to be relied upon. As a matter of fact, a life devoted to values might actually increase 29

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psychological pain in that the inner world is fully embraced, with all of its doubts, sadness, anxieties, and fears. Surely, pursuing what matters most requires taking risks, rather than a cautionary attitude of “playing it safe.” As Hayes (2005) suggests, the pain of missing out on a life devoted to values tends to cause more suffering than the actual psychological distress that naturally, organically emanates from daily living. Values are pursued because they are meaningful and transcend fluctuating, impermanent intrapsychic states that inevitably arise within everyday life. So, too, Bonhoeffer’s concept of costly grace serves as a reminder that living a life that truly matters may necessitate experiencing suffering, hardship, and distress for the sake of God and spiritual maturity. For individuals in a variety of faith traditions, God’s will—­rather than vacillating thoughts, feelings, and sensations—­is of paramount importance, serving as a guide to life and a stable signpost during moments of uncertainty and doubt. Without exception, for Bonhoeffer, costly grace involves “single-­minded obedience,” an act of faith when ascertaining and pursuing God’s will. This understanding is in contrast to self-­reliance, paralleling ACT’s focus on values-­guided action in the face of adversity. Here, though, a distinction can be drawn between the ACT model and spiritual practices and discernment within many faith communities. Values within varying faith traditions are formed and passed along through close-­knit communities of devotion and practice, as well as sacred texts, which speaks to the differing interpretations of the “will of God” operative. Indeed, the discernment process within many faith traditions offers a complementary component to ACT, just so long as the particularities of varied faith traditions are honored for their contributions to this values-­making process. In other words, the ACT notion that values are personally constructed, emanating from a client’s deeply held convictions, can align with this understanding if one acknowledges that the personal construction of values is at least in part historically and socially contingent on community-­based experiences. Overall, faith and spiritual contexts are central for many people in the development of well-­defined values. Within Bonhoeffer’s writings, the willingness to pursue God’s will via “single-­ minded obedience,” despite the turmoil, hinges on a desire to center one’s existence in God. This viewpoint is in contrast to an idolatrous posture toward God, reminiscent of the creation story of the Hebrew Bible. According to Bonhoeffer, this distinction between God at the center and humankind in the middle of existence is foundational to understanding the human condition. Therefore, a brief review of the Genesis account of the origin of humankind, including separation from God, can help to elucidate Bonhoeffer’s understanding of optimal human functioning. Pursuing the will of God, in spite of the costs, is reminiscent of values-­based action within the ACT model. We argue that values-­based action within particular faith communities necessitates a well-­developed theology of nonjudgment, while acknowledging the 30

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importance of discernment within a generosity of spirit, love of God and neighbor, and simple action as a spiritual practice of faithfulness. Concurrently, this theological lens requires acknowledging the substantive limitations of human knowledge and a call to humility regarding claims to certainty. A lack of these requisite ingredients can lead individuals from a variety of faith traditions in the opposite direction of values-­based action. Paraphrasing the Genesis account (Genesis 1–­3) of creation, what follows is a biblical viewpoint of the dilemma of human knowledge.

Suffering, Defusion, and Acceptance: Knowledge of Good and Evil and the Meaning of Shame In the creation story in the book of Genesis, God created humankind in his image—­Imago Dei—­and revealed two trees within the center of the Garden of Eden. The tree of life, according to Bonhoeffer, symbolizes life, emanating directly from God. In other words, God is at the center of existence, with humankind reliant on God, who gives life. This life-­giving tree captures the union, intimacy, and love between God and humankind. The other tree within the Garden, the tree of knowledge of good and evil, represents death, division, disunion, and separation from God. For Bonhoeffer, sicut Deus—­being like God, rather than dependent on God—­is antithetical to trusting God for life. Stated differently, the tree of knowledge symbolizes self-­reliance. In this state, humankind tends to pursue arbitrarily constructed knowledge, rather than knowledge formed in the context of a relationship with God, who emanates from the center. Interestingly, we believe these two trees can help us to better understand several salient, overlapping ingredients within Bonhoeffer’s theological reflections and the ACT model, including: a) the inevitable division in the world that leads to ongoing suffering; b) the challenges inherent in an overreliance on human knowledge, with excessive claims regarding certainty of good and evil; and c) the spiritual and psychological pain that emanates from separation from God. Stated another way, from our perspective, Bonhoeffer’s interpretation of the creation story parallels ACT’s understanding of the inevitability of suffering, the need to relate to language with more flexibility and tentativeness (through cognitive defusion), and the importance of emotional acceptance (in that emotions help us to better understand and interpret our values). Indeed, shame—­although often downplayed as a paralyzing emotion—­ assists us in remembering that we are separated from God, longing to return to our Creator for both healing and human flourishing. (The acceptance of shame will be explicated further in a subsequent section of this chapter.)

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Nevertheless, humankind was originally dependent on God, symbolized by the tree of life, which represents life from God. Humans were also created in God’s image, receiving innate value from God and experiencing innocence. Based on this connection, humans felt no shame, with no awareness of good and evil by which to arbitrarily judge and evaluate each other. Yet, when humankind ate from the tree of knowledge, a paradigm shift occurred, leading to disunion with God. As a result, humans strived to derive life and value from an autonomous sense of self, independent from God. Humankind also experienced a loss of spiritual identity, leading to shame. From Bonhoeffer’s perspective, the shift from God as the source of wisdom and judgment to humankind now assuming the role as the arbiter of good and evil has led to a deep division in the world. In a similar vein, drawing from the creation story, ACT suggests that distortions of language are the culprit, resulting in cognitive fusion with verbal judgments and human suffering. In either case, this deep, penetrating separation has led to “ultimate division” in the world, negatively impacting every area of life, including humankind’s relationship with God and each other. For Bonhoeffer, this disunity is a reality of the choice to eat from the tree of knowledge, resulting in the inevitability of suffering. Even so, as revealed by Bonhoeffer, to suffer means to experience joyful gratitude because of the opportunity for a deeper communion and intimacy with God in the midst of pain. For Christians, this suffering is intermingled with thankfulness and contentment because of the opportunity to suffer with Jesus, who suffered for humankind in his life and death. Similarly, from an ACT viewpoint, life inevitably includes suffering, and unpleasant inner experiences are a reality of the human condition, rather than inner states that must be permanently eradicated, eliminated, or avoided. In fact, in the ACT literature, the “two-­sided coin” metaphor is commonly used to describe the link between pain and values (see Greco, Barnett, Blomquist, & Gevers, 2008), which are intertwined. Overall, these seemingly antithetical, contradictory experiences are actually connected based on division in the world; therefore, acceptance of this reality, at least on some level, is necessary to function in a world split in two. Within this ultimate disunion, humankind’s “thinking is torn apart,” based on an arbitrary, personal construction of reality that is disconnected from the Creator. Because of the tree of knowledge, humankind now has an awareness of division between God, the world, and one another. Originally created in God’s image (Imago Dei), humankind strives for sicut Deus—­to be like God—­placing ourselves at the center of the proverbial garden. Whereas God was originally the source of life, humans now rely on the self, including our own arbitrarily constructed judgment of what is right and wrong. Unfortunately, fusing with our own knowledge of good and evil—­judging, evaluating, and labeling—­leads to separation from God in that God is replaced with our own desire to be at the center of existence. This decision to be sicut 32

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Deus, rather than Imago Dei, unravels the original design for humankind—­a life dependent on God. As such, a significant shift took place when humans turned from relying on God’s knowledge to make sense of daily living to our own personally constructed knowledge with its inherent contingencies. This pursuit of our own knowledge—­a sort of deification of human cognition—­resembles ACT’s emphasis on the problem of cognitive fusion, wherein we place too much emphasis on our own verbal activities at the expense of values-­based living and action. With both Bonhoeffer’s theology and the ACT model, an overreliance on certainty of knowledge—­emanating from language—­frequently prevents humans from living out a life of values-­based action, regardless of whether values come from God or one’s own formation. Concerning mental health, devoted followers of many faith traditions can overly rely on their own evaluation of inner states as “good” or “bad,” undermining efforts to submit to God’s will. In turn, many individuals will struggle to draw from both scriptural teachings/ sacred texts and discerning relationships within their respective faith communities. Yet, there is a salient difference between Bonhoeffer’s theology and ACT regarding the problem of human knowledge. With the ACT model, fusing with language undermines the pursuit of personally constructed values. For Christians, knowledge of good and evil as the prerogative of the autonomous individual leads to disunion from God, others, and the world. From Bonhoeffer’s perspective, division in the world is a reality of life; still, the goal for humans is to return to God at the center of existence, with humankind reliant on, and obedient to, God’s knowledge and will. For this reason, Christians are to recognize the fragility of human knowledge in order to discern God’s will, whereas the ACT model advocates for individually derived values. This distinction—­values emanating from the self versus from God—­is important to consider when attempting to reconcile these two sometimes differing views on human functioning. Within Bonhoeffer’s theological reflections on the human condition, there is a movement from disunion—­with humans placing themselves at the center of the proverbial garden—­toward union and reconciliation, wherein God and a spiritual identity exist at the center. This movement occurs not because humans connect to their own values, but because God accepts us within the human condition, binding our shame and patiently waiting for our reconciliation. Here, though, it is important to mention that ACT commonly advocates for deeper, more meaningful relationships, suggesting that ACT-­derived values are by no means exclusively focused on the self and self-­fulfillment (see Wilson, 2009). Nonetheless, shame, commonly defined as both a moral emotion and self-­ conscious emotional state, has been linked to many forms of psychopathology. Certainly, some authors have highlighted that “shame-­proneness” may play a significant role in the etiology and maintenance of anxiety and depressive disorders (see Candea & Szentagotai, 2013). At a minimum, the frequent experience of shame can 33

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generate significant distress, commonly undermining self-­worth and leading to withdrawal, isolation, and rigid, inflexible avoidance. Within the ACT model, experiential avoidance constitutes efforts to reduce or eliminate unpleasant inner experiences. Shame, of course, is one of the most painful inner states, especially since it is wrapped up in a view of the totality of the self. Ultimately, there is a perceived consequence that inherent “badness” may lead to rejection by others and complete isolation from the community. In fact, a central tenet of shame is the paralyzing need to conceal, cover up, and withdraw, reminiscent of a deeply ingrained struggle with experiential avoidance. This occurrence seems to closely resemble the situation humankind faced after partaking of the tree of knowledge. In this instance, humankind withdrew in shame due to self-­knowledge of their nakedness and estrangement from God, who previously resided at the center of their existence. In spite of this painful experience, which reverberates to this day, Bonhoeffer argued that shame serves as an important reminder of our estrangement and separation from God, coupled with a deep longing to return to God at the center of our existence. Thus, reframing this distressing emotional state involves viewing shame as a signal that depicts the human need for connection with the Creator, reminiscent of ACT’s “two-­sided coin.” On one side of the coin is the experience of shame, including self-­knowledge, separation, disconnection, and disunion from God, contributing to an exposed, vulnerable existence. On the other side of the coin, though, is both the eager longing to reconnect with God at the center and “single-­minded obedience” to God’s will. As a result, shame can be understood as an important signal that points to a desire to surrender to God’s providential care. In order to negotiate painful inner states such as shame, ACT employs mindfulness to cultivate nonjudgmental acceptance, ameliorating experiential avoidance and cognitive fusion in the process. For Christians, this work incorporates an understanding of forgiveness and healing through the redemptive engagement of suffering in the Christian story. This is done by way of the person of Jesus, and enhanced by engaging ACT’s psychological methods and practices with a vision of redemption for the world. Because of this, experiential acceptance comes from God, mediated through contextualized Christian practices and experiences, which distinguishes a faith-­based appropriation of ACT from the standard ACT model. Stated more succinctly, for ACT, experiential acceptance is developed via the client practicing mindfulness, whereas experiential acceptance for Christians is a work of grace and gratitude to God. God’s grace constitutes an unconditional acceptance of humankind, with an eager longing for the redemption of all of Creation. Worded differently, God first modeled experiential acceptance to us, clothing us with a dignifying kindness. Again, shame serves as a cue that we are separated from God; yet, God responds to us in our vulnerable, exposed state by clothing and comforting us as He patiently 34

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waits for our response. Most importantly, the grace God offers is costly, according to Bonhoeffer. As a result, action is required—­Christians are called to faithfully return to a centeredness in God so as to rightfully discern and be formed by God. Moreover, God’s grace is costly because Christians are called to acknowledge guilt and the embodied tragedy of separation from God. This reality is grounded in human idolatry of the self, with its exclusionary and accusatory judgment of others based on distorted presumptions of certainty of knowledge. The call to seek God’s will within a centered and focused attentiveness to values—­formed and nurtured through the habits and practices of faith communities—­is similar to ACT’s emphasis on accepting the inner world, connecting to the present moment, and heading in a valued direction. Consistent with values, following God’s will never involves crossing a “goal” off a list. Rather, deriving life from God in the middle of the proverbial Garden requires present-­moment attentiveness to God and our spiritual formation, despite the suffering and hardship experienced along the way.

Pursing Faithfulness Through Simple Action: A Response to Separation For Bonhoeffer, knowledge of good and evil leads to judgment, inaction, and disunion from God. Put another way, those who stand in judgment of God’s law, eating from their own tree of knowledge, struggle to truly hear and carry out the law of God. Humans can also struggle with obediently submitting to God’s will—­sicut Deus versus Imago Dei. Therefore, human knowledge, with excessive presumptions of certainty, is antithetical to action. This understanding parallels the ACT model’s FEAR acronym, wherein clients get stuck in life by fusing with thoughts, evaluating inner states as “bad” (with the added assumption that their personhood is bad), avoiding inner and outer experiences, and offering reasons to justify inaction. Within the Judeo-­Christian tradition, fusing with the inner world of language involves eating from the tree of knowledge, placing oneself at the center of the Garden—­sicut Deus rather than Imago Dei. In turn, some may evaluate inner experiences (such as shame or some other unpleasant emotion) as “bad,” hiding and avoiding intimacy with God and others because of the pain that distressing emotions can conjure up. To this end, individuals within varying faith traditions may provide reasons for this withdrawal from the world, relying on their own arbitrarily constructed knowledge to convince themselves that loving action is not required. However, from Bonhoeffer’s perspective, relinquishing the pursuit of an assertion of the autonomous self as the primary arbiter of knowledge leads to love, simple action (“single-­minded obedience” by way of faith in God), and union with God, allowing for discernment and wisdom in God. With Bonhoeffer’s theology, certainty 35

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of knowledge and judgment, distorted by idolatry of the autonomous self, undermines simple action and love—­to stand over another, in objectified judgment, prevents us from truly loving the way God first loved us. As a corollary concept, ACT utilizes the ACT acronym to make sense of values-­based action: accepting inner experiences (thoughts, feelings, and sensations) with nonjudgment, connecting to the present moment, and taking action by pursuing heartfelt values. This acronym, of course, closely resembles Bonhoeffer’s “costly grace,” which involves God’s acceptance of humankind, leading to our ability to accept shame as a signal. The ACT acronym also highlights our ongoing struggle with the pursuit of our own distorted misappropriation of arbitrarily, unilaterally constructed knowledge. Still, this acceptance, first emanating from God’s grace, leads to action on our part. In turn, acting is comprised of “single-­minded obedience” in the face of suffering, hardship, and self-­sacrifice. Another way to explore the parallels between Bonhoeffer’s theology and ACT involves ACT’s six core processes, organized around three higher-­level categories: openness, centeredness, and engagement. To be open to experience, from a spiritual perspective, involves being aware of the tendency to fuse with distorted claims of human knowledge of good and evil. This awareness leads to accepting the experience of shame as a cue, representing a longing to return to God at the center. In other words, shame can be embraced as a catalyst toward reaching out to God, rather than withdrawing, hiding, and covering up. Centeredness, moreover, encompasses being connected to God, who is at the center, so as to gain life through spiritual practice and formation, rather than our own self-­assertions of autonomy and exclusivist certainty of knowledge. Also, attentiveness to God leads to the third ACT concept—­engagement. As one more example, centeredness involves deriving our identity in relation to God, who is active at the center. This is in contrast to getting life from our own self-­knowledge, which can keep us stuck because of self-­doubt, overconfidence, pseudo-­contentment, and the recurrent, distorted, self-­consumed, and inaccurate judgment of others. Finally, to be engaged with the world requires attentiveness to God as the Creator and arbiter of human flourishing in the midst of the suffering that is common to us all. Therefore, “costly grace” seems to best capture the call to action, based on our engagement with God at the center. Discerning God’s will, according to Bonhoeffer, involves studying the Bible, as well as submitting to the Word of God as part of a community of faith, practice, and daily prayer. Hence, to follow the will of God, Christians are to let go of a rigid set of rules to guide life; instead, Christians are to depend upon God at the center of existence, which is consistent with many faith traditions. This dependence may give birth to a variety of life directions from moment to moment, relying upon God’s grace as a proverbial road map. A central guiding force, though, involves God’s love, rather than a human understanding of what constitutes loving behavior in relationships. As Bonhoeffer (1955) 36

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explicated, “There arises every day anew the question how here, today and in my present situation am I to remain and to be preserved in this new life with God” (p. 43). Being tethered to God, at the center as the source of love, leads to a compassionate, nonjudgmental attitude as we follow God’s will. Again, love is the cement that binds us to both God and others, given that God is love. It’s worth mentioning that the glue that seems to also hold together ACT-­based values is love, manifested in a caring attitude toward self and others. (We find it difficult to identify ACT values that are not in some way guided by love.) As a psychotherapeutic model, ACT does not take a particular ontological stance on where love originates from in the universe. For people of faith, again, God is the source of love. Thus, we are able to love others based on God’s loving character. The potential to accommodate ACT to the particularity of this and other values formed within faith communities is a distinctive strength of ACT as a contemporary therapeutic modality. Further merging ACT and faith-­based perspectives, the tendencies toward avoidance and inaction can be understood as symptoms of a larger set of problems—­ psychological inflexibility, disunion with God, and paralyzing shame. Stated differently, we might understand the tendency to avoid life because of distressing inner states as due to an overreliance on a distorted, arbitrary, and unilateral sense of knowledge, along with the tendency to circumvent shame by withdrawing, hiding, and covering up (reminiscent of the creation story). On the other hand, movement toward flexibility, the amelioration of shame, and a loving relationship with God involves returning to God at the center of the proverbial garden, accepting our human limitations, and letting go of sicut Deus. However, because God offers us accepting grace, we are thereby formed to discern God’s will and act through “single-­minded obedience.” Health, healing, and human flourishing, then, involve finding a centeredness in relation to God, who is active in the middle, so as to negotiate living with hope in our interdependency in spite of the inevitable pain and suffering of the human condition. For Bonhoeffer, this manifestation takes place in a loving community, which is linked to discerning relationships and the traditions and sacred text of the faith.

Values in Context: Community-­Based Living and the Manifestation of Love In Life Together, Bonhoeffer outlined his beliefs about the role that community plays in spiritual and human development, arguing that physical proximity to others cultivates both strength and joy, along with a shared sense of God’s active, gracious presence. Whether communal engagement involves briefly interacting with someone 37

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else in passing, fellowshipping during church service, or praying together, Bonhoeffer argued that all such contacts are a gift for the faithful, given that devoted communities find their identity together in God and provide a context for values-­making by extrapolation. For Bonhoeffer, God’s fullness is principally revealed in the context of relationships, rather than solely through studying scripture in prayerful solitude, with fellow Christians helping one another to discern God’s will. To be sure, biblical teachings are primarily expressed through loving, caring relationships. Therefore, the cultivation of a deeper union with one another, linked to mindfulness of the Holy Scriptures in loving communities, is central in life. Along the way, those entering into caring relationships are guided by values that are embodied in the Trinity—­mercy, grace, forgiveness, truth, and, ultimately, love—­revealed through the life of Christ. Within devout faith communities, values-­based living manifests in a variety of distinct behaviors and actions that are inherently relational and life forming. ACT viewed through a theological lens involves discerning values in the context of a faithful community, rather than autonomously constructed values, drawing resilience and wisdom from relationships that are modeled after God’s loving grace. Certainly, this integrative lens can be applied to many faith communities, rather than merely those within the Christian religion.

Conclusion Within this chapter, we outlined a theological lens for interpreting and applying ACT within faith communities. We used the theology of Dietrich Bonhoeffer to illuminate how we might consider ACT theologically. For both ACT and lives lived in faithfulness, optimal living involves behavioral action, with the inner world serving as a notoriously unreliable navigation system during moments of adversity and pain. Knowledge, to be sure, is a “double-­edged sword,” helping human beings to plan, build, and problem solve, while also leading to fusion and experiential avoidance with regard to painful inner experiences. The tendency to avoid life, indeed, is reflected in our habit of trying to rid ourselves of unpleasant emotions. Yet, living a life that truly matters involves learning to be more accepting and compassionate toward wavering inner states (rather than automatically viewing all unpleasant inner experiences as pathological and necessitating eradication), relating to thoughts with more tentativeness and flexibility, and accepting painful emotions as a reality of the human condition. For individuals from varying faith traditions, the tendency to fuse with distorted human claims to certainty in knowledge, rather than discerning and pursuing God’s will in the context of communities of faith and practice, is extremely common. 38

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Relying on intrapersonally derived claims of certainty and knowledge is especially problematic when thoughts, feelings, and sensations pull us in a different direction from more interpersonally and communally discerned understandings of God’s will. Interestingly, shame, a paralyzing inner state, is a reminder of both our estrangement from God and a longing to return to centeredness with God. Because of this, shame can serve as a catalyst for reaching out to God, especially in moments of pain, loneliness, and suffering. Finally, “costly grace” involves a two-­step process of embracing God’s compassionate, accepting response toward our humanness, along with pursuing loving action as the manifestation of grace and hope in the context of faith-­based communities. Although the “biomedical” model, popular contemporary theologies, and elements of the religion and health literature tend to advocate for symptom reduction, prosperity, wealth, and happiness, the litmus test for values-­based living in many faith traditions involves formation through God’s loving gesture. For Christians, life is about “single-­minded obedience” based on God’s caring act of reconciliation via the redemptive participation of Christ in human history. Above all else, similar and parallel understandings can be appropriated from other faith traditions to inform the values and commitments embodied within the practice of ACT.

References Bartholomew, M. (2013). Top 200 drugs of 2012. In Pharmacy Times. Retrieved May 6th, 2015 from http://www.pharmacytimes.com/publications/issue/2013/July2013/Top-200-Drugs-of-2012. Bock, D. & Glaser, M. (2012). The Gospel According to Isaiah 53: Encountering the suffering servant in Jewish and Christian theology. Grand Rapids, MI: Kregel Publications. Bonhoeffer, D. (1954). Life together. New York: Harper & Row Publishers, Inc. Bonhoeffer, D. (1955). Ethics. New York: Touchstone. Bonhoeffer, D. (1959). Creation and fall. New York: Touchstone. Bonhoeffer, D. (1995). The cost of discipleship. New York: Touchstone. Candea, D., & Szentagotai, A. (2013). Shame and psychopathology: From research to clinical practice. Journal of Cognitive and Behavioral Psychotherapies, 13, 101–­113. Fournier, J., DeRubeis, R., Hollon, S., Dimidjian, S., Amsterdam, J., Shelton, R., et al. (2010). Antidepressant drug effects and depression severity: A patient-­level meta-­analysis. JAMA, 303, 47–­53. Gámez, W., Chmielewski, M., Kotov, R., Ruggero, C., & Watson, D. (2011). Development of a measure of experiential avoidance: The Multidimensional Experiential Avoidance Questionnaire. Psychological Assessment, 23, 692–­713. Greco, L., Barnett, E., Blomquist, K., & Gevers, A. (2008). Acceptance, body image, and health in adolescence. In L. Greco & S. Hayes (Eds.), Acceptance & mindfulness treatments for children & adolescents: A practitioner’s guide (pp. 187–­214). Oakland, CA: New Harbinger Publications. Hayes, S. (2005). Get out of your mind and into your life: The new Acceptance and Commitment Therapy. Oakland, CA: New Harbinger Publications. Hayes S., Strosahl, K., & Wilson, K. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). New York: The Guilford Press.

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Helliwell, J., Layard, R., & Sachs, J. (2013). World happiness report. United Nations. Hill, P., & Pargament, K. (2003). Advances in the conceptualization and measurement of religion and spirituality: Implications for physical and mental health research. American Psychologist, 58, 64–­74. Insel, T. (2011). Antidepressants: A complicated picture. In National Institute of Mental Health. Retrieved May 6th, 2015 from http://www.nimh.nih.gov/about/director/2011/antidepressants -a-complicated-picture.shtml. Kessler, R., Petukhova, M., Sampson, N., Zaslavsky, A., & Wittchen, H. (2012). Twelve-­month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. International Journal of Methods in Psychiatric Research, 21, 169–­184. Kirsch, I., Deacon, B., Huedo-­Medina, T., Scoboria, A., Moore, T., & Johnson, B. (2008). Initial severity and antidepressant benefits: A meta-­analysis of data submitted to the Food and Drug Administration. PLOS Medicine, 5, 260–­268. Knabb, J., Ashby, J., & Ziebell, J. (2010). Two sides of the same coin: The theology of Dietrich Bonhoeffer and acceptance and commitment therapy (ACT). Journal of Spirituality in Mental Health, 12, 150–­180. Knabb, J., & Grigorian-­Routon, A. (2014). The role of experiential avoidance in the relationship between faith maturity, religious coping, and psychological adjustment among Christian university students. Mental Health, Religion & Culture, 17, 458–­469. Knabb, J., Pelletier, J., & Grigorian-­Routon, A. (2014). Toward a psychological understanding of servanthood: An empirical investigation of the relationship between orthodox beliefs, experiential avoidance, and self-­sacrificial behaviors among Christians at a religiously-­affiliated university. Journal of Psychology and Theology, 42, 269–­283. Nierenberg, A., Petersen, T., & Alpert, J. (2003). Prevention of relapse and recurrence in depression: The role of long-­term pharmacotherapy and psychotherapy. Journal of Clinical Psychiatry, 64, 13–­17. Park, C., & Slattery, J. (2013). Religion, spirituality, and mental health. In R. Paloutzian & C. Park (Eds.), Handbook of the psychology of religion and spirituality (pp. 540–­559). New York: The Guilford Press. Pew Forum. (2006). Spirit and power: A 10-­country survey of Pentecostals. Washington, DC: The Pew Forum on Religion & Public Life. Pew Forum. (2015). America’s changing religious landscape. Washington, DC: The Pew Forum on Religion & Public Life. Pratt, L., Brody, D., & Gu, Q. (2011, October). Antidepressant use in persons aged 12 and over: United States, 2005–­2008. NCHS Data Brief, 76. Retrieved from http://www.cdc.gov/nchs/ data/databriefs/db76.pdf. Rambo, S. (2010). Spirit and trauma: A theology of remaining. Louisville, KY: Westminster John Knox Press. Shuman, J., & Meador, K. (2002). Heal thyself: Spirituality, medicine, and the distortion of Christianity. New York: Oxford University Press. Smith, D. (2014). Theologies for the 21st century: Trends in contemporary theology. Eugene, OR: Wipf and Stock. Vasiliadis, H., Lesage, A., Adair, C., Wang, P., & Kessler, R. (2007). Do Canada and the United States differ in prevalence of depression and utilization of services? Psychiatric Services, 58, 63–­71. Wilson, K. (2009). Mindfulness for two: An acceptance and commitment therapy approach to mindfulness in psychotherapy. Oakland, CA: New Harbinger Publications.

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CHAPTER 3

Bridging ACT and Spiritual Care Robyn D. Walser, PhD University of California, Berkeley National Center for PTSD

Steven C. Hayes, PhD University of Nevada

Jason A. Nieuwsma, PhD Duke University Medical Center VA Mental Health and Chaplaincy

ACT for Clergy and Pastoral Counselors

T

he word spirit derives from the Latin spiritus, meaning “to breathe”—­it is the breath of life. We can use that physical metaphor as a touchstone to examine where acceptance and commitment therapy (ACT) and traditional views of spirituality intersect. The breath is central; it is elemental; it is necessary for life. The breath is present in every one of our waking moments. And yet, like other aspects said to be spiritual, it is easily taken for granted and ignored. There are many uses for the word spirituality, ranging from engagement in religious practices to journeys that are about finding out “who you are” to quests for inner peace and happiness to ultimate understandings of the meaning of life. Spiritual journeys include explorations of beliefs about the world and self, moral and ethical understandings of how humans behave (and how one should behave based on these understandings), and the nature of consciousness itself. Practicing personal spirituality frequently leads individuals to pursue both inner awareness and purpose in life. ACT has similar goals. It fosters examination of meaning and purpose; it deals seriously with such issues as “who you are.” It considers how inner peace can be obtained and addresses the nature of consciousness. The breath—­as it is experienced in the here and now—­is the conduit to awareness of life itself. Attending to it can lead us to recognition of experience and consciousness. An invitation to focus on and attend to one’s breath is the most common starting point for mindfulness exercises, whether in ACT or in a range of other traditions. An invitation to be mindful of one’s breath is an invitation to attend to the intersection of the continuous and the temporal, the literal and the metaphorical, the micro and the macro of human existence. The first article ever written on ACT focused on how the substance of spirituality can be approached from a natural science perspective (Hayes, 1984). In a substantive sense, the Oxford English Dictionary defines “spirit” as a “being or intelligence distinct from anything physical.” The word “physical” comes from a word for nature (thus the science of physics) and is defined as “of or pertaining to the phenomenal world of the senses; matter.” Matter is the “stuff of which a thing is made.” Thus, the spiritual dimension of life has to do with events that are not in the world of sensation, and are not thing-­like, and represents a kind of intelligence. In that article (Hayes, 1984), it was argued that there was indeed a bedrock process that fit that description—­a process that we have since argued to be central to the psychological flexibility model. This process is so central to acceptance and values choices that it seems especially appropriate for the first article on ACT to begin there. When we arrive at the psychological flexibility model later in the chapter, we will return to this issue of spiritual dimensions as being outside of sensation and “things” in a psychological sense.

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Our current point, however, is simply that there is a rich intersection between ACT and spiritual issues and approaches. As we explore this intersection, we will begin this chapter by describing ACT and its basic tenets and then later focus on integrating ACT into spiritual care. This will include examination of shared philosophies and worldviews between religious and spiritual approaches and ACT.

Acceptance and Commitment Therapy Acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 2012) had its beginnings in the early 1980s in the attempt to understand human suffering through a better understanding of human language and cognition. Since then, it has grown to a worldwide intervention being implemented in many countries and cultures. It is a central example of “third-­wave” behavioral interventions (Kahl, Winter, & Schweiger, 2012), joining other acceptance-­based psychotherapies such as dialectical behavior therapy (Linehan, 1993) and mindfulness-­based cognitive therapy for depression (Segal, Williams, & Teasdale, 2002). A key focus of ACT is to encourage acceptance of internal experiences while simultaneously engaging in values-­based actions. ACT clinicians and researchers are interested in theoretical tenets underlying ACT as well as establishing it as a scientifically supported treatment. A growing body of research currently encompassing several hundred studies, including nearly 120 randomized controlled trials, has shown ACT to be effective for depression, anxiety, chronic pain, and a variety of other mental and behavioral health conditions (Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Lappalainen et al., 2007; Powers, Zum Vörde Sive Vörding, & Emmelkamp, 2009; Substance Abuse and Mental Health Services Administration, 2010; Ruiz, 2010). A recent summary of the ACT literature described nearly 250 outcome and process studies (Hooper & Larsson, 2015) and there are several hundred more studies that have used or discussed processes drawn from ACT, such as experiential avoidance or psychological flexibility. ACT is arguably the most process-­oriented treatment among the evidence-­based therapies, meaning there is an extraordinary focus in the ACT literature on how therapeutic change occurs (study of the mediators of change) and for whom (study of the moderators of change). The relationship between ACT processes and the trajectories of human lives even without therapy is the focus of a myriad of studies (Hayes et al., 2006). A vigorous basic science explores the origin of these processes in human language and cognition. Thus, ACT brings several unique features to the table as part of the range of psychotherapy approaches addressing issues of importance to spiritual and religious traditions.

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Philosophical and Basic Science Origins ACT’s philosophical origins rise out of functional contextualism (Hayes, 1993). Functional contextualism refers to a philosophical approach to psychological actions that views them as inseparable from their history and current context (Hayes et al., 2012). Within this perspective, action that is alone and cut off from its context can have no function or meaning. Suppose a person raises her hand. This is not yet an act at all, in a psychological sense of the term, according to this approach. If it turns out that this action occurred because it was hot and the person meant to fan herself, or there was a bag of chips on the shelf, or a friend was walking by to be greeted, then there is a psychological action because the context and function of the hand raise is now available to define the action: cooling off, or reaching for food, or saying hello. From this perspective, behavior is always functionally defined. Because the actions of therapists and scientists are viewed the same way, functional contextualists are very clear about their own scientific and practical goals. While other forms of contextualism exist (such as social constructionism), functional contextualists seek terms and models that help people predict and influence situated actions, with precision, scope, and depth (for definitions of these terms see Hayes, Barnes-­Holmes, & Wilson, 2012). Accomplishment of these analytic goals is the criteria for “truth.” This philosophical approach not only informs the science; it informs the clinical work done in ACT. ACT therapists frequently ask what client actions are in the service of—­how are these behaviors functioning in this person’s life? Just as goals of scientific analyses need to be defined a priori so that we can tell if scientific practices are useful in accomplishing them, the same holds for clinically relevant actions—­ thus the issue of client values is central to any behavior change process. Ultimately, the therapist is interested in the client’s actions as they are linked to the client’s personal values (e.g., is this action in the service of a personally important value?). ACT is linked to a theory of human language called relational frame theory (RFT; Hayes, Barnes-­Holmes, & Roche, 2001; Törneke, 2010). RFT is a well-­ researched behavioral account of human language and cognition. Direct contingency learning is over half a billion years old but human language and cognition may be a young as 100,000 to 400,000 years old (Hayes & Sanford, 2014). According to RFT, the key features of human language are that verbal events are related mutually (e.g., if the object “apple” is called “apple,” then the listener should orient toward apples when hearing “apple”), these relations combine into networks (e.g., if an apple is called “apple” and “apple” is “jabuka” in Croatia, then the listener should orient toward apples when hearing “jabuka”), and the functions of events in the network are changed as a result (for example, the reader of this volume can now imagine what jabuka juice tastes like).

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It is argued that children learn such derived relational responding through multiple examples and feedback. Many different kinds of derived relations are learned; not just naming but also comparison, difference, opposition, and so on. Each type is brought under the control of cues that govern the relational response regardless of the form of the related events. A nonhuman animal could readily learn that a nickel is larger than a dime; it takes a human child to learn that a dime “is larger than” a nickel, as the relational cue “is larger than” comes to control comparisons regardless of the physical properties of the events compared. Humans form vast networks of related events from the building blocks of relational responding controlled by such contextual cues. The functions of language are also contextually controlled, but have the additional feature of allowing symbols to influence behavior differently even if their meaning is intact. For example, moments ago, likely for the first time in your life, you were asked to imagine “what jabuka juice tastes like.” Many readers did so. The functional cue was the word “tastes.” This is a feature put to good use in ACT, as will be noted later, when functional cues are deliberately used to reduce harmful effects of conditioned thoughts. For example, if a depressed person frequently thinks “I’m worthless,” an ACT therapist might assist the person in seeing the ongoing flow of thinking. The therapist might examine how that thought functions when sung to the tune of “Happy Birthday,” or said in the voice of Donald Duck, or of the client as a young child. Symbolic relating of this kind is the fiber of wisdom, allowing us to weave ever larger tapestries of knowledge and information across our lifetimes. Symbolic relating allows us to problem solve, to reason, and to communicate, but it also gives us the capacity to remember painful things in any context, to compare and evaluate, to ruminate over the past, or to project anxiously into the future. Indeed, the human capacity to engage fully with our minds challenges us all with a loss of innocence. As the Bible notes, Adam and Eve’s bite of the apple gave them knowledge of good and evil, but with it they felt ashamed because they were naked. In a sense they were already cast out from the Garden as a result, even before God punished them for failing to follow His word. A basic understanding of language is important to ACT, not only from a theoretical and basic science position, but also in terms of its clinical application. A fair portion of the work done by therapists using ACT is related to drawing the distinction between knowing by symbolic derivation (that is, “by the mind”) and knowing by direct experience. Each of these two ways of knowing is useful for humans who are seeking freedom from suffering. Thus, it is helpful to distinguish these two ways of knowing the world. Verbal knowledge is what we do with our minds. It is problem solving, reading, writing, imagining, talking, planning, and so on. All symbolic behavior is verbal knowledge. Experiential knowledge is knowledge gained from

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direct experience. Contacting this type of knowledge is more challenging as our minds often comment on or describe our experience in such a way that it seems that they are one and the same. However, upon a closer examination, the difference between the two types of knowledge is revealed. Consider the example of learning to walk. It is hard to remember that we were not instructed on how to walk; rather, we moved around, got up on our hands and knees, crawled, stood up, wobbled, fell down, and so on, until through experience we were walking. Research has shown that toddlers fall down about 17 times an hour—­ for a toddler who is active for at least 6 hours that adds up to nearly 100 times a day (Adolph et al., 2012). We learned to walk before we were very verbal, and almost certainly before we were able to understand instructions like “put one foot in front of the other.” We learned many of the things we know how to do that way: by trial and error. Even after we are verbal, experiential learning continues but our ability to formulate verbal rules can make such learning more difficult. Social anxiety has the potential to limit lives in difficult ways, leading both to isolation and loneliness. A verbal understanding of one of the aspects of social anxiety is connected to the experience of feeling embarrassed. Individuals suffering from this problem might experience certain sets of verbal events such as complaining about the feelings of shame, or describing the “death” that might occur due to embarrassment (e.g., “I’d die of embarrassment”). Experiential knowledge will offer a different set of events: physiological sensations including blushing, rapid heart rate, and perhaps sweating. The verbal understanding of this event and the experiential understanding of it are two different things. Our problem as verbal beings is that we fall out of touch with our experiential understanding of events and instead rely excessively on our verbal understanding of the same, despite the fact that both continue across the lifetime. Our capacity to be verbal overtakes our capacity to be in touch with our experience. We begin to live “in our heads.” We become so involved with the world from a verbal perspective that we lose contact with what else we know—­life experienced. Thus, the therapeutic work done in ACT involves working with clients to assist them in getting more in contact with their experiential way of knowing the world. In reconnecting to experiential knowledge, clients can learn to notice the ongoing flow of experience across time, connecting both to the unchanging sense of “I” that experiences events (a core feature of a sense of transcendence), and contacting the ever-­ changing stream of internal experience—­what is felt, sensed, remembered, and thought. Individuals engaging in ACT learn to observe all things occurring inside the skin while resisting or stopping over-­involvement with these same events—­ emotion, thinking, memories, images, and bodily sensations. Individuals who are

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suffering learn to decrease suffering by letting go of excessive and misapplied control. In addition, and just as importantly, individuals consider the life they want to live. Not only are clients taught to observe experience, they are also guided in clarifying their personal values and invited to take action with respect to the latter. These two larger processes of acceptance and commitment are brought together in flexible and interactive ways to assist the individual in living a vital and engaged life. It is worth noting that as a principle-­based intervention, ACT is broadly applicable to all behavior. It is equally applicable to the clinical focus on ineffective or maladaptive behavior, or the developmental growth focus on human prosperity. ACT pays particular attention to the function of all psychological actions as well as the consequences that shape and maintain them. Due to its tradition, the word “behavior” is used to refer to these actions, but thoughts, feelings, remembering, and so on are all part of what human beings do, and therefore are also the focus of study and intervention. Clinically, ACT targets psychological problems that emerge from behavioral rigidity or inflexibility (Hayes et al., 2012). This is defined in ACT as the inability to persist or change behavior in the service of chosen values, or the engagement in repertoire-­narrowing processes such as the dominance of verbal events, avoidance of emotional events, or the failure to maintain flexible contact with the present moment. Examples of this kind of inflexibility might include a person thinking he is unable to take healthy action until his symptoms are eliminated (e.g., until he feels more “good” feelings or has “better” thoughts); or it might include an individual “seeing” only one way to solve a problem (e.g., escape from pain via suicide); or “buying” a specific belief about himself (e.g., “I am a failure”) or the world (e.g., “Everything is bad, nothing is worth living for, there is no purpose and meaning”) and then basing his abilities on that belief or his reactions on that understanding of the world. Rigidity and inflexibility are also linked to other problematic behavior that can arise out of excessive control linked to inappropriate rule following (e.g., “I must not feel anxious” or “My way is the right way”), loss of contact with the present moment (such as spending excessive time thinking about the past or worrying about what comes next), or over-­ identifying with only one aspect of the self (e.g., “I am a victim,” “I am broken,” “I am evil,” and so on). Inflexibility can also be found in excessive efforts to control others, in an overly rigid focus on being right, or in an inability to forgive or let go. Finally, rigidity and inflexibility may occur when an individual persists in a kind of problem solving that doesn’t lead to desired outcomes, or in other words, that doesn’t work. One of the main goals of ACT, then, is to decrease rigidity and increase flexibility in the service of workability as compared to personally chosen values through a number of core processes.

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ACT Processes ACT maintains that a large part of psychological suffering is related to attempting to escape or avoid internal negatively evaluated experiences. This is referred to as experiential avoidance—­the process of being unwilling to contact, or remain in the presence of, certain negatively evaluated private experiences such as difficult thoughts, painful feelings and memories, or unpleasant bodily sensations, even when this causes behavioral harm. Moreover, the individual unwilling to feel these experiences is often cognitively “entangled” with thoughts. Cognitive fusion in ACT refers to the human tendency to get caught in thought content in such a way that it comes to dominate over other, potentially more useful, sources of behavioral regulation (Luoma, Hayes, & Walser, 2007). From an ACT perspective, symbolic thought tends to be treated as synonymous with the referents of thought when the process of thinking itself becomes invisible (Hayes et al., 2012). In this process, there is a failure to recognize thoughts as passing behavioral events. Negative self-­judgments, for example, are seen as attributes of self; the individual and the judgment become one. A person having the thought “I am worthless” is viewed internally as worthless, not as having had the thought “I am worthless.” Under these circumstances, it becomes difficult to pursue healthy living in the presence of such thoughts. It is sensible and logical under this circumstance then to make large and persistent efforts to change thought content before any steps toward values-­consistent living are taken. The individual engaged in this behavior takes steps to get rid of “worthlessness.” The battle with internal experience has begun. Unfortunately, if the thought has to go away before the person is acceptable, it means the person is not acceptable now, confirming the very thought the person is trying to eliminate. As life gets put on hold while this war is fought, valued living is sacrificed to problem solving. ACT, then, is designed to target and reduce harmful experiential avoidance and nonacceptance of internal experience while encouraging clients to clarify values and change behavior by making powerful life-­enhancing choices. Given these treatment targets, ACT works by supporting clients in a shift from viewing negatively evaluated internal experience as a problem to be solved to an “event” to be experienced—­ emotions and thoughts are not like math problems; they are more like sunsets (Wilson & Dufrene, 2009). ACT employs six core processes to achieve these goals. These core processes are specifically designed to decrease maladaptive behaviors and unhealthy attempts to avoid internal experience by focusing on increasing behavioral and psychological flexibility. Included among these processes are strategies that help the client to identify and abandon problematic control and to accept negatively evaluated emotions and thoughts (as well as all thinking and feeling), while also taking specific behavioral actions that produce meaningful life outcomes based on personal values. 48

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We will briefly describe these six core processes, but with special attention to the process most closely tied to a sense of spiritual transcendence (as we noted, the very first ACT process described in detail, Hayes, 1984). Part 2 of this book will further elucidate and explore these processes in detail; therefore, we only present an overview. In clinical application, there is no required ordering of these processes (i.e., the therapist can start with any of the processes and constantly moves between them), but we number them here for the sake of clarity. Process #1, acceptance, is the process of fostering an open and willing stance toward internal experience, undermining the behavioral dominance of emotional control and avoidance in the client’s response hierarchy. Process #2, defusion, is the use of function-­altering cues to help clients notice verbal categorization, prediction, and evaluation as an ongoing automatic process, instead of simply interacting with the world structured by such verbal events without awareness of this process. Both process #1 and #2 are repertoire expanding processes, undermining the language-­based processes that promote cognitive domination, needless reason-­giving, and unnecessary avoidance of private experiences, causing them to function as psychological barriers to life-­enhancing activities. Process #3, flexible attention to the present moment, is the ability to actively notice what is going on internally and externally in the here and now, and having the attentional flexibility to direct, broaden, or narrow stimulus control, allowing the context of action and the affordance of situations to be more evident. Process #4, self-­as-­context, is the process whereby the individual makes contact with a deeper sense of self that can serve as the context for experiencing ongoing thoughts and feelings. This is the flexibility process most closely tied to spiritual experience, as we will discuss below. Processes #3 and #4 are awareness or centering processes, situating action in consciousness and in the present moment. Processes #5 and #6 are values and committed action. These processes involve first identifying chosen qualities of being and doing that help clients choose purposive life directions while confronting verbal processes that serve as barriers (e.g., avoidance, fusion), and then taking committed action, which involves building ever larger patterns of values-­based action. These two processes are both focused on active engagement in living. Each of the six core processes is designed to create and support psychological and behavioral flexibility. Psychological flexibility is defined as contacting the present moment fully as a conscious human being, experiencing what is there to be experienced, and working to change behavior such that it is in the service of chosen values (Hayes et al., 2012). Figure 1 shows these six flexibility processes and their inflexibility counterparts.

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TARGET PROBLEM: Area of Rigidity/Inflexibility

ACT INTERVENTION: Process to Increase Flexibility

Experiential avoidance; unnecessarily running away or escaping from emotions and thoughts, even when that creates behavioral harm

Acceptance

Fusion with the mind; arguing with the mind; believing the mind

Defusion

Living in the past or worrying about the future; lack of self-­knowledge

Flexible contact with the present moment

Attachment to the conceptualized self

Self-­as-­context: perspective taking; conscious awareness per se; experiencer vs. the experienced

A life disconnected from chosen meaning and purpose

Values: chosen qualities of being and doing

Inaction and/or avoidance persistence

Committed action: making and keeping behavioral commitments that exemplify chosen values

Psychological Inflexibility

Psychological Flexibility

Figure 1: Six Flexibility Processes and Their Inflexibility Counterparts One of the more pivotal processes is “self-­as-­context.” It is distinct from the self that may be defined by the content of those thoughts and feelings (conceptualized self), and thus helps to establish a position from which acceptance of private events is less threatening. In the original article that began ACT as a specific endeavor (Hayes, 1984), it was pointed out that self-­awareness does not just involve being aware of something—­it involves doing so from a consistent perspective or point of view: “we (the verbal community) must not only know that you see and that you see that you see, but that you see that you see.” (p. 102). Hayes et al. speculated on how this might emerge: First, words such as “here” and “there” are acquired which do not refer to a specific thing but to a relation to the child’s point of view. For example, 50

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“there” is always anywhere else but “here” and “here” is always “from this locus or point of view.” Second, children are taught to distinguish their perspective from that of others…a young child, asked what she had for breakfast, may respond with what her brother actually ate, but an older child will not make such a mistake. Through correction (“No, that is what your brother ate. What did you eat?”), a child must learn to see seeing from a consistent locus. Finally, it is also possible that a sense of locus emerges by a process of elimination or by metaphorical extension. Suppose a child can give correct answers to the question “What did you x?” where “x” is a wide variety of events such as eat, feel, watch, and so on. The events constantly change… Only the locus does not… Thus, in some real sense, “you” are the perspective. (p. 102) It was also noted that metaphorically, this sense of perspective is much like looking from one’s eyes: If you could leap aside yourself faster than the speed of light you would see yourself looking (as you might if you took a snapshot) but you would be doing so from a changed perspective… You cannot truly see your perspective and at the same time view from that perspective. To see perspective, perspective must change. (p. 103) This action is decidedly not thing-­like: To see a thing we must also see “not-­thing.” Thus, all things must be finite—­ they must have edges or limits. It is the edges or limits that allows us to see a thing. If a thing was absolutely everywhere, we could not see it as a thing. For the person experiencing it, you-­as-­perspective has no stable edges or limits—­it is not fully experienceable as a thing. Perspective is precisely the aspect in which things are held. As soon as perspective is viewed as content from what perspective is it viewed? Perspective must move one step back. (p. 104) In the 32 years since this analysis was written, RFT researchers have not only provided support for its outlines, they have added many details that only increase the linkage between a naturalistic consideration of spirituality with views drawn from our spiritual traditions. We now know that a sense of “I/here/now” develops in people, and that is key to empathy, enjoying human company, and having compassion for those in stigmatized groups (Vilardaga, Estévez, Levin, & Hayes, 2012; Levin et al., manuscript under review). This sense of self involves what are now called deictic relational frames: I/you; here/there; and now/then (see McHugh & Stewart, 2012, for a book length treatment of the issue). These individual relational skills emerge in that 51

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order (person, place, time) in children (McHugh, Barnes-­Holmes, & Barnes-­Holmes, 2004) and normally become fully integrated in middle childhood. Together they foster Theory of Mind skills—­being able to know something about the mental life of others (Weil, Hayes, & Capurro, 2011). Having a sense of perspective—­acquiring the “fromness” of awareness—­thus involves relational processes that allow that sense of perspective to expand across time, place, and person. This means that consciousness per se is not alone and cut off from others—­we all experience it and it connects us to others, at other times, and other places. The basis of consciousness awareness gives it a sense of ineffability or transcendence because it is not possible to know the limits of consciousness consciously. It is not thing-­like; there are no known edges. Its expansive qualities across time, place, and person also connect this aspect of awareness to a sense of boundlessness (not being limited by time or place) and a sense of interconnection or belongingness (being part of humanity as a whole). Considered all together, this fosters also a sense of oneness. We are not arguing that these abilities define spirit in a religious sense. Rather we are arguing that a sense of spirituality is built into human consciousness itself—­it is in a deep sense “who we are.” Furthermore, it is the pivot point of the psychological flexibility model. From the oneness of this more spiritual side of humans, it becomes possible to face the hell of our own history without a sense of threat to our survival, to come into “the now” without needless defense, and to focus on what brings meaning and purpose to our life moments. In summary, ACT involves the use of acceptance and mindfulness strategies combined with commitment and behavior change strategies to increase psychological flexibility. It includes enhancement of a spiritual sense of self. In addition to knowing things with the mind, an experiential sense of knowing is contacted and fostered. The latter sense of knowing affords great contact with internal experience in a way that is more open. It is from this place that freedom is found and the capacity to choose is engendered. Clients can come to be guided by their chosen values, rather than the literal content of their negatively evaluated experiences. The focus in therapy is not on feeling better; rather, it is on living well.

Shared Intersections: ACT, Spirituality, and Religion Both religion and ACT psychotherapy can work in the same spheres of human struggle to reduce suffering. Indeed, each has been identified as having important connections to mental health. For instance, those who report they feel close to God or practice religion have less psychological stress, less loneliness and depression; as well, 52

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they report greater self-­esteem and psychosocial competence (Reiner, 2007). Dailey, Curry, Harper, Moorhead, and Gill (2011) note that fewer mental and physical health disorders are found among those who have some kind of spiritual or religious practice. As well, it is broadly known that psychological therapies are helpful in reducing suffering and in helping people to reduce stress, improve relationships, or overcome problems such as depression and anxiety. For example, mindfulness, a practice often supported in psychotherapy and used in ACT, has been shown to be related to better physical and mental health (see Greeson, 2008). In acknowledging these shared features between spiritual practice, religion, and psychotherapy, we would like to explore three broad qualities of human experience that have been proposed as key ideas in spiritual and religious traditions (Pargament, 2007). All are touched upon in ACT as we have already argued. These three senses are interrelated—­we are not arguing that they are distinct. We are also not attempting to state that other psychotherapies do not address or explore some of these same issues. Rather we are focusing on some of the aspects of ACT that connect ACT and spiritual/religious practice. The first broad quality of human experience that is shared is transcendence, or the sense that an experience and awareness goes beyond our everyday, usual, or ordinary understanding. Given this more global definition, it is recognized that transcendence has different meanings depending on the spiritual or religious approach held, but may broadly be referred to as the aspect of nature, or God’s nature, that goes beyond the material. In a religious and spiritual domain, transcendence provides both a sense of divine presence that is omniscient, and a sense of hope and safety as the limits of the material world are seen from the perspective of oneness. Transcendence in ACT occurs as an individual “transcends” the ordinary processes of mind and experiences a larger sense of awareness that is beyond categorization. Defusion skills help reduce the attachment to categorization, but the sense of self as beingness or fromness carries a felt sense, of oneness or ineffability: of having “no edges.” The perspective-­taking sense of self in ACT, pure awareness rather than awareness of something, is key to this sense of transcendence. Boundlessness is the second quality mentioned by Pargament (2007). Boundlessness is the experience of vastness, a sense of self that is not restricted by space and time. A problem-­solving mode of mind thinks in terms of minutes and hours and categories and problems, to state a few of its jobs, many of which are finite and measured. This quality of mind then limits our understanding of an unrestricted space and time. We are bound by time relationships such as “running out of time,” “losing time,” “being late,” and “not on time.” We are bound by space relationships such as “I am here” and “you are over there”—­we are separate. In ACT theory, verbal relations include both poles: hot contains within it the idea of cold; good contains within it the idea of bad. In that same way, the deictic frames of space and time are expansive: now includes 53

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then, and here includes there. Expanding from either/or to both/and allows a connection to a sense of boundlessness. Time and space become not points on a continuum, but the entire continuum all at once: everywhere at all times. There is a sense of the eternal and the infinite. This sense of boundlessness is related to the third dimension pointed to by Pargament—­interconnectedness—­which is a similar process focused on the dimension of “I” and “you.” Interconnectedness refers to an underlying sense of unity with others and the world (Pargament, 2007). I and you are defined relationally—­they are interconnected. Inside consciousness, consideration for “you” is equal to consideration for “me.” “Love” might be a word for this experience. As I open up to awareness, I see that awareness is shared with others. In theological traditions interconnection is spoken of as being “children of God” or of the church being “one body” (e.g., 1 Corinthians 12: 12–­14). Everything is connected and interconnected. ACT theory contains a similar idea, based on the natural science of awareness. For the spiritual and religious work done by humans and the therapeutic work from an ACT perspective, transcendence, boundlessness, and interconnectedness may play roles in reducing human suffering. In a religious context, relying on a transcendent being to relieve pain “gives suffering over” to God; in ACT, acceptance and mindfulness based on a transcendent sense of self allows the ongoing flow of experience to be encountered untethered—­suffering is “given over” to simply being. In ACT, boundlessness and interconnectedness are encouraged as part of psychological flexibility work. These concepts are also reflected in the ACT model of the therapeutic relationship. Client and therapist explore the pervasiveness of suffering—­that humankind is one in this experience of being aware. The problem isn’t that humans experience pain. The problem is our relationship to the pain that we experience. Life contains change, loss, and death. Pain is an inevitable part of these experiences. How we relate to that pain, however, is not inevitable. By guiding the client to flexibly relate to internal events by observing experience from a contextual or transcendent point of view, a felt sense of boundlessness and interconnectedness is promoted.

Specific Shared Qualities Although religion and psychotherapy have major differences in approach, each focuses on moving people in healthy directions when considering an individual’s relationship to negatively evaluated emotion and thought. There are undoubtedly specific religious groups that adhere to beliefs that do not resonate with psychological flexibility and ACT, but the world’s great religions all seem to share meaningful

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overlap, as we will explore in this volume. All major religious traditions include a mystical wing, and these in particular resonate with an ACT model. Beyond issues of belief, religious participation allows an individual to participate in something more than narrow self-­interest, which may result in resilience and overall better mental health (Miller & Thoresen, 2003). Religion may offer social support systems, such as attendance to services or participating in related activities, in time of need, while psychotherapy may encourage engagement in similar social support systems in the service of mental health. Religious leaders may suggest coping with psychological challenges through use of prayer, reading of scripture or other religious texts, and forgiveness (of self or other). Psychotherapists who are not working from a pastoral counseling perspective might do quite similar things, such as practicing mindfulness, exploring chosen values, or working on forgiveness. This last process is a rich example. Forgiveness in a religious context is achieved through grace or penance and is followed by a sense of relief, as the pain of guilt is channeled into a lesson learned in the context of redemption. Those who do psychotherapy from an ACT perspective treat forgiveness as giving what went before. Literal innocence is not possible, but experienced innocence is. A person who has been betrayed, or who has betrayed others, can heal the wounds of betrayal by accepting the pain and reaffirming the values that were breached, in the context of wholeness provided by consciousness itself. The purpose is to assist the client in taking specific actions that establish a relationship with the self that has the sense of openness that was there before the harm, but now with the knowledge that harm can be done. For example, let’s say a client wants to forgive a history of abuse. This is not about changing the judgment of the act: abuse is and remains wrong or even illegal. It is not about going back to ignorant innocence—­wiping the memory away so that we no long know of the abuse. Instead, the work would focus on what kind of activity would reestablish what was taken away by the abuse: a sense of safety, of wholeness, or of an ability to play without fear of harm. These are fostered by knowing that the pain of abuse itself did not crush the person’s spirit: she is whole in consciousness. The pain she experienced shows how important safety and kindness are. What was taken away by the abuse (such as childhood innocence or the ability to play) can be given back through self-­kindness, creating a context for play, being a loving parent, and experiencing the wholeness of awareness. It might even include reporting the abuse, speaking truthfully to family, or confronting a parent. But holding the parent “on the hook” in the sense of “I cannot move on until this abuse goes away” has too high of a cost: a life put on hold until time goes backward or until a parent begs for forgiveness. The “giving” in forgiveness is not to the parent per se—­it is to oneself.

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The capacity to assist the individual in taking multiple perspectives can assist in this work. Exercises such as seeing the self at an earlier age, witnessing another’s suffering in imagination, witnessing one’s own suffering, and imagining a future self with lived values and without, help the client to step outside of ordinary perspectives, creating flexibility. Perspective taking engenders the capacity to have empathy, to reflect on outcomes, to be in the moment; and in this allows the individual to contact a sense of wholeness that is “I,” rather than to sink into the sick, broken, disordered, verbally based relationship to the self. Perspective taking may improve emotional awareness, not just for self, but for other, increasing the capacity to connect and relate. Both ACT therapists and religious counsel engender these processes. ACT clinicians and religious counselors also both focus on issues related to existence, purpose, and meaning. ACT’s focus on values-­based living guides the therapeutic process and more fully represents positive outcomes from treatment than any reductions in symptoms might. Finding meaning in life and letting that purpose guide choices and actions is fully part of the ACT intervention. This too is often part of the larger plan for religious and spiritual development. Many of the values held by individuals are part of religious doctrine and are specifically designed and taught in the service of well-­being and in honoring the religious practice. In this section we have considered how ACT and pastoral work have shared qualities. But this book is about an exciting additional step: seeing these shared qualities, can clergy and pastoral counselors actively borrow from this evidence-­based method to foster their own work? In a secular setting, an ACT therapist cannot expect to use scriptural reading with many clients. Mindfulness practices will be used but only with the content from mystical traditions thoroughly removed; values will be explored, but on the basis of individual choice, not necessarily informed by a spiritual tradition. Pastoral work removes these shackles. For example, there is no reason not to use scripture to help foster empirically demonstrated psychological flexibility practices. There is no reason not to inform values choices with scriptural guidance or to use the data showing that choice is supported by defusion skills to help the pastoral counselor guide the client to make leaps of faith in a psychologically skillful manner.

Applications of ACT: Mental Health and Spiritual Care Providers Spirituality and religion are important to many if not most mental health clients, but there is no widely shared approach to addressing spirituality in mental health. In one sense there is a bit of irony, in that the word “psychology” is literally derived from the 56

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Latin word psychologia, meaning the study of the soul. In another sense it fits, however. Psychology is trying to become more legitimate through science and researchers have dared not to tread into this domain of human experience for fear of threatening that agenda. Psychology has dealt with issues of interest to clergy and pastoral counselors, from Maslow’s theory of self-­actualization to Jung’s emphasis on the impulse toward spirituality (Cashwell & Young, 2011), but evidence-­based psychotherapy has tended to embrace a Western medical model that is difficult to link to spiritual and religious issues. That is not the case with ACT. Its focus and philosophical underpinnings reach toward a broader understanding, focusing on treating whole human beings in their contexts given their histories, rather than diagnostic categories tied to reductionistic views (Hayes et al., 2012). This allows mental health providers operating from the philosophical and theoretical underpinnings of ACT to move fully into broader areas of human experience. The possibilities to learn from spiritual and religious practice, as well as consider joint efforts in counseling those who suffer, are worthy of pursuit. There is a continuum of religiousness and spirituality (Cashwell & Young, 2011), and learning where clients or constituents fall on this continuum may be helpful in guiding them through their personal sufferings. Is a client spiritual but not religious, religious but not spiritual, involved in religious organization, or fearful about what will happen if he is not involved or doesn’t adhere to religious practices and beliefs? Recognizing a client’s personal spiritual journey or readiness to address religious and spiritual issues can either lead to a strength in working together to heal from psychological pain or can lead to further feelings of alienation and separation, perhaps even increasing pain. Whether therapist or religious leader, a shared desire to reduce human suffering calls us to consider these sacred and valued positions in the lives of those for whom we care.

References Adolph, K. E., Cole, W. G., Komati, M., Garciaguirre, J. S., Badaly, D., Lingeman, J. M., et al. (2012). How do you learn to walk? Thousands of steps and dozens of falls per day. Psychological Science, 23, 1387–­1394.  Cashwell, C. S., & Young, J. S. (2011). Integrating spirituality and religion into counseling: A guide to competent practice. Alexandria, VA: American Counseling Association. Dailey, S.F., Curry, J. R., Harper, M. C., Moorhead, H. J. H., & Gill, C. S. (2011). Exploring the spiritual domain: Tools for integrating spirituality and religion into counseling. Retrieved from http://counselingoutfitters.com/vistas/vistas11/Article_99.pdf. Greeson, J. M. (2008). Mindfulness research update. Complementary Health Practice Review, 14, 10–­18. Hayes, S. C. (1984). Making sense of spirituality. Behaviorism, 12, 99–­110.

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Hayes, S. C. (1993). Analytic goals and the varieties of scientific contextualism. In S. C. Hayes, L. J. Hayes, H. W. Reese, & T. R. Sarbin (Eds.), Varieties of scientific contextualism (pp. 11–­27). Reno, NV: Context Press. Hayes, S. C., Barnes-­Holmes, D., & Roche, B. (2001). Relational frame theory: A post-­Skinnerian account of human language and cognition. New York: Plenum Press. Hayes, S. C., Barnes-­Holmes, D., & Wilson, K. G. (2012). Contextual Behavioral Science: Creating a science more adequate to the challenge of the human condition. Journal of Contextual Behavioral Science, 1, 1–­16. Hayes, S. C., Luoma, J., Bond, F., Masuda, A., & Lillis, J. (2006). Acceptance and Commitment Therapy: Model, processes, and outcomes. Behaviour Research and Therapy, 44, 1–­25. Hayes, S. C. & Sanford, B. T. (2014). Cooperation came first: Evolution and human cognition. Journal of the Experimental Analysis of Behavior, 101, 112–­129. Hayes, S. C., Strosahl, K., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change. New York: Guilford Press. Hooper, N. & Larsson, A. (2015). The research journey of acceptance and commitment therapy (ACT). Forlag: Palgrave Macmillan. Kahl, K. G., Winter, L., & Schweiger, U. (2012). The third wave of cognitive behavioral therapies: What is new and what is effective? Current Opinion in Psychiatry, 25, 522–­528. Lappalainen, R., Lehtonen, T., Skarp, E., Taubert, E., Ojanen, M., & Hayes, S. C. (2007). The impact of CBT and ACT models using psychology trainee therapists: A preliminary controlled effectiveness trial. Behavior Modification, 31, 488–­511. Levin, M. E., Luoma, J., Vilardaga, R., Lillis, J., Nobles, R., & Hayes, S. C. (manuscript under review). Examining the role of psychological inflexibility, perspective taking, and empathic concern in generalized prejudice. Linehan, M. M. (1993). Cognitive-­behavioral treatment of Borderline Personality Disorder. New York: Guilford Press. Luoma, J. B., Hayes, S. C., & Walser, R. D. (2007). Learning ACT: Acceptance and commitment therapy skills training manual for therapists. Oakland, CA: New Harbinger Publications. McHugh, L., Barnes-­Holmes, Y., & Barnes-­Holmes, D. (2004). Perspective-­taking as relational responding: A developmental profile. The Psychological Record, 54, 115–­144. McHugh, L., & Stewart, I. (2012). The self and perspective taking: Contributions and applications from modern behavioral science. Oakland, CA: New Harbinger Publications. Miller, W. R., & Thoresen, C. E. (2003). Spirituality, religion, and health: An emerging research field. American Psychologist, 58, 24–­35. Pargament, K. I. (2007). Spiritually integrated psychotherapy: Understanding and addressing the sacred. New York: Guilford. Powers, M. B., Zum Vörde Sive Vörding, M. B., & Emmelkamp, P. M. G. (2009). Acceptance and Commitment Therapy: A meta-­analytic review. Psychotherapy and Psychosomatics, 78, 73–­80. Reiner, S. M. (2007). Religious and spiritual beliefs: An avenue to explore end-­of-­life issues. Adultspan Journal, 6, 111–­118. Ruiz, F. J. (2010). A review of Acceptance and Commitment Therapy (ACT) empirical evidence: Correlational, experimental psychopathology, component and outcome studies. International Journal of Psychology and Psychological Therapy, 10, 125–­162. Segal, Z., Williams, M., & Teasdale, J. (2002). Mindfulness-­based cognitive therapy for depression. New York: Guilford Press. Substance Abuse and Mental Health Services Administration. (2010). National registry of evidence-­based programs and practices. Acceptance and commitment therapy (ACT). Retrieved on August 10, 2015 from http://174.140.153.167/ViewIntervention.aspx?id=191.

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Törneke, N. (2010). Learning RFT: An Introduction to relational frame theory and its clinical application. Oakland, CA: New Harbinger Publications. Vilardaga, R., Estévez, A., Levin, M. E., & Hayes, S. C. (2012). Deictic relational responding, empathy, and experiential avoidance as predictors of social anhedonia: Further contributions from relational frame theory. The Psychological Record, 62, 409–­432. Weil, T. M., Hayes, S. C., & Capurro, P. (2011). Establishing a deictic relational repertoire in young children. The Psychological Record, 61, 371–­390. Wilson, K. G., & DuFrene, T. (2009). Mindfulness for two: An acceptance and commitment therapy approach to mindfulness in psychotherapy. Oakland, CA: New Harbinger Publications.

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PART 2

Linking ACT Core Processes and Spiritual Practices

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eing human brings both joy and sorrow. Life is filled with amazement, growth, love and kindness; yet, it also contains pain, sadness, fear, and its own measure of suffering. Amongst these varied and meaningful experiences, spiritual and religious journeys unfold. Faith is tested, convictions challenged, prayer questioned, and purpose explored. Indeed, these very efforts may be part of the suffering itself. As those involved in spiritual and religious counseling may seek to ease the heartaches and anguish experienced by those who visit them, so too do those who use acceptance and commitment therapy (ACT). Developed as a psychotherapy model, ACT offers a unique set of processes and intervention techniques that fit well to the issues of meaning and purpose in life, and to the work done by spiritual and religious counselors. This behaviorally oriented psychotherapy addresses the individual’s relationship to their cognitions, emotions, sensations, and memories and seeks to promote vitality and meaningful participation in life through engendering psychological flexibility. ACT gauges therapy success via the workability of the individual’s life in terms of individual functioning, engagement in the world and relationships, seizing the moment, and finding love, connectedness, and belonging. Likewise, the intervention is applied with warmth, genuineness, and a true sense of compassion for the human condition. It is recognized in the ACT “tradition” that therapists (as well as clergy) have their own measure of suffering; we are all in this human struggle together. It is with this unique approach and comradery that lives can be lifted and engaged in their spiritual and values-­based fullness. The chapters in this section review key processes and interventions in ACT. We explore two of the six core processes at a time in each of the three chapters. The processes presented in each chapter reflect a broader set of intervention activities related to supporting the ultimate outcome of individuals seeking support from therapists and clergy alike—­helping humans to be open, aware, and active.

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Present Moment

Acceptance

Values

Psychological Flexibility

Defusion

Self-as-Context

Committed Action

Figure 1: Processes in ACT

Chapter 4 opens this section and examines the ACT processes of present moment and self-­as-­context. Even though it appears second in the open-­aware-­active framework, the section intentionally begins here, as these two processes combined establish awareness, a fundamental condition of openness and action. Next, chapter 5 reviews acceptance and defusion, the two processes supporting openness. Acceptance of thoughts, feelings, and sensations frees individuals to make choices about how they want to live, allowing them to make space for and to be guided by more than a thought or a feeling (events that can lead to harmful choices). Defusion assists individuals in “seeing” the ongoing process of thinking, creating a room for nonjudgmental connection to ourselves as verbal beings. Each of these clears the path to values-­based living. Chapter 6, then, describes the processes of committed action and a life based on personally chosen values. This final leg of the three-­pronged journey—­ open, aware, active—­assists the individual in clarifying what matters in life while also choosing meaningful and specific actions that bring these values to life. These three chapters in total provide an overarching review of ACT. It is hoped that the material will prove useful to counselors in description and practice, supporting those they counsel in creating rich and meaningful lives. —Robyn D. Walser, PhD 62

CHAPTER 4

Developing Awareness: Being Present and Self-­as-­Context Robyn D. Walser, PhD University of California, Berkeley National Center for PTSD

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T

ransforming suffering into freedom entails recognizing certain truths about the human experience. One of these is that life contains joy, but it also contains pain; indeed, the throes of psychological pain are born in the very awareness that one lives. Perhaps unique to humans is their capacity to be consciously aware, to “see” that they see. This kind of knowing brings with it great benefit, but also great sorrow. In living, we know that we will die. This knowledge can be fraught with anxiety, fear, and existential worry. It is in this place that the acceptance and commitment therapy (ACT) practitioner and clergy can meet. Each is interested in compassionately addressing the suffering of humankind and in assisting people in finding vital and meaningful purpose during our time here on earth. Developing awareness through contacting the present moment and connecting to a larger, “experiencing self” is part of that journey from the ACT perspective. It is the middle link in a chain of intertwined processes designed to promote well-­being through living openly and being fully engaged in the present moment. Broadly speaking, awareness, inside of the ACT tradition, is the ability to be conscious of events in the here and now, whether these events are of an internal nature or of external experiences. Conscious awareness in many spiritual practices signifies the relationship between mind and God, or the relationship between mind and profounder truths. In the context of this chapter, consciousness of what is felt, thought, and sensed will be explored. Aspects of conscious awareness, such as the ability to have a sense of selfhood or to “know” that you are awake, will be examined, as will our sensing of the world of the body. The purpose, overall, of developing awareness from the ACT perspective is so that we as human beings can live more fully in the present and connect to the ongoing flow of experience. This is the foundation of acceptance and, more importantly, supports psychological and behavioral flexibility (Hayes, Strosahl, & Wilson, 2012)—­the harbinger of well-­being (Kashdan & Rottenberg, 2010). It is from conscious awareness that choice can be made, wholly and fully, without defense, and in the service of what is personally meaningful and vital. In many spiritual and religious traditions, choosing values-­based living can be broadly viewed to be at the heart of richness and depth in life, as well as the path to growth and transformation. There are a number of spiritual and religious traditions that promote and encourage conscious awareness as a way to develop spirituality, as a way to engage particular religious practices like prayer, and as a way to become alive to what is here in this moment. For example, in the Buddhist tradition, although Buddhist schools vary on the exact nature of the path to enlightenment or liberation, it is generally held that the ordinary state of mind is limiting and resembles a dream, rather than a state of wakefulness (Kabat-­Zinn, 1994). Meditation—­or what Kabat-­Zinn has defined as “paying attention in a particular way, on purpose, in the present moment and

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nonjudgmentally” (p. 4)—­nurtures awareness, clarity, and acceptance. An invitation to conscious awareness can be found in Christian traditions as well, both in prayer and scripture. For instance, in his letter to the Ephesians, Paul writes, “This is why it is said: ‘Wake up, sleeper, rise from the dead, and Christ will shine on you.’ Be careful, then, how you live—­not as unwise but as wise, making the most of every opportunity” (Ephesians 5:14–­15). Paul’s admonition here to be aware, mindful, and engaged in every moment and every opportunity has been greatly expanded upon throughout a protracted history of Christian meditations, to include notions of reflecting, studying, and practicing in the service of developing a relationship with God (Antonisamy, 2000). A full review all of the ways in which spiritual practices and religions incorporate mindful awareness or the like is beyond the scope of this chapter, and several explorations of ACT and other religions are found elsewhere in this book. Given this, the current chapter will focus on and explore two key ACT processes that are the foundation of awareness inside of the ACT model, briefly linking them to spirit or soul. The processes of contact with the present moment and experiencing self-­as-­context will be reviewed. Examples of techniques and client-­counselor dialogue will be presented in an effort to demonstrate their application as well as provide useful direction for clergy interested in exploring the ACT approach.

ACT in Brief: Why Awareness The aims of ACT are exemplified in its very name. The counselor works with clients to assist them in accepting internal experiences such as thoughts, emotions, sensations, images, and memories while simultaneously supporting them in making and keeping commitments. The commitments, or behavioral activities, are carried out in the service of personally held values (Hayes et al., 2012). ACT uses a number of different strategies to promote acceptance and mindfulness and a number of behavior change strategies to encourage values-­based living. Indeed, six core processes are used in the model to foster psychological flexibility. These are acceptance, defusion, contact with the present moment, experiencing self-­as-­context, values clarification, and committed action. And as noted earlier, these six can be divided into three overarching concepts that encompass the ACT approach to living: open, aware, and active. Acceptance and defusion, explored in chapter 5, are foundational to being open. Willingness to experience both negatively and positively evaluated emotions while defusing from thoughts is the essence of acceptance. The individual engaging in these processes is taking a stance of openness to emotions and thoughts—­whole parts of the human experience are allowed to be encountered for what they are. From

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this open and accepting place, freedom to choose based on values, rather than a particular thought or feeling, is possible. It is important to define and clarify values while working to bring them to life in an active and engaged way. Individuals employing these two processes—­values and committed action—­are living life with meaning and purpose, concepts explored in chapter 6. Contacting the present moment and self-­as-­context make up the middle leg of this trio: awareness. Awareness funds both openness and engagement or activity. Being aware of what is occurring in the present moment and contacting a sense of self that is larger than thought, feeling, and sensation, a sense of self that is the experiencer in the here-­and-­now, and not the experienced of the there-­and-­then, helps to establish freedom and liberation. If, in this moment, one is more than the content of one’s life, then one is free to move, openly, in values-­based directions. There is an often-­quoted legend that illustrates this issue: A Taoist story tells of an old man who accidentally fell into the river rapids leading to a high and dangerous waterfall. Onlookers feared for his life. Miraculously, he came out alive and unharmed downstream at the bottom of the falls. People asked him how he managed to survive. “I accommodated myself to the water, not the water to me. Without thinking, I allowed myself to be shaped by it. Plunging into the swirl, I came out with the swirl. This is how I survived.” (Jyotsna, 2010) The old man did not try to control; he simply went with the flow. If one is present to this moment, experiencing oneself as larger than the things experienced (e.g., thoughts, emotions, sensations), then going with the flow of human experience is entirely possible—­accommodating oneself to the swirl of life allows its richness to cascade without needless suffering. Included among the processes of acceptance and willingness, then, are strategies that help the client to identify and abandon problematic control, and to accept negatively evaluated emotions and thoughts (as well as positive ones), treating them much like other emotions and thoughts (as dynamic and flowing), while also taking specific behavioral actions that produce meaningful life outcomes. Getting in contact with the present moment means actively working to live in the here and now, contacting more fully the ongoing flow of experience as it occurs. Self-­as-­context is the process whereby the individual makes contact with a deeper sense of self that can serve as the context for experiencing these ongoing thoughts and feelings. It is distinct from the self that may be defined by the content of those thoughts and feelings (the conceptualized self), and thus helps to establish a position from which acceptance of private events is less threatening. If you are not the content of your life—­feared emotions or negatively evaluated thoughts—­then you are in a position to be less directed by it.

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Contacting the Present Moment Mindful awareness to the present moment is explored and practiced in ACT. Present moment awareness includes paying attention to the five senses, and being aware of body and environment. It is in the here-­and-­now moment that life unfolds. Individuals struggling with worldly matters are often lost to thought and are away from the present moment. That is, they are stuck in what has happened in the past, they are worrying about the future, or they lack self-­knowledge. The word “mindfulness”—­a way to bring us back from being lost and away—­is a translation of the Buddhist term “sati” from the 2,500-­year-­old language of Pali. Sati connotes “awareness, attention, and remembering” (Germer, Siegel, & Fulton, 2005). Essentially, being mindful means being awake and aware of the present moment as it is. In further exploring mindfulness, we can distinguish it from formal meditation. The latter practice is one way to produce mindfulness, but it is not mindfulness itself. Mindfulness involves both formal and informal practice, whereas meditation tends to have a formal quality, with specific types of practice being engaged. Being mindful is characterized by seeing clearly, with receptivity and equanimity (Cashwell & Young, 2001) and can be done at any time or place. Mindfulness is encouraged and taught in ACT for many reasons, but most importantly, because mindlessness, or the cost of being out of contact with the present moment, is too great. For instance, many anxieties and fears are based on worrying about what may come, or contain memories that are considered “bad” and in need of forgetting. There may also be a fixation on what has happened in the past or a sadness about what will never be. This kind of cost can show up as a counseling matter for both therapists and clergy in a number of ways: not being able to “get over” a divorce or loss, holding onto painful memories in such a fashion as to cause interference in current functioning (such as remaining angry at a past harm and being “unable” to attend family functions as a result), wishing that certain events had not happened, or questioning why events occurred at all. As well, a kind of paralysis can occur when trying to prevent bad things from happening in the future, or when trying to overcontrol self and others for the same reason. These and many other kinds of dwelling on the past or worrying about the future may lead to significant distress and often pull people out of values-­based living. People can fail to live in accordance with their values by insisting that past events be repaired in some way first, or by controlling life to such a degree as to prevent something from happening in the future (e.g., If I control my children, they will never be harmed). The problem with these control efforts (i.e., trying not to have the past, or preventing a feared future based on the past) is that control in these situations is impossible. The past will always be what it was—­ the failed marriage, the loss, the trauma, these cannot be undone. As far as is known,

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history only moves in one direction and no amount of wishing or trying to forget will take what has happened away. It appears the only thing to do, then, is to “let go” and show up to where life is in this moment. Being out of contact with the present moment also means having decreased self-­ knowledge. Self-­knowledge allows us to be aware of our thinking, emoting, and sensing selves. When we are “in touch” with what we feel, think, and sense, we are better able to engage in life in authentic and important ways. We can create intimate and loving connection with others, or make choices that contain our personal purpose, ones that are not impulsive and are in our best interest. We are better able to communicate and understand our affective and cognitive experience and to recognize that others have these experiences too. Self-­knowledge allows us to be present to the many varied and changing aspects of ourselves. When aware in this fashion, we learn that we are complex and not defined by a single memory or event. We learn that emotion and thought have many qualities and that we encounter them as changing and fluctuating depending on the circumstance. When we have self-­knowledge, we are better able to respond to the world’s joys and pains in a flexible manner. In the realm of fear and control, a mindless and automatic mode, we often miss out on more fully experiencing our lives. We miss the beauty and ongoing flow of each moment. The cost, from the ACT perspective, is loss of values and engagement—­a cost that is a poison to vitality and, as already noted, too great. Inviting mindfulness, inviting contact with the present moment, is the antidote. That is not to say that individuals are able or even encouraged to always be in the present—­ problems need to be solved and work done—­rather, they are supported in building more capacity to be aware, to come off of autopilot and out of fear and worry, and to connect to the place where vitality is alive and well: here, now.

Contacting the Present Moment: What We Know from Science If being aware of the here and now is the place where vitality is alive and well, it may prove useful to provide a brief overview of the research findings on mindfulness, both for the counselor and the counselor’s clients. When working with clients, and depending on their individual situations, it is often helpful as part of a “why mindfulness” rationale to explain and explore the benefits of mindfulness. Firstly, mindfulness has been associated with well-­being, broadly speaking (Brown & Ryan, 2003). It is related to a number of well-­being constructs such as enhanced self-­knowledge, positive emotional states, and the ability to better regulate emotion. A number of research studies have demonstrated both emotional and physical benefits of mindfulness programs (see McCracken, 2011). 68

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Secondly, mindfulness has been used to treat a number of disorders and problems (see Baer, 2003). These benefits include improvement in symptoms of chronic pain conditions (Kabat-­Zinn, Lipworth, Burncy, & Sellers, 1986; Goldenberg et al., 1994), improvement in fibromyalgia (Goldenberg et al., 1994; Kaplan, Goldenberg, & Galvin-­Nadeau, 1993), improved quality of life and sleep among cancer patients (Carlson, Speca, Patel, & Goodey, 2003), and improved brain and immune functioning (Davidson et al., 2003). Mindfulness has also been found to reduce symptoms of anxiety and depression (see Hofmann, Sawyer, Witt, & Oh, 2010 for a review). The research on and interest in mindfulness has grown substantially over the last 15 to 20 years, despite its thousands-­year-­old history, and the topic is currently a hotbed of investigation. Its utility and beneficial application in areas of medical and psychological difficulties continues to grow. Lastly, mindfulness practice can help to sharpen concentration, allowing greater focus in activities undertaken in life and greater opportunity to draw into and involve ourselves in work, play, and values. It can help to cope with stress, anger, and other forms of emotion. Much of the suffering we experience when we face difficult and stressful events in life comes from our struggle with nonacceptance of the reality of the event, or from our judgments about the event and how well or poorly we are coping with it. Mindfulness helps us to experience these events simply for what they are. We can notice and be present to these experiences without self-­judgment and the added struggle against reality. In a similar way, mindfulness can facilitate finding peace with painful memories and experiences. By fully engaging in the present, we can experience the events in our lives, both those evaluated as good and those evaluated as bad, in a richer, fuller way.

Contacting the Present Moment: Mindful Awareness in Practice Along with the many benefits of mindful awareness, it can be helpful when working with clients to make a few clarifications if necessary and to know your own stance on the benefits of present moment living. Inasmuch as some clients may be unmotivated to practice mindfulness, so too are therapists, clergy, and chaplains. It may be helpful in these circumstances to first explore mindful practices and their intent, as well as their spiritual and religious connections. For instance, some religious clients may have been warned or may be concerned that practicing mindfulness means they are practicing Buddhism. This is not the case, however. Although Buddhists use mindfulness to develop their paths to peace and well-­being, mindfulness contains many core components—­ such as acceptance, compassion, and awareness—­that are a part of both psychotherapy traditions (see Linehan, 1993; 69

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Segal, Williams, & Teasdale, 2003; Hayes et al., 2012) and spiritual traditions (Siegel, 2010). For instance, mindfulness and contemplative practices have been equated with practice involving not only focused attention to the moment but also contemplative prayer. Heartfulness, defined here as a calm awareness of the body and its state, in some Christian traditions, is also associated with mindfulness. Heartfulness is “the cultivation of interior silence in relation to the ultimate reality, what in the Abrahamic traditions is called God. It is a cultivation of spiritual will, the seat of the deepest level of love in the organism. It has roots in the Old Testament, going back 3000 years. It is a contemplative tradition” (Garrison Institute, 2009, p. 1). These are only two examples of religious connections to mindful awareness; however, when introducing the process and practice of mindfulness, it may be important to convey its intent, whether it be about developing a path to peace, acceptance, compassion, or heartfulness. Related to heartfulness, the practice of being mindfully aware may facilitate a broader perspective of life and sense of connectedness, creating greater empathy for and forgiveness of others. Through this process, we may come to see that suffering is a universal experience, perhaps facilitating greater acceptance of life’s challenges and recognition of and compassion for others. Relatedly, and perhaps one of the greatest benefits of using mindful awareness with clients, is the opportunity it affords for openness to emotion and its transient nature. This may assist in decreasing overidentification with a momentary emotional state. It is important to remember, though, that decreasing identification with a momentary state (whether it be emotion or mind) is not a form of disconnection. Rather, when one is contacting, in the moment, emotional experience, it affords authentic and true connection but also presence to the changing nature of emotions. Rather than dwelling on the typical past and/or future representations of emotion and all that is associated with it, present-­moment awareness may facilitate greater self-­understanding of the process of emotion, and therefore greater self-­compassion as well. Mindful awareness is also not to be confused with positive thinking. Awareness to the moment and to thought is not the same as thinking positive thoughts. There have been many spiritual leaders that have espoused positive thinking as the antidote to challenges in life. Awareness of thinking is not about thinking some more; it is about being present in this moment and recognizing that one is having a thought. ACT’s focus is not on whether a particular thought is evaluated as negative or positive; rather, it focuses on the function of the thought. More specific to present-­ moment work, one is asked to be aware of thinking—­an activity that can be taught and cultivated (Shapiro & Carlson, 2009). Engaging in processes that are about creating positive thought, or about reducing or eliminating negative thought, moves the individual from engagement in awareness to problem-­solving activities using the

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mind. In this place, awareness of mind is lost and the focus becomes about the goodness or badness of the thought. Awareness, as intended here, lies beyond thinking. Many patients will also confuse mindfulness practice with “relaxation” exercises. Although mindful awareness may facilitate feelings of calm and peacefulness, it can also put clients in contact with experiences that are not so pleasant. Being aware of the many thoughts and feelings of the mind and body can be challenging, and at times, even distressing. The pain of some moments can be quite powerful—­but also quite meaningful (such as remaining present to a loved one in her last moments alive). Since contacting the present moment is about showing up to what is here and now, it involves a kind of “non-­striving.” This is an essential stance to bring to present-­ moment work; it is important to let go of ideas of finding or creating peace or even reaching an enlightened state. This kind of striving often takes one out of the moment in that the individual is trying to get somewhere other than where he is. Instead, the peacefulness gained through mindfulness practice is more about finding peace with all aspects of experience: the positive, the negative (including moments of suffering), and the neutral. When individuals report feeling relaxed following a mindful awareness practice, it is generally viewed as a byproduct of living in the now, not a goal or sought-­after outcome. As noted in the opening to this chapter, present-­moment awareness is intimately linked to acceptance. Through mindful awareness practice, one can begin to cultivate consciousness of the internal and external world. Observing thought, emotion, and sensations as processes—­as experiences that are ongoing like the flow of a river—­the individual can begin to understand the mind and how it works (i.e., continuously producing thoughts), and begin to recognize the rise and fall of emotion and sensation. These experiences can be distinguished for what they are—­thoughts, emotions, and sensations. The vagaries of mind and experience can be viewed from a conscious perspective, from a place of noting the tendencies of these experiences. The mind produces thoughts that are helpful, instructive, and include meaning and values, as well as thoughts that are evaluated as negative, and seem to promote misery and suffering. We experience the full range of feelings and sensations, living in a thought-filled and emotionally vibrant world; through present-­moment awareness, we can connect to its vivid intensity as well as its softness. In this place of contact with the present moment, we can learn to consciously view ourselves and our world, noting the ever-­changing quality of experiences, choosing which to respond to and which to let pass. Rather than grasping or avoiding, we gently acknowledge and choose. In sum, awareness of the present moment is part of what makes acceptance possible. It is not a “thing” or a “technique,” but rather a practice. It is nontheistic and therefore is not intended to clash with any particular religion or spiritual belief system. Present-­moment awareness facilitates a broader perspective of life and a sense of

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connectedness. It is about individuals facing themselves and their lives as they are, without judgment, in the here and now. It is about awakening to the moment. Being awake and aware of the moment establishes a relationship with experience that is embodied by movement—­experience is constantly changing. As such, experience is much less threatening when painful. Mindful awareness creates a place where individuals can choose a stance of acceptance toward internal experience. Inside the stance of acceptance, another kind of movement is possible—­“movement with the feet,” or behavior change. It is noted by Germer et al. (2005, p. 26) that “acceptance precedes behavior change”—­and it is in this place of supporting the client in creating meaningful and significant change that ACT counselors are most interested. The following client and counselor exchange illustrates the use of contact with the present moment.

CASE EXAMPLE Client background: A 30-­year-­old, single, white, divorced male presented to a counseling session with the complaint that he was depressed and unable to eat, get out of bed, or complete many of his daily self-­care activities (such as showering and cleaning the house). In his initial encounter with the counselor, he noted that he routinely showed up late to work and that he was receiving negative performance reviews from his supervisors. His key complaints were loneliness, fears of never being married again, and thoughts about himself as a “complete failure.” After several sessions, the counselor began to do present-­moment work in the service of freeing the client to take action, working to change the relationship between the client’s thoughts and emotions and the client himself, rather than trying to convince the client that he was not a failure. CL: [Frustrated, adamant, argumentative] I have proof that I am a failure. All you have to do is see that I can’t get out of bed. I can’t even get up if I set the alarm… I stay in bed even though I know that I could get fired. Something has to be wrong with me. CO: I can sense the frustration and I can hear the pull for me to agree with you and to get to work on solving this problem. CL: [Adamant again] Exactly, I have been living this way for two years now. It wouldn’t be like this if I weren’t a failure…if I were not truly a failure. CO: [Patiently and softly] I wonder if you might be willing to slow down and show up to something here, something that is present in the room? CL: If you think it is going to make a difference, then sure… 72

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CO: I would like to invite you to pay attention, to become aware of what is happening with your body…to notice what you are experiencing as you sit here with me now. CL: [Quickly, forcefully] I am experiencing frustration! I am failing and nothing is happening. CO: I hear you and do not want to make light of your experience, but want to persist for just a moment. If I can invite you to slow down a bit more and to become aware of your posture…your muscles…your face. What do you notice as you attend to each of these right now? CL: Why would I even do that? How is this going to help me? CO: I don’t know that it will, but I am curious…and wonder if you might see what’s happening in your experience. If you notice what is going on for you… CL: [Following a pause and reflection] Tightness…I feel rigid…strained (sighs). CO: [After a short pause] The invitation is to simply be present to tightness, rigidity, and strain. CL: It’s exhausting. The counselor and client continued to work in the session on present-­moment awareness. Part of the client’s struggle had to do with his excessive focus on eliminating thoughts of failure. Indeed, he at times asked the counselor to simply take those thoughts away. However, in exploring the possibility of eliminating thoughts about failing, both therapist and client learned that the client had been experiencing these since he was a young child. The likelihood that he would unlearn these thoughts was very low. As such, the two turned to a more fruitful path: awareness of his bodily states. His lack of awareness of his experience was actually complicating the problem—­the more time he spent tight and rigid, the more tired he felt, and the harder it was to engage in healthy behavior. Ultimately, the goal was to build awareness of his body so that he could respond in a healthier way (such as with exercise, yoga, or progressive muscle relaxation). As the counselor continued to work in this fashion with the client, both inviting awareness in the room and asking the client to practice outside of their sessions, the client began to slow further, recognizing the tightness he experienced when he breathed and noticing how his jaws clenched when he was feeling frustrated. About halfway through their work together, the client began to cry during a present-­moment exercise, and for the first time experienced the grief around his loneliness and divorce from his wife. This opened up a new direction for the sessions as the client learned to be present to himself with compassion and 73

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gentle awareness, and ultimately found that he could take action by choosing what to do that was values based, in the presence of these experiences, rather than thought based (e.g., I can’t because I am a failure). In addition to the more practical uses of mindfulness (such as awareness of bodily states and emotions) in creating space for choice, mindful awareness also helped this client to cultivate a deep connection to his experience, ultimately creating a greater self-­knowledge that better guided him through his pain. But it also opened him to the joys he had been missing by so steadily focusing on what he didn’t have, rather than what was actually there. Once he worked on contacting the present moment, he was able to see that he experienced laughter and friendship in addition to his current challenges. Working to cultivate awareness can easily occur in session, as in the example, but can also be encouraged out of session. Clients using ACT are often invited to practice awareness by routinely engaging in the behavior outside of session. Many methods are used to cultivate mindful awareness to the moment, spanning from short exercises of present-­moment attention to full and organized meditation exercises. Ultimately, listening to our innermost experience in the here and now, and connecting in this moment, allows us to contact not only that which is painful yet important, but also that which is joyful—­this full range of experience perhaps being vitality itself.

Self-­as-­Context Self-­as-­context is conscious awareness. Conscious awareness is challenging to define, as it is a felt experience that is not easily translated into words. Indeed, the words themselves are there to be observed. But in defining self-­as-­context in this way, it is helpful to write of it as an experiential perspective in which “I” equates with ongoing consciousness itself (Hayes et al., 2012). This sense of self is consistent and present at all times. It is an extended sense of “I” that stretches across time and space; you have always been there for yourself as you have aged and you have always been in every place you have been (also see Hayes, 1984). It is from this perspective that observations about your experience are made. You are the observer of your life—­the observer of your thoughts, emotions, and sensations. Therefore, conscious awareness is beyond the content of your observations; rather, it is the sense of you that is making the observations. It is what is left when all content is taken away. In this sense, it is literally innocent. Much like an infant who has not yet learned to language (i.e., to talk or speak), it is pure awareness. (Indeed the term “I” is also language. It is a sound that refers to an individual speaking of himself. If held as fully intended in self-­as-­context, even “I” would be an experience to be observed by the observer). Given that this 74

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sense of self is nonphysical and stretches across time and space, it has been compared to spirit or soul, and clients, at times, connect to it in this very way. ACT welcomes such connection, and as a therapeutic approach does not take a position one way or another on ontological issues such as the existence and nature of the soul, nor does ACT in any way intend to dismiss the soul as a phenomenon that can be reduced to explanation by psychological concepts. Instead, self-­as-­context is merely the label used in ACT to describe a particular experience and sense of self. Self-­as-­context stands in contrast to two other aspects of the self: self-­as-­process and self as conceptualized (Hayes et al., 2012). In self as a process of knowing, we learn about ourselves and respond to others about our feelings and reactions. This is valuable, as it assists with processes of socialization—­we can let others know of our feelings, intents, and states. This allows us to function well in our social environment. If a person has difficulty describing her emotions or being able to accurately express herself, then self-­knowledge through present-­moment awareness can assist the person in identifying current emotion and thought experiences as a means to overcome this difficulty. In ACT, however, the counselor is most concerned with the differences between self-­as-­context and self-­as-­content because each seems to be differentially threatened by the prospect of change (see also Hayes et al., 2012; McHugh & Stewart, 2012). As we grow and learn, we begin to take on conceptualized roles (i.e., self-­as-­ content). The notion of a conceptualized self comes from our languaging processes (see Relational Frame Theory, Hayes, Barnes-­Holmes, & Roche, 2001). We are the wife, the husband, the pastor, mother, or father, or we are tough, ill, smart, quiet, good, bad, and so on. These “costumes” become so familiar, elaborate, and well-­worn that we forget that we can take them off. For some, the costumes are so fitting and appear to be so crucial to survival that it seems as if the costume itself is the person. Each of us has stories about ourselves, formulated histories, definitions of what we believe our personal characteristics to be, and we have made statements that express the content of our conceptualizations of who we are (such as “I am a good person,” “I am a hard worker,” “I am damaged,” or “I am a victim”). We continually interpret, review, reconstruct, relate, and organize our experiences to make sense of the world. So when asked, “Who are you?”, you might define yourself in terms of your job, or whether you are married, or you might describe yourself in terms of your history or a particular historical event. People define themselves by their experiences. We hold concepts of ourselves that are derived through language. However, these concepts are necessarily skewed and can be problematic when we are overly attached to them. For instance, a person might describe himself as a hard worker who learned as a child that persistence is the key to success. There is nothing inherently wrong with this self-­concept, and indeed it might prove useful most of the time. However, this concept couldn’t possibly be all that he is—­there are too many 75

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variables (all that he has learned and been shaped by across time), parts of his history that we cannot know (we don’t have access to all memory from all time), and instances where persistence didn’t pay off with success—­and instead limited freedom and movement (such as persisting in a dead-­end job, or persisting in pursuing a failed or abusive relationship). Clinging to this identity under certain contexts might be a bit like a straitjacket. That is, the person holding to this sense of himself quite tightly might find that other aspects of himself get lost—­if one is persistent in being a “hard worker” and overly attached to this sense of self, then love, play, and fun are gone. Hayes, Strosahl, and Wilson (1999) also point out that the conceptualized self can come to dominate behavior in other ways that are problematic: “We begin to behave in a way so as to maintain our own process of self-­reflective categorization and evaluation…we try to live up to our own and others’ views of ourselves” (p. 182). In so doing, we cling to these views at great cost. For instance, we might justify values-­inconsistent behavior for the sake of maintaining a consistent sense of self or in order to prove others wrong. A simple example of this might be found in telling a lie. If you hold to the concept that you are a hard worker and you take time off or slouch around watching television, then you might say to others that you did so because you didn’t feel well. This justifies the behavior and helps to maintain the self-­ conceptualization. Again, we can become so drawn into protecting our conceptualized selves that we begin to treat them as if they were the same as our physical selves, and essential to our very existence. It is important to note the degree of the cost. Telling a lie about feeling ill may not be that costly. However, you might imagine scenarios where holding too tightly to the conceptualized self can become quite painful. For instance, imagine the victim of a terrible crime who begins to build a conceptualization of herself and then relates to herself and to others as a victim. Across time this can lead to painful disengagement, anxiety, and fear, and perhaps even psychological paralysis wherein her victim story is borne out in nearly every area of living—­she comes to believe that she has no power or capacity to take responsibility for herself. It is here, when the cost of clinging to the conceptualized self is too high, that assisting the individual to contact a larger sense of self is most helpful. It should be noted, however, that not all tightly held self-­ concepts are costly. Holding on to a self-­concept of being loving or kind can actually guide behavior in important ways. The key distinction between healthy and not is the function of the concept of self and how it is working in the individual’s world. Evaluating the workability of attachment to a sense of self is worth doing in counseling. Even being overly attached to “positive” self-­concepts can prove problematic, perhaps removing oneself from the realities of life (e.g., “I am always a kind person” may be problematic if anger toward another is experienced). Counselor and client can begin to explore and create a place in which the client can come to see himself as context rather than content. Furthermore and related to 76

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the processes linked to openness, the observing self is crucial to acceptance. It provides at least one stable, unchangeable, immutable sense of self that is whole and beyond evaluation.

Self-­as-­Context: Conscious Awareness in Practice Self-­as-­context is the core awareness process in ACT that assists clients in recognizing a sense of self that is larger than thoughts, feelings, and sensations. In the self-­as-­context work, the client and couselor explore awareness itself. The place where experiences (such as thoughts, feelings, and sensations) are “held” is contacted, and the person is the context for the content. The client is assisted in observing himself as one who is experiencing these events. He is supported in taking the perspective of being aware of the ongoing flow of experience as an active observer. This latter part ties contacting the present moment to self-­as-­context. Consciousness is active, in this moment. And being mindfully aware involves contacting a sense of you that is awareness. This “I” being referred to is not simply a physical organism experiencing sensations, but a sense of perspective, defined as the experience of knowing and seeing from one’s unique and individual vantage point across time. In assisting others to contact this sense, it is acknowledged that, while experiential content changes (such as memories, thoughts, and sensations), the perspective of “I” does not. Counseling, then, involves helping clients to decrease their attachment to their conceptualized selves. They learn to first observe the content of their lives (e.g., I have thoughts, I have feelings); localizing past memories and events (e.g., that was me then), and observing current experience (e.g., this is me now)—­all of which puts the client in contact with this sense of “I” (e.g., the “me” that was there for everything). The counselor assists the client in contacing the felt perspective of observer as expansive and able to hold all eperience as acceptable—­whether evaluated as good or bad. It is worth acknowledging here that we are not talking about accepting bad or harmful behavior. The kind of acceptable experience found here is of internal events—­ thoughts, emotions, sensations, and memories. ACT would not ask someone to accept behavior that is harmful to the self or others. Thoughts and feelings, however, are not considered harmful; they are only labeled and related to as the result of learning histories (e.g., “If I cry I will fall apart,” “I can’t stand it,” “This experience is destroying me”). The feelings, thoughts, and sensations associated with such things as anxiety, depression, and fear are not harmful themselves; it is the relationship to them that matters. If they are held literally, and accepted as absolutes, then individuals might respond to them in unfavorable ways. However, if they are held for what they are, and experienced as dynamic, they become less threatening and can be related to as experiences one has, not experiences one is. 77

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Helping the client to take the observer perspective is accomplished through a number of exercises and metaphors. With self-­as-­context explorations, clients are taught to identify with their sense of consciousness and continuity. This may decrease the attachment to history and dearly held, yet ineffective, identities (depending on the context). Here the individual learns that they are whole (with their thoughts, feelings, and sensations) now; there is no need to become whole. An instance of the observer perspective is found in the chessboard metaphor (Hayes et al., 2012), which suggests that the pieces on the board are the thoughts, feelings, sensations, and the concepts of the self, whereas the chessboard itself is the “I,” the place where the pieces make contact but are clearly not the board. The board is unchanged by any arrangement or assortment of pieces, just as the fundamental perspective of “I”—­ consciousness—­is unchanged by the situation or by any momentary experience. Additionally, counselors can do work with clients in meetings or session that help them contact the observer self. Let’s take a client example. In one therapist’s encounter with a particularly religious client, she learned that the client had fully committed her life to Christian faith and practice. The client felt strongly about her identity as a dedicated churchgoer and believer. She attended church daily, prayed often, dressed modestly, spoke kindly, and completed all callings from her church, such as being a treasurer and Sunday school teacher. She was fully admired by those in her congregation who praised her dedication. It should also be noted, however, that she was a mother of four, a wife of a loyal husband, a grandmother of ten, and a neighbor of many. In her dedication to her religion, in stepping into this role only, she lost these other aspects of herself. She was her religion. Now, on the whole, some might wonder what the problem would be here, and in some contexts there may indeed be none. The cost for her in standing solely in the role of religion, however, was the loss of her family and friends. Her children and husband found that she was challenging to relate to as she was often quoting the Bible or asking her children to pray. But more painful to those who loved her was her absence. She was always at church (she served as the church librarian for a long period of time and worked seven days a week) and had become estranged to her own family. And more telling, when asked what was most important to her, she noted it was to be loving, as God would, to others and her family. She was stuck in the notion that she would not be a good parishioner if she wasn’t spending every moment in the service of a calling from her church. She felt guilty if she spent time away from the church itself. In stepping into this important role, she was afraid to step out and see the other roles she could take in her life, such as being a loving mom, loving wife, and loving neighbor. Helping her to contact a sense of self that was larger than this single role gave her the freedom to step in and out of it, turning more to what mattered to her most—­being loving—­and bringing that to life in other roles. In summary, as self-­as-­context and the path to self-­awareness is engaged and explored, we become aware of the roles we play, and inside of this 78

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awareness, we have great choice to step in and out of these roles as is workable with respect to the meaning and purpose we hold in our lives. There are times when we lose self as experiencer (conscious awareness) to self as the experienced (conceptualized self) in ways that are incredibly painful, and unfold such that the content of certain experiences begins to dominate all areas of our lives. A chaplain or clergyperson might encounter this when working with someone who is steeped in guilt and shame based on an actual event, where the guilt of an experience is truly an appropriate response. In these cases, the content of the experience(s) may filter into many aspects of an individual’s life. Although there is a range of experiences that can lead to feelings of guilt and shame, the focus here will be on one of the more challenging. In chaplaincy work, as well as psychotherapy, there are times when you encounter an individual who has engaged in behavior that is harmful to others. For a number of these individuals, the behavior is directly opposed to personally held values, like honoring human life or loving others. Let’s visit another client example. This is an example of a soldier who committed a war crime. These types of crimes can be considered a serious violation of customs, values, and principles; and to respond with guilt and shame following this kind of activity is most likely an appropriate response. This particular soldier had killed an unarmed enemy who had begged for his life prior to the gun being fired. He came to therapy at the age of 78, more than 50 years after the event. He explained that he was “evil” and that he would spend eternity in hell. As his history was explored, it became clear that many parts of his life circled around the story of his evilness. He had to stay away from his family so that the “evil would not wear off on them”; he drank heavily to drown his thoughts and memories of the event and to escape the knowledge that he was going to “burn for eternity”; he had to hide his “true” nature or others would find him vile. An elaborate story about how this event had impacted his whole life unfolded in the room. Rather than try to convince him that he needn’t be so hard on himself or that he should not think of himself as evil, the counselor worked with him to establish a sense of self that was larger than this original, seemingly vilifying, event. Below is an exchange between client and couselor in the work they were doing in the area of self-­as-­context, with comments for understanding in brackets.

CASE EXAMPLE CL: I can’t see anything beyond the wrong that I did. I am truly ashamed and flawed; there is no forgiveness [conceptualized self as flawed and evil]. CO: I wonder if it is possible to see the wrong, but also to see beyond the wrong… beyond that time in your life [acknowledge the “evil” and the accompanying judgment, and start the process of contacting experiencer]. 79

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CL: Everything is tainted by what I did; there is nothing to see beyond [more words related to the same content: evil]. CO: [Softly] Perhaps, but I am worried about how limiting this perspective is. I wonder if you might be willing to take a little journey with me, into your past [first touching on the limitations of “buying” the content of this story, and inviting the client to take a look at other possibilities]. CL: I don’t want to talk about what happened [avoidance, nonacceptance]. CO: Understandable. We actually won’t be talking for a few minutes, but we will visit several parts of your past, including the event. We can stop at any time should you choose. CL: Okay. CO: I am going to ask you to close your eyes and just for a few moments settle into the awareness that you are here with me in this room and that there is a struggle present. [Client closes eyes and a few moments pass.] I would now like to invite you to consider an event from your past, but your more recent past, an event from this morning. Simply choose a memory from something you did this morning. It can be anything. Raise your finger when you have a memory [client raises finger]. Now let yourself swim around in this memory, noticing the sights and sounds of this event. Notice what you are up to; notice what is happening in this memory [a small amount of time is spent in silence]. Also notice who is noticing the memory [helping the client to take perspective; helping him to see that there is an observer observing the memory]. Now I would like you to pick a memory from last week—­any memory—­and raise your finger when you have it [client raises finger]. Take a look around this memory too—­what do you notice, what is seen and heard, what is felt as you observe this memory? [Pause.] Now notice the observer—­there is a you there observing this memory. The same you that had the memory [assisting the client to see that memories are things that people have, that they are not the literal content of the memory] from this morning, and observed it, is the you that is observing the memory from last week [creating a sense of self that is larger than either memory and extends in time]. This sense of you that stretches across both of these memories, and is aware of both, is vast and actually stretches way back in time: a kind of continuous perspective, an observer [again, getting the client connected to a sense of self that is larger than any single memory]. Leaving this memory, I invite you to go way back in time and to find a memory from your childhood. Any memory. Raise your finger when you have it [client raises finger]. Take a look around this memory. What are 80

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the images, sights, sounds? Take a moment to observe this memory [pause] and I will ask you to do a bit more this time. Zoom in on this child and see how young he is. See if you can see his face, his size, his vulnerability, his innocence [pause]. And as you continue to observe this child, see if you can catch the observer, the you that is there observing the memory. The session continued in this fashion, picking a memory of a time before the war and a memory of a time while in basic training. During these times, the client was asked to see the content of the memories while also noticing something about his demeanor or idealism. And each time, the counselor returned to the perspective of the observer—­the experiencer of these memories, helping the client to notice the place (i.e., the context) wherein the memories were occurring. The client was then asked to visit the event that brought him into therapy (this type of event is often called a moral injury; for more information see Farnsworth, Drescher, Nieuwsma, Walser, & Currier, 2014; for ACT and moral injury see Nieuwsma et al., 2015). The following is a continuation of the exercise: CO: Now I will invite you to bring to mind the memory of the event that brought you here, the event that has led to your current struggle, but as you do this I would like you to take the perspective of looking at yourself rather than the unarmed man. Bring to mind the moments before this event and see if you can see you: the young man, in war, coming upon this situation. See if you can keep observing yourself at that time. I know that you might see the whole event, but bring yourself back to seeing you, being aware and observing what is happening for you in this memory. Notice what you see… pull in close…[client’s face is expressive]…simply observe what is happening to you [pause], and even in the face of this difficult memory, see if you can notice that there is a you there, observing you. The same you that was there for the memory of yourself as a child, the you that was there for the memory of yourself in basic training, and the you that was there for this painful event—­a you that is larger than these events…a you that is aware of these events, but is not these events themselves [continuing to explore self-­as-­ context; observer perspective]. It is important to note here that the counselor took care not to visit the death of the unarmed man (although it is recognized that this memory is likely to happen). This was not in the service of avoidance, but rather in the service of maintaining the purpose of the exercise—­helping the client to connect to a sense of self that is the experiencer; helping the client to connect to a sense of self that is the place where memories occur, yet is larger than the memories themselves. When working with these kinds of events, clients can “get lost” to the memory and subsequently lose the 81

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point of the exercise. Helping the client to keep the perspective of observing the self at a younger age serves another purpose—­to see yourself experiencing this event. As this client observed himself at that time, he discovered that the killing was not a coldhearted act of brutality. Rather, he saw himself as afraid and vulnerable, and he remembered that he was under orders; he recognized his own humanity. The exercise was continued by visiting a few other time points in his life, one immediately post event, one post war with his family, and, finally, seeing himself sitting with the counselor in the room. At the end of the exercise he was invited to open his eyes and spend time processing the exercise. He noticed a number of things about himself, including times when he was innocent and idealistic, and times when he was harsh and unforgiving. He noticed a wide range of emotions and thoughts, and a wide range of images. Importantly, he was able to connect with a sense of himself that was larger than these experiences, and noted that this part of him seemed to be his “soul” or “spirit.” It was from this larger sense of self that he explored the possibility that he was more than the event that he had clung to so tightly and had thought defined him as a person. Counselor and client also spent time talking about how, if he were to do this exercise again in the future, he would be able to look back and see other memories. Here the focus was on the possibilities of what those memories could contain based on whether he lived a life connected to his values or a life engulfed by his story of being evil. The choice rested with him, although no outcome when living his values could be guaranteed; it was agreed that living the story of the painful event would look quite different from living a life defined by values. Connecting the client to a continuous sense of self made this choice possible. Finally, in the process of holding a perspective where he could see himself at once as young, idealistic, and scared, the client also felt a small but growing sense of compassion. In these moments, he was able to explore forgiveness, not as a sustained feeling of relief or an absence of remembering the event; rather, as an action that one could take in the literal sense of the word—­giving what came before. Here the client acknowledged that if he were to give back to himself, as an act of forgiveness, what came before the harmful event, that he would be taking time with his family and living healthily—­all actions that could be defined and engaged. Ultimately, the self-­as-­context work done in session and assisting clients to observe experience in the present moment serves to liberate them from the cultural notion that they must first “fix” or control their internal experience so as to eliminate or reduce it, so that they can then be whole. In the place of this moment, in being consciously aware, we are already whole.

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Conclusion In sum, in connecting to self-­as-­context, in engaging this kind of perspective taking, we can experience a sense of transcendence. Self-­awareness (consciousness, or I/ here/now; see McHugh & Stewart, 2012; Hayes, 1984) as a continuous locus or point of view allows the individual to connect with himself or herself across time and space. While we experience thousands of memories, emotions, thoughts, and sensations across the life span, we are always experiencing them from a stable perspective—­I/ here/now—­a fundamental aspect of psychological flexibility (McHugh & Stewart, 2012). Additionally, awareness allows us to connect to a felt sense of ourselves as larger than these many and varied human experiences. We can learn to see the flow of experience from this perspective, freeing us from clinging too tightly to negative concepts of ourselves or to what will be passing experience if we are not stuck in the struggle of forcing it to go away. Awareness places us in a better position to engage in behavior that is consistent with chosen and valued paths. Some have likened the transcendent self to God’s nature, the universe, or the divine, and it can be found in prayer, heartfulness, and mindful activity. In finding harmony—­ the quality of forming a consistent wholeness, a sense of self that is transcendent to thought and emotion (consciousness itself)—­we can assist others to make powerful and vital life choices that are connected to being in life on this earth in meaningful and inspired ways.

References Antonisamy, F. (2000). An introduction to Christian spirituality. Bandra, Mumbai: St. Pauls. Baer, R. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice, 10, 125–­142. Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in psychological well-­being. Journal of Personality and Social Psychology, 84, 822–­848. Carlson, L. E., Speca, M., Patel, K. D., & Goodey, E. (2003). Mindfulness-­based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients. Psychosomatic Medicine, 65, 571–­581. Cashwell, S. C., & Young, J. S. (2001). Integrating spirituality and religion into counseling: A guide to competent practice. Hoboken, NJ: Wiley. Davidson, R. J., Kabat-­Zinn, J., Schumacher, J., Rosenkranz, M., Muller, D., Santorelli, S., et al. (2003). Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic Medicine, 65, 564–­570. Farnsworth, J. K., Drescher, K. D., Nieuwsma, J. A. Walser, R. D. & Currier, J. M. (2014). The role of moral emotions in military trauma: Implications for the study and treatment of moral injury. Review of General Psychology, 18, 249–­262. Garrison Institute (2009). Mindfulness and heartfulness: An interview with Father Thomas Keating. Retrieved from http://www.garrisoninstitute.org/component/docman/doc_view/39-­ mindful ness-­and-­heartfulness-­an-­interview-­with-­father-­thomas-­keating?Itemid=66.

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Germer, C. K., Siegel, R D., & Fulton, P. R. (Eds.). (2005). Mindfulness and psychotherapy. New York: The Guilford Press. Goldenberg, D. L., Kaplan, K. H., Nadeau, M. G., Brodeur, C., Smith, S., & Schmid, C. (1994). A controlled study of a stress-­reduction, cognitive-­behavioral treatment program in fibromyalgia. Journal of Musculoskeletal Pain, 2, 53–­66. Hayes, S. C. (1984). Making sense of spirituality. Behaviorism, 12, 99–­110. Hayes, S. C., Barnes-­Holmes, D., & Roche, B. (Eds.). (2001). Relational frame theory: A post-­ Skinnerian account of human language and cognition. New York: Plenum Press. Hayes, S. C., Strosahl, K., & Wilson, K. G. (1999). Acceptance and Commitment Therapy: An experiential approach to behavior change. New York: Guilford Press. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and Commitment Therapy, 2nd edition: The process and practice of mindful change. New York: Guilford Press. Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-­based therapy on anxiety and depression: A meta-­analytic review. Journal of Consulting and Clinical Psychology, 78, 169–­183. Jyotsna. (2010, November 27). Going with the flow…[web log post]. Retrieved from http://jyotsna -­collectionofshortstories.blogspot.com/2010/11/going-­with-­f low.html. Kabat-­Zinn, J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday life. New York: Hyperion. Kabat-­Zinn, J., Lipworth, L., Burncy, R., & Sellers, W. (1986). Four-­year follow-­up of a meditation-­ based program for the self-­regulation of chronic pain: Treatment outcomes and compliance. Clinical Journal of Pain, 2, 159–­173. Kaplan, H. K., Goldenberg, D. L., & Galvin-­Nadeau, M. (1993). The impact of a meditation-­ based stress reduction program on fibromyalgia. General Hospital Psychiatry, 15, 284–­289. Kashdan, T. B., & Rottenberg, J. (2010). Psychological flexibility as a fundamental aspect of health. Clinical Psychological Review, 30, 467–­480. Linehan, M. M. (1993). Cognitive behavioral treatment of borderline personality disorder. New York: The Guildford Press. McCracken, L., (2011). Mindfulness & acceptance in behavioral medicine. Oakland, CA: Context Press. McHugh, L. & Stewart, I. (2012). The self and perspective taking: Contributions and applications from modern behavioral science. Oakland, CA: New Harbinger Publications. Nieuwsma, J. A., Walser, R. D., Farnsworth, J. K., Drescher, K. D., Meador, K. G., & Nash, W. P. (2015). Possibilities within Acceptance and Commitment Therapy for approaching moral injury. Current Psychiatry Reviews, 11, 193–­206. Segal, Z. V., Williams, J. M. G., & Teasdale, J. D., (2003). Mindfulness-­based cognitive therapy for depression. New York: The Guilford Press. Shapiro, S. L. & Carlson, L. E. (2009). The art and science of mindfulness: Integrating mindfulness into psychology and the helping professions. Washington, DC, US: American Psychological Association. Siegel, D. J. (2010). The mindful therapist: A clinician’s guide to mindsight and neural integration. New York: Norton.

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CHAPTER 5

Opening Up: Acceptance & Defusion Hank Robb, PhD, ABPP Private Practice, Lake Oswego, Oregon

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his chapter will cover two important aspects of the acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 2012) approach to spiritual development. Its aim, metaphorically speaking, is to provide general recipes for making cakes and pies without much reference to either general principles of food chemistry, on the one hand, or the specific details of Bundt cakes verses cherry pies on the other. A full exploration of acceptance and defusion as detailed in other literature and as explored more broadly by the community interested in ACT is beyond the scope of this chapter. Nonetheless, the chapter will provide some specifics of acceptance, and its synonyms such as “willingness,” and “opening up,” as well as defusion. It will also explore issues related specifically to religious and spiritual counseling, including how acceptance and defusion apply to forgiveness, reconciliation, and righteous indignation. Finally, the chapter provides the reader with practical activities designed to offer direct experience with each of the concepts presented and for use with those seeking pastoral counseling.

Acceptance One might think that a good place to begin addressing the issue of acceptance is with the most famous part of Reinhold Niebuhr’s prayer: “God grant me the grace to accept the things I cannot change, to change the things I can and the wisdom to know the difference” (Brown, 1987, p. 251). However, if taken as stated, this prayer may stand in contradiction to the approach offered in this volume, promoting “acceptance” as an alternative to “change.” Rather than “acceptance or change,” the approach offered here is “acceptance and change.” Consider instead the words found in the English translation of Psalm 118:24, “This is the day the Lord has made.” While this particular text comes from Jewish and Judeo-­Christian scriptures, most religions recognize creation by powers that are not human powers. The acceptance approach offered here might add, “And don’t get into an argument with that!” (i.e., the day the Lord made). Our days, each one, being set with a myriad of experiences, are here for us to relate to in a number of ways. We can fight against what has been set before us or made, perhaps increasing our suffering and struggle; or we can work with and relate to what has been made with an openness to encounter the flow of the day, to be willing to experience it as it was made. Furthermore, not arguing with what you have been given is not the same as responding passively to it. Make as much change in the day you have been given as you care, and are able, to make. Simultaneously, you can be accepting, rather than non-­accepting, of each life moment, including the gift of a new day.

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When clients come to counseling, they are often struggling with how they feel about themselves or others, with what they are currently going through with family and work, or they may be struggling with their past. No matter the particular kind of pain, a lack of acceptance is often found in their relationship to self, others, and situations. This lack of acceptance easily sets the tone for how they might experience the world and what is happening for them. Cultivating a stance of acceptance often decreases unnecessary suffering—­opening up lends itself well to change and the freedom to make choices in life based on meaning and values, rather than fighting with what the day brings. Let’s take a closer look. I often give the example of moving the door to my office to illustrate the importance of acceptance and change. Suppose I refuse to accept that the door to my office is located where it is located. But rather than paying those who own the building the money to relocate the door, I do something else. I simply refuse to accept that the door is where it is. I keep incanting, “No, it’s not there! No, it’s not there! I do not accept that the door is there!” That refusal to accept the world as it is may actually prevent change. I could get so caught up in denying the door’s current placement that I lose contact with other possibilities for change. This illustrates that acceptance, in this case acceptance of the door’s current location, is actually a prerequisite to change, rather than an alternative to it. Acceptance of what is here, in this moment, and as it was created, opens the possibility for something new. If I accept my experience as it is and relinquish my effort to resist it, then perhaps change is possible. Perhaps I can become more flexible—­an antonym to resistance and denial. Exploring acceptance (with change) as an alternative, then, sets the stage for an option that supports change. It is worth noting that the key places for acceptance in ACT are related to human experiencing of emotion, thought, and sensation; acceptance of other; and acceptance of this moment, as well as the past. It doesn’t preclude other events “made” in life, like death and loss or unpredictable changes in life circumstances (these, too, are there to be accepted as made), but importantly, acceptance as an alternative is directed toward the internal experiences of life. Nonetheless, being open to the day that was made clears the path for human transformation and the reduction of suffering.

An Alternative: Acceptance To underline the importance of acceptance and change, consider this alternative to Reinhold Niebuhr’s prayer: Let me give my permission (accept) for life to be as I find it (as life is, was, or may be) even though I may not approve of what I find. I have wisdom to see what

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would be good to change, willingness to act, willingness to follow through, and the gratitude for the opportunity to try to live my life as best I can. As rewritten, we can now break down how the different elements of the above prayer might map onto principles in ACT and the practice of opening up.

PERMISSION The initial words, “Let me give my permission for life to be as I find it,” underscore the notion of willingness to experience in ACT. These words harken back to, “This is the day the Lord has made,” while also adding, “…and I am not going to get into an argument with that.” The distinction between “giving one’s permission” and “giving one’s approval” is important. Approval implies an endorsement of or authorization for what was made. Permission as it is used here, however, implies a simple “reception” or “taking in” of what was made. It is the failure to make this distinction that leads many individuals into sticky and problematic places, closing themselves off from (i.e., refusing to accept) life as it is actually experienced. This distinction is made because one may not agree with, or approve of, the world as it was experienced in the past, as it may be experienced in the present, or as it might be experienced in the future. This sort of disagreement may lead to a kind of psychological and emotional closing off to what is present—­rejecting rather than accepting the moments of our lives. The ultimate cost is the closing of one’s heart to experience. Yet, acceptance or “permission giving” is about opening up to life as actually experienced—­ actively taking a stance that is not closed-hearted, but rather gentle and willing, free to experience all that life brings.

WISDOM “May I have the wisdom to see what would be good to change” is about recognizing one’s values and changing behavior in the service of the same. A large part of human suffering is found in rigid unwillingness to move one’s feet in ways that bring our values to life. Instead, we often engage in efforts to decrease our fears and anxieties about change. Unfortunately, these efforts are usually met with hollow outcomes—­ our fears and anxieties remain, and what we wish for ourselves and for those we love is placed on hold. Wisdom, here, is about taking those actions that are consistent with what brings deep fulfillment to one’s life, rather than acting on or pursing those things that might simply make us momentarily feel good. If we take a playful look at holding the literal, full-­on philosophy of “eat, drink, and be merry, for tomorrow we die,” we might learn a sobering lesson: tomorrow

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comes and we aren’t dead! Time can trick us. In the way human beings experience time, there is always an “after.” And that “after” is often related to what went “before.” And, “right now” is always a “before” to some future “after.” Even if one literally dies, one might find oneself in an afterlife in which “after” is still showing up. Additionally, what one does in this life leaves an “after” for those who continue to live in this world even after one has passed from it. One might say that wisdom is acting in the little picture of the present moment in the service of the big picture of what one would have one’s life be about. In some circumstances wisdom calls for change, while in other circumstances it recommends that things are better left alone.

WILLINGNESS “Willingness to act and willingness to follow through” denotes action. Willingness is an active process. It involves an intention that is lively and sentient. It involves a wholeness of self in motion. In this wholeness one’s thoughts, feelings, and sensations are full participants, both the ones we like and the ones we don’t, in the experience of life. Inside of this stance, it is recognized that the way to make a difference in the world and in one’s life is to take action; and that “getting finished” requires more than simply “getting started.” Willingness is a fundamental process in ACT and can be foundational in counseling when needing to find the place where healthy and values-­based movement is possible.

GRATITUDE Finally, “gratitude for the opportunity to try to live my life as best I can” underlines that none of us are “self-­made.” Whatever the forces or powers to which we attribute our very being, they are surely forces and powers beyond our own. Most, if not all, religions embrace gratitude in some form. As a lived value, we can exercise willingness in the service of expressing our appreciation for life. The day that the Lord has made is one in which we have a chance to live our life as best we can. We can live wisely. We can live authentically. We can serve divinity. We can serve humanity. We have the opportunity to try to do our best with what we have been given. The point is that whatever else we have been given, we have also been given the opportunity to try to do our best with it, and that is a very special gift indeed. We are invited to be grateful for life’s richness as a lived value, as a gift rather than a must. At times, acceptance of what is experienced is a part of this process. For instance, we may not be grateful when we are feeling fearful or anxious or when we are not pleased with what the day has brought. However, willingness to be present to the day that was made affords us the opportunity to engage gratitude, actively

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participating in behaviors that represent an appreciation for full and meaningful lives (also see Emmons & McCullough, 2004).

Two Kinds of Willingness We can contact another aspect of, or synonym for, acceptance by returning to the phrase, “willingness to act and willingness to follow through.” Willingness can be expressed in two forms. The first is illustrated in the phrase above and involves overt behavior (i.e., actions that everyone can see). We might call it, “willingness with your hands, arms, feet, and mouth,” or shortened, willingness with your feet. Exploring this concept by example will assist in conveying its meaning. Many individuals who are “flight phobic” will simply not get on an airplane. It can be said that they are not willing with their feet. Others, who are also flight phobic, go ahead and fly. It can be said that they are willing with their feet despite the phobia. Willingness with the feet might include attending church services even when angry at God, or when feeling forsaken. It might include acts of forgiveness when not feeling forgiving. It might include a broad range of activities that can be observed and are in line with personally held values. Individuals might demonstrate their unwillingness with their feet by refusing to take themselves places where they will encounter certain experiences, including those they might find unpleasant or challenging. This, however, can be quite costly, but is only known to be so when compared to the values-­based life that the person would rather create. The ultimate goal is to be willing with one’s feet in the presence of unpleasant and challenging internal experiences while continuing to engage personally chosen values. Being unwilling with one’s feet is not all bad. Indeed, it may be an act of wisdom! When I am out fishing and my wife expects me home for dinner, it will be wiser if I am unwilling to explore the water around the next bend with my feet and, instead, turn them toward my car. It probably won’t take anyone that long to generate quite a list of places or circumstances that would be wise to avoid. The “tell” is in what is most important to the person being counseled. The question might be, “Are my feet moving in line with my chosen values?” The second kind of willingness is called “willingness with your heart.” The first kind of willingness is easy for all to see. Either one’s body moves, or it doesn’t. The phrase willingness with your heart is metaphorical, as it does not refer to that fist-­size muscle that pumps blood through one’s body. Willingness with your heart is found in the way you “hold” experience. Given that this kind of willingness is not necessarily observable, it can be helpful to work with clients using metaphors and exercises to help them contact its meaning. 90

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WILLINGNESS METAPHOR FOR YOU AND YOUR CLIENT As you read, you are invited to engage in this small exercise. Take a moment and cup your hands. Now imagine that you are holding a small feather inside of your cupped hands. Hold this feather in such a way that it will not be disturbed or destroyed. Notice the experience of holding this feather. It would most likely be light and gentle, and you could hold it with tenderness or kindness. Continue to imagine gently holding this small feather for a few moments. Now imagine that instead of a feather, you are holding the fruit of a cactus. Imagine that this fruit has spines with sharp ends. The cactus fruit does not sit so gently in your cupped hands as compared to the feather. And yet, you can also hold the cactus fruit as gently, and with the same kindness, as you did the feather. Willingness with your heart is like that. No matter what is being held, whether it’s a painful thought, a painful feeling, a loss, or a fear, it can be held willingly—­with tenderness or kindness. No matter what the day brings, it can be encountered with this kind of willingness—­willingness with the heart. No matter what is done, it can be done willingly. No matter what is experienced, it can be experienced willingly. This kind of willingness might be likened to serenity—­a kind of greeting oneself and the world with a sense of quietude and equanimity. Finally, willingness with your heart is not to be found in any particular thing one holds, but is found in the particular way one holds anything. Willingness, acceptance, and permission-­giving are all words pointing to a way of being with experience, namely, an invitation to hold all experience gently and openly. Working with clients to explore and engage in these two kinds of willingness may prove quite useful in making positive change. When working to build and create willingness, it will also be helpful to consider several potential issues. I explore these in turn.

WILLING AND WANTING What if we just don’t want the experience we are holding? Fortunately, we don’t have to want to do something in order to do it. If we did, many things would never get done—­most homework, most house or yard work, walking the dog, practicing the piano, you name it! Willingness with your feet means that, as Paul McCartney and John Lennon once wrote, “There’s nothing you can do that can’t be done.” And, though it has a bad reputation based on the advice of Yoda, a character in the film Star Wars (e.g., “Do. Or do not. There is no try”), “trying” is also something that can be done. The outcome produced by our “tries-­of-­the-­moment” may improve over time. No matter what the outcome, the opportunity to give our effort, including our 91

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best effort, is always with us. Being willing to act with your feet does not require that we first want to act.

WILLINGLY AND GRUDGINGLY Most of us have done things grudgingly at one time or another. Doing something grudgingly is a choice in a way that liking what you are doing, or wanting to do it, is not. If you don’t like something, on the one hand, well, you don’t like it. On the other hand, if there is something you could do, even if you don’t like doing it, then, not only could you do it, you also could do it willingly. Not that doing it grudgingly isn’t an option—­it is just that doing it this way tends to change the experience. Consider the things you’ve done grudgingly. Without regard to any particular context, have actions you have resisted taking ever gone better when they were done grudgingly as compared to when they were done willingly? Did doing it grudgingly prove satisfactory? From the perspective of the ACT model presented here, the point, or the meaning, of doing something in the first place—­the basis on which you determine what it is to “act wisely”—­is all about personal values. Whatever the method for picking what you are going to do, on each day that is made, you also have it within your power to take action willingly or unwillingly. The choice lies with you. Talking about the difference between willingly and grudgingly may help clients who are resisting taking action because they don’t like what needs to be done, or are challenged to find the time or are upset that it will take time. Said differently, in counseling you can work with clients to explore the distinction between choosing to and having to. The following exercise can be used in session to demonstrate this issue. Give it a try yourself.

THE TWO BANNERS EXERCISE: CHOOSE TO AND HAVE TO Anyone can do this activity to help with making the important distinction between “choose to” and “have to.” If you stand far enough from the wall of a room (five feet or so) so as not to be able to touch it, then it can be said that the nature of the universe is such that in order to touch that wall, you will “have to” move closer to it. For our purposes, this might be called the “have to of physics.” Let us now switch from the way of physics to the way of the spirit and note that there are different ways of making the journey of getting close enough to the wall to touch it. One might say that there are different “banners” under which one can travel. The first banner to consider is the “I have to” banner. If you would like to add a little drama, as you travel across the room to get close enough to the wall to touch it, say out loud

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and repeatedly, “I have to. I have to. I have to.” Additionally, do your traveling grudgingly. Before reading further, actually give the proposed activity a try: grudgingly travel under the banner of “I have to.” Having made the trip once, you are now invited to make the trip again, but under a different banner: the banner of “I choose to.” You are again invited to add a little drama as you travel across the room by saying out loud and repeatedly as you travel, “I choose to. I choose to. I choose to.” Additionally, rather than traveling grudgingly, take your journey willingly. Take a moment and give this second trip a try. On completion of the exercise, the first thing to notice is that the contingencies of the world did not change. In the physical world there are “have tos” in the sense that you “have to” do A to achieve B. A second thing to be noticed is that there are options when it comes to the way a person operates in the world of physical contingencies. When one operates willingly from a perspective of “I choose to,” one is more likely to have the sense of being a liberated human being. When one operates unwillingly, from a perspective of “I have to,” one is more likely to feel like a slave. Most individuals find they prefer to live life as a liberated human being rather than a slave. And, more importantly, if one is living life as a slave, one is more susceptible to “slave revolts”: “I have to! Oh, yeah? Watch this!” If this is, indeed, the day the Lord has made, then, without argument about this day, one can willingly choose to try to live life as best one can with an open heart. Or, one can grudgingly do what one “has to” do.

The Problem of Control A useful way to parse human experience is to distinguish between our thoughts, images, and bodily sensations on the one hand, and moving bodily parts such as our hands, arms, feet, and mouth on the other. It is also helpful to note what is meant by thoughts, images, and bodily sensations as we explore the problem of control as it is applied to these inner experiences versus moving bodily parts. Thoughts are those words and sentences making the continuous stream of thinking experienced inside of our heads. Thinking can be likened to an endless talk radio program, constantly playing louder and softer depending on whether we are attending to it or not. Images may also be considered a kind of thinking but refer specifically to the “pictures” and symbols we see in our minds. These can be still pictures, moving pictures, or moving pictures with sound. Our mind, then, is filled with radio programs and lots of pictures. Bodily sensations are those experiences felt in the body and include aches, pains, emotions, tingling, itches, and so on. 93

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The problem of control as it is related to acceptance (and also to defusion) is found in its deceptive nature. We humans have learned to control and manipulate the world around us in ways nearly without number. For instance, we are able to control the temperature in a building, where and when food is grown, the delivery of knowledge, and the placement of roads. The list of the physical things we control is enormous. Given this broad ability to control the physical world, we have come to believe that we have the same kind of control in all aspects of our lives. And we don’t. We put our control efforts where they fail routinely—­namely in those areas occurring inside the skin. Let’s take a closer look. The short exercise below can also be used in session to demonstrate the problem of control. Just below, you will have an opportunity to read a phrase. When you do, notice what happens. And here’s a request. Try your best to keep it from happening. Here’s the phrase: Jack and Jill went up the         . If your history includes the anticipated learning, you will most likely have included the final word—­“hill.” And you will not have had to do anything for this to have happened. You didn’t have to look it up or take a wild guess. It just happened, and even if you tried, I suspect you couldn’t really stop it. Let’s try another, but this time, work harder to try not to have the final word. Work to control your mind in such a way as to not have it: Little Miss Muffet sat on a         . Again, if your history is as anticipated, you most likely finished the sentence with the word “tuffet”—­even though you were instructed to stop it from happening. It is possible, based on your learning history, that “tuffet” wasn’t readily available. Regardless, your mind went searching for it anyway. Additionally, even though “tuffet” showed up, you may not actually know what it is. Even without knowing what it means, tuffet, or anything else, can show up simply based on your past learning and the context of the moment. You are now invited to do the same activity but instead of not thinking the words, attempt to not speak them. If you took time to briefly engage this latter activity, you almost certainly were more successful in controlling what happened. The main point is probably clear: we have much more control over our hands, arms, feet, and mouth (our bodily moments) than we do over our thoughts, images, and bodily sensations (thoughts and feelings, for short). This brief activity quickly demonstrates the problem of trying to excessively control thoughts, images, and bodily sensations (often done when a person is struggling or in emotional pain; e.g., “I don’t want to think about this”). It can be 94

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quite hard to do. And, indeed, a paradox exists in the very effort to control thinking. If a thought is not liked and there is a desire for it to go away, it necessarily has to be contacted in order to try to control it. For example, suppose I told you that it was really important to forget what Little Miss Muffet was sitting on. Indeed, your very existence relied on you being able to forget this word. Hopefully, you can see the irony in the request. The more you try to forget “tuffet,” the more you will remember it. This is a result of your learning history—­“tuffet” will be there. This is true with other “inside our skin” experiences as well, including those that are painful and those we wish would go away. Willingness to experience thinking as thinking, imaging as imaging, and feeling as feeling while also being willing with one’s feet opens up possibility. Part of the view offered in this book more broadly is that it will prove much wiser to put efforts at control into the areas you have the most ability to control, namely, what you do with your hands, arms, feet, and mouth. Since we have much less control over our thoughts and feelings, it is often more effective to accomplish goals related to values by putting control in places where we have the most of it—­our hands, arms, feet, and mouth. Relinquishing ineffective efforts to control thinking and feeling is not always easy. It is helpful to explore ways to make willingness possible. The next section provides an alternative to efforts related to controlling thinking and brings forward the nature of language itself as the context in which that alternative exists.

Defusion “Defusion” is a strange word created to help us stay focused on an important psychological phenomenon and the way we relate to it. Language, itself, works as it does because we treat one thing as if it were another. Said differently, we treat our words about things as if the words were the actual things the words are about. For instance, we relate to the sound of the English word “cup” as if it were actually a round object that holds drinks. The object and the sound “cup” are responded to as if they were the same. This works well enough much of the time but consider what happens when we do the same with other words like “worthless” and “broken” as they relate to our very essence or being. The value of being able to make the psychological move called “defusion,” then, will be made clear. First, let’s take a look at the big linguistic picture into which defusion fits. Consider an example that makes an important point about how language works: the mystery novel. In this mystery novel there are no pictures. There are only lines of squiggles on a page. And yet, when people who “read the language” interact with them, things, typically, begin to “show up.” And in the case of the mystery novel, it might be fear and excitement. The writer intends for these sensations to be there. If 95

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those sensations do not show up for readers who know the language, the material might be described as “poorly written.” However, for some readers, other sensations might show up instead, such as disgust. In either case, the person interacting with the lines of squiggles on the page experiences bodily sensations and perhaps images. In the world of living beings, this is very odd! Odd, indeed; but again, as we shall see, that is the way language itself actually works. It should be noted that within the ACT model, learning to “language” is based on behavioral principles. A full description of the theory underlying language—­ relational frame theory (RFT; see Hayes, Barnes-­Holmes, & Roche, 2001, for further exploration of RFT)—­is beyond the scope of this chapter, but let’s explore how “languaging” has come to dominate our existence and cause trouble with our well-­being.

Verbal Dominance We can call this tendency to treat our words and images as if they were the things the words and images are about “verbal dominance,” because the tendency to treat words and images as if they were the things the words and images are about is dominating our experience (Hayes et al., 2001). In a certain sense, we have “fused” the words with what the words are about. When we “don’t know the language,” all that can dominate is the form of the squiggles on the page, such as Romroet feirn or   . When we hear poetry, we are not only impacted by the “meaning of the words” but also by their rhythm. We can sense that rhythm, even if we cannot “understand the words,” just as we are often impacted by songs in a language we “don’t understand.” Such things as “understanding” or “meaning” are occasions when the verbal rather than the physical aspects of squiggles on a page, or sounds coming out of someone’s mouth, “dominate.” If the physical aspects were all that were affecting us, the squiggles and sounds would have no “meaning” and we would say things like, “we don’t understand.” When we are “using” language (speaking, hearing, thinking, writing, or reading), which we might call “languaging,” we experience many advantages. We can share ideas, create, be connected, write, and read. But few things are all upside with no downside. This is true for languaging and is the very reason defusion can be helpful—­ because when the downside of languaging is present, great suffering may be the result, such as when “worthless” and the person are the same. Suppose we want to disrupt verbal dominance in the service of freeing an individual from believing that the word “worthless” and the person are the same. When it comes to written language, we can stop reading. When it comes to spoken 96

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language, we can stick our fingers in our ears, move away, or try to get the person to stop talking. We also can point out, “Hey, it’s just talk!” If we are watching a scary movie, we can point out, “Hey, it’s just a movie!” Likewise, it is often said about the theater, be it live or cinematic, that one must “suspend disbelief” to fully benefit from the experience. If “Macbeth” appears on stage and what we see is a Scottish nobleman, rather than an actor playing a role, we are getting the full benefit of the play. What we are calling “verbal dominance” is working just the way we would want it to work and we become “absorbed in the play.” Acting on the admonition to “suspend disbelief” is simply an aid in doing so. Statements like “it’s just a play” or “it’s just a movie” can break the spell of the verbal dominance. This break in verbal dominance occurs because such phrases create a different perspective about the experience. The new perspective is one in which we notice that “things are not as they seem to be”—­in other words, we are experiencing an actor playing the role of a Scottish nobleman named “Macbeth” rather than truly witnessing the unfolding life events of an actual Scottish nobleman. In noticing that “it is just talk,” or “it is just a movie,” we “defuse” from verbal dominance. Or said another way, we are released from the practice of treating one thing as if it actually were another. We recognize the experience for what it is, an actor playing a role, and not what it seems to be, the unfolding life of a Scottish nobleman. Just because words are spoken does not mean they have to be taken seriously. They can be treated as “just a bunch of words.” This is the very act of defusion. By recognizing that if I think, “I am a worthless toad,” I do not have to treat “worthless toad” as if it actually were “me,” I am freed from the power of language to make me miserable. Helping those in counseling to see thoughts for what they are, namely thoughts, and to reconnect to the ongoing nature of thinking, with thoughts continually coming and going, can be a helpful strategy in assisting clients to experience thinking from a less harmful perspective. The lines of squiggles are not literally the thing itself, nor are the sounds related to those squiggles. Sounds and squiggles are simply ways of languaging about things, events, and so on. From this position, the downside of languaging, such as speaking poorly about one’s self or others, imagining the worst or dwelling on the past, does not have the same power. It can be treated as simply talk. Let’s take a closer look.

ON THE “INSIDE” Several of the moves used to interrupt verbal dominance with respect to written and spoken language, such as sticking our fingers in our ears, can break the spell of verbal dominance in the land of bodily movement and the world outside the skin. As

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we also have seen, it is different in the land of thoughts, images and bodily sensations, the world inside the skin. Here we have much less control. In the first world, we, as verbal humans, can stop talking, but “on the inside,” we go on “hearing our thoughts.” Even with our eyes closed, we still “see images.” Let’s take the example of remembering. Let’s suppose a client was in a car crash. Rather than only having a “memory” of a car crash that happened at another time and place, he can remember a car crash and “relive” it over and again. In the latter case of “reliving,” in contrast to merely “remembering,” verbal aspects are dominating his experience—­the tendency to treat the images and sounds of wrecking as if the remembering were the wreck itself. We humans can be connected with the sounds and images of wrecking in the same way that we might get absorbed in Macbeth. Only now, mostly likely, the client will no longer find this kind of verbal dominance helpful or desirable. We might call verbal dominance where or when we don’t want it “fusion” to distinguish it from “absorption,” or verbal dominance where we do want it. This kind of verbal relating (fusion) can be problematic in what gets lost—­that the wreck isn’t actually happening, but the client continues to respond to it as if it is. It is in these places that helping clients, and ourselves, to defuse can prove useful.

Breaking Verbal Dominance It is possible to break the spell of verbal dominance where you don’t want it just as the spell of verbal dominance can be broken even though you do want it—­like when you are absorbed in a story, play, or movie. The method is the same in both cases: you take a different perspective. In this case, you take a different perspective on thoughts, images, and bodily sensations. Rather than relate to a thought or image as the thing the thought or image is about, in ACT, you are taught to relate to it “as it actually is,” namely as a thought or an image. If you call verbal dominance where you don’t want it “fusion,” you can say that you are “defused” when bursting the bubble of such verbal dominance.

Defusion and True/False Popping the verbal dominance bubble when you don’t want verbal dominance occurring has nothing to do with “true” or “false” in the sense of words “truly corresponding” to what the words are about. If you think the thought, “I am reading words on a page,” it will be true and the thought “I am reading words on a page” will not be you actually reading anything. It will be a thought. I invite you to make the effort right now and see if you can discriminate between the thought and what the thought is about, in this case reading and thoughts about reading. 98

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Here’s another opportunity. Think this thought, “I am sitting while I read.” If you are, indeed, sitting while you are reading, that thought is also “true.” Now notice what the experience of the seat cushion, or other object, supporting your body is actually like. Whatever your experience of support is, I am confident you will find it silent, unless the cushion has a squeaky spring! And, even it if has a squeaky spring, I doubt the squeak sounds anything like “the sounds in your head” that correspond to the written words, “I am sitting while I read.” Make the effort again to see if you can discriminate between the thought and what the thought is about, in this case the difference between thoughts about sitting and actual bodily sensations of being supported by a chair. Let us consider yet another example of distinguishing thoughts from what the thoughts are about.

THOUGHTS OF RISK If over the next few days, you are going to be in an automobile as either a driver or a passenger, then if you think this thought, “When I am next driving or riding in a car, there is some possibility of my being in a wreck,” the thought will, again, be “true.” After all, there is some possibility, no matter how large or small that possibility may be. However, this “possibility” exists someplace out on the road. It doesn’t exist in your head. What you are experiencing is a thought about a possibility. But, if verbal dominance is occurring, it will seem like that possibility is here and now rather than then and there. Rather than “suspend disbelief,” as you would be advised to do if you wanted the full effect of theater, you could “instantiate disbelief.” It’s not that you would stop believing the thought was “true” and that there is no chance of being in a moving automobile and wrecking. Rather, you would stop treating the thought as if it were the thing the thought is about, namely, the possibility of you being in a wreck. The thought remains “true” but you stop believing that the thought is the same thing that it says it is about. You experience it, mainly, as a thought. If one were able to push this to the extreme, thoughts would be no different than the sounds of languages one does not speak—­just a bunch of sounds. The same can be said of images whether they are “still” or “moving.” They would become nothing more than collections of shapes and colors. Many individuals, who will in fact eventually take risks, could greatly reduce their terror in response to their thoughts about these risks if only they could recognize their thoughts as just thoughts. In session, defusion can help people to relate to their thoughts, images, and bodily sensations in a more flexible way. Some thoughts about the way the world is (such as it being a scary or horrible place) or the way we are (worthless, not okay, not loveable, and so on) are just not that helpful when responded to as if the thought about the world or about the self are one and the same. Assisting with this discrimination frees individuals from the potential burdens of verbal dominance. 99

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The Value of Defusion Defusion is important to acceptance because it allows acceptance of two quite different things. First, you come to accept the world as it is, was, or might be. Second, by noticing that thoughts and images about the world are not the world itself—­by defusing—­you can also accept those thoughts and images as simply thoughts and images. Defusion can also assist in helping people to see the ongoing flow of thought, the way that thoughts and images are constantly coming and going—­we are thinking, we are imaging. Let’s explore an example. When verbal dominance is strong, a client might respond to the thought, “One day my loved one will die,” as if that thought is the thing the thought is about—­actual dying happening here and now. Being fused with that thought, the client may respond with fear, intense grief, or both; all as if the actual death were happening. What is being asked of the client when she is confronted with the death of a loved one is one thing. What is happening when she is being asked to accept the thoughts of death as thoughts is quite another. Defusion, then, tempers verbal dominance enough to allow the client to make the distinction between the two and the fear and grief that come along with each. Defusion aids acceptance by making clear to individuals what precisely it is that they are accepting: actual events or thoughts about them. Asking yourself, or those you serve, to accept painful life events is one thing. Asking acceptance of thoughts about those events is another. Asking for the latter can only be done once it is made clear that there is a distinction between the two. The act of defusing allows us to experience that distinction. The same can be said of images. The image of someone you care about suffering does not have to be treated as the direct experience of someone you care about suffering. You can defuse, and, by doing so, notice that you are experiencing an image of suffering rather than actual suffering itself. Defusion can even be important in relation to bodily sensations, including painful ones. In almost no time at all, we can treat bodily sensations as if they “mean” something and then quickly experience them differently—­as the meaning we have verbally assigned them. Consider the experience of tightness in your chest that can sometimes accompany anxiety. Often the thought that comes with it is “I am dying.” When verbal dominance is in full swing, the tightness in your chest is you dying rather than a meaning you are giving to that tightness. To say that a coward dies a thousand deaths while a brave person dies but one is to say that a “brave person” notices that thoughts about dying are not dying itself. Accepting those experiences that we wish were different, such as bodily sensations we don’t like, is one thing. Accepting thoughts, or images, about such sensations can be rather different but only when we notice they are, indeed, thoughts and images rather than the actual bodily sensations. Being able to notice one’s thoughts that the tightness in one’s chest is a 100

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heart attack as thoughts has saved large numbers of individuals from yet another trip to an emergency room where they would be told, yet again, they are experiencing panic rather than a problem with their heart. Just as we can change our perspective on a play to help us increase verbal dominance and become more absorbed in that play, we can also change our perspective on our thoughts, images, and bodily sensations to help us reduce verbal dominance and become less fused with (defused from) our thoughts, images, and bodily sensations. We, and those we seek to serve, are all going to have thoughts, images, and bodily sensations and we are all going to find their arrival and departure difficult to control. That is why it is useful to have a different way of relating to them, namely defusion. Accepting them becomes much easier when we realize that all we are asking of ourselves to accept is nothing more, and nothing less, than a bunch of thoughts, images, and bodily sensations rather than the “realities” they so often seem to be when verbal dominance is high.

MAKING A DEFUSION MOVE While there are a number of ways to defuse, or instantiate disbelief (Blackledge, 2015), a simple and straightforward one is to say out loud, “I’m having the thought” and then, also out loud, say the words that constitute the thought. Thus, if I were to think, “I’ll never understand this chapter,” I could say out loud, “I’m having the thought, I’ll never understand this chapter.” Such tactics tend to quickly burst the bubble of verbal dominance that the thought of never understanding the content of this chapter is actually me never understanding the content of the chapter. Similarly, one can also use, “I’m having the image of…” and “I’m having the sensation of…” Though images and sensations are not words, verbal dominance is not about words per se. Rather, verbal dominance is about treating one thing as if it were another. Using such phrases as “I’m having the image of…” or “I’m having the sensation of…” helps us get the perspective that just as words can be treated as simply what they are rather than what they may seem to be, so can images and sensations.

A PLACE FROM WHICH Though it is beyond the scope of this chapter, and it is covered more thoroughly in chapter 5, you might note here that there is “a place from which” you can make these acceptance and defusion moves, and can willingly experience the thoughts and images of your mind and the sensations of your body as “things experienced” rather than “things we are.” I suggest that a good name for that “place from which” is our “spiritual center.” It is from our spiritual center that we can notice that our thoughts, images, and bodily 101

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sensations can be contacted as simply thoughts, images, and bodily sensations. Regardless of them, we can, from our spiritual center, choose what we do with our hands, arms, feet and mouth and also choose to make those moves willingly. Further, it is from our spiritual center that we can choose what purpose or value we will serve by our actions—­actions we are capable of taking no matter how our body feels, or what our mind says, about them. Exploring the place from which can be helpful to clients. Again, this means growing the space where acceptance is possible.

Special Topics There are a few special topics that seem useful to include in a chapter on acceptance and defusion: righteous indignation, forgiveness, and reconciliation. Each will be covered in turn. You cannot be long in the field of pastoral counseling without encountering someone who enters your office in a fury and seems determined to remain so. It is also difficult to imagine a day in the life of a pastoral counselor wherein forgiveness and reconciliation are not touched upon and explored.

Righteous Indignation: A Drug of Choice for Some Humans There is one particular group of thoughts that are worth considering. This series of thoughts often starts with an assertion that the target of the thoughts is somehow “less than.” It goes on to include an absolute demand that the world cannot be the way it is, was, or might be, and finishes with a sense of worthiness, or justification, that buttresses both the sense of “I’m better than” and the demand that follows. Put into words, it usually sounds something like: “You (insert nasty name here)! You must (or must not) treat me that way! I deserve (I’m entitled to) something different!” If your clients take these thoughts seriously, they are likely to get all “steamed up,” and be “righteously indignant” about it. Defusion, here, can be very helpful. Such experience is often combined what we might call “the pressure cooker theory of upset.” The theory goes something like, “I can’t hold this in; I’ve got to let it out!” However, an alternative to “blowing off steam” is to “turn down the flame,” by noticing that these thoughts, just like all other thoughts, can be treated as only thoughts. However, a defusion move with righteous indignation can be a little tricky. Sometimes individuals may see themselves as “The Avenging Angel of the Lord who has been sent to straighten you out!” This self-­righteousness can feel good, and it can certainly be energizing! And often, it quickly anesthetizes the pain and disappointments of life. Regardless of how it feels, it is important to consider how righteous indignation actually functions. 102

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Here, the workability of the situation is important to evaluate. The main issue on which to focus is the workability of blaming and condemning and, especially, righteous blaming and condemning. Consider as much of human history as you know, or simply the history of your own life. If blaming and condemning the world or others were going to work, wouldn’t they have worked by now? Hasn’t righteous indignation toward the world or others actually gotten quite a good series of experimental trials? In addition to blaming and condemning others, or the world in general, we often, perhaps very often, blame and condemn ourselves. And how has all this self-­blame and self-­condemnation actually turned out? A question to consider asking in session is, “Is yet another round of taking seriously these thoughts of how you, others, and the world in general are less than and deserve to struggle likely to produce a fulfilling life for you and those you care about?” Furthermore, foregoing righteous indignation doesn’t equal foregoing action. Passivity is not the only alternative to getting all steamed up. Determination to do the best at what one wants to make important in life can be had without buying into any of the notions embodied in the words previously used to indicate what righteous indignation often sounds like. Clients do not have to get steamed up in order to stand up. Being willing to experience (accepting) what is, was, or may be is the opposite of insisting that it absolutely must be otherwise. Defusion assists in helping clients to make this willingness move.

Forgiveness The topic of forgiveness is large and meaningful in the religious and spiritual traditions. Chapters, indeed books, could be and have been written on the issue. For the purposes of defusion, the topic will be narrowed to a few points and examples. It is recognized that forgiveness has a much broader and more powerful role in many counseling sessions. Let’s start with a simple exercise that can be done in session that points to the problem of holding on to the past in such a way that oneself or another is not forgiven. Holding a past harm against another provides both a metaphorical and literal starting place to consider the act of forgiveness. It is one thing to systematically list all of one’s grievances against another. It is a different thing to hold that list against them. To get the sense of this, you can have a client who is stuck in being unforgiving or is struggling with issues of forgiveness write down one or more statements that constitute the grievances your client has against another. In this activity you will represent the person with whom your client has grievances. Arrange yourself in the room with the client so that he can hold the list against you with his index finger (literally hold the list of facts against the deltoid muscle of your upper arm). Have the 103

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client push hard enough that both you and she report pain. Also, have the client notice this in particular: to create pain in the other (make him pay for his harm), you must create pain for yourself. Next, have the client hold the list against your upper arm lightly rather than forcefully. While the pain may subside, in order to continue to hold the list against you, a different problem arises. Have the client notice how difficult it becomes to do much else in life as he will still be limited if he is going to continue holding the facts against you. That can get pretty inconvenient! Pain and inconvenience are the price paid for continuing to hold the facts against another (or yourself). Yes, you may be able to bring pain and difficulty to the other person’s life, but only at the cost of bringing pain and difficulty to your own. There is an alternative: letting go. The question to be asked is, “What happens if you simply stop holding the facts against another?” In that act of release, the client is freed, while the facts simply remain what they are. Gravity takes over and the paper falls. Have the client pick it up and take a look. Have the client notice that the facts were not changed, excused, explained, or forgotten. The facts are exactly as they always were. What has changed is the relationship to the facts—­namely the relationship of holding the facts against someone. And the truth is, more often than not, there really isn’t anyone there to hold the facts against. It is more like one is holding the facts against a wall. Push hard and pain is generated; but only for you because no one else is actually present to feel the pressure being exerted. No one else experiences either the pain or inconvenience because there is, literally, no one else there; it is only the client—­and his relationship to the facts. You can also hold the facts against yourself. Now you are on both sides and, if you push hard enough, you can experience two sources of pain. Yet, whether you hold the facts against another, “the wall,” or yourself, the option to “release” is always available. No matter how many times you reestablish the “holding-­the-­facts-­against” relationship, you can also change that relationship with a simple release move. You can forgive over and over again. You can forgive as often as is necessary to free yourself from a painful and inconvenient relationship with the facts. And, you can make that move regardless of your thoughts and feelings. You don’t have to think, “release” in order to release. You don’t have to first “feel like” releasing in order to release. You don’t have to first get your mind and emotions “right” before making this move because the move comes from your spiritual center rather than your mind or body. Since the source of control for this willingness-­with-­your-­feet move isn’t your thoughts or feelings, forgiving is always available simply by noting your ability to act from your spiritual center and then doing so. One more thing, have the client look closely at the paper with which this activity began. Have your client notice if the words on that paper are the actual facts or if they are only a bunch of words about the facts. The way this activity was described 104

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made it easy for verbal dominance to slip in. While going through this activity, your client likely did not notice that whatever the grievances, the words on the paper were not those grievances. They were only words—­words written down on a piece of paper. Relating to those written words as only written words is an act of defusion, just like noticing that your thoughts and images about your grievances are only thoughts and images. But what about the actual events (the client might ask)? Yes, one may have thoughts and feelings about events; these may even be quite difficult and painful. However, doing defusion work doesn’t mean the events are not, did not, or might not happen! Indeed, this leads us right back to acceptance. Defusion is helpful when working on acceptance because, by means of defusing, we recognize we are only asking ourselves to accept thoughts and images about events rather than the events themselves. And yet, no matter how much we disapprove of and work to change or prevent what is, was, or may be, we do better at it when we approach these tasks willingly rather than unwillingly. We can do this because acceptance is not an alternative to change, or attempts at change. Instead, acceptance provides a more effective way to pursue change.

Reconciliation We might define reconciliation as giving someone, like the sibling who wronged you, or something, like the horse that previously bucked you off, a chance to do it again. Typically, reconciliation is something that happens after pain. Additionally, no matter what the other person says or does after painful experiences, there is no guarantee that such pain will not be brought, once again, in exactly the same way. This is part of what can make reconciliation so challenging: fear of the pain happening again. Consider sexual infidelity. No matter what the partner who was sexually unfaithful says or does, there is no guarantee that the same thing will not be done again. And so it is with drinking, gambling, wrecking cars, skipping work, or an almost unlimited number of actions that can bring pain. The pain might come again. Will you take that risk? Reconciliation is answering “yes” to that question, and answering “yes” involves both willingness with your feet and willingness with your heart.

The Two Kinds of Willingness “Will you take that risk?” is really a two-­part question because one can be willing with one’s feet and not with one’s heart. Returning to the example, it is not unusual to see couples continuing to live together after sexual infidelity by one or both. They 105

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are, so to say, willing with their feet. And yet, their hearts may be closed. You might say that they are taking a chance “physically” but not “spiritually.” You might say they are unwilling to open their hearts and be vulnerable to the pain they might, again, experience. Part of full reconciliation is to open oneself to “not knowing” and taking a risk while feeling the feeling that comes with it, namely fear or apprehension. Without taking this risk, reconciliation is only partially accomplished, more apparent than real. Full reconciliation often entails knowingly taking actual risk. Why? Because you can’t “not know” what you already know, and you know you’ve been hurt, what was done, and who did it. That previously experienced pain might come again: from the same source and in the same way. That is the risk you are taking. Taking that risk almost certainly entails thoughts and images about risk—­thoughts and images from which you can defuse by accepting them simply as the thoughts and images they are rather than the risk they so often seem to be. Our thoughts or images about our mate meeting someone else can be noticed as just thoughts or images and accepted as such. But what about the actual risk of future hurt brought to us by the same person who hurt us before and in exactly the same way? Do we willingly take that risk? That is what reconciliation is really asking of us. We feel afraid because that’s the feeling that shows up when we knowingly take a risk. Accepting the feelings of fearfulness as a side effect of opening our heart to the risk is part of building a values-­based life.

Who Benefits? Forgiveness is for the person doing the forgiving. Forgiveness is ultimately about an individual being freed from a particular relationship with past events (Enright & Fitzgibbons, 2000). Reconciliation, however, involves more than oneself. It is true that you, yourself, cannot go on having a life with someone else if you refuse to be with that person and so reconciliation can, in part, be about the person who is willingly taking the chance. But it is also importantly about the person who is being given a chance: a chance to avoid bringing pain again. Finally, reconciliation is not always about someone else. For not only can you forgive yourself, you can also reconcile with yourself, or not. You can choose to “open your heart” and “take a chance” on yourself with full knowledge that you might bring pain to yourself in exactly the same way as before. Will you take the risk or not? If it is true that we remain alienated from ourselves when we refuse to forgive ourselves, it is also true that we remain alienated from ourselves when we refuse to reconcile. Exploring these issues with your clients can be quite helpful in freeing them to live a values-­based life. 106

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Summary Acceptance and defusion are two important aspects of the ACT approach to human suffering and to thriving in life rather than merely surviving for a long time. “Acceptance,” “willingness,” and “giving one’s permission” all point to our ability to relate in a particular way to our experience. This way is not an alternative to change but rather a way in which change may be engaged, or not. Change efforts are best undertaken from wisdom. We can see what we might make of the day we have been given rather than insist on receiving a particular kind of day before we live. Defusion breaks the hold that verbal dominance can have when such dominance is not helpful. It can be useful as it shows us that what we may be asking ourselves to accept are only thoughts, images, and bodily sensations and not what those thoughts and images are about or what those bodily sensations “mean.” While defusion is helpful, it can also be tricky because we are swimming in a sea of language. Like the young fish that was asked by the old fish, “How’s the water?” we wonder, “What’s water?” Languaging is so thoroughly infused into our lives that we easily fail to sense languaging itself and how it functions. Defusion provides us the perspective on languaging that we often do not have: a perspective that can prove very useful, indeed. It’s a perspective that assists our being willing with our feet and willing with our hearts.

References Blackledge, J. T. (2015). Cognitive defusion in practice. Oakland, CA: New Harbinger Publications. Brown, R. M. (Ed.) (1987). The essential Reinhold Niebuhr: Selected essays and addresses. New Haven: Yale University Press. Emmons, R. A., & McCullough, M. E. (Eds.) (2004). The psychology of gratitude. New York: Oxford University Press. Enright, R. D., & Fitzgibbons, R. P. (2000). Helping clients forgive: An empirical guide for resolving anger and restoring hope. Washington, D.C.: American Psychological Association. Hayes, S. C., Barnes-­Holmes, D., Roche, B. (Eds.) (2001). Relational frame theory: A post-­Skinnerian account of language and cognition. New York: Plenum. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). New York: Guilford Press.

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CHAPTER 6

Enhancing Religious and Spiritual Values Through Committed Action Jacob K. Farnsworth, PhD Denver Veterans Affairs Medical Center Eastern Colorado Health Care System

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ary sought a meeting with her religious counselor after years of physical and emotional abuse1. She had endured many of her husband’s alcohol-­ fueled assaults over the course of their 30-­year marriage, and they’d had several children together over that time. Although Mary never condoned her husband’s behavior, she still felt it was important that she stay by his side, despite the pain that it caused her and her adult children. Devoutly religious from childhood, Mary believed that the bonds of marriage were sacred and offering forgiveness to others, though difficult, was a practice that God expected of her. Guided by these beliefs and values, Mary remained in her abusive marriage until one day her husband, intoxicated again, pointed a pistol at her and fired, missing her head by only a few feet. After fleeing to a neighbor’s home, Mary waited until authorities arrived and arrested her husband. Shortly after this incident, Mary requested an advice counselor, expressing indecision and distress over her marriage. Her husband, still imprisoned and awaiting trial, was writing daily letters to her expressing his remorse and desire to work through their marital troubles. Although Mary held no illusions about the inability of her husband to live up to his promises, she was wary to pursue a divorce, perceiving that it would violate her religious beliefs about the sacred importance of forgiveness and marriage. In hearing Mary’s story, her counselor felt conflicted. She was deeply concerned that Mary’s safety would be in jeopardy if she was reunited with her husband, but also felt it important to respect Mary’s religious beliefs and values. In difficult cases like the one above, the client’s religious and spiritual values pose critical questions for those seeking to provide support. How can issues of harm be respectfully explored without appearing to challenge Mary’s religious and spiritual values? Are there ways that Mary’s religious values can be utilized to enhance her well-­being, without putting her at further risk? These and similar questions demonstrate the salience that religious and spiritual values can have for providers of either professional or religious counseling (referred to within this chapter simply as “counselors”) and reinforce the need for thoughtful and flexible approaches to the religious and spiritual values of those seeking their services. By drawing on the psychological theory and clinical interventions of acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 2012), the following chapter attempts to address these and other questions relevant to religious and spiritual values. Recognizing that no one perspective can adequately cover a domain as complex as religion and spirituality, the chapter applies the clinical perspective of ACT to identify ways to support the values of individuals seeking spiritually or religiously and spiritually informed counseling. It begins by comparing and contrasting 1 Examples have been drawn from details of multiple cases and names changed in order to protect confidentiality.

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religious and spiritual values and actions with values and actions as understood within the ACT framework. Next, ways in which religious and spiritual values can pose potential challenges to individual functioning are addressed, accompanied by suggestions for intervention.

Religious and Spiritual Values Many individuals locate their most meaningful values within a religious or spiritual framework (Park & Edmondson, 2011). Although differences abound in how religious and spiritual values and beliefs are enacted, the shared importance of religion and spirituality (R/S) is a topic that is embedded deeply within human civilization and experience (Hayes, 1984; Sosis & Alcorta, 2003). Though professional psychology has had difficulty agreeing on a single definition of either religion or spirituality, there is broad consensus that the two are distinct from one another (Oman, 2013). Whereas spirituality has been defined as a “search for the sacred” or the transcendent, whether in the form of deity, a higher power, or ultimate truth and reality (Pargament, Mahoney, Exline, Jones, & Shafranske, 2013), religion has been defined as an organized system of beliefs, practices, rituals, and symbols designed to facilitate closeness to the sacred or transcendent (Koenig, McCullough, & Larsen, 2001). Religion, then, often provides a framework, structure, and social community for individuals as they attempt to make contact with sacred or transcendent realities. R/S traditions often address a wide array of topics and concerns, which range from the mundane to those of central importance to human experience. For example, R/S beliefs and practices typically address domains such as interpersonal relationships, and offer principles like compassion, fairness, and acceptance to guide interactions. These R/S principles may also be directed toward one’s relationship with a deity or even toward all forms of life generally. Amongst their diversity, most R/S traditions emphasize the importance of an internal commitment to sacred principles, which then allow the individual adherent or spiritual explorer to connect to or join with the sacred as well. Additionally, most major religious traditions include provisions for how spirituality is to be practiced or enacted. Many religious traditions incorporate specific codes of behavior as essential elements of spiritual practice (such as the Jewish Torah). For Muslims, the very name “Islam” means both an internal and external voluntary submission to God. Likewise, the Christian New Testament teaches that “faith without works is dead” (KJV, James 2:26), and the Eightfold Path of Buddhism includes Right Action among its tenets. Other religious behaviors pertain to regulation of self, including ritual cleanliness, discipline, and forsaking of lifestyles and behaviors perceived to impair one’s access or sensitivity to spiritual experiences (such as 111

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materialism or substance use). Thus, in many religious traditions, spirituality is viewed not simply as an internal experience, but as a quality that is reflected in individuals’ external behavior as well. How one acts both reflects and influences one’s connection to the sacred realm.

Values and Committed Action in ACT Through even this cursory review of religious traditions, it is evident that they share much in common with ACT’s emphasis on values and committed action. Just as R/S practices often encourage the adoption of guiding principles of action, so too in ACT, clients’ values are identified by helping them to define and describe the qualities of action that give them an intrinsic sense of meaning and purpose (Hayes et al., 2012). For example, a client may identify “being loving” as one of their core values. In ACT, a value such as “being loving” is not a static goal but rather is a moment-­by-­moment decision on the part of the individual that serves both to motivate behavior and dignify pain that may accompany such actions. Thus, ACT will encourage a person to choose to behave lovingly even if doing so means they sometimes experience disappointment as a result. In this way, ACT encourages individuals to let values guide their behavior, allowing them to function as an internal compass in making decisions. This grounding of choice in values is emphasized as ACT recognizes that individuals may engage ostensibly in values-­consistent behavior for a variety of reasons other than their personal values. For example, they might act lovingly because they fear abandonment, because doing so helps obtain secondary benefits, or simply because it is expected of them by others. However, in ACT, values are not a means to an end. Rather, if being loving is a value, then acting lovingly is its own reward. As with most religious traditions, in ACT values always entail some form of committed action. If a client values being loving, it implies that they are actively performing behaviors which reflect the quality of love. These behaviors may take different forms depending on the situation at hand but they always serve as intentional reflections of the underlying value or values being embraced by the individual. The requirement that values-­driven actions be intentional and committed is important for the work of the religiously-­or spiritually-­sensitive counselor. Actions that occur impulsively, out of thoughtless habit or through social pressure, tend to be inflexible and under control of the individual’s learned history and circumstances rather than under the control of the individual. For example, although individuals may engage in actions that outwardly appear to be congruent with their proclaimed values, they may cease such behaviors in private or when inconvenienced by them. As a different example, individuals may perform regular religious devotions solely because these have become part of their daily routine, and they fear breaking this pattern. 112

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In contrast, people’s ability to select and commit to how they will enact their values in a given moment increases their flexibility so as to better move toward their most prized goals and desires. The intentional choice to embrace a value through action also allows individuals to intentionally select how they will enact it. Rather than reacting to their current circumstances or repeating past experiences via habit, they can envision new responses and new possibilities that best exemplify their chosen value. For instance, in order to help refresh a sense of spiritual connection, a devotee might radically redesign a devotional practice even though doing so may break from tradition. Furthermore, consciously selecting values also allows for those values to be adhered to even in the face of opposition or discomfort. Such actions will not be determined by the social pressure of critics nor congregation members, but instead by the individual’s commitment to personal R/S values. Thus, from the perspective of ACT, values offer an alternative path to the tyranny of mindless habit or the restraints of social conventions. Before continuing on, it is important to note briefly how ACT approaches the topic of transcendent truth and moral absolutes. In contrast to many R/S traditions, which often make ontological claims about the nature of the universe or the existence of moral absolutes, ACT takes a pragmatic approach to truth. A pragmatic approach to R/S truth means that ACT does not address the question of whether sacred or transcendent realities actually exist (e.g., whether there is a God) or what constitutes morally correct behavior. Instead, ACT only considers whether an R/S belief, rule, or behavior helps to accomplish an individual’s values-­based goals. Although this approach to truth differs from many R/S traditions, it also creates a bridge between the client’s R/S worldview and ACT as a clinical theory. Because ACT declines to make assertions about absolute truth, it presents a highly flexible approach to R/S values. Rather than imposing an alternative definition of counseling success based in secular theories about psychological health, ACT allows clients to define the parameters of success according to their own R/S perspectives, whether they be R/S related or not. With ACT, the counselor respectfully works with clients to explore what a successful outcome to counseling would look like for them and defers to the client’s experience to indicate whether such outcomes are workable and when they are achieved. The importance of helping clients commit to values-­guided actions is a central focus of ACT. As stated by Hayes et al. (2012), “All ACT techniques are eventually subordinated to helping the client live in accord with his or her chosen values. This statement means that even such key ACT interventions as defusion and acceptance are, in a sense, secondary” (p. 322, italics in original). Even with this importance, it should be recognized that living one’s values is facilitated by other ACT processes as well. Failing to attend adequately to the other core ACT processes will lead to clinical challenges in the realms of values construction and committed action. Increasing 113

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committed action to R/S values will therefore draw deeply from interactions that promote willingness, defusion, contact with the present moment, and a sense of self-­ as-­context. It is recommended that counselors make themselves aware and comfortable with these other components of ACT, as found in this book, before approaching the topic of R/S values with clients.

Looking at R/S Values More Closely Despite their central role in the lives of many individuals, R/S beliefs and practices can nonetheless be the source of significant pain and distress (Murrell, Schmalz, & Sinha, 2014). As in the example presented at the beginning of this chapter, the attempts individuals sometimes make in an effort to be consistent with their values can place them at risk for further harm or suffering. When presented with these types of dilemmas, counselors may likewise feel confused about how best to respect their clients’ R/S values and beliefs, while still helping them to reduce unnecessary suffering and supporting them in finding greater freedom. In pursuing this goal, ACT’s theory of values and committed actions makes several important distinctions that can assist counselors to serve individuals struggling in these areas.

Rules vs. Values One important distinction to be made is the difference between values and rules. As discussed above, values are principles or qualities of conduct that an individual intentionally uses to define what a fulfilling and meaningful life looks like. Rules, in contrast to values, reflect directions or imperatives about what actions are appropriate or inappropriate. Rules abound in human civilization at large, and R/S traditions are no exception. From broad prohibitions against unjustified aggression to more tradition-­specific regulations such as religious dietary restrictions, R/S rules provide behavioral outlines regarding how a tradition is to be practiced. R/S rules can also serve important functions, such as creating spiritual routines and rituals that enhance group cohesion (Graham & Haidt, 2010). Rules also provide convenient shortcuts for moral decision-­making by specifying actions to take in particular circumstances. However, in addition to their advantages, rules also have the potential to increase suffering and interfere with values-­oriented living. One limitation of rules is their tendency to be more rigid and less flexible than values. Rules therefore provide clear directions about how to behave through reducing the range of potential responses available to the individual. However, if held in an extreme fashion, rules can become cages that obscure and interfere with the values that they may have originally been intended to reflect. 114

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As an example, scrupulosity is a condition in which individuals develop extreme concerns about engaging in moral transgressions (Cefalu, 2010). In this condition, concern about violating moral rules may be so severe that individuals develop compulsive and exaggerated attempts to avoid or undo perceived transgressions, such as excessive confession about trivial shortcomings, self-­punishment, or repetitive self-­ purification rituals. Ironically, in scrupulosity, paralyzing concern with following moral rules often impairs the ability to participate in R/S practices. The person may stop attending worship services for fear of offending others or be so preoccupied with anxiety and guilt over perceived failings that she neglects opportunities to assert her values. Scrupulosity therefore points to the problem of holding to rules too tightly in that attempts at following R/S rules themselves become self-­defeating. Although rules can provide a useful way to direct R/S behavior, when rules become problematic, other approaches are warranted. A more flexible approach that R/S counselors can introduce involves identifying and strengthening contact with the valued qualities of the rules themselves and allowing this contact to guide the client’s future behavior. Drawing on the example presented at the beginning of this chapter, Mary’s counselor might invite her to first articulate the rule that she explicitly or implicitly is attempting to follow in not ending her marriage with her abusive husband (e.g., Divorce is a sin, I must not break my marriage vows). Once these verbal rules are articulated, they can be further explored in terms of the contexts in which they were taught to the client, whether it was in a family environment, through formal religious education, or through personal R/S devotions and study. If for whatever reason the counselor is not of the individual’s faith tradition (such as a hospital chaplain), offering validation of the important role these rules have played helps to ensure the individual does not perceive the counselor’s actions as somehow devaluing his previous religious beliefs. Rather, the counselor can emphasize that she is seeking instead to better understand and respect the importance of the rule in the client’s personal life. Once the content and context of the rule has been explored, the counselor can invite the client to shift focus more deeply into the value underlying it. The counselor may ask something to the effect of, “So this belief is clearly important in your life, and I’m wondering what is at the heart of it. What is this belief about for you?” By focusing the client past the surface-­level instructions of the rule to its personal significance, it becomes possible to explore the underlying values that give the rule meaning. For clients, rules that appear on the surface very restraining or harmful may be revealed to reflect deeply important and adaptive values such as loyalty, integrity, commitment, love, and compassion. Exploring the values underlying the R/S rules thus helps to distill the essence of why the rule is important in the first place. Once R/S values have been articulated, discussion can proceed to expand in terms of how the client has seen these qualities demonstrated through concrete actions in his own life. One might ask, “So what has this value looked like so far in 115

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your life? Where have you seen it in play and how has it shown up?” Care should be taken by the counselor to include other situations and contexts aside from the original rule in question to create a diverse palette of examples. This step will help put the rule in a broader context and may help clients see it as one stroke of a much larger painting. In the process of identifying the values underlying rules and expanding the range of possible behaviors that could reflect these values, the individual and counselor may explore ways in which the values underlying the rule could be enacted (e.g., “If it were up to you, how would you go about demonstrating that this was something important in your life?”). With the presence of additional options, clients may be asked to consider whether their current course of action is maximizing their ability to live these values in all domains of life and, if not, the counselor and individual can then work together to problem solve on how best to address this discrepancy.

Destinations vs. Directions R/S traditions often include moral expectations, a natural byproduct of which may be that adherents sometimes compare themselves or others against these standards. Sometimes these expectations are attached to religious figures that epitomize the essence of the religion’s value system. Such exemplars include the Islamic prophet Muhammed, the figure of Jesus Christ, or Gautama Buddha. By virtue of their role as models of the core values and beliefs of a religious tradition, such figures can and frequently are regarded with deep reverence and respect and so function as moral templates for R/S adherents. In addition to figures in R/S narratives, moral exemplars can also be observed within an individual client’s more immediate social networks. Families or other intimate groups that have strong historical ties to particular religious traditions may have attended a local site of worship for generations and have developed individual and family identities that are strongly associated with R/S piety and devotion. Prominent family members or other individuals within these R/S communities may thus serve as more immediate moral exemplars when individual clients use their R/S behaviors as blueprints after which to pattern their own spiritual development. Although these exemplars provide useful behavioral models, the way that R/S adherents relate to moral exemplars may also become problematic for their personal functioning depending on how the individual emulates the model. As the narratives of R/S exemplars often are used as ideal representations of values-­consistent behaviors, it is highly unlikely that they will resemble the lives and actions of typical R/S adherents. Far from perfection or holiness, many individuals presenting for counseling carry with them histories of having strayed from or violated their R/S values, and may be negatively comparing themselves to R/S exemplars. In other cases, individuals may 116

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lead lives highly devoted to their R/S tradition, and yet, for whatever reason, fall short of the magnitude or scope of devotion modeled by pious religious figures. In viewing this perceived discrepancy between themselves and R/S exemplars, clients may feel anxious, inadequate, or ashamed, assuming that they are not living their own R/S values, and label themselves as weak, irredeemable, or ruined (Ano & Vasconcelles, 2005). In more severe cases, repeated failure to meet or approach the standards set by R/S exemplars may lead to disappointment and disillusionment to the point that conviction to enact the R/S values themselves is reduced or abandoned. Clients believing they have violated their values may report, “Why try? My life is already messed up. I can never go back, so what’s the point?” On the other hand, those who feel inadequate in their efforts to live up to problematically high standards may express resignation through statements such as, “No matter how much I try, I’ll just never be good enough.” In these clients, their relationship to their R/S exemplars, rather than lifting them up as intended, can function to create additional emotional and psychological burdens. When R/S values and expectations are experienced by R/S adherents as inhibiting, rather than promoting, growth and vitality, it can be useful to reorient discussion to the ACT conception of values. In ACT, an important distinction is made between values and goals, with goals being defined as discrete objectives that can be achieved at some point in time (Hayes et al., 2012). For example, an individual may have the R/S goal of visiting a holy site, participating in sacred rites of passage, or taking a position of service or leadership within a religious community. Such R/S goals mark milestones in the spiritual journey of adherents toward the ultimate destination of greater spiritual awareness or connection to the sacred. In contrast to these R/S goals, R/S values reflect directions in life that can never be fully achieved. To be faithful in one moment does not relieve an R/S adherent from being faithful in the next moment, and so on for the rest of their lives. Although this stance places the responsibility of self-­awareness and self-­monitoring on individuals, it also frees them to return to values-­based living the very instant they choose to embrace it, regardless of their past success or failures in accomplishing goals. Whereas a goal initially set in the future eventually arrives in the present and then continues on into the past, values are seen as being confined wholly to the present moment. In other words, it is never too late to act on values. Quite the opposite, acting on values can only happen in the here and now. If clients struggle by negatively comparing themselves to R/S expectations, some exploration of these standards may be helpful in order to unearth the values that lay buried beneath the surface. To this end, a counselor might say, “I really can see how troubling it is for you that there’s this distance between where you are and where you’d like to be, but I guess it would be helpful to know what closing that gap represents to you. What would closing that gap mean?” The clients’ responses might then 117

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be mirrored back to them as reflecting implicit values they are already enacting in the present moment. It should be noted that values construction of this nature can also be paired with other core ACT processes, such as a willingness to be imperfect even if only while on the journey to perfection. Combining values-­based work with the other elements of ACT may help clients feel a deep sense of connection to their values even while recognizing that discrepancies will continue to exist between R/S ideals and their own efforts. As much or more difficult are instances where clients feel their own violations of R/S values have damaged themselves beyond redemption. Even in these circumstances, values can play a key role in opening the client to renewed engagement with life as it unfolds. Consider the following exchange between a client (CL) and counselor (CO) during a session: CL: I know I’m going to hell. I’ve done way too many bad things to get into heaven. CO: I remember you saying that earlier. It seems like that’s a thought that really leaves you lost about where to go in life. CL: No offense but even if I believed in a God, I don’t see how He could let me into heaven. CO: Well, I don’t really know what will happen after we die, but let’s just say for the sake of argument that you are going to a place like hell after this life. That still leaves you here now—­able to make choices. I’m wondering what would be the most meaningful way to spend the rest of your time on earth? CL: That’s kind of depressing. I try not to really think about it. CO: Yeah, there’s a lot of pain there and it makes sense to have the urge to avoid it. And, at the same time, I also want to ask if not thinking about it has actually made anything better. CL: Not really. I get really numbed out but then my wife feels like I’m distant. Then I start drinking and it kind of ruins everything. CO: So numbing the pain just seems to create more pain. What if we could make some space off to the side for that thought about where you’ll go in the afterlife, and focus instead on what you want to do in this life? CL: [Somewhat agitated] But if I’m going to go to hell, what’s the point? CO: [With softness in her voice] I know this may sound like a strange answer, but that’s exactly the question I’m giving to you. If you only had a year, or a 118

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month, or even one week, what would make that time worth it to you? What would be the greatest gift you could give yourself or someone else? What would you want your point to be? In this example, by choosing not to convince the client about an eternal destiny, it became possible to emphasize the client’s power to choose how to live in the present moment. As demonstrated in the example above, evoking contact with the client’s power to choose can sometimes elicit anxiety and irritation and so it is important that the counselor respond with compassion and gentleness. The foregoing example also illustrates that in working with clients who are disconnected from their R/S values, the counselor should not assume that success always equals helping the client reconcile with R/S beliefs. When appropriate, the counselor may instead focus on helping clients explore and construct a set of values, R/S-­oriented or otherwise, that they find personally meaningful and intrinsically fulfilling.

Protection vs. Pain Finally, a third way in which R/S values may function to either help or hinder individuals pertains to the ways that clients perceive values as related to pain and suffering. Human beings appear designed to avoid pain (e.g., when we touch a hot surface, we instinctively pull away). It is perhaps understandable then how many individuals approach R/S practices, at least in part, as a way to avoid pain and discomfort. To this end, they may choose to emphasize R/S teachings that promise an eventual escape from pain in the afterlife or that claim that obedience to R/S practices will guarantee protection from harm. Clients with these or similar beliefs may approach R/S values and practices as ways to avoid experiencing the pain inherent in human existence. Somewhat paradoxically, in ACT, pain and values are seen as intrinsically connected to one another. To value means to care and to care means to open oneself to vulnerability and the possibility of disappointment. Although this connection is difficult, it is also a necessary and growth-­promoting element of vitality that grants individuals a sense of purpose as they engage with life. Furthermore, the underlying theory of ACT suggests that most individuals will find it difficult to suppress the experience of particular unwanted emotions without suppressing emotional experience as a whole (Hayes et al., 2012). Thus, attempting to separate values from pain can result in a limited ability to experience meaning and wholeness across other domains as well. Despite individual attempts to separate the two, the intimate connection between values and pain has not been lost on many of the world’s ancient R/S traditions. From commitments to self-­denial such as celibacy, fasting, and vows of poverty to the even 119

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more remarkable examples of R/S adherents choosing to suffer imprisonment and martyrdom rather than deny their convictions, many R/S traditions have rich histories of individuals embracing pain as a necessary, though by no means easy, outgrowth of their spiritual values. Approaching the connection between pain and R/S values with clients may be assisted by inquiring about examples of what might be called “sacred pain” (Glucklich, 2001). The term sacred pain can refer to emotional or physical discomfort that is willingly experienced as a means or byproduct of developing greater spiritual connection or awareness. Sacred pain may range from the extreme examples of sacrifice to relatively simple acts such as an elderly man walking several miles to his worship services every week in order to demonstrate devotion to his faith. In these cases, the use of sacred values to dignify pain can transform the pain itself into something sacred as well. An example of sacred pain being used to help clients connect with their values was encountered with a client named Monica. Monica presented to therapy depressed and anxious. She had a history of childhood sexual abuse and chronic illness that left her struggling to cope with the demands of daily life. Despite her constant physical discomfort and deep sadness from the mistreatment she suffered as a child, Monica gravitated toward Eastern spiritual traditions as a means of seeing the good in the world and motivating herself to use what little resources she had to improve the lives of others. However, whenever Monica’s counselor would attempt to empathize with her emotional pain as it came into the room, Monica would quickly change the subject by noting an inspirational story she had read about or seen in the media. After this pattern occurred several times, the following conversation took place: CO: You know, Monica, I’m noticing that when I comment on something painful, you quickly change the subject. I’m wondering what that’s about. CL: Yeah, I guess I do that [smiles nervously]. I don’t really know why I do it. CO: I’m not sure either…but for some reason it also seems really important. CL: I guess…[Starting to become tearful] I guess I just feel like I’ve experienced so much pain in life already that I just don’t want to feel it anymore, you know? I want to be done with it and focus on positive things instead. Like this book I’ve been telling you about on the life of Gandhi. He lived this really wonderful, compassionate life and I just feel like it would be nice to focus on some humanity for a while instead of all the horrible, inhumane things in the world. CO: Sure, that makes sense. It makes sense why you wouldn’t want to get in touch with that pain, and yet it seems like that’s exactly where Gandhi would be if he were here. 120

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CL: What do you mean? CO: Well, one of the reasons you find Gandhi to be so inspirational is that he brought love and compassion to those places of inhumanity, right? [Speaking softly] He went and tended to those who were considered untouchable by society, those who had been cast out and ignored. CL: [Silent but showing signs of emotion in her face] CO: Could it be that you have places of inhumanity and pain in you, and that like Gandhi, you need to go and compassionately be with them? CL: [Crying openly and nodding] Yes, I get what you mean…I’ve just been scared of going there for so long that I’ve thought that I could keep that door shut and just ignore it. In this example, the client’s values of compassion and “being human,” as exemplified by Mahatma Gandhi, are reinforced by the counselor, not as an escape from pain and inhumanity, but as a response to it. By weaving these together, Monica was able to see the connection between experiencing her own pain and fully living her R/S values of compassion and connectedness. In addition to the above suggestions, it is also possible to adapt preexisting ACT exercises in order to address client’s R/S values. For example, the tombstone/eulogy exercise (Hayes et al., 2012) asks clients to imagine and discuss what they would want their inscription to read on the headstone at their gravesite or alternatively, what the content of their eulogy would be at their funeral if they had lived their life according to their values. Because many R/S traditions include beliefs and practices surrounding death and the afterlife, it is natural for many adherents of these traditions to place such exercises in an R/S context. Thus, in imagining their own memorial service, they may picture the service being held in a building of worship, led by a religious authority, and the eulogy referencing a life of spiritual devotion and values-­based living. Successfully incorporating R/S elements into standard ACT values and committed action exercises like these requires developing a thorough understanding of the function and salience of R/S issues for the client. Before embarking into these types of exercises, it is recommended that counselors have a solid understanding of the role of R/S practices and beliefs in their clients’ lives and to what extent the clients desire these practices and beliefs to inform their values (Vieten et al., 2013). As with all aspects of diversity, it can be helpful to learn from clients and from collateral sources about how their R/S tradition deals with common issues such as obedience, forgiveness, and reconciliation.

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Committed Action As can be noted from the foregoing sections, the process of values construction will generally entail discussion about committing to values-­related actions as well. In fact, the topic of R/S values frequently emerges in the context of questions about R/S practices and behaviors. Values construction interventions like those discussed previously can be helpful to first ground the client and counselor in a clear sense of the client’s R/S values before planning and committing to specific actions. This grounding helps ensure that actions are established in R/S values and not in other motivations such as social approval or the avoidance of pain. Once a clear sense of the client’s central values has been developed, the counselor and client can again revisit the issue of how to implement these values in the client’s life. As with the process of values construction, fostering committed action with regard to R/S values will be most effective when it is tailored to the individual client’s experiences and current context. Thus, counselors should ask clients how R/S values were enacted in their past and if there are any R/S practices they feel would reflect their values currently. Counselors may wish to ask their clients to be very concrete in this process in order to help specify replicable action steps to be engaged. For example, a counselor may ask a client, “If you saw someone living this value around town, what might you see them doing? Where would they go and what would they do there?” Follow-­up questions along these lines may be necessary to help narrow broad statements, such as “help others,” into more specific actions and goals, like “volunteer Saturday mornings at the soup kitchen on 47th Street.” If not contraindicated by perfectionism, R/S exemplars can also serve as useful templates after which clients can pattern their behavior. By eliciting narratives about the values-­consistent behaviors of R/S exemplars, counselors and clients can identify ways in which these behaviors can be generalized to the client’s current context.

Barriers to R/S Committed Action One common reason given by clients who fail to act in accord with their personal values relates to a mismatch between their preferred emotions and the behavior in question. For example, for many clients an avoidance of guilt, shame, or embarrassment prevents them from engaging in valued R/S activities like attending religious services, confessing wrongdoings, or making amends with others. When avoidance of discomfort has prevented the client from engaging in R/S behavior in the past, planning concrete R/S actions is likely to bring up anxiety and other difficult emotions. It may be helpful for counselors to have anticipated this issue with clients beforehand. A counselor might say to a client, “Now, as we talk about specific steps that would be 122

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in line with your spiritual values, it’s possible that we’re going to touch on some of those difficult emotions we talked about before. It’s okay if that happens, but let me know if it does so we can show up to it.” Then, if negative emotions do appear in session, the counselor can help the client to get in touch with the present moment and develop willingness around the emotional discomfort in order to continue forward with planning and taking specific action steps. Another mismatch between emotional experiences and R/S-­related actions can occur when clients experience an absence of emotion in relation to their R/S values. R/S beliefs, practices, and values often evolve over the course of an individual’s lifespan and may be accompanied by changes in the type and intensity of accompanying emotions. For some clients, this means that R/S practices that once engendered awe and inspiration now seem mundane or unexciting. If clients experience a lack of vitality about their R/S practices it warrants further attention in order to first assess whether there is a problem with value construction, as feeling bored may potentially indicate a disconnection from values. Second, potential areas of avoidance should be explored to make sure that an unwillingness to experience discomfort is not also impeding clients from connecting their values to a sense of vitality. If neither of these issues appear salient to the client’s experience, the counselor can explore whether the client’s unmet expectation for positive emotions is functioning to prevent value-­ oriented action. As discussed previously, many R/S traditions emphasize the importance of actions in engagement with their faith, rather than simply the pursuit of emotional states or intellectual assent. What is often less discussed in many R/S traditions are instances of spiritual crisis, doubt, or disillusionment despite continued R/S involvement. For these individuals, the absence of positive emotions associated with R/S practices may lead them to wonder if they have “lost their faith” or been abandoned by their deity (Exline & Rose, 2013). As before, reorienting to the nature of values can be helpful in freeing clients to make life-­enhancing and spiritually-­enhancing decisions. In particular, the counselor can note how emotions, like all internal experiences, are often outside the range of human control and will naturally change over time. In contrast, the values individuals select serve as an internal compass or rudder to steer them in a direct course regardless of fluctuations in emotional states. Said another way, whereas emotions are subject to change, values are subject to choice. Grounding committed action in values and not in emotions can be a powerful way to help clients intentionally decide what role they would like R/S practices to play in their lives. For some clients, the absence of positive emotions associated with R/S will indicate that it is time to reconstruct their values and explore growth in other domains and contexts of life. However, for others, engaging in R/S practices despite an absence of inspiring emotions can itself become a powerful example of values-­driven living. An example of this can be found with Mother Teresa of Calcutta 123

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who for many years, despite ongoing feelings of disconnection from deity and questioning of belief, continued to serve the poor and devote her life to the values she attributed to Jesus Christ. If spirituality can be defined as “the search for the sacred” (Pargament et al., 2013), then examples such as Mother Teresa demonstrate that the very process of searching for the sacred can be as much an R/S value as being able find and connect with the sacred itself.

Conclusion By integrating R/S values and actions into ACT, counselors may find greater opportunity to assist individuals in developing meaningful patterns of action. As a therapeutic approach, ACT is well suited to address R/S values and practices in ways that respect the personal and cultural meanings they present to clients. Likewise, ACT can offer valuable insights and possible directions to R/S leaders who provide counseling to those within their stewardship. In either case, ACT’s focus on enhancing flexibility and active engagement with values can assist individuals who have become trapped in unworkable patterns of living find new freedom and renewed purpose on their spiritual journeys. Returning to the example of Mary, presented at the beginning of this chapter, may serve as a final illustration of how connecting to R/S values can help free clients in moving forward. Sessions with Mary involved coming into contact with immense amounts of pain and grief over the years of silent suffering she experienced at the hands of her violent husband. She frequently noted how different she had imagined her future before marriage and how for so long she had hoped that it would eventually come true. She continued to feel intense ambivalence about taking protective action against her husband. Exploring Mary’s values, however, showed that more was at stake for her than her marriage. In discussing the costs of remaining in the relationship, she acknowledged that her children and grandchildren had been and would continue to be negatively affected by her husband’s presence. For Mary, this recognition was powerful because she viewed her role as a mother and grandmother as equally sacred and as much a part of her commitment to God as was her role as a spouse. Invigorated by her sense of devotion to her posterity, she made the commitment to file a restraining order against her husband and stopped receiving letters and phone calls. She also began the process of filing for divorce. In the midst of these actions, Mary was also committed to finding ways to honor her marriage vows. Even in the midst of the divorce process, she continued to show respect for the man with whom she had once fallen in love. Rather than throw away his belongings, Mary made efforts to store them with his family members. Despite 124

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continuing to feel anger toward him for his actions, she chose to pray for her husband’s well-­being as a way to demonstrate forgiveness and acceptance of the past. Although she continued to carry tremendous emotional pain, she took solace in not exacting revenge but instead “letting God be the judge” of her husband’s actions while she began life anew surrounded by her children and grandchildren.

References Ano, G. G., & Vasconcelles, E. B. (2005). Religious coping and psychological adjustment to stress: A meta-­analysis. Journal of Clinical Psychology, 61, 461–­480. Cefalu, P. (2010). The doubting disease: Religious scrupulosity and obsessive-­compulsive disorder in historical context. Journal of Medical Humanities, 31, 111–­125. Exline, J. J., & Rose, E. D. (2013). Religious and spiritual struggles. In R. F. Paloutzian & C. L. Park (Eds.), Handbook of the psychology of religion and spirituality. (4th ed., pp. 380–­398). New York: Guilford Press. Glucklich, A. (2001). Sacred Pain: Hurting the body for the sake of the soul. New York: Oxford University Press. Graham, J., & Haidt, J. (2010). Beyond beliefs: Religions bind individuals into moral communities. Personality and Social Psychology Review, 14, 140–­150. Hayes, S. C. (1984). Making sense of spirituality. Behaviorism, 12, 99–­110. Hayes, S.C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: An experiential approach to behavior change (2nd ed.). New York: Guilford. Koenig, H. G., McCullough, M., & Larsen, D. B. (Eds.). (2001). Handbook of religion and health: A century of research reviewed. New York: Oxford University Press. Oman, D. (2013). Religion and spirituality: Evolving meanings. In R. F. Paloutzian & C. L. Park (Eds.), Handbook of the psychology of religion and spirituality (2nd ed., pp. 23–­47). New York: Guilford Press. Murrell, A. R., Schmalz, J. E., & Sinha, A. (2014). Religion and spirituality in acceptance-­and mindfulness-­based treatments. In A. Masuda (Ed.), Multicultural approaches to acceptance and mindfulness (pp. 166–­180). Oakland, CA: New Harbinger Publications. Pargament, K. I., Mahoney, A., Exline, J., Jones, J., & Shafranske, E. P. (2013). Envisioning an integrative paradigm for the psychology of religion and spirituality. In K. I. Pargament, J. Exline, J. Jones, A. Mahoney, & E. Shafranske (Eds.), APA handbooks in psychology: APA handbook of psychology, religion, and spirituality. Vol. 1, Context, theory, and research. Washington, DC: American Psychological Association. Park, C. L., & Edmondson, D. (2011). Religion as a quest for meaning. In M. Mikulincer and P. Shaver (Eds.), The psychology of meaning. Washington, DC: American Psychological Association. Sosis, R., & Alcorta, C. (2003). Signaling, solidarity, and the sacred: The evolution of religious behavior. Evolutionary Anthropology, 12, 264–­274. Vieten, C., Scammell, S., Pilato, R., Ammondson, I., Pargament, K. I., & Lukoff, D. (2013). Spiritual and religious competencies for psychologists. Psychology of Religion and Spirituality, 5, 129–­144.

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PART 3

ACT Across Different Religious Landscapes

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art of what is appealing about ACT as a model of evidence-­based intervention for pastoral counselors, chaplains, and clergy is that it addresses core issues that connect with a wide variety of spiritual and religious traditions. ACT is not a religion and does not take religious positions, but its focus on common core issues in human functioning dovetails remarkably well with all of the world’s major religious traditions and indeed with people who are spiritual and not religious. This fit is so tight that it is common when ACT becomes known to specific religious traditions for it to be thought that ACT was derived in part from these specific traditions. Over the years, I have received notes and e-­mails from people asking if ACT derived from Jewish mysticism, Buddhism, Christian mysticism, Sufi writings, Hinduism, and several others. It is interesting that the questions usually do not have to do with specific religious dogmas or even practices. The most common connection is with religious mysticism, and the larger space in which religion functions. There is a reason for that. All of the major religious and spiritual traditions have mysticism and spiritual experience at their core. Often the religious or spiritual leaders who established the specific tradition were themselves people with mystical experiences. Every mystical method in the world’s great religions undermines a linear, analytic, judgmental, problem-­solving mode of mind. People in these traditions seek wisdom and spiritual transformation through silence, chanting, dancing, koans, mantras, meditation, prayer, focused attention, open attention, focused movement, and other practices, but what is common to all of these methods is that that they undermine a more usual problem-­solving mode of mental activity. Neuroscientists and behavioral scientists more generally note that mystical practices lead to changes in brain activity, emotional responsivity, attentional control, and similar processes. They also lead naturally to an expanded sense of awareness in which there is a sense that the limits of time, place, and person are diminished and the dominance of social interconnection, in consciousness, is enhanced.

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Every major spiritual and religious tradition uses these more spiritual modes of mind to foster self-­care and caring for others. Issues of forgiveness, self-­acceptance, values, empathy, pro-­social action, and so on are generally argued by spiritual and religious leaders to be positive markers of a spiritual life. Here is another way to say this: spiritual and religious practices are designed to foster experiences and actions that are touched on by the psychological flexibility model. The spiritual and religious traditions were there first. ACT and the psychological flexibility model did not arrive in this common place because it mimicked spiritual and religious traditions. Rather they arrived at the same place because that place is important, and a scientific focus on what is fundamental and common in human experience leads there. A metaphor may help. Suppose we arrived in a beautiful clearing deep in the forest—­a place with expansive vistas, room to play, and plenty of food and water. In the clearing there were many groups of people in different corners of the clearing and each group had come there by following a distinctive path. It might be disorienting to see that different groups arrived there by taking different steps, but those different steps would not undermine the importance of that place one iota. Many paths led there precisely because the clearing itself was so profoundly useful. As we will see in each of the chapters in this section, ACT overlaps with the major religious and spiritual traditions. It overlaps with Judaism, with Christianity, with Islam, and with Buddhism. Each of them also overlaps to a degree with each other, and all of these religious traditions also overlap to a degree with the issues thought to be important by those who are spiritual but not religious. To be sure, each of these is distinctive as well. One corner of the clearing is not the same as another, and the path to get there may matter too. By no means are we suggesting that all religions are the same, nor that ACT covers the same territory as religious traditions. Our point is merely that at a deep level there is a shared space. It is that space that allows religious communion across denominations and faith traditions, but we hope that it also allows the use of scientifically derived and validated principles of behavior that are connected with and are supportive of the spiritual and religious views of clergy, pastoral counselors, and chaplains. That exciting possibility is precisely what ACT provides. That is the grand vista this section is designed to open up. —Steven C. Hayes, PhD

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CHAPTER 7

ACT and Buddhism Hiroaki Kumano, MD, PhD Waseda University, Japan

Phrayuki Naradevo Wat Pa Sukato, Thailand

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n this chapter, the Buddha’s life and teachings are initially explored, followed by an outline of the Buddhist core teachings and practices in reference to the acceptance and commitment therapy (ACT) perspective. The authors of this chapter bring both sides of this dialogue to the writing. The first author is an ACT therapist and researcher in Japan and the second is a Japanese monk of Thailand Theravada Buddhism. Together we have been researching this area in previous writings (see Phrayuki & Kumano, 2014).

The Buddha and Psychological Flexibility Although it is difficult to express an individual’s personality and characteristics, if we have the courage to describe the Buddha’s personality, then the word “flexibility” is apt. In this case, flexibility means being “soft and supple.” Maintaining one’s physical flexibility is important to living a healthy life. This is the same for the mind. Psychologically flexible individuals suffer less psychological damage, and are not prone to mental disorders even if unpredictable events occur in their lives (see Kashdan & Rottenberg, 2010). In other words, they live a psychologically healthy life. It was the Buddha who aimed to cease all types of suffering, beginning with himself. According to the Buddhist tradition, even when he was told something unreasonable, verbally abused for something without being responsible, or on the verge of being killed, he simply accepted it and interacted with the other individual without anger or confusion. This raises the question of how the Buddha learned to have such a flexible mind. It must have been accomplished through the Buddha’s meditation that was said to be supreme “calisthenics of the mind.”

The Buddha’s Meditation The Buddha’s meditation is currently referred to as “mindfulness meditation” or “vipassana meditation.” The Buddha had been practicing all types of penance, including severe fasting, since he had entered the priesthood. Initially led by two prominent teachers, he enthusiastically performed meditation for concentration (samatha meditation) after which his ability eventually exceeded that of his elders. However, he could not obtain enlightenment and culminate suffering. Thus, he left his teachers to practice vipassana meditation, and gained wisdom by understanding the body and mind as they were and finally attained a total release from suffering. The pronounced feature of mindfulness meditation is to see and observe all of the mental formations as they are, without any evaluations. Unlike the concentration meditation that was widely practiced in India at that time, which aimed to control 130

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the mind and obtain silent mystic experiences by concentrating on one particular object, the meditators accepted, observed, and focused on all the phenomena occurring in the body and mind with awakened consciousness and discernment of wisdom. Only then can one be released from all attachments and allowed to obtain total liberation. It is this type of meditation that cognitive and behavioral therapies, such as ACT, apply in their theories and practices. Jon Kabat-­Zinn, one of the leading figures who introduced mindfulness meditation into psychiatric and psychosomatic medicine, expressed mindfulness as follows: “Paying attention in a particular way, on purpose, in the present moment, non-­judgmentally” (Kabat-­Zinn, 1994, 4). This definition can be regarded as a summary of the practices exercised in mindfulness meditation. Traditionally, four foundations of mindfulness are sought to be systematically developed during meditation: 1) the body, 2) feelings, 3) mental formations, and 4) wisdom (Rosenberg, 1998). Mindfulness meditation not only cultivates the power of mindfulness but also the following five faculties: 1) disillusionment/mindfulness, 2) willingness/faith, 3) commitment/persistence, 4) receptivity/concentration, and 5) insight/ wisdom. These faculties can be viewed in reference to the psychological flexibility of ACT; thus, we will review them in a later section.

Loving-­Kindness, Compassion, and the Method of Preaching We usually live a life believing that we have a self or an ego, as seen in the well-­ known phrase, “I think, therefore I am.” Moreover, as long as we believe in a self, we should live in the service of the ego and in fear of its collapse and death. We, so to speak, unknowingly become prisoners of the ego, bound by a fixed mindset, and are driven by the desire to demonstrate that we are “good people.” The Buddha realized that no self exists in the phenomena of the body and mind, and attaching to anything as “me or mine” is the cause for suffering. In other words, if we were to free ourselves from such attachments, then suffering would cease. Furthermore, we would be free from self-­centeredness (living “for me”), after which we could help resolve others’ suffering. The five aforementioned faculties cultivated by meditation would be directed to others and become the powers of seeing, confidence, commitment, acceptance and empathy, and comprehension toward others. In this case, the desire to eliminate the suffering of others is referred to as “loving-­ kindness and compassion.” One well-­known story demonstrating Buddha’s loving-­kindness and compassion as well as mental flexibility is the story of Kisa Gotami. After losing her only child, she became so desperate that she carried the dead child to all her neighbors and 131

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begged for medicine until a sympathetic old man told her to meet the Buddha. With futile intentions, she visited the Buddha and was instructed the following: “Bring back a handful of mustard seeds, provided that it be taken from a house where no one has died.” She immediately went from house to house with her dead child in her arms. As people offered her mustard seeds, she would ask, “Did you lose someone in your family?”, after which they consistently answered, “Of course we did.” After searching the entire town in vain, she eventually realized the truth that death was common to all. She then regained her senses and buried her dead child; she became a nun and eagerly meditated to become totally awakened. In this story, the Buddha did not present a sound argument to Kisa Gotami, who was confused because she could not accept the death of her beloved child. Rather, the Buddha first accepted her as she was, indicated a way in which she could help her child, and then gave her enough time to regain her senses. Such actions show that the Buddha was an extremely skillful teacher who acknowledged an individual’s situation and ability to understand his teachings. In Japanese, this is referred to as taiki-­seppo, or “the best suitable expression of teaching for the target audience.” The Buddha, who had attained full awakening by himself, hesitated to preach his teachings initially since they were simply very difficult to convey to others. However, he eventually changed his mind and continued performing missionary tours until his death at the age of 80. Taiki-­seppo enabled the distribution of his teachings to a diverse range of people after which it has continued to release the suffering of individuals even thousands of years later. The Buddha’s adoption of taiki-­seppo is one of the significant examples of his flexibility. Additionally, the Buddha was not the only one who attained full awakening but he was a prominent teacher. This is why the Buddha is called “the man with wisdom and action.”

Buddhist Core Teachings and ACT Assumptions As mentioned earlier, Buddhism is a religion that has enabled individuals to relive the Buddha’s enlightenment by practicing the same procedures that he utilized thousands of years earlier. It is not a religion in which followers believe that a so-­called superpower will eventually rescue them, but a religion in which one attempts to attain full awakening through a deep seeing into one’s mind and body. Moreover, the Buddha, through his teachings, asks that we examine the outcomes of practice in order to see if the teachings are true. Basically, there is just one teaching in Buddhism, but it is expressed in two ways: commonsensical truth and ultimate truth (Inoue, 2005). Commonsensical truth is 132

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the truth for everyday living, and the causes of suffering and their solutions are explained by the Four Noble Truths based on the Buddha’s personal experiences of the inevitable sufferings (birth, aging, sickness, and death) in human life. However, the ultimate truth is the truth from a scientific or at least an empirical perspective, and the mechanisms underlying suffering and their solutions are explained by the Twelve Links of Dependent Origination, based on the Buddha’s meditation experiences.

The Four Noble Truths The Four Noble Truths are as follows: 1) there is suffering; 2) there is a cause for such suffering; 3) there is an end to it; and 4) there is a means to that end. The truth about suffering points out the basic unsatisfactoriness of our lives. All things, including our bodies and minds, are ever-­changing (impermanence) and none of them can be sufficiently controlled (not-­self). The truth about the cause of such suffering points out that we tend to suffer when we crave something. Three defilements or poisonous states of the mind, including greed, hatred, and delusion, are the immediate consequences of craving, after which they proliferate into all types of suffering. The truth about an end to such suffering is that a cessation will occur when we let go of these cravings. How we can let go of such cravings? The answer to this question is expressed in the last truth regarding the means to the end of suffering: a deep seeing into the formations of the body, the feelings, and the mind. We can easily understand that there are striking similarities between the first truth about suffering and the assumption of destructive normality of ACT (Hayes, Strosahl, & Wilson, 1999; 2012). ACT was designed as a transdiagnostic treatment approach based on the common core processes that can account for human psychological suffering. According to Hayes, Strosahl, and Wilson (1999; 2012), when ACT was developed in the early 1980s, it began with fairly simple and straightforward questions such as the following: How is it that bright, sensitive, caring people who have everything they need to survive and prosper in life must endure such suffering? Are there ubiquitous human processes that somehow are linked to widespread suffering? Can we develop a solid theoretical understanding of how suffering develops and then apply psychological interventions to neutralize or reverse the core processes responsible?

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These questions are much like the latter three truths. From an ACT perspective, human suffering is assumed to emerge from normal psychological processes, particularly those involving self-­reflective language and thought (Hayes et al., 1999; 2012). Then, how is this applied in Buddhism? To answer this question, let us refer to the Twelve Links of Dependent Origination that logically describe the mechanism behind the Four Noble Truths.

The Twelve Links of Dependent Origination The Twelve Links of Dependent Origination are the cause-­and-­effect chains that begin with ignorance and end with suffering, which are said to be the contents of the Buddha’s insight during his first awakening experience. The twelve links can be categorized into two types of causal chains: causes in the past that produce the effects in the present, and causes in the present that produce the effects in the future. While the former is already determined before birth and cannot be changed, the latter can be modified in everyday life, which is not possible without conscious effort. Additionally, the former chain consists of: 1) ignorance, 2) activities, 3) consciousness, 4) mind and matter, 5) six sense-­spheres (including sense organ-­object pairs), 6) contact, and 7) feelings, while the latter chain includes: 8) craving, 9) attachment, 10) action, 11) birth, and 12) suffering. These two chains connect at the point between feelings and craving and at the point between suffering and ignorance since samsara (“wheel of life”) is assumed in Buddhism (see Figure 1). Feelings are extremely important in Buddhist theory and practice. Moreover, feelings that are used synonymously with sensations refer to everything that enters through the “six sense doors” including the automatic thoughts of the mind. There is an immediate and spontaneous feeling that is either pleasant, unpleasant, or neutral when we sense every object. Craving usually ensues and produces either greed, hatred, or delusion depending on the color of the feelings. The experiences of those poisonous states of the mind are countlessly repeated and the entire processes are respondently and operantly conditioned into attachment. Finally, the action pattern or identity is formed, and it composes our daily lives. The strategy of Buddhism for providing an end to suffering is to cut the weakest link in the chain, which is possible by thoroughly seeing the link and withholding responses thereafter. In this regard, the Buddha saw feelings as the ideal target since they condition the way in which the mind behaves. Mindfulness can alter that connection somewhat, by short-­circuiting the process. If we can catch feelings at their source, if we can skillfully see them, we can liberate ourselves from unnecessary suffering (Rosenberg, 1998).

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Effects in the Future

Causes in the Past

Causes in the Present Effects in the Present

Figure 1: The Wheel of Life

Buddhist Concepts and ACT Behavioral Processes It has been stated that all of the Buddha’s teachings can be reduced to one statement: under no circumstances attach to anything as “me” or “mine” (Rosenberg, 1998). “Selfing” is the function of delusion or ignorance; thus, the goal of the Buddhist approach is to burn up ignorance by clear seeing of it. Additionally, four levels of enlightenment are known in the Buddhist tradition, and they differ regarding to what extent attachment to selfing is released.

Defilements and ACT Pathological Processes It is evident that pathological processes as defined by ACT are related to the links between feelings, craving, attachment, and action. Feelings produce greed, hatred, and delusion, while the selfing function of delusion produces identification 135

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with either greed or hatred. Furthermore, the basic function of delusion or ignorance is selfing, which in ACT is viewed as fusion with the “conceptualized self” and the “conceptualized past and future.” Greed brings about behaviors that grasp all the contents of the body and mind at that moment; thus, it conditions “cognitive fusion.” Finally, hatred brings about behaviors that eliminate all the contents of the body and mind at that moment; thus, it conditions “experiential avoidance.” From a Buddhist perspective, these poisonous states of mind grow if we cannot catch feelings at their source. However, the method of preventing such states of mind from further proliferation is the same as that for feelings, that is, thoroughly seeing and experiencing greed, hatred, and delusion and withholding responses thereafter.

Five Faculties and ACT Core Processes The five faculties cultivated by mindfulness meditation (mentioned earlier) can be viewed in reference to ACT core processes. The first faculty, “disillusionment,” is almost the same as Kabat-­Zinn’s “mindfulness.” It is the faculty to see and become aware of all of the phenomena of the body and mind as they are, without any evaluations. This faculty frees us from being fused with others’ words and deeds, losing contact with the present moment, and pondering useless thinking, through which “defusion,” “acceptance,” and “self-­as-­process” gradually develop. This can allow meditators to always be vividly aware of the phenomena occurring “here and now” in order to live a mindful life. The second faculty, “willingness,” means having an attitude of being open to facing whatever phenomena occur in and out of the body and mind. This allows meditators to cultivate an attitude of not setting a priori standards of good or evil (or of what is valued or not) as well as faithfully accepting whatever sensations, emotions, and thoughts arise in order to learn from them all. Additionally, they learn to let go of their fear and angst against undesirable objects and live cheerful and active lives. The third faculty, “commitment,” means having relations with all of the phenomena with devotion and pure curiosity. In this case, dependency, indecisiveness, and weak will are abated, whereas self-­control, confidence, and independence are cultivated. The fourth faculty, “receptivity,” combines not only stability but also the vast capacity of the mind, which is realized by sustained concentration. In this case, meditators do not become disturbed or anxious about whatever occurs, and they have stability, tranquility, and equanimity of the mind. Furthermore, they have positive feelings such as rapture and happiness. The three faculties of willingness, commitment, and receptivity gradually develop the field of the mindful self, which is equivalent to “self-­as-­process” and “self-­as-­context.” 136

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Finally, the fifth faculty, “insight,” means observing all the formations of the body and mind as they are. The wisdom of impermanence, suffering, and not-­self is realized concerning all the phenomena of the body and mind as well as the laws of relationships with other people, through which “self-­as-­context” matures. Meditators can be released from various attachments and are likely to achieve full enlightenment and liberation from suffering. Through the aforementioned five faculties, there is a mindful consciousness, a willingness to face and accept all phenomena faithfully, and an understanding and realization of total wisdom. These faculties not only help prevent suffering but they also cultivate another precious quality of the mind: loving-­kindness and com­passion.

Summary The Buddhist approach is clearly based on the non-­self regarding all the formations of the body and mind; thus, it stresses mindfulness and acceptance processes more than commitment and behavioral change processes. In fact, it actually aims to let go of all “selves,” especially conceptualized ones. ACT also sees little or no use for attachment to the conceptualized self, although like any thought or emotion, considering its presence may reflect one’s history. One point of difference is the great emphasis in ACT on values choices, which does not have a clear parallel in Buddhism. Does this mean that Buddhists spend most of their lives performing meditation and committing few prosocial actions? Definitely not. The answer to the question is derived from the aforementioned explanation regarding loving-­kindness and compassion. In other words, if we are free from self-­centeredness, then we can focus on the suffering of all beings. Prosocial behaviors thus ensue and become more interrelated and altruistic. This type of commitment is argued in ACT to flow from perspective-­taking and empathy, provided the person is low in experiential avoidance. This entire domain may be a fertile realm for ACT to explore in relation to Buddhist teachings.

References Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). New York: Guilford Press. Inoue, U. (2005). Teaching of awareness through respiration: Discussion on “Anapanasati Sutta” in Pali. Tokyo: Kosei Publishing.

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Kabat-­Zinn, J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday life. New York: Hyperion. Kashdan, T. B., & Rottenberg, J. (2010). Psychological flexibility as a fundamental aspect of health. Clinical Psychology Review, 30, 865–­878. Phrayuki, N., & Kumano, H. (2014). The practice of clinical psychology and Buddhism for coping with “anger.” Samgha Japan, 16, 33–­82. Rosenberg, L. (1998). Breath by breath: The liberating practice of insight meditation. Boston: Shambhala Publications.

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CHAPTER 8

ACT and Islam K. Fatih Yavuz, MD Bakirkoy Mazhar Osman Mental Health and Neurological Diseases Education and Research Hospital, Istanbul, Turkey

ACT for Clergy and Pastoral Counselors

Do not say I’m in my self I am not in me There is an I within me Deeper than me. —­Yunus Emre (1240–­1321)

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ognitive behavioral therapies (CBTs) have a great deal of empirical data for working with psychological problems (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012). Most CBT approaches focus, however, on aversive symptoms and problematic behaviors rather than functionality, growth, and prosperity. This tends to diminish the emphasis in traditional CBT on experiences of the client that are related to the cultural and faith-­related contexts of the client’s life. As a form of third wave CBT, acceptance and commitment therapy (ACT) has a unique place that helps change that emphasis, with its intentional focus on a valued life along with several other specific features. ACT not only sees values-­based living as an opportunity to increase functional behaviors; it also treats values as a compass for a meaningful life. For many clients, one of the most important areas of a values-­based life is religion and/or religious belief systems. Islam is one of the three Abrahamic religions and the second largest. It has a very unique structure with revelation (wahy) as an epistemological base and a prophet-­ referenced behavioral model (sunnah). In addition to routine religious practices and rituals, Islam puts forward general—­and sometimes specific—­moral and ethical principles for believers and for all humankind. These general principles, depending on context, encompass all moments and areas of living for Muslims. Accordingly, Islam expects that Muslims will behave consistently with these principles rather than being under the control of immediate short-­term goals of daily life. Islam and functional contextualism, the philosophical foundation of ACT, share many intersecting points both conceptually and practically. While there are of course differences in these two traditions, this chapter will focus on intersections between the six processes in ACT’s psychological flexibility model and Islam’s approach. Because of the many different Islamic interpretations, we will use main Islamic resources, The Holy Qur’an, and Prophet Muhammad’s (peace be upon him) accounts or hadiths.

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Intersections Between the ACT Model and Islam As a clinical model of ACT, psychological flexibility includes six interconnected dimensions called acceptance, cognitive defusion, contact with the present moment, self-­as-­context, values, and committed actions (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). ACT aims to increase psychological flexibility by using interventions oriented toward these dimensions. For this reason, the present chapter will be organized around them. Examining interactions between common aspects of Islam and an ACT model of psychological flexibility may help clergy and counselors enhance their ACT interventions when working with Muslim clients.

Acceptance ACT emphasizes the importance of acceptance, which is an intentional stance of openness and willingness toward experiences in a particular moment (Hayes et al., 2006). Acceptance is not an attitude of fatalism or resignation; rather it is a way of relating to internal experience in order to live a more values-­based life. There are many similarities between Islam and ACT on the subject of acceptance. Islam leads Muslims to take certain actions when they encounter aversive or appetitive stimuli that reflect on acceptance in interesting ways. Islam emphasizes a stance called sabr [(‫ )ربص‬meaning patience, endurance, and self-­restraint] when faced with an aversive stimulus. As a term, sabr appears more than 70 times in The Holy Qur’an and is viewed as an essential quality of a Muslim individual and community. It contains an active aspect involving faith and behaving in accordance with a meaningful life rather than struggling with or retreating away from an aversive situation or stimulus. The Holy Qur’an suggests Muslims to dhikr [(‫)ركذ‬ meaning remembrance of God] Allah and persist toward values based on what the context requires. For example: “Except for those who are patient (sabr) and do righteous deeds; those will have forgiveness and great reward” (Hud#11). Another verse from The Holy Qur’an says: “And We will surely test you with something of fear and hunger and a loss of wealth and lives and fruits, but give good tidings to the patient (sabr)” (Baqarah#155). The Holy Qur’an also tells the parable of Prophet Yunus. He was distressed because his people denied him, and Yunus went off in anger (Anbiya’#87). The Holy Qur’an says: “Then be patient (sabr) for the decision of your Lord, [O Muhammad], and be not like the companion of the fish (Yunus) when he called out while he was distressed” (Qalam#48).

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Prophet Muhammad also has several hadiths on sabr. One is, “Whoever remains patient, Allah will make him patient. Nobody can be given a blessing better and greater than patience” (Khan, 1976a). Thus, Muslims are asked to be patient (sabr) and to persist in their commitments when encountering an aversive situation. As told in Prophet Yusuf’s parable, giving up a committed action related to values as a result of an aversive stimulus is not approved of in Islam. The presence of this example in The Holy Qur’an from a prophet’s life shows how important it is to continue to take action even in the face of wanting to avoid pain. Allah also gives a harbinger of ease to humans; The Holy Qur’an says: “Indeed, with hardship [will be] ease. So when you have finished [your duties], then stand up [for another].” (Inshirah#6–­7). In this verse, we can also see the advice about remaining active and engaged in the moments of our life. Humans are often focused on immediate positive consequences as well. This too can become a problematic behavioral pattern if it starts to narrow the person’s behavioral repertoire and cause him to be insensitive to long-­term goals and values. ACT, again, does not aim to directly change the intensity or frequency of the appetitive stimulus, but rather proposes that people build a rich and meaningful life by using acceptance to widen repertoires linked to long-­term values. Here also we can see similarities between ACT and Islam. Islam addresses the problem of behavioral excess and following appetites when they conflict with values. For example, The Holy Qur’an says: “O children of Adam, take your adornment at every masjid, and eat and drink, but be not excessive. Indeed, He likes not those who commit excess” (A’raf#31). Additional verses from The Holy Qur’an say: “…So follow not [personal] inclination, lest you not be just…” (Nisâ’#135), and “But as for he who feared the position of his Lord and prevented the self (nafs) from [unlawful] inclination. Then indeed, Paradise will be [his] refuge” (Nâzi’ât#40–­41). We understand from these verses of The Holy Qur’an that the main problem is not having inclinations, needs, or behavioral dispositions; rather Allah asks humans not to follow them if they will be incongruent with a just and meaningful life. Additionally, The Holy Qur’an says: “…And this worldly life is not but diversion and amusement. And indeed, the home of the Hereafter—­ that is the [eternal] life, if only they knew” (Ankabut#64). Islam always turns the attention of humans to long-­term consequences and suggests actions on how to remain on this path. In summary, when faced with an aversive or an appetitive situation that might deflect from values-­based actions, Islam suggests being in the moment (dhikr) while keeping with a behavioral pattern of values-­based living rather than avoidance. Islam always advises humans to focus on long-­term consequences rather than immediate positive consequences. This strategy can be useful in promoting ACT’s acceptance and willingness processes, especially with Muslim clients.

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Cognitive Defusion Defusion, a posture that involves distancing from cognitive content and taking perspective, is another dimension of the ACT psychological flexibility model (Hayes et al., 2006). ACT aims to change the function of cognitions rather than necessarily changing their content. Defusion and acceptance can provide a space of awareness, allowing more attention to chosen values. Islam also addresses at least two points in regard to thoughts and thinking. One is about thought content and the other is about thinking behavior. In The Holy Qur’an, Allah uses a specific term for negative thought content called waswasa (repeated, unfounded doubts, fears), which is especially about faith. An example is: “And We have already created man and know what his self (nafs) whispers (waswasa) to him, and We are closer to him than [his] life vein” (Qaf#16). As we see in this verse, The Holy Qur’an uses perspective (“self/nafs” and “us”) to separate waswasa content from humans. Besides a defusion emphasis, there is also reference to awareness of the closeness of Allah and humans, which will be a timeless reminder of life’s meaning and togetherness. Waswasa also functions as labeling these thoughts, empowering a kind of defusion. In the same way, in one of His hadith, Prophet Muhammad said: “Undoubtedly—­as long as they do not behave like that—­ Allah exempt my people from questioning because of their inner thoughts” (Khan, 1976b). Here again, it can be easily seen that, from Islam’s perspective, the important point is behaving toward a meaningful life with or without distressing or intrusive thought content. The second issue related to defusion is the approach of The Holy Qur’an to thinking behavior. Theologically, acknowledging the content of The Holy Qur’an is an essential requirement for Muslims. So a Muslim individual has a unique stance that human thinking (behavior) is always prone to deficits. Only The Holy Qur’an’s content has no deficits because of Its source, Allah. This point has been told in several verses of The Holy Qur’an. One example is: “And do not pursue that of which you have no knowledge. Indeed, the hearing, the sight and the heart—­about all those [one] will be questioned” (Isra#36). We can see a strong emphasis leaning toward defusion from this verse. In addition to this, the highlighting of awareness (hearing, sight, and heart) is also remarkable. From this verse, we also learn that knowledge cannot be obtained without hearing, seeing, and wisely thinking. In another verse, The Holy Qur’an says: “But perhaps you hate a thing and it is good for you; and perhaps you love a thing and it is bad for you. And Allah Knows, while you know not” (Baqarah#216). Here human thinking is itself categorized as a human action that is not error free. According to The Holy Qur’an, humans need to behave in accordance with their values rather than with respect to their own thinking processes. One more verse from The Holy Qur’an emphasizes this stance: “O you who 143

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have believed, avoid assumption too much. Indeed, some assumption is sin…” (Hujurat#12). This verse of The Holy Qur’an also emphasizes the potential negative consequences of human assumptions and thinking behavior. In conclusion, the standpoint of Islam helps humans to take perspective on their thoughts and thinking behaviors and suggests that they take actions in accordance with a meaningful life rather than suggesting new thinking styles.

Contact with the Present Moment Flexibility in the present moment is a fundamental skill for values-­driven behaviors. ACT promotes contact with present-­moment stimuli as a part of opening a space for psychological flexibility (Hayes et al., 2006). In contacting the ongoing moment, a sense of self called “self-­as-­process” is contacted, and being aware of this sense of self assists in helping us to notice our experience from a nonjudgmental perspective. This kind of present-­moment awareness is very important for the Islamic faith. As mentioned before (Inshirah#6–­7), Islam always inspires humans to live with purpose. There is no “dead” time for a Muslim. The Holy Qur’an says that: “Whoever is within the heavens and earth asks Him; every moment He is bringing about a matter” (Rahman#29). Allah is creating every moment and humans have to be aware of every moment if they want to be successful in living fully and experiencing the meaning of life. Prophet Muhammad says: “If the Day of Judgment erupts while you are planting a new tree, carry on and plant it” (Pekcan, 2013). It’s very clear in this hadith that being in the present moment and acting toward values, without attachment to the past and the future, is a fundamental principle in Islam. This is also an example of a values/process-­based approach rather than a goal-­oriented approach. The Holy Qur’an, in several verses, has suggested being mindful at the moment, especially in difficult situations. One verse is: “So be patient over what they say and exalt [Allah] with praise of your Lord before the rising of the sun and before its setting; and during periods of the night [exalt Him] and at the ends of the day, that you may be satisfied” (Taha#130). Praise during difficult situations can help release an individual from cognitive entanglement and bring him or her into present moment awareness. Another verse from The Holy Qur’an points to the importance of being wisely aware during the day: “Who celebrate Allah while standing or sitting or [lying] on their sides and give thought to the creation of the heavens and the earth, [saying], ‘Our Lord, You did not create this aimlessly; exalted are You’” (‘Ali Imran#191). The most fundamental and common prayer ritual of Islam is salat, which has to be performed five times a day. Each prayer provides present-­moment awareness about what is going on in life. Another essential behavior in Islam, called tawba (means 144

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retreating or returning to the right path), is a unique way of returning to present-­ moment awareness and values-­based actions. Tawba takes the person out of failure-­ related ruminative processes and motivates him or her to meaningful actions. It only needs genuine intention, so a person can do tawba anytime, anywhere, and especially during times of failure. There is a famous hadith of Prophet Muhammad: “The door of tawba is open till the sun rises from the west.” The most awareness-­and present-­moment-­focused Islamic tradition is known as tasawwuf. Sufis (who are in the line of the tasawwuf path) give special importance to being in the present moment. There are three main issues related to awareness of time for a Sufi: Vukuf-­ı zamani (being aware of every moments of time), Huş der dem (being awake on every breath), and Nazar ber kadem (placing eyes over feet, focusing only on one’s own behavior) (Cebecioğlu, 1997). Every Sufi practices several rituals during the day that are designed to increase this awareness of the present moment. In tasawwuf tradition, the term “time” is explained as “time (vakt) is a status, Sufi is experiencing” (Uludağ, 2014). This is a unique explanation of time based on personal experience: If a person feels happy, his or her time is happy. If a person feels pain, his or her time is pain. As a result, we can say that Islam and Islamic tradition promotes present-­moment awareness in both theological and practical levels for supporting a values-­congruent, purposeful life.

Self-­as-­Context Attachment to evaluative stories about self can lead to narrowed behavioral repertoires. The psychological flexibility model aims to foster detachment from one’s own stories about who one is. This sense of self is called “self-­as-­context” and is instantiated in taking perspective from I/here/now (Hayes, Strosahl, & Wilson, 1999). According to Islam, humans are being tested by Allah only with their behaviors. At this behavioral level, Islam requires acting in the service of long-­term purposes, not in the service of inner events and self-­stories. As mentioned before, the tawba action focuses on changing behavior—­nothing has to be changed other than one’s behavior. So a person does not need to remain attached to self-­stories after tawba, even if those self-­stories are linked to what is sinful. In the Islamic literature, multilevel approaches to sense of self exist. Because of limited space, we will only take a general view of this sense of self in The Holy Qur’an. When we look to The Holy Qur’an, the main term pointing to sense of self is nafs. Here are three verses from The Holy Qur’an telling about nafs: “And his self (nafs) permitted to him the murder of his brother, so he killed him and became among the losers” (Maidah#30); “And I swear by the self-­accusing soul (nafs)” (Qiyãmah#2); 145

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“And whoever is protected from the stinginess of his soul (nafs)—­it is those who will be the successful.” (Hashr#8). As we see in these verses, a multilevel sense of self exists in The Holy Qur’an. A human has a nafs that can serve him or her rightly or wrongly, a nafs that can be self-­accusing, and a sense of self (nafs) which can choose to follow or not follow the first nafs. In ACT terms, in the first verse, nafs seems nearly equal to self-­as-­content; in the second verse, self-­accusing nafs seems nearly equal to self-­as-­process; and the owner sense of nafs is equal to self-­as-­context. Another The Holy Qur’an verse says: “[To the righteous it will be said], ‘O peacefulness soul (nafs), Return to your Lord, well-­ pleased and pleasing [to Him]’” (Fajr#27–­28). The nafs in this verse again seems to equal self-­as-­context. At this point, we have to focus on another sense of self (nafs) level, which Allah tells of in The Holy Qur’an: “And [beware the Day] when Allah will say, ‘He (Jesus) will say, ‘Exalted are You! It was not for me to say that to which I have no right. If I had said it, You would have known it. You know what is within nafs, and I do not know what is within Your nafs. Indeed, it is You who is Knower of the unseen’” (Maidah#116). In this verse, we can see that Allah also uses the term nafs for Himself. So here is an issue of relation between humans’ nafs and Allah’s nafs. And from this point, there is another sense of self (nafs), which is in relation to Allah’s nafs. At least for the Muslim individual, research needs to be done on whether this sense of self (self as servant) can be related to the psychological flexibility model. We can close this part with Mevlana C. Rumi’s Mesnevi: “Even the sea gives whole water to rivers and arks, still keeps all rubbish on the top of its head, above its face. This kindness does not decrease anything from the sea; the sea because of this kindness neither gets bigger nor smaller” (Örs & Kirlangic, 2007).

Values From an ACT point of view, values can be defined as chosen, verbally construed, dynamic long-­term life goals (Wilson, Sandoz, & Kitchens, 2010). One of ACT’s aims is to increase access to values and to widen behavioral repertoires in relation to values. This stance of ACT arises from the truth criteria of functional contextualism, which is successful working (Hayes, 1993). Values function as reference points for behavior and so enable us to analyze the function of a certain behavior. When we look to similarities, it is easy to say that the most compatible dimension between Islam and ACT is values. Islam’s general message to humankind is in showing the temporariness of this world and human life. The Holy Qur’an always emphasizes behaving in the direction of Islamic references whatever a person does. As emphasized in The Holy Qur’an’s verses above, the most important posture of a person is continually acting in the service of his or her values. In The Holy Qur’an, Allah says: 146

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“Man was created of haste. I will show you My signs, so do not impatiently urge Me” (Anbiya#37). Humans have a tendency to seek immediate consequences; therefore Islam asks humans to be patient, to take the long-­term perspective that includes the afterlife, and to be aware of judgment day and of how behavioral patterns will be judged. This is much the same as the tombstone metaphor (see Hayes et al., 2012), which is commonly used in ACT. The emphasis of long-­term consequences has a central place both in Islam and ACT. The previously mentioned parable of Prophet Yunus and Prophet Muhammed’s hadith about “planting a tree” are clear examples of Islam’s values-­based approach. This values-­and process-­based view of Islam is generally consistent with an ACT approach and can play a strengthening and facilitating role during therapy sessions, especially with Muslim clients. In Islamic theology, there is no secular area of life, and because of this connectedness of life to a Muslim’s faith, ACT therapists can find a unique opportunity for augmenting clients’ behaviors in line with their values.

Committed Action Stemming from functional contextualism, ACT always focuses on taking actions that are meaningful and that relate to a values-­congruent life. This emphasis toward action aims at broadening behavioral repertoires and reinforcing behaviors related to long-­term life goals. Islam has several moral and social behavioral principles that it asks humans to follow (Muzzammil#20). All of these principles can be seen as committed actions from an ACT point of view. Islam also promotes commitments toward values. There is a fundamental template in The Holy Qur’an for orienting Muslims in this way: “But as for those who believed and did righteous deeds, He will give them in full their rewards, and Allah does not like the wrongdoers” (‘Ali Imran#57). As we see in this verse, “believing” and “doing righteous deeds” principles often exist together in The Holy Qur’an. Doing righteous deeds is referenced more than 100 times and encompasses all areas of a human life. One other issue is taking committed actions step by step. As The Holy Qur’an says: “Allah does not charge a soul except [with that within] its capacity…” (Baqarah#286). Planning behaviors beginning with easy ones and focusing little by little on meaningful actions is a principle in Islam. There are also many hadiths of Prophet Muhammad on this issue; one is “Make it easy and do not make it difficult!” (Khan, 1976c). Eventually, we can see that believing in Allah is never enough without taking action, and the appropriate way of taking action is small steps with permanency. This seems very close to ACT ideas of how to build patterns of committed action. 147

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Conclusion ACT (and functional contextualism) is a scientific theory, and Islam is a religion; therefore it is not possible to compare them point by point or purpose by purpose. Scientific theories can use every resource in the world for maximizing their effectiveness and for reaching a better working model. During this development process, they can consider other traditions including traditional belief systems and religions. However, contributions on a theoretical level have to be tested by scientific research on the technical impact of these ideas and their utility for increasing successful working. Because of the close connection in concepts, an Islamic approach can make significant contributions to ACT and contextual behavioral science. Similarities between ACT and Islam appear much greater than their differences. Also, being aware of these similarities can help religious leaders and counselors support Muslim clients in using ACT as an evidence-­based psychotherapy.

References Cebecioğlu, E. (1997). Tasavvuf terimler ve deyimler sözlüğü. Ankara: Rehber Press. Hayes, S. C. (1993). Analytic goals and the varieties of scientific contextualism. In S. C. Hayes, L. J. Hayes, H. W. Reese, & T. R. Sarbin (Eds.). Varieties of scientific contextualism (p. 11–­27). Oakland, CA: Context Press / New Harbinger Publications. Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behavior Research and Therapy, 44, 1–­25. Hayes, S. C., Strosahl, K., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press. Hayes, S. C., Strosahl, K., & Wilson, K. G. (2012). Acceptance and commitment therapy: An experiential approach to behavior change (2nd ed.). New York: Guilford Press. Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-­analyses. Cognitive Therapy and Research, 36, 427–­440. Khan, M. M. (1976a). The book of belief (i.e. Faith), The translation of the meanings of sahih al-­ Bukhari. Book 24, number 548. Chicago: Kazi Publications. Khan, M. M. (1976b). The book of belief (i.e. Faith), The translation of the meanings of sahih al-­ Bukhari. Book 63, Number 194. Chicago: Kazi Publications. Khan, M. M. (1976c). The book of belief (i.e. Faith), The translation of the meanings of sahih al-­ Bukhari. Book 3, Number 69. Chicago: Kazi Publications. Pekcan, U. (2013). El edebü’l müfred. (Imam al-­Bukhari, trans. 2013). Istanbul: Serhat Kitabevi Press. Örs, D., & Kirlangic, H. (2007). Mesnevi. (Mevlânâ Celâleddin Rûmi, trans. 2007). Konya: Kültür A.Ş. Press. Uludağ, S. (2014). Keşfü’l-­mahcûb. (El-­Hucviri, trans. 1996). Istanbul: Dergah Press. Wilson, K. G., Sandoz, E. K., & Kitchens, J. (2010). The valued living questionnaire: Defining and measuring valued action within a behavioral framework. Psychological Record, 60, 249–­272.

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CHAPTER 9

ACT and Judaism: Suffering and the Commitment to Valued Action Barbara S. Kohlenberg, Ph.D. University of Nevada School of Medicine

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Let not the fierce sun dry one tear of pain, before you yourself have wiped it from the sufferer’s eye. But let each burning human tear drop onto your heart and there remain; nor ever brush it off until the pain that caused it is removed. —­Chaim Stern, Gates of Repentance: The New Union Prayer Book, p. 500

Nothing is more whole than a broken heart. —­Rabbi Menachem Mendel of Kotzk, found in Sacred Therapy, p. 15

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cceptance and Commitment Therapy (ACT), an evidenced-­based therapy grown from basic scientific principles of behavior (e.g., Hayes, Strosahl, & Wilson, 1999), converges quite often with traditions and principles found in the Jewish faith. The quotations above, drawn from Jewish writings, suggest human suffering brings with it unique opportunities for healing, and that brokenness and pain are opportunities for connection and for behavioral action. It is the purpose of this chapter to show how some of the basic principles found in ACT are quite consistent with some Jewish teachings. Extending from ACT to Jewish principles, and vice versa, may strengthen one’s ability to work with clients that are familiar with Jewish cultural traditions. And if you are reading this from the point of view of a Rabbi or someone from within the Jewish culture, I hope to show that ACT would be entirely consistent with much of the wisdom found in many Jewish rituals and teachings. Jacob: Dr. Kohlenberg, I am struggling… I can’t sleep, eat, I can’t get rid of my bad thoughts, I want to kill myself or just die… I’m alone, I want to stop suffering and I have lost so many people to death…recently my wife… The world is so cruel…can you help me? I’m patiently waiting, I’m praying, but it doesn’t help…my mood and problems don’t leave. My family is worried and impatient with me… My Rabbi said I should see a psychologist… In the above scenario, two repertoires would be invited into the psychotherapy relationship for this writer. First, as Jacob is seeking help from a psychologist, my science-­based psychotherapy repertoire would be activated. Specifically, my ACT skills, my knowledge of behavioral philosophy, and my training in the science of human behavior would be called to the fore. In addition, my years of studying and practicing in the Jewish faith would also inform my psychotherapeutic interactions. That is to say, whether explicitly or implicitly, my history would lead me to link 150

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evidence-­based conceptions of suffering and the path to health with age-­old Jewish sensibilities and practices. In the case of treating a client who is grounded in Jewish culture and beliefs, delivering treatment that is consistent with these beliefs may allow for a more effective treatment. In this chapter, I will focus on an assortment of Jewish practices and beliefs that converge with sensibilities present in ACT. I am not writing as an expert on Judaism. However, in my years of attending synagogue and participating in Jewish communities, there are times when I read a prayer or meditation or experience a practice that is so consistent with ACT that I copy it and send it to my non-­Jewish ACT colleagues, because of the delightful convergence of science-­based sensibilities and religious principles. In this chapter, I will describe selected core sensibilities in ACT, and will describe selected Jewish practices and sensibilities that are consistent with ACT. I will describe how the separate traditions, science and religion, sometimes travel to very similar places, and can inform psychotherapy with our hypothetical depressed client, “Jacob.”

Selected ACT Sensibilities and Judaism Acceptance In ACT, the concept of acceptance is central. Acceptance is defined as being open to one’s thoughts and feelings, being willing to feel what there is to feel, fully and freely, in the service of moving toward cherished values and growing a meaningful life. ACT imparts skills that help people learn to have painful thoughts and feelings, feel them, change their relationship with them, and move forward in meaningful and heartfelt directions. It departs from much of mainstream culture that links positive and meaningful action to first reducing or eliminating these painful thoughts and feelings. Imagine the painful loss of a loved one. A person skilled at acceptance would be open to feel the pain and still reach out to others, and be open to love again even though loss and pain is a decided possibility. Acceptance is a willingness to be open to life even when pain and discomfort is a part of the landscape.

Judaism and Acceptance Judaism is a faith that promotes heading in valued directions without regard for changing or eliminating troubling thoughts and feelings. There are countless examples of this sensibility. Judaism for the most part is more concerned with action than

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with the regulation of thoughts and feelings. In the Torah (the Old Testament), there are 613 commandments or mitzvoth, and all of them are focused on behavioral actions to do or to not do. There is not an emphasis on changing thoughts or feelings in the service of living a good and a meaningful life, or on having to think or feel a certain way in order to be pious. Rather, there are prescriptions focused on behavioral action. Judaism is a faith that embraces the possibilities that emerge from—and actually require a leaning into—suffering and darkness. For example, Jewish holidays always begin after sundown. One starts in darkness before the light comes. This practice and metaphor is central. In addition, the statement that “the only whole heart is one that has been broken” is based on the idea that when the heart breaks, the opportunity for compassion and connection with people and the divine can occur. When the heart is shattered, light, love, spirit, and community can enter. And there are many stories about the commingling of the broken and the whole. When Moses tried to bring the tablets with the written law from God to the people, the first set was broken in anger, by Moses. Then God gave Moses the second, unbroken set. Both sets, the unbroken and the shattered, were kept and carried together. The whole and the broken were housed together, implying that one does not need to get rid of the brokenness in order to have the wholeness. In fact, they must and do live together. Similarly, wedding ceremonies involve the breaking of a glass at the moment the marriage happens and the ceremony erupts with joy. This is to cement the marriage of joy and brokenness: that even during moments of great joy, one must remember, and actually invite, suffering. In the case of our client Jacob, the notion of acceptance of his painful thoughts and emotional suffering would be a central aspect of the therapy. His tears would be tended to with kindness and compassion in the therapy room, with the therapist. His desire to rid himself of his “bad” thoughts, as well as the “bad thoughts” themselves, would be treated with reverence, in the service of growing connection and closeness both in the therapy and with others in his life. Nothing about Jacob’s experience would need to be eliminated in the service of growth and life. As will be shown, all aspects of grief and mourning are consistent with ACT sensibilities.

Experiential Avoidance In ACT, the opposite of acceptance is experiential avoidance. Experiential avoidance describes the very human and culturally mainstream wish to get rid of, minimize, or avoid feeling painful thoughts and feelings. Of course, there are times when avoidance is an essential part of life, such as feeling cold and then putting on a sweater in order to avoid the cold. Other times, however, avoiding thoughts and 152

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feelings such as painful memories, anxiety, sadness, and depression, can result in much harm and a narrowness of experience. How would one love again without being willing to remember and feel the heartbreak of a lost love? How can one take a professional or personal risk without being willing to feel the pain should one fail? One can see how a commitment to avoiding painful emotions can set the stage for such problems as trauma, depression, relationship problems, anxiety, and substance use disorder (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). For example, imagine Jacob’s emotional pain associated with the loss of his wife and others he loves. And imagine that he decides that he can never feel that way again. Culturally normal methods to protect against the feelings associated with such a painful loss might be to self-­medicate, to drink or use substances to get rid of the pain. Some people may even try to end their lives via suicide. Other ways could include a private commitment to never risk love again, or an intense waiting for the pain to go away, while remaining quite still. Any of these paths might in fact reduce the pain somewhat, but would have other costs such as a narrowing of contact with what most people cherish and hold dear. Of course suicide would eliminate pain yet it would also eliminate all other options in life.

Judaism and Experiential Avoidance While many Jewish rituals are sensitive to the notion of experiential avoidance, rituals involved in mourning are highly congruent with what is known scientifically about the pitfalls of experiential avoidance. What follows is a synopsis of some aspects of mourning rituals.

JEWISH MOURNING RITUALS Jewish rituals around death and mourning illustrate sensibilities around acceptance of painful emotions and actively discourage experiential avoidance. The process and rituals are focused on facing the death fully and deeply. For example, at the funeral, friends and family of the deceased shovel earth on top of the coffin. One smells the earth, hears it thud against the casket, sees the casket slowly disappear under the earth, and the reality of the death is hard to deny. Brener (2001), in her book Mourning and Mitzvah, writes: “Judaism demands honesty. Our rituals are designed to help us directly confront death. We do not use embalmers or make-­up artists to restore our dead… We hear the sound of each shovelful of earth hitting the wooden casket as we bury the dead. These rituals are part of our attempt to not distract the mourner from grim reality” (p. 14).

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In the service of honesty, Brener (2001) also writes: “So, I will tell you the truth… The person you have lost is not going to return. Contrary to what you may hear from others, you will never get fully get over this loss. You are likely to miss this person for the rest of your life… But there is something else, something that co-­exists with this sobering reality: Despite the fact that the death will remain the same, you—­and life as you know it—­can change. And in that change an entire world, filled with possibilities can open up” (p. 4). Brener (2001) describes how connecting with and expressing painful feelings are also built into the mourning rituals, and are linked to these new possibilities. “Avoiding your feelings means avoiding your own depth. It means avoiding the transforming experiences that life offers and failing to come to terms with your own personal history. Avoiding a feeling only prolongs it. Becoming familiar with the dimensions of the pain allows you to be less frightened and to cope more readily when the feeling comes up again” (p. 14). After the burial, a ceremony known as shiva begins. Mourners stay home for seven days, and are surrounded by supportive community. They are encouraged to grieve and to face the reality of the death. They are isolated from normal life, mirrors are covered to discourage the distractions of vanity, and mourners wear a symbolic torn piece of clothing or fabric in order to be clearly identified as being shattered and in mourning. During this week, mourners are in the midst of loved ones, are fed, and are visited by their community in their home. After this first week, less restrictive mourning begins, lasting up to a year. In working with Jacob, it would be seamless to integrate ACT sensibilities around feeling what there is to feel about loss and suffering with what is clearly present in the tradition. Talking about feelings, prolonged encouragement to “lean into” the emotional and physical aftermath of the loss, and the built-­in connection with community is all part of the cultural tradition.

Contacting the Present Moment In ACT, being present in the moment is an important skill. Contacting the present moment involves awareness and connection with the world as it touches us. Mindful awareness of the present moment is practiced, and multiple exercises and metaphors exist to help people learn this skill. Mindful awareness is not being absorbed in thoughts about the past and the future. It is about being aware and in contact with the worlds within us and outside of us in this very moment. It involves being aware of and being connected with what is happening right here and right now.

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With our grief-­stricken Jacob, contacting the present moment might involve noticing his heartache, the cat in the sunlight, the grandchild playing with her doll, the empty chair where his wife used to sit. His sorrow. Of course, this skill also can be practiced in the therapy room, and involve noticing the books, the therapist’s eyes, caring, and presence…and not being led away from the moment by stories about the past and how the future will be forever worse.

Judaism and Contacting the Present Moment Judaism is a faith that is both practical and pragmatic and very mystical. In a practical sense, there are countless ways in which Judaism demands a “here and now presence.” Frankel (2003) writes: “when we encounter a poor person, instead of saying to ourselves that it must be God’s will that he is poor or that God will provide for the poor man or woman, we are instead commanded to act as though there were no God and we alone are responsible for helping that person” (p. 228). This example shows that appealing to God may take one from the present moment and that being in that moment, with the poor person, obligates one to take action and help. On the more mystical side, Frankel (2015) writes: “The Kabbalah teaches that every moment is a gateway to the Infinite if we are fully present. The Hebrew name for God, which is spelled Yod-­Heh-­Vav-­Heh, (or YHVH, for short) is, in fact, a meditation on being present. Often referred to as “the Holy Name of Being” or Shem Havayah, YHVH is a composite of the three Hebrew words hayah, hoveh, yihiyeh—­ was, is, will be—­suggesting that divinity is pure beingness. If we can be fully present in the moment, we gain access to our divine nature.” The value of being in the present moment with Jacob is both an aspect of ACT and clearly also highly valued within Jewish tradition. Nowhere is more valuable or highly charged than being able to be right here, right now, and all opportunities for both spiritual and behavioral connection start with the ability to be present.

Values In ACT, knowing what matters and what is deeply important to an individual is critical to guiding action and direction. Values are not goals that can be accomplished, but directions that one travels throughout life. Values are discovered in ACT when clients are asked to look deeply into their heart, and to ask what legacy they want to leave behind. Describing how one wants to be eulogized, and what one wants on one’s tombstone, are two methods of helping people orient to what is deeply important.

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Working on values with Jacob may entail wondering what he wants on his tombstone: “avoided feeling the pain of my wife’s death,” or “beloved father.” It is reflexive for many to want to not feel extraordinary pain; ACT is based on helping people feel what there is to feel, and keep their eye and their behavior (their feet) focused on deeply held values.

Judaism and Values Judaism discusses heavily the area of values. Two categories of values sensibilities in Judaism will be explored. The first is the notion of an “ethical will,” which is entirely consistent with ACT, and the second is the value of “tikun olam,” or “repairing the world,” which is different than the idiographic aspects of values exploration in that it is considered a duty, not a self-­discovered choice.

THE ETHICAL WILL Everyone is familiar with the concept of a “will,” a legal document that specifies how financial holdings will be dispersed after death. The concept of an “ethical will” follows suit, though it is not a legal document, and the holdings to be dispersed are life lessons, what one has learned and wants to pass on. One excerpt from an ethical will is from Kim, age 52: I don’t believe we are meant to understand ourselves, grow, grieve, change, or fully enjoy life without other sets of eyes that see us through love. If you can’t let other people in, really in, to influence you and love you when you’re at your worst, or save you sometimes, you are going to have a tiny little life and probably be very angry on your deathbed that you missed something and you don’t know what it is. I pray for all of you that that never happens. (Celebrations of Life, 2015) This of course would be consistent with the ACT sensibility with regard to the value of focusing on what matters most to the person. With Jacob, encouraging him to write an ethical will could be another way of growing his awareness of what he has learned in life, and what is most cherished and precious.

TIKKUN OLAM (HEALING AND FIXING THE WORLD) An important and central Jewish teaching is the idea that one must work to repair the world. Every Jewish person is, in fact, obligated to work toward repairing and healing the world, a concept known as Tikkun Olam. This concept is discussed

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by Krista Tippett in her interview with Dr. Rachel Remen (2010) and an excerpt from the interview (reprinted with permission) is offered below: DR. REMEN: In the beginning there was only the holy darkness, the Ein Sof, the source of life. And then, in the course of history, at a moment in time, this world, the world of a thousand things, emerged from the heart of the holy darkness as a great ray of light. And then, perhaps because this is a Jewish story, there was an accident, and the vessels containing the light of the world, the wholeness of the world, broke. And the wholeness of the world, the light of the world was scattered into a thousand fragments of light, and they fell into all events and all people, where they remain deeply hidden until this very day. Now, according to my grandfather, the whole human race is a response to this accident. We are here because we are born with the capacity to find the hidden light in all events and all people, to lift it up and make it visible once again and thereby to restore the innate wholeness of the world. It’s a very important story for our times. And this task is called tikkun olam in Hebrew. It’s the restoration of the world. MS. TIPPETT: Right. DR. REMEN: And this is, of course, a collective task. It involves all people who have ever been born, all people presently alive, all people yet to be born. We are all healers of the world. And that story opens a sense of possibility. It’s not about healing the world by making a huge difference. It’s about healing the world that touches you, that’s around you. MS. TIPPETT: The world into which you have proximity. DR. REMEN: That’s where our power is, yeah. Yeah. Many people feel powerless in today’s situations. MS. TIPPETT: Right. I mean, when you use a phrase like that just out of nowhere, “heal the world,” it sounds like a dream. Right? A nice ideal, completely impossible. DR. REMEN: It’s a very old story, comes from the 14th century, and it’s a different way of looking at our power. And I suspect it has a key for us in our present situation, a very important key. I’m 157

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not a person who is a political person in the usual sense of that word, but I think that we all feel that we’re not enough to make a difference, that we need to be more somehow, either wealthier or more educated or somehow or other different than the people we are. And according to this story, we are exactly what’s needed. And to just wonder about that a little, what if we were exactly what’s needed? What then? How would I live if I was exactly what’s needed to heal the world? The concept of tikkun olam differs from an ACT conception of value in that one is obliged to heal the world, interaction by interaction, opportunity by opportunity. In ACT, more emphasis is placed on people arriving on their own as to what they cherish and want to stand for in life. Tikkun olam could absolutely be among a person’s values from an ACT standpoint, and there is room in ACT for values to have other flavors. This is a primary difference between ACT and any religious tradition in that specific values can be prescribed by the tradition, whereas ACT as a psychotherapy affords choice. In working with the imposed/commanded value of tikkun olam, it is quite consistent to be able to rely on all ACT sensibilities and skills to get there. In addition, both ACT sensibilities and Jewish sensibilities in this area arrive at the importance of behavioral actions that are linked to making progress in these vital areas of life. For Jacob, a values discussion could connect him with both his personally cherished and heartfelt life lessons and what he wants to stand for, and he could also be nudged to look at how he is changing the world in the daily moments that are in front of him. As he leaves the therapy office, and sees a homeless person, can he meet the gaze of that person? Can he offer him charity of some sort? Can he treat him with dignity by addressing him with respect, such as by saying “Hello, sir”? These acts of tikkun olam require presence with what is right here right now, and acceptance of difficult feelings and experience.

Committed Action In ACT, actually engaging in committed action in the service of one’s values is key to living a valued life. Committed action is directly linked to values, and keeping people moving toward their values while being open to their painful, unwanted thoughts and feelings. Working on committed action with an individual who values being a good father, and who is overwhelmed with the pain associated with the loss of his wife, may involve letting himself be visited or cared for by his adult children even though they 158

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bring up painful memories for him. Or it may involve going to the birthday party of a grandchild even though it brings up the absence of his wife in a way that feels deeply painful.

Judaism and Committed Action Jewish tradition is highly focused on committed action. In addition to Judaism being a faith that is highly spiritual, mystical, and full of miracles, it is also a faith that is grounded in behavior. In the Jewish faith, it is important to behave in ways that are consistent with Jewish values. Thinking, feeling, and prayer are aspects of the faith, of course; however, these private events are not considered to be as important as overt behavior and action. For example, thinking or feeling a prayer is not considered to be as effective as saying it out loud. And, some would argue, the most important prayers involve one’s feet, in the service of committed action. One respected Rabbi, Abraham Heschel, after joining Martin Luther King, Jr., in a civil rights march in Selma, was asked: “Did you find much time to pray, when you were in Selma?” Rabbi Heschel responded, “I prayed with my feet.” What was his point? That his marching, his protesting, his speaking out for civil rights was his greatest prayer of all. In the Jewish faith, there are many instances in which the path to holiness lies in human behavior, rather than intellectual or prayerful activity. For example, Mogel (2001) writes: In Judaism, the path to holiness lies in human activity, or what the modern philosopher Abrahan Heschel calls “right action.” Judaism values deed over creed and learning by doing. The sages believed that life should be a work-­ study program—­we have to apply our knowledge. In fact, intellectual study alone is suspect. The first-­century priest Eleazar ben Azariah said, “Anyone whose wisdom exceeds his good deeds—­to what can he be compared? To a tree whose branches are numerous but whose roots are few. The wind will come and uproot it and turn it upside down.” (p. 134) Thus, Judaism is a faith dependent on committed action. Committed action is also a central focus during the Day of Atonement, Yom Kippur, the holiest day of the Jewish year. During this holy period, Jews are given the opportunity to repent for their sins. The repenting process is called teshuvah. This process involves four steps (Simmons, 2002): Step 1: Regret. Realize the extent of the damage and feel sincere regret. Step 2: Cessation. Immediately stop the harmful action. 159

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Step 3: Confession. Articulate the mistake and ask for forgiveness. Step 4: Resolution. Make a firm commitment not to repeat it in the future. Importantly, if the sin involved hurting another person, one must ask that person for forgiveness before asking God for forgiveness. This is a process that is dependent on committed action, as well as all other ACT processes. For Jacob, committed action is central to Judaism and thus would be consistent with ACT procedures around commitment and action. Sessions might end, for example, with commitments to engage in behavior that reflects personal and commanded values in life.

Conclusion The science supporting ACT and the science testing and evaluating ACT has resulted in the development of a treatment that can profoundly help individual suffering people, and can touch and improve the world in deeply meaningful ways. So much that is found in Jewish tradition is consistent with what has been arrived at scientifically. Ultimately, it is exciting and humbling to have the privilege, in my daily life, to work with clients who come in with broken hearts and who can find that life can still be lived meaningfully and lovingly. From an ACT and from a Jewish perspective, I find that there is great unity in the aims and in the process. The aim of ACT, in lay terms, is to create a rich, full, and meaningful life while accepting the pain that inevitably goes with it (Harris, 2009). But in the end, if we are brave enough to love, if we are strong enough to forgive, if we are generous enough to rejoice in another’s happiness, and if we are wise enough to know that there is enough love to go around for us all, then we can achieve a fulfillment that no other living creature will ever know. We can reenter Paradise (Kushner, 1996).

References Brener, A. (2001). Mourning and mitzvah: A guided journal for walking the mourner’s path through grief to healing (2nd ed.). Woodstock, VT: Longhill Partners. Celebrations of Life (2015). Ethical wills. Retrieved from https://celebrationsoflife.net/ethical wills/. Frankel, E. (2003). Sacred therapy: Jewish spiritual teachings on emotional healing and inner wholeness. Boston: Shambhala Publications. Frankel, E. (2015). Sacred therapy. Retrieved from http://www.sacredtherapy.com/meditate.shtml. Harris, R. (2009). ACT made simple: An easy-­to-­read primer on acceptance and commitment therapy. Oakland, CA: New Harbinger Publications.

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Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press. Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64, 1152–­1168. Kushner, H. S. (1996) How good do we have to be?: A new understanding of guilt and forgiveness. New York: Little, Brown and Company. Mogel, W. (2001). The blessing of a skinned knee: Using Jewish teachings to raise self-­reliant children. New York: Penguin Books. Remen, R. (2010). Listening generously. Retrieved from http://www.onbeing.org/program/listeninggenerously/transcript/845. Simmons, S. (2002). Teshuvah: Dry cleaning for the soul. Retrieved from http://www.aish.com/h /hh/gar/atonement/48954551.html. Stern, C. (1978). Gates of Repentance: The New Union Prayer Book. New York: Central Conference of American Rabbis.

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CHAPTER 10

ACT and Christianity Ingrid Ord, MSc Private Practice, Western Cape, South Africa

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he purpose of this chapter is to explore the relationship between the psychological flexibility processes in ACT and Christianity. ACT has been well described in this volume; therefore, my focus will be on providing a scriptural example of that relationship. Rather than explicating ACT per se, I will be drawing on a book-­length treatment I have written on the topic, detailing how Matthew 11:28–­30 can provide an easy-­to-­memorize ACT protocol for Christians (Ord, 2014). I plan to use these verses in this short chapter to examine the lives and teachings of two major Christian figures: Peter and Paul.

Why Peter and Paul? Peter and Paul were leaders of the early Christian church. Passionate and committed to the same cause, they both struggled to adjust to a radically different life path than where they started out. Thus, their lives touch on some of the difficulties of life transformation that can be contacted in clinical work. Simon (later called Peter) was a fisherman on the shores of the sea of Galilee, when Jesus recruited him, along with his brother, Andrew. Peter developed political ambitions for Jesus as the liberator of the oppressed Jewish nation, with himself as his privileged deputy. Years later he had stopped thinking in such a worldly way, writing to Jewish Christians: “whoever has suffered in the flesh [having the mind of Christ] is done with [intentional] sin [has stopped pleasing himself and the world, and pleases God]” (1 Peter 4:1 Amplified Bible). Saul (later called Paul) is introduced in the Bible witnessing a violent stoning and being an activist against followers of Jesus. He was transformed into the man who wrote: “For in Christ, neither our most conscientious religion nor disregard of religion amounts to anything. What matters is something far more interior: faith expressed in love.” (Galatians 5:6, Peterson, 2002) Both of these converts to Christianity believed in the grace of God, as not only a justifying power but also as a transforming power. They believed that the crucifixion of Jesus, together with the power enabling the resurrection, was sufficient to redeem them from all past, present, and future sin. Furthermore, they believed that they were given power in their daily lives, based on the continued presence of the Holy Spirit. This enabled them to do whatever God had planned for them to do and gave them the strength to endure whatever hardship attended this activity (Ord, 2014). They both changed dramatically. Let us study these changes from the perspective of the processes identified as important in ACT.

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Intersections Between ACT and the Lives of Two Christians: Peter and Paul Peter Peter is recorded as behaving paradoxically at first, combining impetuous strength with weakness of understanding. He was almost a comical figure at times, twice jumping out of boats whilst fully clothed in hasty attempts to get to Jesus. He was transformed into a tower of moral strength who led the early Christians, through much suffering, with comfort, wise counsel, and a strong awareness of purpose. Peter’s life traced an arc from mindless impulsivity to mindful commitment. Peter heard his teacher, Jesus, claim that if anyone wanted to get to know God experientially, the following words held the key: Are you tired? Worn out? Burned out on religion? Come to me. Get away with me and you’ll recover your life. I’ll show you how to take a real rest. Walk with me and work with me—­watch how I do it. Learn the unforced rhythms of grace. I won’t lay anything heavy or ill-­fitting on you. Keep company with me and you’ll learn to live freely and lightly. (Matthew 11:28–­ 30, Peterson, 2002) As mentioned, these verses can serve as verbal cues for the ACT flexibility processes. In the following sections I will group these processes by the “pillars” in the ACT hexagon—­being present (flexible attention to the now from self-­as-­context), opening up (acceptance and defusion), and doing what matters (values and committed action)—­and will link them to specific parts of the verses above.

BEING PRESENT: “COME TO ME. GET AWAY WITH ME AND YOU’LL RECOVER YOUR LIFE.” Throughout the gospels we witness Peter’s growing realization of the divinity of Jesus. In Matthew 16 we read this about an occasion where Jesus asked His closest followers who people were saying He was: He said to them, “But who do you say I am?” And Simon Peter answered and said, “You are the Christ, the Son of the living God.” Jesus answered and said to him, “You are blessed, Simon, son of Jonah, for flesh and blood did not reveal it to you, but My Father in Heaven.” (Matthew 16:15–­17 Modern King James Version) 165

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In that moment Peter made a leap of faith, committing himself to his growing belief in the divinity of Jesus. In the next moment, however, he objected to Jesus stating that He would die at the hands of the authorities, reverting to his own ideas about who Jesus was. Jesus then rebuked Peter, switching from blessing Peter to calling him “Satan.” It was crucial, for the success of Jesus’s mission as Savior of mankind, that His disciples developed a spiritual perspective of who He was, and understood themselves as being totally dependent on Him. He was encouraging all His disciples, in that moment, to be aware of activity in the spiritual world, and of how this might interfere with their focus. Hence the injunction: “Get away with me and you’ll recover your life.”

OPENING UP: “WALK WITH ME AND WORK WITH ME—­ WATCH HOW I DO IT. LEARN THE UNFORCED RHYTHMS OF GRACE.” Again Peter is seen wavering from one point of view to another: And Peter answered Him and said, “Lord, if it is You, tell me to come to You on the water.” And He said, “Come.” And when Peter had come down out of the boat, he walked on the water to go to Jesus. But seeing that the wind was strong, he was afraid. And beginning to sink, he cried, saying, “Lord, save me!” (Matthew 14:28–­30 Modern King James Version) Peter’s loss of nerve, and subsequent sinking, illustrate the interference of fusion with his mind in the development of his faith. At first he displayed “blind” faith and obeyed Jesus, but then his mind rightly assessed that logically and on his own he could not walk on water, disregarding the fact that he actually already was. Learning from this, and other experiences, he began to see his faith in action. This enabled him to experience grace. In this way he learned to give up the demand for control, or self-­reliance, and accept, with humility and faith that working with the Master would allow grace to determine the timing and occurrence of events in his life. This increased his willingness to experience, with flexibility, the relationship with Jesus, and to begin to replace religious rules with “grace theology”: Grace theology is based on the belief in a personal relationship with a personal God. This relationship is based solely on the ability and faithfulness of God and the believer’s response to this, and does not rely in any measure at all upon any achievement of the individual. (Ord, 2014, p. 154)

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DOING WHAT MATTERS: “I WON’T LAY ANYTHING HEAVY OR ILL-­FITTING ON YOU. KEEP COMPANY WITH ME AND YOU’LL LEARN TO LIVE FREELY AND LIGHTLY.” Peter answered “…though all shall be offended because of You, I will never be offended.” Jesus said to him, “Truly I say to you that this night, before the cock crows, you shall deny Me three times.” Peter said to Him, “…though I should die with You, yet I will not deny You.” (Matthew 26:33–­35 Modern King James Version) Peter did deny Jesus that night, three times as prophesied. After witnessing the trial and execution of Jesus he hid away with the other disciples in the last, desperate days before the resurrection. We don’t know what his thoughts were at this time. After the resurrection Peter waited with the other disciples, as they had been told to by Jesus: “you sit in the city of Jerusalem until you are clothed with power from on high.” (Luke 24:49, Peterson, 2002) When suddenly there came a sound from heaven like the rushing of a violent tempest blast, and it filled the whole house in which they were sitting. And there appeared to them tongues resembling fire, which were separated and distributed and which settled on each one of them. And they were all filled (diffused throughout their souls) with the Holy Spirit…. That’s when Peter, standing with the eleven, raised his voice and addressed them: You Jews and all you residents of Jerusalem, let this be [explained] to you so that you will know and understand; listen closely to what I have to say. …those who accepted and welcomed his message were baptized, and there were added that day about 3,000 souls. (Acts 2:2–­4, 14, 41 Modern King James Version) Peter, the unsure, bumbling follower of Jesus, became a man of power and conviction. Convinced that Jesus had died and was resurrected to make grace available to mankind, and experiencing the power of the presence of the Holy Spirit in his life, Peter’s internal context was changed forever. His values were rewritten in such a radical way that spreading the gospel throughout a hostile nation was not “heavy or ill-­fitting.” He learned to keep company with Jesus as committed action propelled him in the direction of his values. This carried him through a great deal of suffering and he was martyred, unwavering to the end.

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Paul Paul’s voice reverberates down through the ages with one word: grace! How did this bully become a bearer of love, and the most prolific writer of all in the Bible? This somber, learned, and scholarly man, seemingly harsh at times and not one to mince his words, became the one who eloquently began the chapter on love (1 Corinthians 13, Modern King James Version): “Though I speak with the tongues of men and of angels, and have not charity, I have become as sounding brass or a tinkling cymbal.” What, or who, brought about the change? Paul’s life traced an arc from Christ as the enemy to Christ as the entire reason for living. We can examine that arc using the same verses and grouping of ACT flexibility processes as we did with Peter.

BEING PRESENT: “COME TO ME. GET AWAY WITH ME AND YOU’LL RECOVER YOUR LIFE.” Probably the most dramatic incident in the life of this apostle occurred as he was on his way to persecute Christians. He was defending his religion from a cult that was spreading at an alarming rate. Then this happened: …as he…came near to Damascus…suddenly a light from heaven flashed around him, …he fell to the ground…and heard a voice saying to him, “Saul, Saul, why are you persecuting me?”… And Saul said, “Who are You, Lord?” And He said, “I am Jesus.” Trembling and astonished he asked, “Lord, what do You desire me to do?” The Lord said to him, “…arise…go into the city…you will be told what you must do.” Then Saul got up from the ground, but though his eyes were opened, he could see nothing; so they led him by the hand… (Acts 9:3–­8 Amplified Bible) Helpless and humbled, Paul was catapulted into a relationship with Jesus. In order to stay upright, all he could do was to focus on the present moment. For three days he sat in darkness, without food and water, praying and experiencing his new relationship with Jesus. Ananias was sent by God to lay hands on him, and as soon as he could see, he was baptized and went straight to work. The process of him recovering his life had begun, and later he was to say: “I’ve dumped it all in the trash so that I could embrace Christ. I didn’t want some petty, inferior brand of righteousness that

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comes from keeping a list of rules when I could get the robust kind that comes from trusting Christ—­God’s righteousness” (Philippians 3:8–­9, Peterson, 2002).

OPENING UP: “WALK WITH ME AND WORK WITH ME—­ WATCH HOW I DO IT. LEARN THE UNFORCED RHYTHMS OF GRACE.” Paul, as he became known, was destined to suffer greatly as a result of his walk with Jesus. A summary of his suffering as a Christian is given in his second letter to the Corinthians: Five times from the Jews I received forty stripes minus one. Three times I was beaten with rods, once I was stoned, three times I was shipwrecked. I have spent a night and a day in the deep. I have been in travels often; in dangers from waters; in dangers from robbers; in dangers from my race; in dangers from the heathen; in dangers in the city; in dangers in the wilderness; in dangers on the sea; in dangers among false brothers. I have been in hardship and toil; often in watchings; in hunger and thirst; often in fastings; in cold and nakedness. (2 Corinthians 11:24–­27 Modern King James Version) All the while he was plagued by an undisclosed handicap, yet even that became his teacher in grace: I was given the gift of a handicap to keep me in constant touch with my limitations…he told me, My grace is enough; it’s all you need. My strength comes into its own in your weakness. Once I heard that, I was glad to let it happen. I quit focusing on the handicap and began appreciating the gift. It was a case of Christ’s strength moving in on my weakness. (2 Corinthians 12:7-­10, Peterson, 2002) Herein lies Paul’s secret: seeing his troubles as an opportunity to experience grace. The Greek root of the word “grace” means “acceptable” or “gift.” In ACT with chronic pain patients we know that accepting pain, with willingness rather than with reluctant endurance, which can so easily switch to futile efforts to take control, allows patients to spend energy and time on going toward what is important in their lives, increasing their quality of life (McCracken & Vowles, 2014). Paul was able to accept his handicap with willingness (“appreciating the gift”) as he came to understand that it was a channel for Christ’s strength to move in:

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“Therefore I am pleased in weaknesses, in insults, in necessities, in persecutions, in distresses for Christ’s sake; for when I am weak, then I am powerful.” (2 Corinthians 12:10 Modern King James Version) Paul was very aware of how his mind could throw up obstacles to committed action. He urged Christians, throughout his letters, to observe this process and to allow God to “renovate” their minds by “transforming” their thinking. In an oft-­ quoted verse in Paul’s letter to the Romans, he wrote: “And be not conformed to this world, but be ye transformed by the renewing of your mind” (Romans 12:2 King James Version, 1769). This verse is, unfortunately, sometimes quoted as evidence that Christians must eradicate wrong thinking. In the original Greek text, however, the word that is now translated as “transform” is based on the root word from which we get “metamorphosis.” The Oxford English Dictionary defines metamorphosis as “The process of changing in form, shape, or substance; especially transformation by supernatural means” (Definition 1a., Oxford English Dictionary Online. Retrieved December 1, 2015 from http://www.oed.com). The Message translates this part of Romans 12:2 more in line with how such transformation may occur, saying: “Don’t become so well-­adjusted to your culture that you fit into it without even thinking. Instead, fix your attention on God. You’ll be changed from the inside out.” Attentional focus is clearly not the same as a cognitive eradication strategy. Seen in the context of the original Greek, Paul advocates a process more like defusion here and does not indicate that he, or others, should judge themselves on the content of thoughts, or feel guilty, or forcefully try to get rid of unwanted thoughts. Many Christians suffer needlessly because of thoughts that they feel guilty about and chastise themselves for having them in the first place, and not being able to eradicate them (Ord, 2014). There is a need to emphasize that Paul is not advocating eradication by self-­effort, nor is he advocating that “anything goes” without discernment. He is encouraging an awareness of when thoughts are going away from God, and an intentional, mindful refocusing on the relationship which brings meaning and purpose to Christian lives. Mindfulness is very helpful in this regard.

DOING WHAT MATTERS: “I WON’T LAY ANYTHING HEAVY OR ILL-­FITTING ON YOU. KEEP COMPANY WITH ME AND YOU’LL LEARN TO LIVE FREELY AND LIGHTLY.” Protecting his religion and its rule-­governed approach to behavior defined Paul’s original life stance, resulting in cruel hatred and religious prejudice. He changed, as he writes about his Christian values in his letter to the Ephesians: “This is my life work: helping people understand and respond to this Message. It came as a sheer gift to me, a real surprise, God handling all the details… And so here 170

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I am, preaching and writing about things that are way over my head, the inexhaustible riches and generosity of Christ” (Ephesians 3:7,8, Peterson, 2002). Paul committed his life to his journeys to Syria, Cyprus, Asia Minor, and Europe, starting churches and teaching “first Jesus and who He is; then Jesus and what He did—­Jesus crucified” (1 Corinthians 2:2, Peterson, 2002). He worked tirelessly at taking this message to places where it had never been before, and returned when he could to ensure that the fledgling churches were not being tempted back into legalism, as he had discovered to his dismay in Galatia. When he was imprisoned he wrote letters of encouragement to the churches at Corinth, Galatia, Ephesus, Philippi, Thessalonica, Colosse, and Rome, and to individuals such as Timothy, Titus, and Philemon. Trained as a lawyer, and adept at reasoned and logical argument, he carefully laid the foundations for a theology that has stood the test of time. Despite knowing that his final journey to Jerusalem would lead to his death, he answered those urging him not to go: Why do you insist on making a scene and making it even harder for me? You’re looking at this backwards. The issue in Jerusalem is not what they do to me, whether arrest or murder, but what the Master, Jesus does through my obedience. Can’t you see that? (Acts 21:13, Peterson, 2002) As a prisoner he was sent from Jerusalem to Rome where he established a church and, according to an early church historian, Eusebius, was beheaded by Emperor Nero.

Conclusion Peter and Paul disagreed on a few important issues. Both agreed, however, that adherence to the law had been replaced by the free gift of forgiveness and the power of the Presence of the Holy Spirit. Some of Paul’s final words addressed this issue: …what the law code asked for but we couldn’t deliver is accomplished as we, instead of redoubling our own efforts, simply embrace what the Spirit is doing in us. Obsession with self in these matters is a dead end; attention to God leads us out into the open, into a spacious, free life. (Romans 8:4,6, Peterson, 2002) Rules and legalism still inhibit many Christians (Ord, 2014). ACT is focused on undermining the excesses of rule-­governed behavior, replacing it with mindful openness to experience and the expression of chosen values. These same themes are

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echoed in Christian writings and in the lives of Christian saints, such as Peter and Paul. In the present day, the flexibility encouraged by the six ACT processes may release Christians who are struggling with mental entanglement and pursuing behaviors which are not taking them toward their values. The power of grace can provide the confidence to move forward if “the unforced rhythms of grace,” including suffering, are willingly accepted, in each present moment.

References McCracken, L. M., & Vowles, K. E. (2014). Acceptance and commitment therapy and mindfulness for chronic pain: Model, process, and progress. American Psychologist, 69, 178–­187. Ord, I. (2014). ACT with faith: Acceptance and commitment therapy with Christian clients: A practitioner’s guide. Great Britain: Compass Publishing. Peterson, E. H. (2002). The Message: The Bible in Contemporary Language. Colorado Springs: NavPress.

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CHAPTER 11

ACT and the Religiously Unaffiliated Steven C. Hayes, PhD University of Nevada

Jason A. Nieuwsma, PhD Duke University Medical Center VA Mental Health and Chaplaincy

Robyn D. Walser, PhD University of California, Berkeley National Center for PTSD

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or many years, national surveys have asked people to indicate their religious affiliation among a list of major religious groups. At the bottom of this list has long lay a somewhat ambiguous alternative that was rarely checked off: “none.” In 1972, only 5% of adults listed in the United States listed no religious affiliation in response to such surveys; nearly 20 years later, in 1990, that number had increased, but just to 8%. Then something began to happen: a notably increasing percentage of people looked at that list of alternatives and their eyes moved to that last option. The percentage of “nones” approached 15% in 2000, nearly doubling the rate from just a decade earlier. Only four years later it shot up to 23%. For the first time, the “nones”—­as they began to be called—­became one of the largest single groups in terms of religious affiliation. Figure 1 shows this trend using combined survey results from national samples compiled by Pew Research and by the University of California, Berkeley (Hout, Fischer, & Chaves, 2013; Pew Research Center, 2012; Lipka, 2015). We have added an exponential curve as a trend line to the figure, which fits the data startlingly well. It is in the very nature of exponential growth curves that they cannot last. If this trend line were to continue, in a few decades two-­thirds of the nation would be “nones,” and long before the turn of the next century the last believer in a specific religious approach would have ceased to exist. That will certainly not happen. Still, it is undeniable that something has changed, and changed quickly. In order to think through how the people with no religious affiliation can be cared for by clergy, chaplains, and pastoral counselors, we need to be clearer about the “nones.” Who are they, and what does it mean that they have suddenly arrived in force? In the section below, we will briefly review what we know about them and why their number may be growing. We will then move on to how these people and their providers may be served using an acceptance and commitment therapy (ACT) model. Parenthetically, if no citation is provided for the statistical facts below, they can be obtained from the main citations for Figure 1.

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Figure 1: Percentage of the US Population with No Religious Affiliation

Demographic and Political Factors The “nones” are young. In 2014 the median age of the “nones” was 36, as compared to 46 for the population as a whole. If you examine the millennials—­those born between 1981 and 1996—­fully 35% are “nones.” Thus, this change in religious affiliation is occurring from the bottom up, as a strong cohort-­based effect. Nones are more likely to be male, educated, and childless (Baker & Smith, 2009). An actual loss of religious affiliation is most likely to occur in young adulthood, and

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is increased by cohabitation, nonmarital sex, drugs, and alcohol use (Uecker, Regnerus, & Vaaler, 2007). Politically liberal young people are especially likely to be “nones” (Baker & Smith, 2009; Hout & Fischer, 2014). “Nones” have notably open views of sexual morality (Francis & Robbins, 2014) and support for same-­sex marriage is a significant predictor of whether religiously affiliated people become unaffiliated (Vargas, 2012). While higher education level is robustly associated with non-­affiliation, young adults who avoid college actually exhibit the highest levels of movement from affiliated to unaffiliated status (Uecker et al., 2007). This suggests a possibility that it may not be education per se that leads to higher levels of non-­affiliation; rather, it may in part be why and when people seek education.

The Atheists and Agnostics Many “nones” are self-­declared atheists or agnostics, but these are not the majority. Currently, about a third of all religious “nones” are assertively non-­believing. Less than a decade ago that same group was a fourth of “nones,” so it is fair to say that atheists or agnostics are growing somewhat as a share of all religiously unaffiliated people. Nearly two-­thirds of atheists and agnostics are men, and they currently make up about 7% of all US adults. As a whole, this subgroup tends to be more educated and whiter than the population in general.

The Vagues The most dominant subgroups of “nones” are vague about their religious beliefs. About 16% of Americans (and the largest group of “nones”) say they believe in God but their religion is “nothing in particular.” About two-­thirds of these say that religion is not important in their lives, but the rest say that religion is “very” or “somewhat” important to them, despite their lack of a formal affiliation. Indeed, one out of five of the “nones” say they pray every day!

The Spiritual Nearly three-­fifths of the “nones” say that they often feel a spiritual connection with nature and the earth, and more than a third of these classify themselves as “spiritual” but not “religious.” They feel generally positive about churches and other religious institutions, feeling that they benefit society by strengthening community bonds and aiding the poor.

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In Summary The “nones” are a diverse group, believing in God or not; valuing religion and spirituality, or not; praying or not, and so on. Thus a lack of religious affiliation is only a very broad guide to thinking through the needs of this subpopulation. Indeed, some of the subgroups of “nones” are more like certain subgroups of religiously affiliated people.

Changes Ahead Overall it seems likely, in the Western world at least, that the “nones” will grow as a percentage of the population, although when the entire world is considered, that may not hold over time, due to the higher birthrates of some religious groups (see Hackett, Stonawski, Potančoková, Grim, & Skirbekk, 2015). Religious affiliations often form in young adulthood, and the large number of young people who are religiously unaffiliated suggests that this group will become more prevalent over the foreseeable future as the children of “nones” themselves come into adulthood. This hardly means that religion or the importance of religious and spiritual issues themselves are disappearing. While church attendance has declined significantly in Europe, it appears to be bottoming out in the 5 to 20 percent range (Burkimsher, 2014), and a similar pattern of postwar declines followed by stabilization appears to have occurred in the United States (Presser & Chaves, 2007). Furthermore, spiritual care providers are used to dealing with a range of spiritual and religious interests even within religiously affiliated people, and the “nones” are often surprisingly engaged in spiritual and even religious issues. For example, while many religiously affiliated people are indifferent to religion or even to issues of spirituality (Porpora, 2001), many religiously unaffiliated people, even atheists, think deeply about issues of morality and spirituality (Pasquale, 2010). Similarly, although life satisfaction and various character strengths are associated with religious participation, there are essentially no differences in these areas between those who are unaffiliated and those who say they are religious, and have a specific religious affiliation, but do not participate regularly in religious practices (Berthold & Ruch, 2014). Thus, this diverse group known as the “nones” does not present an entirely new challenge to spiritual care providers: their spiritual needs overlap with those of religiously affiliated people. Indeed, most “nones” identify with broadly spiritual and religious topics, such as meaning, purpose, transcendence, God, connection with the earth, and connection with others. Thus, the rise of the “nones” can best be thought of as a variation in the range and details of the challenges faced by spiritual care providers rather than an entirely new set of issues. 177

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Rising to the Challenge of the Nones In what follows, we consider some of the challenges presented by the rise of the “nones” to spiritual care providers, and ways that ACT and its research base may be relevant. We begin with a broad overview that builds on the data already provided. People without religious affiliation do not have the same built-­in support system that comes from church membership and participation. That can mean both that they face more psychological challenges without a full network of support, and that providing spiritually related care may need to occur outside of the full trappings of religious institutions and organizations. Spiritual care providers who operate in secular settings (such as chaplains or pastoral counselors in hospitals, military, or prisons) encounter the “nones” regularly and yet may need to develop additional innovative structures to be able to serve this population adequately. This part of the picture is not purely due to a change in religious practices. There are broad trends toward weakening of social institutions of all kinds (Putnam, 2000), not just organized religion. At the same time, new forms of social connection are emerging in the form of the Internet and means of social networking. Thus, there are both challenges and opportunities presented to spiritual care providers by the current situation and the religiously unaffiliated. It should be acknowledged that these challenges can themselves create stress for providers. Clergy may face pressure in attempting to foster the sustainability of their congregations and the ability to attract the young. Those who respond by reaching out to the “nones” in a specifically nonreligious form can be accused of watering down their religious message. In a parallel way, those who operate in pastoral counseling settings not overtly affiliated with a particular church will contact “nones” regularly, and yet may need to negotiate new ways to reach them since structuring greater religious involvement directly may not be possible. The push by “nones” to have their views of spirituality be acknowledged and affirmed by spiritual care providers can also be psychologically difficult for religious people, who may have a hard time, for instance, agreeing that a sunset and the divine should be treated in a similar way. The pressure to reach the “nones” may be all the more intense when mental health needs are considered because “nones” can present different constellations of needs when facing psychological challenges. For example, depressed inpatient “nones” are more likely to raise issues of suicidality, in part due to fewer moral objections to suicide (Dervic et al., 2004), and thus chaplains in inpatient facilities may need to address these issues of suicidality but without the ready reliance on moral and scriptural supports that would be relevant to more religiously oriented recipients of care. Innovative programs have been created to reach the “nones,” such as providing anonymous pastoral care via the Internet. The resulting requests are themselves revealing. For example, anonymous pastoral care via the Internet leads to notably 178

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high rates of questions about sexuality, especially premarital abstinence, gender roles, contraception, sexual orientation, and masturbation (Van Drie, Ganzevoort, & Spiering, 2014). This suggests that there may be a body of people wanting help with moral issues but who are blocked by shame or fear of judgment from discussing these issues face-to-face with spiritual care providers.

Using ACT to Help Serve the Nones ACT is a secular approach, but it naturally raises and addresses issues of importance to spiritual care providers. Thus, ACT itself might usefully be explored as a way to reach the “nones” and to address their needs. Several parts of the ACT model seem relevant to the unique challenges being faced by the nones and also the challenges they bring to spiritual care providers. We will consider these by briefly examining all six flexibility processes.

Values In a religious context, values are often specified by the specific religious tradition, but in all of the major religions, values also require an affirmative action by believers. In ACT, values issues are raised as chosen qualities of action. Virtually all ACT values clarification and choice processes can be used by spiritual care providers in their current form, but a feature that is particularly useful when working with the “nones” is that these questions can be focused on the choices of individuals. This requires a deeper understanding of the ACT approach to values to be done properly, since, unguided by data or theory, values conversations easily can turn into a list of “what I want” or “what my goals are” instead of active engagement with “what are the qualities of my own actions I would choose to put into the world.” There may be a fear that values choices will commonly be selfish, individualistic, or self-­serving, but when used in combination with the other elements of an ACT model, values choices are almost always obviously prosocial and communitarian. Issues of love, appreciation, and contribution are very often at the center of values work when people are allowed to dig into what brings them a sense of meaning and purpose.

Commitment In an ACT model, values are a quality of action, and thus values always lead naturally to behavioral commitments. The evidence base on behavioral methods is 179

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notably strong, and linking values conversations to such behavioral issues as exposure, skills building, communication, social involvement, job seeking, compassionate care of others, and so on, provides a way to put values into practice and to make them more habitual.

Being Present Being effective in the here and now requires actually being in the here and now. People understand that, but they often do not know how to direct their attention toward what is of importance. All of the world’s major religions include processes of contemplation, meditation, or prayer that help bring greater control over attentional processes, but these skills can be taught in ways that do not require a specific religious commitment.

A Transcendent Sense of Self The ACT model began with consideration of the issue of spirituality and transcendence from a naturalistic point of view (Hayes, 1984). This aspect of the model is one that links processes of self-­kindness and acceptance to compassionate concern for others. Relational frame theorists have shown that self-­awareness (McHugh & Stewart, 2012) is based on perspective-­taking skills that help people see the world from other people’s eyes. Transcendence, interconnection, and oneness are common qualities of deeply spiritual experiences (Renz et al., 2015), and the ACT model includes a number of specific methods that can be used to promote these qualities of awareness.

Acceptance and Compassion Acceptance of self and others is a core feature of virtually all of the world religions. Although religion often views humans as flawed in some way (such as through original sin), humans are also viewed as children of God and as savable (through grace, redemption, faith, good works, or other means depending on the particular religious viewpoint). Acceptance processes frequently serve to bring individuals into contact with a compassionate recognition not only of their own struggles, joys, and failures, but with those of others as well. In providing sets of methods related to acceptance and compassion, ACT can be used to raise such issues with people who are not necessarily currently prepared to view themselves within a specific faith tradition.

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Acceptance does not mean that anything goes, or that actions and situations are acceptable regardless of what is happening. It means that human beings are whole and as such, all of their experience is part of what it means to be alive. All of the struggles, joys, failures, and triumphs can be held with openness and kindness.

Defusion Mindful awareness of thought offers a gap between automatic habits of mind and the likely embrace of belief. In most religions, thoughts that are willed or believed have consequences, but thoughts that are not embraced are not determinative of actions or outcomes. Wet dreams are not sins, for example, in major religions. Defusion sits exactly on that cusp between automatic thoughts and thoughts embraced, fused with, or believed, and provides for greater freedom of choice when automatic thoughts occur.

In Sum This chapter takes the view that the psychological flexibility processes in ACT can be used by spiritual care providers when working with “nones” to help open the door to issues of meaning, purpose, spirituality, compassion, and so on, but without first having to have specific religious commitments or affiliations. Chaplains and clergy can use these methods not as forms of psychotherapy, but as ways to help provide spiritual care within their current roles. Conversely, pastoral counselors can use these methods as forms of mental health treatment that comports with their spiritual traditions, but without having to have recipients of care first adopt those traditions. The growing group of people wanting spiritual care outside of having any religious affiliation, or even outside of a theistic belief system at all, ensures that chaplains, clergy, and pastoral counselors will increasingly face situations in which such methods are needed or are useful. Many forms of evidence-­based psychological care make it difficult for spiritual care providers because the underlying model is so foreign to spiritual traditions. ACT began by taking spirituality seriously, and its entire model echoes sensitivities that are foundational to our spiritual and religious traditions.

References Baker, J. O., & Smith, B. G. (2009). The nones: Social characteristics of the religiously unaffiliated. Social Forces, 87, 1251–­1263.

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Berthold, A., & Ruch, W. (2014). Satisfaction with life and character strengths of non-­religious and religious people: It’s practicing one’s religion that makes the difference. Frontiers in Psychology, 5, 876. Burkimsher, M. (2014). Is religious attendance bottoming out? An examination of current trends across Europe. Journal for the Scientific Study of Religion, 53, 432–­445. Dervic, K., Oquendo, M. A., Grunebaum, M. F., Ellis, S., Burke, A. K., & Mann, J. J. (2004). Religious affiliation and suicide attempt. American Journal of Psychiatry, 161, 2303–­2308. Francis, L. J., & Robbins, M. (2014). The religious and social significance of self-­assigned religious affiliation in England and Wales: Comparing Christian, Muslim and religiously-­unaffiliated adolescent males. Research in Education, 92, 32–­48. Hackett, C., Stonawski, M., Potančoková, M., Grim, B. J., & Skirbekk, V. (2015). The future size of religiously affiliated and unaffiliated populations. Demographic Research, 32, 829–­842. Hayes, S. C. (1984). Making sense of spirituality. Behaviorism, 12, 99–­110. Hout, M. & Fischer, C. S. (2014). Explaining why more Americans have no religious preference: Political backlash and generational succession, 1987–­2012. Sociological Science, 1, 423–­447. Hout, M., Fischer, C. S., & Chaves, M. A. (2013). More Americans have no religious preference: Key finding from the 2012 General Social Survey. Berkeley, CA: University of California, Berkeley Institute for the Study of Societal Issues. Lipka, M. (May 2015). A closer look at America’s rapidly growing religious ‘nones.’ Pew Research Center. Retrieved on August 6, 2015 from http://www.pewresearch.org/fact-tank/2015/05/13/a -closer-look-at-americas-rapidly-growing-religious-nones/. McHugh, L., & Stewart, I. (2012). The self and perspective taking: Contributions and applications from modern behavioral science. Oakland: New Harbinger Publications. Pasquale, F. (2010). A portrait of secular group affiliates. In P. Zuckerman (Ed.), Atheism and secularity, Vol. I. (pp. 43–­87). New York: Praeger. Pew Research Center. (2012). “Nones” on the rise: One-­in-­five adults have no religious affiliation. Washington, DC: Pew Research Center’s Forum on Religion & Public Life. Presser, S., & Chaves, M. (2007). Is religious service attendance declining? Journal for the Scientific Study of Religion, 46, 417–­423. Porpora, D. (2001). Landscapes of the soul: The loss of moral meaning in American life. New York: Oxford University Press. Putnam, R. D. (2000). Bowling alone: The collapse and revival of American community. New York: Simon & Schuster. Renz, M., Mao, M. S., Omlin, A., Bueche, D., Cerny, T., & Strasser, F. (2015). Spiritual experiences of transcendence in patients with advanced cancer. American Journal of Hospice and Palliative Care, 32, 178–­188. Uecker, J. E., Regnerus, M. D., & Vaaler, M. L. (2007). Losing my religion: The social sources of religious decline in early adulthood. Social Forces, 85, 1667–­1692. Van Drie, A., Ganzevoort, R. R., & Spiering, M. (2014). Anonymous pastoral care for problems pertaining to sexuality. Journal of Religion & Health, 53, 1634–­1652. Vargas, N. (2012). Retrospective accounts of religious disaffiliation in the United States: Stressors, skepticism, and political factors. Sociology of Religion, 73, 200–­223.

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Applying ACT in Different Spiritual Roles

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roviders of spiritual care assume a wide range of identities (such as priest, counselor, chaplain, and so on) and operate across a great diversity of settings. While by no means exhaustively covering the varieties of roles in which spiritual care providers function, this section will explore how acceptance and commitment therapy (ACT) might be integrated into some of the more common settings where clergy and pastoral counselors operate. ACT offers exciting potential for flexible application across diverse contexts in part because many of the principles within ACT can be fluidly adapted beyond ACT’s formational roots as an approach to doing psychotherapy. Indeed, a number of propositions in ACT have far-­ reaching implications. Although properly speaking ACT is not a formal philosophy, it does explicitly adopt some key existential assumptions in a manner that is distinct from other psychotherapies. Among these are assumptions about the existence of pain in human lives, assumptions which can be summarized as: 1) pain is inevitable; 2) pain should not always be avoided; and 3) pain can be valuable. These assumptions are explored from a variety of vantage points throughout a number of the chapters in this book, and it is evident that they run contrary to mainstream cultural impulses. Contemporary society is filled with platitudes like “do what makes you happy” and “follow your bliss.” While certainly not opposed to happiness, ACT can be understood as adopting something of a countercultural stance. Religions also frequently advocate countercultural messages. Certainly, the origins of many religious movements have run against prevailing culture in profound ways. Even when a society takes on an identity associated with a particular religious heritage (such as being a “Christian nation”), the great truths of that religion often persist in being countercultural. Humans simply struggle with things like practicing self-­control and loving one another, and so it is that religious truths have a way of resonating afresh in response to familiar problems down through the generations.

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Individuals from Judeo-­ Christian traditions are familiar with the book of Ecclesiastes (Kohelet in Hebrew), which is generally attributed to King Solomon. Despite his myriad attempts to find happiness in all of the obvious places—­sex, money, and whatever the ancient world’s equivalencies were to rock and roll—­ Solomon again and again returns to the refrain: meaningless. Personal happiness was as seductive to chase centuries ago as it is today, yet as elusive too. From an ACT perspective, chasing happiness is unlikely to yield success. Rather, as detailed throughout this book, ACT proposes a stance of active acceptance with respect to the inevitabilities of life, good and bad, and a behavioral orientation that moves people in the direction of their values. This understanding in ACT, along with the various methods for helping to actively engender it, need not be confined to counseling contexts. It can be applied broadly. For spiritual care providers, it can be used not only in counseling individuals but in pastoring a church, ministering to the ill, serving as a chaplain, and even in caring for one’s self. The chapters in this section cover some of the more common roles that spiritual care providers assume, but ACT principles can certainly be applied even more broadly than that across a wide range of religious and spiritual settings. Some time back, one of this book’s editors learned that a fellow congregant suffering from anxiety had been reading an ACT self-­help book. Weeks later, this individual provided the opening congregational prayer for the Sunday service. The parallels with ACT were unmistakable. The prayer beautifully interwove laments of global, community, and individual significance with sincere expressions of gratitude, petitions for help, and affirmations of the faith community’s values. In the parlance of ACT, the prayer evidenced a willingness to be in full contact with a range of life’s realities along with a communal commitment to the ongoing work of realizing collectively held values. The creative possibilities for integrating ACT with religion and spirituality are boundless. The chapters in this section are intended to offer insights for spiritual care providers functioning in various contexts as well as to stimulate new and imaginative thoughts for further application of ACT. —Jason A. Nieuwsma, PhD

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CHAPTER 12

ACT and Clergy Kent D. Drescher, MDiv, PhD National Center for PTSD

Daniel M. Saperstein, DMin Presbytery of Lake Huron

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arish clergy, as leaders of religious communities, utilize a unique and broadly diverse skill set as helping professionals. In addition to administrative, educational, and liturgical roles, clergy members also engage with people in the midst of significant life crises, and with those who suffer from significant mental health disorders. A recent NIH national survey indicated that parish clergy members are highly sought out by those challenged by mental health problems and suicidal thoughts. Nearly as many individuals with these problems seek help from clergy as seek help from physicians and psychologists (Wang, Berglund, & Kessler, 2003). The focus of this chapter is the relevance of acceptance and commitment therapy (ACT) principles and processes for the many and varied roles that parish clergy members play in the lives of suffering people. Specifically, this chapter will examine areas of ministry and theological models where these principles and processes intersect directly and helpfully with that work of ministry. Four key areas of the practice of ministry will be examined: pastoral care, congregational leadership, worship, and clergy self-­care. The authors of this chapter bring both direct psychological and parish ministry experience; however, the views herein are reflective of their experience within a specific mainline Protestant denomination (PCUSA) and may not be fully consistent with the ministry experiences and expectations of clergy members serving other religious traditions.

ACT and Pastoral Care Clergy provide leadership and emotional/spiritual support to communities of people. This work of ministry allows clergy members to encounter community members not only during the mundane experiences of day-­to-­day living, but also during the most significant moments of both joy and suffering. Clergy members visit the sick, comfort the bereaved in the midst of grief, and celebrate with parents and community the arrival of new life. Religious communities provide for many people an important framework for understanding those most difficult moments of living, particularly human suffering.

ACT and Human Suffering “Theodicy” is a term coined by the 18th century philosopher G.W. Leibniz to describe the philosophical and theological challenge of human suffering (McKim, 2014, p. 316). Theodicy attempts to provide a rationale for evil and suffering in the world. Theodicies answer a core question faced by religious communities: “If God is all good, and God is all-­powerful, why do evil and human suffering exist?” For if God 186

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were all good, God would prevent suffering, and if God were all-­powerful, God could prevent suffering. Leibniz, however, was preceded by many religious leaders in providing insight into these questions. Early Christian leaders also struggled with these questions. In the second century, Irenaeus, Bishop of Lyons, formulated an argument suggesting that evil is necessary for human moral and spiritual development and is a part of God’s purpose (Hick, 2010). Two hundred years later, the theologian Augustine suggested that human free will is responsible for the presence of evil in the world. Because human beings can choose to do evil, evil exists. In essence, suffering is the cost associated with the freedom to choose between good and evil (Hick, 2010). ACT also has a perspective on human suffering. But rather than address the metaphysical origins of human suffering, ACT seeks to distinguish between what it calls pain and suffering. ACT simply acknowledges the universality of physical, emotional, and spiritual pain among humans. From an ACT perspective, suffering comes about when human beings engage in intense internal struggle with pain of all sorts. From this perspective, struggling with pain (i.e., maladaptive attempts to avoid and control one’s thoughts, emotions, and bodily sensations) not only fails to relieve pain, but often intensifies or prolongs the experience. Each present moment spent in internal struggle with thoughts and emotions is ultimately lost to the meaning and satisfaction that could be derived from living one’s values. ACT seeks to enhance human flourishing, or what it calls “psychological flexibility.” This term can be understood as the ability to live meaningfully, engaged in values-­directed actions, even in the presence of pain. To accomplish this new way of living, ACT engages individuals in three distinct therapeutic processes. The first of these processes, opening up, involves enhancing an individual’s willingness to experience (acceptance) all that life brings without engaging in unhelpful avoidance or attempts at control of internal experience. It also involves holding less tightly (defusion) to various thoughts and emotions that would discourage one from engaging in values-­directed actions. The second of these processes, awareness, involves developing the practice of living in the present moment using mindfulness (present moment). Jon Kabat-­Zinn, professor emeritus of medicine at University of Massachusetts Medical School, defines mindfulness as “paying attention in a particular way: on purpose, in the present moment, and non-­judgmentally” (Kabat-­Zinn, 1994, p. 4). Awareness also involves enhancing the ability to take perspective, to see oneself in a larger context as an agent free in each moment to decide how to act (self-­as-­context). Finally, the third of these processes is doing what matters. This involves a continuing search for one’s most important values (values), along with a moment-­by-­moment commitment to take actions that move one forward in valued directions (committed action).

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There is significant overlap between elements of the Judeo-­Christian tradition and these three ACT therapeutic processes. The Christian gospels portray Jesus as promoting a life lived in the present moment. In Matthew’s gospel, Jesus says, “And can any of you by worrying add a single hour to your span of life? And why do you worry about clothing? Consider the lilies of the field, how they grow; they neither toil nor spin, yet I tell you, even Solomon in all his glory was not clothed like one of these” (Matthew 6:27–­29 NRSV). In Luke’s gospel, Jesus introduces his own ministry as commitment to values-­based action on behalf of others. Jesus states: “The Spirit of the Lord is upon me, because He has anointed me to bring good news to the poor. He has sent me to proclaim release to the captives and recovery of sight to the blind, to let the oppressed go free” (Luke 4:18 NRSV). There are similar themes in the Hebrew Bible: the wisdom tradition speaks to living confidently in the present (e.g., Proverbs 3, Psalms 23 and 46); the books of Deuteronomy, Proverbs, and many of the prophets speak to values-­based action.

ACT in the Context of Ministry The work of parish clergy differs substantially from that of other health care providers in ways that create great opportunity. Parish ministry places clergy members directly and experientially into the lives of others in ways not available to most therapists, pastoral counselors, and even chaplains. Parish clergy function in a myriad of roles during the course of their work week, many of which place them in direct face-­ to-­face contact with individuals experiencing both the heights and depths of human emotional experience: celebrating new life in the hospital room with young parents at the birth of their child; mourning with those who have lost a loved one to a sudden, unexpected, and tragic death and wonder how they can possibly go on; sharing a meal with a family in turmoil due to job loss and impending financial ruin; engaging in a deep conversation about highly personal marital distress with a board member at the end of the church business meeting. Each of these experiences and many others illustrate ways in which parish clergy touch the lives of others outside of the traditional therapy office. In spite of the fact that ACT is a therapeutic approach designed to help people come into experiential contact in the present moment with thoughts and emotions previously avoided, traditional therapeutic environments actually distance individuals both physically and emotionally from the places where they live their lives. The therapy room is an artificial landscape for simulating engagement in the real world. Parish clergy, in contrast, have the ability to help individuals make contact with their experiences in the present moment because they are physically present with them in those moments. ACT principles have enormous potential when they are modeled 188

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and experienced in vivo, outside the confines of the traditional therapy room. This increases the potential for parish clergy to be powerfully effective in assisting hurting individuals in making life-­enhancing behavioral choices at key moments in their lives. The therapeutic stance of ACT is highly consistent with traditional models of pastoral care, more so than is the stance of some other counseling and therapeutic styles. ACT as a therapy is “transdiagnostic,” meaning that it attends less to issues of psychiatric diagnosis, and rather more to issues of life functioning, which ACT calls “workability.” ACT takes a therapeutic stance that is “peer-­to-­peer,” in that even in the therapy room clients are approached as fellow human beings that suffer, and the therapist communicates himself as another human being who suffers as well. Rather than taking a hierarchical stance where the therapist is the more knowledgeable, powerful one in the relationship, ACT therapists attempt to meet clients as equals and simply share and demonstrate therapeutic elements that help their own lives to work. In describing the therapeutic relationship in ACT, Roger Vilardaga & Steven Hayes (2009) write, “The therapeutic relationship is also a process that can be difficult, on both sides, because it too evokes avoidant responses of all kinds of forms and sizes. When they are overcome, however, it is a relationship that can lead to meaningful and transformative experiences” (p. 2). While the Christian church certainly has many hierarchical elements, particularly in how churches are governed, a key theological element of the Protestant Reformation has been called the “priesthood of all believers.” In essence, this theological position led to a leveling of the differences between priest and laity. In practice, it supports a more “peer-­to-­peer” pastoral response.

ACT and “The Wounded Healer” Carl Jung was an early psychologist who has had a strong influence on the development of modern models of pastoral care. In his writings, Jung noted that clinician self-­awareness of personal suffering is an important component of care for others. He made reference to the Greek myth of Chiron, the “wounded physician” (Jung, 1966). In the Greek myth, Chiron was a centaur to whom the gods Apollo and Artemis taught medicine. Chiron was wounded by an arrow from Heracles’s bow but did not die (as he was immortal). Instead, he suffered excruciating pain for the rest of his eternal days. It was due to his enduring wound that Chiron became legendary for his healing in ancient Greece (Daneault, 2008). Henri Nouwen was a Catholic priest and writer who also made a significant contribution to modern models of pastoral care. His perspectives on caring dovetail well with an ACT perspective. His classic book The Wounded Healer provides a guide for 189

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parish clergy that is highly consistent with an ACT therapeutic stance. He suggests that parish clergy must be willing to step down from the pedestal of their ministerial role and encounter others as fellow human beings who share the same wounds and suffer similarly to those to whom they minister (Nouwen, 1979). In one of his sermons, published while he was a professor at Yale, Nouwen writes about friendship in a way that captures both the willingness and present-­moment elements of ACT: “The friend who can be silent with us in a moment of despair or confusion, who can stay with us in an hour of grief and bereavement, who can tolerate not knowing, not curing, not healing and face with us the reality of our powerlessness, that is a friend who cares” (Nouwen, 1973/2004, p. 38).

ACT and Congregational Leadership Of all the roles performed by parish clergy, perhaps the most iconic is that of the pastor/shepherd who leads the flock. Pastors are spiritual leaders. Yet, virtually no attention is paid in seminaries, divinity schools, or rabbinical schools to the study of leadership. Congregations are complex organizations, and unprepared clergy are easily entangled in unproductive or even destructive patterns of congregational behavior, often fueled by their own ego needs. ACT can be a helpful tool both in the pastor’s own practice of self-­differentiated leadership, as well in building healthier, more effective congregations. Two models widely employed in leading congregations are congregational systems theory and adaptive leadership. Both have elements that either parallel the ACT process, or can be enhanced by it.

ACT and Congregational Systems Theory Congregational systems theory, modeled after Bowen family systems theory, a clinical approach to family therapy developed by Murray Bowen (2002), was popularized for use in congregations by Rabbi Edwin Friedman (1985). Friedman attributes persistent regressive behavior in congregations to a state of chronic anxiety (2007). All parts of the system are interrelated; therefore, altering one part of the system in relationship to the whole affects the whole system. Thus, in congregational systems theory, the leader’s ability to differentiate emotionally from the system is the most powerful tool to restore health to the whole system. When the leader maintains a self-­differentiated “non-­anxious presence” within the system, the system adapts to the leader’s functioning, systemic anxiety is reduced, and healthy patterns of relationship emerge. “If a leader will take primary responsibility for his or her own position as

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‘head’ and work to define his or her own goals and self, while staying in touch with the rest of the organism, there is a more than reasonable chance that the body will follow” (Friedman, 1985, p. 229). Friedman identifies three essentials to leadership that will improve congregational functioning, moving it toward its goals. First, the leader must stay connected to the system while maintaining a differentiated posture despite pressures to fuse with the system. Second, the leader should have a “capacity and willingness…to take non-­reactive, clearly conceived, and clearly defined positions” (1985, p. 229). Here the goal is for the leader to “define self and continue to stay in touch” (p. 229). This does not mean to impose a particular posture or position on the congregation, only to define him-­or herself within it. More differentiated members will follow the pattern of the leader, while others may reactively resist. This leads to the third essential, the capacity to deal with sabotage by remaining connected and maintaining self-­differentiation (p. 230). A leader trained in ACT has a tremendous advantage in leading congregational systems by possessing the tools to hold her anxiety and reactive tendencies lightly while choosing to act in a values-­based, self-­differentiated way. ACT processes don’t prevent reactive thoughts or emotions; however, they can provide present-­moment awareness of them along with the space to choose to react intentionally in ways consistent with important values. ACT increases the leader’s ability to remain in connection by developing and maintaining awareness, both of the leader’s self and of the leader’s functioning within the congregational system.

ACT and Adaptive Leadership Over the past 50 years, religion in American society has become increasingly marginalized, religious affiliation has waned, and religious institutions have declined in public trust and influence. Religious communities—­especially more established, less nimble “mainline” denominations—­have been slow to adapt to the changing cultural landscape. The old ways of “being the church” simply do not work anymore. Quick fixes—­typically organizational restructuring on the national level and cosmetic adjustments locally—­have failed. Religious leaders and their congregations face challenges of enormous magnitude in order to maintain, much less restore, a thriving organizational life. “Adaptive leadership” is a concept introduced by Ronald A. Heifetz of Harvard University in his groundbreaking book Leadership Without Easy Answers (1994). It refers to the kind of leadership required for an organization to meet an “adaptive challenge.” Such a challenge requires the organization to learn new ways of functioning and develop new norms in the organizational culture that allow it to adapt to 191

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changes in the broader environment. Adaptive challenges are distinguished from technical problems in that adaptive challenges require the organization to withstand an extended period of disequilibrium while it participates in adopting new values, attitudes, or habits of behavior (Heifetz, 1994). Technical problems, by contrast, can be diagnosed and solved through established know-­how, and are amenable to top-­ down management (Heifetz, Grashow, & Linsky, 2009, pp. 303, 307). We propose that the problems facing contemporary religious communities in America require adaptive leadership. ACT can benefit clergy in the practice of adaptive leadership. As with congregational systems theory, adaptive leadership requires the leader to maintain a differentiated presence within the organization. Heifetz identifies seven suggestions for self-­management to deal with the stress of resistance to adaptive change: 1) adopting a “balcony” perspective to observe one’s self as one functions within the organization, 2) distinguishing one’s self from one’s role, 3) externalizing the conflict, 4) using partners, 5) paying attention to oneself as a listener and being willing to reevaluate one’s perceptions, 6) finding a sanctuary, and 7) preserving a sense of purpose. The acceptance and commitment process of ACT builds capacities for letting go of automatic reactions, holding past failures loosely, differentiating self from role, increasing awareness of the self within the system in the present, and directing actions toward a future based on chosen values to help the self and the organization thrive in the new landscape. The table that follows illustrates the associations between the adaptive leadership model and ACT processes.

Adaptive Leadership and ACT Adaptive Leadership Principle

Related ACT Processes

Comments

Adopting a “balcony” perspective

Awareness

Mindfulness cultivates the ability to notice one’s inner experiences (thoughts, emotions); self-­as-­context aids in separating one’s choices from that experience.

Distinguishing self from role

Opening up, Awareness

Defusion is holding one’s thoughts and emotions less tightly. Self-­as-­context is the ability to see oneself as distinct from one’s inner experience, including one’s role.

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Externalizing conflict

Opening up

The processes of willingness and defusion can allow an individual to experience the emotions associated with conflict but to hold them less tightly.

Using partners

Awareness, Do what matters

Awareness of self can allow for an appreciation of the strengths that others bring, and to see how valued directions might be achieved through partnered action.

Paying attention Awareness to oneself as a listener

Mindfulness cultivates awareness of one’s inner experiences and what arises in present-­ moment experiences. This allows for deeper listening that goes beyond a person’s words, to the reactions those words elicit.

Finding a sanctuary

Mindfulness cultivates awareness of one’s inner experiences. Willingness allows the inner struggle with one’s experience to diminish by holding lightly to whatever that inner experience may bring. Freedom from struggle creates a space where valued action can grow and thrive.

Opening up, Awareness

Preserving a Do what matters sense of purpose

Values are at the core of a sense of purpose, yet purpose not rooted in committed action is meaningless.

ACT and Conflict in Congregations Parish ministry is inherently social. While clergy certainly do some work in isolation, particularly preparation for preaching and teaching, most clergy activity involves engagement with people, whether it be in dyads, small groups, a full congregation, or other large community activity. Some of the most challenging social interactions for clergy members may involve interpersonal conflict and the emotion of anger. Facilitating social connectedness and values-­reflective action in the midst of strong emotion can be difficult for a group of any size. ACT principles provide guidance for working productively with such a group. Individuals engaged in an intense angry dialogue frequently become highly fused to very specific thoughts as well as to intense emotion. This may lead to attempts to avoid the experience by leaving in anger, or to

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control the situation through behavioral acting out (such as yelling, sarcasm, or other forms of verbal aggression) that then escalates the emotional experience of others with corresponding avoidance and control behaviors by other group members. Each of the ACT processes is relevant here and can be brought into play to help a group engage conflict more productively. Using awareness processes might allow the clergy member to encourage the group to engage together in a brief mindful breathing exercise to allow members to return to the present moment and to be aware of the thoughts and strong emotions that are present within themselves and in others in the room. Perspective taking can assist group members in calling to mind earlier times when that particular group has had different, more productive emotional experiences and thoughts and allow for the possibility that the current conflict may not continue forever. Perspective taking can also allow members to take on the perspective of others in the room and attempt to see the conflict through their eyes. The opening up processes of ACT can encourage individuals to hold less tightly onto their powerful and seemingly singular thoughts and emotions in the midst of conflict. Loosening the hold of these thoughts and emotions can allow for the awareness that there may be other (possibly conflicting) thoughts and emotions also present that had been pushed out of awareness by the intense holding to the angry thought or feeling. Defusing can allow for the recognition that within the room these other experiences might simultaneously be present or possible. Willingness, which is simply allowing and acknowledging what is actually present within the individual or group, can create the space necessary to allow for this broadened set of thoughts and emotions. Finally, the doing what matters processes allow the group to hold the conflictual angry thoughts and feelings alongside a shared awareness and acknowledgment of the group’s core values. Allowing values to make their presence known in the midst of conflict can enable individuals within the group to begin to choose to move in the direction of those values even in the midst of group friction. Helping a group make movement together toward shared values is one of the core leadership competencies required in the clergy vocation. Clergy ministry is enormously challenging. Small tensions within a community of people can rapidly escalate with painful consequences for clergy members and parishioners alike. To illustrate, we offer the following case based on actual events. Specific identifying elements have been changed to protect those involved.

Case Study Peace Memorial Church was anything but peaceful. This congregation of about 200 members in a small rural town had experienced a high level of

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conflict surrounding the pastor’s job performance. In this, his second appointment, the pastor had been unable to deal with the politics and personalities of the parish, and had been bullied by several of the more powerful members. The church personnel committee required that he account for his time in a running log in 15-­minute increments. The pastor’s wife was acting out inappropriately within the congregation, publicly chastising the congregation into accepting her husband’s ineffective leadership. The congregation was split between factions supporting the pastor and those seeking his removal. As with all escalating conflicts, both factions began constellating unrelated actions into perceived patterns of hostile behavior. Communication between factions was limited and calculated. The church board was in over its head; it was unable to restrain ad hoc decision-­making or to establish accountability for breaches of civility. A tree given as a memorial to the late husband of the pastor’s chief antagonist had been purchased and planted on church grounds without the authorization of the church board. When this was discovered, the pastor and the chairperson of the building and grounds committee moved the tree to a different location they felt was more appropriate, without consulting either the widow or the church board. The conflict instantly exploded and the denomination’s regional council on ministry was called in. Following the protocol for highly conflicted churches, representatives of the council scheduled “listening sessions” with groups of church members. Members were encouraged to sign up and attend sessions with people of the same faction, so that people could speak more freely. During one of these sessions, it was discovered that a friend of the chief antagonist had been secretly tape recording the session. The facilitator from the regional council insisted that the recorder surrender the tape to him, which she did. However, when the antagonist learned this had happened (immediately after the session), she summoned the local constabulary to reclaim the “stolen” item. When the sheriff arrived, he insisted the facilitator surrender the tape to the antagonist, which the facilitator refused to do. The sheriff stated that if the facilitator did not surrender the tape, he would be placed in jail for petty theft. Upset with the subversion of the listening sessions and the bullying of the antagonist, the facilitator still refused. Meanwhile, the other representative of the council present asked for some time to consult with the regional executive. The executive was briefed by phone about the circumstances while the sheriff and the antagonist stood by. 195

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The executive counseled with the facilitator and invited him to acknowledge the feelings that were leading him toward an unwelcome outcome. He invited the facilitator to defuse from the feelings of betrayal and subversion and to be mindful of his situation. He then helped the facilitator identify behavior that would promote the purposes of reconciliation and congregational healing, without either violating the civil law or empowering the antagonist. He surrendered the tape, but instructed the antagonist that the contents of the tape were not to be shared with others in the congregation, and that doing so would subject her to ecclesiastical discipline for violating the peace of the church. Had the pastor or the facilitator been trained in ACT, the scenario might have been averted altogether. Much of the pastor’s difficulty with the church was due to a paralysis of action stemming from interpersonal rigidity in his relationship with his antagonist, as well as a perceptual set toward congregational conflict he carried from his previous congregation. Had he been better able to accept his feelings of frustration and the nagging failures from his previous call and gain perspective by seeing his present self as not fused with those past events, he might have been able to recognize the antagonist’s issues of grief and loss of control, experience compassion, and engage her with values-­consistent behaviors. He might also have been able to help the congregation to identify its own systemic issues regarding leadership and power (fed by enduring beliefs about prior injustices and intense emotions ready to flare among members). He could then have helped the congregation to realign with core values and choose to act in ways more consistent with their self-­perception as a community of peace. Similarly, the listening session facilitator might have responded to the surreptitious recording incident with greater self-­awareness of how fusion with his feelings of betrayal was impeding his intended purpose and violating his values. Rather than being a non-­anxious, values-­aware presence in the midst of the conflict, his behavior instead inflamed the anxiety and met the antagonist at her own level of conflict.

ACT and Worship Leadership If there is a role or function that is held uniquely by parish clergy, as opposed to other helping professionals, it is presiding over communal spiritual/sacramental practices. The liturgical role of clergy is such a visible and central activity that people sometimes joke that clergy members only work one hour per week—­that being their public sacramental role. The theological nature and the number of sacraments may vary across Christian denominations. However, in all Christian traditions that 196

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acknowledge sacraments, they are a symbolic and ritualized experiencing of what are seen as underlying spiritual truths. Whether it be the group sharing and eating of the bread and cup in the Eucharist, or the symbolic washing with water leading to new life in baptism, engaging in symbol and metaphor conveys deeper understanding to those participating in the worship experience. Similarly, ACT makes extensive use of experiential exercises and enacted metaphor to assist individuals in becoming more aware of their inner experiences (i.e., thoughts and feelings) and to develop new ways of relating to those inner experiences that bring them closer to and more ready to act on their personal values. There are a number of spiritual practices long associated with the Christian tradition. These spiritual disciplines are intended to foster spiritual health and growth by intentionally engaging in values-­oriented activity directed both inwardly and outwardly. Among these are inward practices such as prayer, meditation, and contemplation; outward practices such as living simply, serving others, and giving; and communal and interpersonal practices such as worship and confession. All of these spiritual disciplines provide a means of focusing one’s attention toward a particular values-­based activity. Similarly, ACT utilizes mindfulness, a technique often associated with Eastern spiritual traditions, but also present in Judeo-­Christian spirituality, as a tool to help an individual focus attention on present moment-­to-­moment experience in the service ultimately of living fully in accordance with one’s highest values. Clergy knowledgeable of ACT principles could powerfully assist parishioners in utilizing long-­standing Christian religious activities to help define life values and to enhance commitment to sustained actions to move individuals in those valued directions. There are elements of the broad traditions of worship across Christian denominations as well as in Judaism which present themselves as opportunities to engage congregations in processes of opening up, awareness, and doing what matters. Many services begin with a time of “centering prayer” in which worshippers are invited to be fully open to the presence of God, and to be fully aware of themselves in the divine presence. Clergy with knowledge of ACT can incorporate liturgical prompts in the rituals of confession and absolution. Likewise, benedictory comments can remind worshippers to commit to values-­directed activity as they go out into the world. Another opportunity within the worship context for facilitating individual and collective awareness and participation in ACT-­like processes comes in the sermon, homily, or reflection. The connections between the Christian and Jewish scriptures and ACT are too many to list. An ACT-­aware preacher might well shape sermons, either individually or as a series, to highlight the path to wholeness set forth in ACT. For example, each of the six themes of the ACT “hexaflex” could serve as a theme for homilies:

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• Acceptance (acknowledging internal negative experiences): An example would be the Apostle Paul’s discussion of the “thorn in the flesh” which he accepts so that God’s power may be made perfect in his weakness (2 Corinthians 12:7b-­10). • Defusion (shifting the context of thoughts and language to defuse their negative potency): A preacher might use the theme of justification by faith in Paul’s letter to the Romans to explain how a person can hold lightly their sense of self-­condemnation while embracing and living out of a new sense of freedom. • Getting in contact with the present moment: Passages such as Ecclesiastes 3 (“To everything there is a season”), Romans 12:1–­2 (“Be transformed by the renewing of your minds”), as well as the Matthew 6:27–­29 exhortation (noted earlier) not to worry can be useful. • Self-­as-­context: The Apostle Paul’s struggle with his two natures in Romans 7:19–­20 would be a fruitful text (“For I do not do the good I want, but the evil I do not want is what I do. Now if I do what I do not want, it is no longer I that do it, but sin that dwells within me.”) • Values: The prophets of the Hebrew scriptures, such as Amos (e.g., 5:14, “Seek good and not evil, that you may live”), are rich sources of texts calling the faithful to align actions with professed values. • Committed action (the need consistently to choose values-­directed behavior): The experience of Israel in the wilderness, repeatedly falling back into doubt and idolatry, is but one of many biblical examples.

ACT and Clergy Self-­Care While the work of parish ministry can be extremely rewarding, there can also be large personal costs experienced by clergy. There may be expectations placed on clergy members that are not experienced by professionals in other disciplines. Because the clergy member functions as a visible leader in the religious sphere, members of both the religious and secular communities may have very high and potentially unrealistic expectations about behavioral norms for clergy leaders. They may place clergy members on a pedestal and expect them to live as consistent exemplars of spirituality. Words and actions of clergy members may be viewed and evaluated by others in terms of their consistency with that higher level of spiritual existence. They are expected to

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be wise, humble, caring, and even-­tempered at all times, and they are likely to be looked down upon for failing to meet those standards. Clergy members may also internalize those lofty behavioral expectations about their own spirituality and over time may struggle with dissonance at trying and failing to live a life fully consistent with those expectations. Parish ministry in many ways is a job that is never fully complete. There are always more families to visit, individuals in crisis, classes to be taught, meetings to be facilitated. Especially to the degree that they share in those high expectations often perceived from parishioners, clergy members may find it difficult to slow down. Over time this may lead to neglect of oneself, and of one’s family. It’s not uncommon for clergy members to experience marital tension, and often to feel constrained about seeking help, lest parishioners feel the clergy members have failed in their calling. Clergy members and their families may perceive that their lives are lived in a “fishbowl.” This can lead to a perceived or actual experience of having dual lives, one lived while in the spotlight in full view of parishioners, and another that exists behind the scenes when no one is looking. For some, this duality may produce painful discordant thoughts and emotions that can lead to maladaptive attempts to avoid or control this inner experience through risky behavior and even moral lapses. Financial pressures can at times increase family tensions for clergy. In many denominations, clergy salaries are below the average for other professionals with similar levels of education and experience. At the same time, church members may hold the expectation that clergy should not be concerned with “material things.”

Stress and Clergy Burnout The pace and pressures of ministry expose clergy to two common maladies: stress and burnout. These are separate but related phenomena. Roy Oswald, a Lutheran pastor and longtime consultant for the ecumenical Alban Institute, identifies the most common sources of clergy stress as role ambiguity, role conflict, role overload, time demands, lack of pastoral care, lack of opportunities for extra-­dependence, geographical relocation, political/economic uncertainty, the demands of a helping profession, and loneliness (Oswald, 1991). These stresses characteristically involve the overuse of adjustment capacities due to an overload of transition, novelty, and change. Oswald suggests that these stressors commonly result in a perceived loss of options, behavioral acting out, inability to change destructive relationship patterns, fatigue, depression, and physical illness (Oswald, 1991). According to Maslach (1976), burnout is “a state of physical, emotional and mental exhaustion marked by physical depletion and chronic fatigue, feelings of

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helplessness and hopelessness, and by development of negative self-­concept and negative attitudes toward work, life and other people” (cited in Oswald, 1991, p. 58). It is a unique form of job stress that results from an overuse of our listening and caring capacities, born of the demands of too many needy people and too much responsibility (Oswald, 1991). The effects of ministry burnout are physical and emotional exhaustion, cynicism, disillusionment, and self-­depreciation. There are numerous strategies for the treatment of both stress and burnout, but ultimately they all require the minister to increase self-­awareness about her condition, and to break the systemic and behavioral patterns that engender stress and burnout. Oswald suggests multidimensional strategies addressing biological, psychological, sociological, and spiritual factors. The use of ACT within a therapeutic relationship—­with a psychologist, counselor, or spiritual director—­can assist the overstressed or burned-­out clergyperson to defuse from the feelings of stress and the role expectations that contribute to the condition. There are also spiritual exercises that either embody or parallel ACT processes which can be of benefit to clergy. One classical spiritual practice that resonates with ACT is the discipline of the “examen,” a prayer exercise initiated by Ignatius Loyola and practiced twice daily by Jesuits. Following the publication of “Consciousness Examen” (Aschenbrenner, 1972), the prayer has been adapted not as a moralizing examination of conscience, but as a liberating and transformative awareness of consciousness. Aschenbrenner’s five steps of the examen prayer (1972, p. 17) mirror the ACT process: 1. Prayer for enlightenment: This calls for “Spirit-­guided insight into our life and courageously responsive sensitivity to God’s call in our heart.” (Willingness, values) 2. Reflective thanksgiving: This cultivates an attitude of openness to the gifts of the present moment and seeks to hold less tightly to reactivity based on our own demands or expectations. (Opening up, awareness) 3. Practical survey of actions: As a nonjudgmental examination of consciousness, this part of the examen considers the self as context of one’s actions. It cultivates awareness of “our interior feelings, moods, and slightest urgings,” so that “we are not frightened by them but have learned to take them very seriously.” (Opening up, awareness, do what matters) 4. Contrition and sorrow: This is not a sense of shame or depression, but an acknowledgment of areas where we have moved away from valued directions. What emerges from this honest self-­assessment is increased commitment to values-­based actions. (Opening up, do what matters) 200

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5. Hopeful resolution for future: A renewed vision and sensitivity to the chosen path forward, lived and enacted with faith, humility, and courage. (Do what matters) The purpose of the consciousness examen is to develop an ongoing self-­awareness that permits one to be unshackled to the past, open to and active in the present, and hopefully oriented to the future. As Aschenbrenner wrote of Ignatius, Being able to find God whenever he wanted, Ignatius was now able to find Him in all things through a test for congruence of any interior impulse, mood, or feeling with his true self. Whenever he found interior consonance within himself (which registers as peace, joy, contentment again) from the immediate interior movement and felt himself being his true congruent self, then he knew he had heard God’s word to him at that instant. (1972, p. 21) In other words, Ignatius exemplified how the regular use of the examen can assist the supplicant to accept but not be bound by unhelpful feelings or impulses, and to choose values-­congruent actions in a particular moment. Thus, the consciousness examen is a classical spiritual tool which can effectively augment and facilitate the personal utility of ACT for clergy. Parish clergy engage in a diverse array of ministry activities. In contrast to the work of other helping professionals, parish clergy have numerous opportunities to encounter suffering individuals in the most significant moments of their lives. This provides fertile ground for facilitating movement toward human flourishing. The therapeutic processes of acceptance and commitment therapy are potentially powerful, and highly consistent with modern models of parish leadership. When utilized personally by clergy members, these processes can assist the leader in being both self-­ aware and intentional in providing values-­based leadership to support faith communities and individuals in crisis. ACT principles utilized and modeled by clergy can provide a solid foundation from which to provide effective and life-­ enhancing ministry.

References Aschenbrenner, G. (1972). Consciousness examen. Review for Religious, 31, 14–­21. Bowen, M. (2002). Family therapy in clinical practice. Northvale, NJ: Jason Aronson. Daneault, S. (2008). The wounded healer: Can this idea be of use to family physicians? Canadian Family Physician / Médecin de famille canadien, 54, 1218–­9, 1223–­5. Friedman, E. H. (1985). Generation to generation: Family process in church and synagogue. New York: Guilford Press. Friedman, E. H. (2007). A failure of nerve: Leadership in the age of the quick fix. M. M. Treadwell and E. W. Beal (Eds.). New York: Seabury.

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Heifetz, R. A. (1994). Leadership without easy answers. Cambridge, MA: Belknap Press. Heifetz, R. A., Grashow, A., & Linsky, M. (2009). The practice of adaptive leadership: Tools and tactics for changing your organization and the world. Boston: Harvard Business Press. Hick, J. (2010). Evil and the God of love. Reissue edition. New York: Palgrave Macmillan. Jung, C. G. (1966). Practice of psychotherapy [sic], Collected Works of C. G. Jung, Volume 16, Princeton, NJ: Princeton University Press. Kabat-­Zinn, J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday life. New York: Hyperion Books. Maslach, C. (1976, September). Burned-­out. Human Behavior 9, 16–­22. McKim, D. K., ed. (2014). Theodicy. The Westminster dictionary of theological terms. Second edition, revised and expanded. Louisville, KY: Westminster John Knox Press. Nouwen, H. (2004). Out of solitude: Three meditations on the Christian life. Notre Dame, IN: Ave Maria Press. (Original published 1973.) Nouwen, H. (1979). The wounded healer: Ministry in contemporary society. New York: Image. Oswald, R. M. (1991). Clergy self-­care: Finding a balance for effective ministry. Washington, DC: The Alban Institute. Vilardaga, R., & Hayes, S. C. (2009). Acceptance and Commitment Therapy and the therapeutic relationship stance. European Psychotherapy 9, 117–­140. Wang, P. S., Berglund, P. A., & Kessler, R. C. (2003). Patterns and correlates of contacting clergy for mental disorders in the United States. Health Services Research, 38, 647–­673.

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CHAPTER 13

ACT Core Processes in Faith-­Based Counseling Mark R. McMinn, PhD Brian C. Goff, PhD Clinton J. Smith, MA George Fox University

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F

aith-­ based counseling is a rich, multifaceted, and potentially complex endeavor. Counselors who identify themselves as explicitly integrating faith content into their therapeutic work are likely to encounter clients who describe their psychosocial and spiritual struggles as seamlessly interrelated. To illustrate, consider the following example: a client expresses a deep sense of loss and struggle in relationship with God: “I feel so alone. God is nowhere to be found. [Pause.] I know that’s not actually true. I’m probably just not doing very well at finding God in this messy life I live.” Here the counselor has options. One option, surprisingly common among mental health professionals, perhaps because they tend to be less religious than the clients they serve (Delaney, Miller, & Bisonó, 2013), is simply to ignore the religious content of this expression and focus on how alone the client feels: “That sense of being alone seems important. Can we look further into that?” Another option is to attend to the faith content and help the client press toward a theologically congruent experience: “I notice a tug-­of-­war in you. On one hand, you feel God’s absence, but on the other hand you know God is present with you.” This approach would be consistent with many religiously adapted forms of cognitive behavioral counseling. A third option is to both attend to the faith content and to the experiential avoidance that causes a degree of psychological inflexibility in the client. For example, the counselor might say, “I notice a tug-­of-­war in you, and how quickly you backed off when you said God can’t be found. I wonder if we could try something different for a moment. Can I just have you see if you can sit with the feeling of being alone and experience what that feels like?” At first glance, the third option may seem to contradict faithful expressions of religious devotion, but it could in fact end up being a faith-­affirming alternative. It is also consistent with an acceptance and commitment therapy (ACT) approach. Rather than continuing to avoid the existential fear that God is absent, the client might enter into areas of profound unknowing and ultimately experience an intentional decision to move forward in ways of faith. In order to explore the place of ACT core processes in the counseling office, we will first overview a few varieties of faith-­based counseling, consider the empirical support for faith-­based approaches, and explore two dimensions of a faith-­based approach to counseling. After setting this essential foundation, we will discuss the six ACT core processes and how they relate to what happens in the counseling office when both the counselor and client desire faith to be part of the conversation.

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Varieties of Faith-­Based Counseling Some faith-­based counseling is best described as across faith traditions, where the counselor and client hold substantially different religious views. Other faith-­based counseling can be considered within a faith tradition, where the counselor and client hold roughly similar religious views (McMinn, Snow, & Orton, 2012). Because each of these approaches is quite distinct from the other and the scope of this chapter is limited, we have elected to consider within-­faith counseling approaches. Further, because our own religious background is Christian, and the majority of the available literature pertains to Christian approaches, we will draw most heavily on Christian faith-­based counseling. In an effort to explore various types of faith-­based counseling, McMinn, Staley, Webb, and Seegobin (2010) distinguish between certain types of Christian faith-­ based counseling, including biblical counseling, pastoral counseling, Christian psychology, and ministry approaches. Biblical counseling is characterized by reliance on the Bible as the guiding structure for counseling. In our experience, most biblical counselors avoid using ACT in their work because of various ideological differences. This is not necessarily because ACT and the Bible are incompatible, but rather because biblical counselors prefer to use scripture as their guiding paradigm rather than psychological theory. Pastoral counseling can either have an informal meaning or a more formal definition. Informally, any pastor or religious leader who provides counseling services offers pastoral counseling. Formally, pastoral counselors are dual-­credentialed with degrees in both theology and a mental health field. Pastoral counselors typically work in an explicitly religious setting (Clinebell, 1984). Because formally trained pastoral counselors have mental health degrees, many are interested in understanding and applying ACT in their work. When McMinn et al. (2010) refer to Christian psychologists, they describe those whose primary training and licensure is in psychology, but who also identify as religiously informed practitioners.1 This is often called an integrationist approach, as practitioners attempt to integrate state-­of-­the-­art psychological training with religious and spiritual awareness. A number of doctoral programs exist that train psychologists while also preparing them with advanced training in religious and spiritual issues. A similar line of reasoning could be used to identify Christian social workers, Christian psychiatrists, Christian marriage and family therapists, and so on. Christian mental 1 Christian psychology is also used to denote a specialized interest group of psychologists, philosophers, and theologians who are members of the Society of Christian Psychology (SCP). The work of SCP is to find the psychology that is intrinsically part of the Christian tradition, much of which is found well before the advent of contemporary scientific psychology.

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health professionals are likely to be interested in ACT because much of their work is guided by evidence-­based practice. Ministry approaches to faith-­based counseling vary widely, from inner healing prayer approaches (e.g., Smith, 2004) to lay counseling (e.g., Tan, 1994) and religious recovery groups. Because of the wide diversity of ministry approaches to faith-­based counseling, the appropriateness and utility of ACT will depend on the specific approach and context. In summary, we expect that ACT will be most applicable to faith-­based counselors who identify as integrationist in their particular mental health discipline or to pastoral counselors who have formal training in a mental health field.

Empirical Support for Faith-­Based Counseling Current research on the effectiveness of faith-­based counseling tends to focus on standardized forms of treatment, modified to include religious and spiritual variables (Worthington, Johnson, Hook, & Aten, 2013). Hook et al. (2010) reported a total of 24 studies in a comprehensive literature review. Most of the studies addressed treatment of depression and anxiety, and most were Christian adaptations of established treatments. The authors note, “the majority of research in this area has found that integrating R/S [religion and spirituality] into an established secular therapy has produced an R/S therapy that is at least as efficacious as the existing secular therapy” (p. 67). Though religious adaptations of current interventions are likely to be successful, it is important to note that existing psychotherapy outcome research tends to focus on particular protocols more than processes. Psychotherapy research works best if a manual guides treatment for each psychotherapist providing services as part of the study. Typically, these manuals describe step-­by-­step events that should occur in each session. Though these step-­by-­step manuals can also be useful in ACT research, the more essential dimension of ACT is fidelity to the six core processes. Rather than engaging in a prescribed therapeutic activity in each session, it is more important to consider how the therapeutic encounters from week to week help promote psychological flexibility. More research is needed to assess the effectiveness of faith-­based adaptations of ACT. This research will be especially meaningful as researchers continue evaluating the core processes used in the counseling office, and not just adherence to a particular prescribed treatment protocol.

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Two Dimensions of Faith-­Based Approaches It might seem quite natural to reduce faith-­based practice down to particular behaviors (such as praying with clients, or considering sacred texts), but we believe the better starting point is at the worldview and anthropological level (Jones & Butman, 2011; McMinn & Campbell, 2007). We suggest two processes to faith-­based work in counseling: 1) some degree of interdisciplinary reasoning occurs, and 2) this reasoning ultimately has an impact on the actual practice behaviors of the faith-­based counselor. Regarding the first process of theoretical, interdisciplinary reasoning, the faith-­ based counselor must wrestle with a number of questions. To what extent does a theoretical orientation from a particular psychological theory mesh with the assumptions and values inherent in a particular faith system? Where are the points of congruence? Where are the points of tension? And how does mutual adaptation occur? By mutual adaptation, we refer to the possibility that faith might change one’s understanding of psychological theory, and that psychological theory might change one’s understanding of faith. This is not to say that the two necessarily have equal authority over matters of metaphysics, but more that faith-­based approaches remain open to the possibility of mutual adaptation. Regarding the second process of enacted practices, a reasonable consequence of the theoretical and conceptual work just described is that it will influence the actual practice behaviors of the counselor. In some cases, the traditional ACT therapist and the faith-­based ACT therapist may make the same choices for the same reasons; in other cases, they might make different choices for different reasons; and in still other cases, they may make the same choices for different reasons. For each of the ACT core processes, we explore areas of theoretical convergence and potential areas of tension.

Considering ACT Core Processes The following six core processes of ACT show up in various chapters throughout this volume, reflecting both the importance of therapeutic processes in ACT (as compared to therapeutic protocols for particular disorders) and the relevance of these processes in various dimensions of religion and spirituality. In the remainder of this chapter we attend to these processes from a faith-­based counseling perspective, considering both interdisciplinary reasoning and counseling behaviors.

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Acceptance In the second edition of their seminal work on ACT, Hayes, Strosahl, and Wilson (2012) observe that “it takes both wisdom and courage to live a vital life, and our culture offers little guidance on how to do this” (p. 271). In writing this, they acknowledge every life can be difficult and is likely to encounter a degree of suffering. Some suffering can be avoided, but some cannot. If we move through life with the fantasy that pain is bad, then we will likely live a life of disillusionment and frustration. One of the key core processes of ACT is to move from an inflexible tendency to avoid suffering toward a more willing, accepting, and flexible posture where we remain open to all that life brings, even those things that are difficult and unpleasant. The ACT emphasis on acceptance is congruent with various religious worldviews, including the Christian worldview. Roman Catholic priest Ronald Rolheiser discusses a similar notion in his book The Holy Longing, where he writes, “in the end, we all die…our lives incomplete, our deepest dreams largely frustrated, still looking for intimacy, never having had, in terms of consummation, the finished symphony” (1999, p. 156). Rolheiser then describes the importance of accepting this reality, and even mourning it. It is when we fail to [mourn]…that we go often through life demanding, angry, bitter, disappointed, and too prone to blame others and life itself for our frustrations. When we fail to mourn properly our incomplete lives then this incompleteness becomes a gnawing restlessness, a bitter center, that robs our lives of all delight. (p. 157) Rolheiser’s words may seem shocking at first, in part because they are countercultural in a time where so many marketing dollars attempt to persuade us to buy products and services that will allow us to stay indefinitely happy, young, healthy, and entertained. Rolheiser’s abrupt words confront our tendency to avoid what is true and inevitable: we will face suffering. In the Bible, the Apostle Paul takes this a step further when writing to Roman Christians, explaining that we may actually encounter inexplicable joy and hope once we learn to accept the inevitability of suffering rather than scurrying about to prevent or avoid it. As Paul writes, “We can rejoice, too, when we run into problems and trials, for we know that they help us develop endurance. And endurance develops strength of character, and character strengthens our confident hope of salvation. And this hope will not lead to disappointment. For we know how dearly God loves us, because He has given us the Holy Spirit to fill our hearts with his love” (Romans 5: 3–­5, New Living Translation).

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Although a Christian worldview is consistent with an ACT view of accepting what life brings, it assumes a different telos (i.e., the end or purpose of life) than is assumed in ACT. Though there is nothing in ACT that precludes the possibility of life after death, many religions, and most monotheistic religions, frame an acceptance of suffering in the context of some better reality yet to come. Suffering here is made more tolerable, in part because a day will come when God will set all things right and justice and peace will prevail. Regarding mutual adaptation, on one hand, a religious telos that focuses excessively on life after death might be rightly perceived as a form of experiential avoidance. That is, rather than accepting what the present moment brings, it is possible to escape the present by focusing on the future. ACT therapists might well help clients enter back into an accepting posture of the present moment. On the other hand, it is important for ACT therapists to recognize that the religious telos is nonnegotiable in many faith systems and that a belief in a better future can help provide resilience to accept present realities—­a secondary benefit from a faith perspective, but a potential psychological benefit nonetheless.

Cognitive Defusion Though suffering is inevitable, there is little point in generating additional suffering through inflexible psychological processes. We can inadvertently generate angst by fusing our verbal and cognitive processes with our direct experiences so that we cannot distinguish one from the other (Hayes et al., 2012). Rather than seeing our cognitive processes as a flow of words that are “only words,” we may see them as reality itself. ACT asserts that we are not our thoughts. Thoughts are just thoughts. Words are just words. ACT calls us to defuse, to back up a step or two and observe our thoughts for what they are, not for what they say they are. Providing committed Christian clients with the meta-­cognitive skills to notice and observe their experiences can be useful, especially in response to Gnostic (e.g., “I am what I believe”) or legalistic (e.g., “I am what I do”) forms of faith. Both can lead to rigid and anxious forms of religious experience. The Apostle Paul confronted this directly in writing to New Testament Christians in Colossae: Why do you keep on following the rules of the world, such as, “Don’t handle! Don’t taste! Don’t touch!”? Such rules are mere human teachings about things that deteriorate as we use them. These rules may seem wise because they require strong devotion, pious self-­denial, and severe bodily discipline. But they provide no help in conquering a person’s evil desires. (Colossians 2:20–­23)

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A means of cognitive defusion is found in the Christian doctrine of grace (McMinn, Ruiz, Marx, Wright, & Gilbert, 2006). This doctrine teaches that God’s love is offered freely, and is not earned by good works. ACT offers some practical possibilities for helping individuals to experience such grace. After attending an ACT workshop, a Christian doctoral student of one of the authors reported that ACT allowed her to understand grace, perhaps for the first time. Whereas second wave cognitive behavioral therapy (CBT) postulates that we do something (e.g., change thoughts) and then we will feel better, ACT turns this around: “Stop trying to do something. Observe and accept what is, and then live into your values.” This student applied analogous reasoning to her Christian way of understanding the world. Rather than saying, “Do something, then I will experience the presence of God,” she turned it around: “God loves me. Notice it. Accept it. Now I freely choose to live into my values.” This is the essence of grace. It is important for ACT therapists to recognize and not minimize that behavioral standards are important to Christians. Still, these behavioral standards are meant to emerge out of a relationship characterized by grace. When choosing particular practice behaviors for faith-­based counseling, this grace-­based approach is important to consider. For example, some faith-­based counselors use prayer in session with their clients, or prescribe prayer outside of the sessions. There are a number of complicated considerations when it comes to praying with clients (McMinn, 2011), but for those who chose to do so in the context of faith-­based counseling, it is helpful to recognize that prayer itself can contribute to fusion or defusion. Prayer that adds to fusion is likely to be performance based (“I am defined by my beliefs or actions”), while in prayer that helps with defusion a person takes on the role of an observing self in the context of a meaningful relationship with the divine. It is common for spiritual directors to use prayer as a way to notice present experiences that might otherwise go unnoticed. When I repeated these words to God, what did I notice in my body? How was I able to integrate various sensations, sights, and sounds into this prayer experience? Did I push them away as distractions from true prayer, or did I open myself fully to this moment and bring all of my experiences to God?

Being Present Present-­moment awareness can be viewed as the common denominator of openness to one’s internal experiences (i.e., acceptance) and engaging in life in a valued way as it presents itself (i.e., commitment), as both occur in the present and only with awareness. It is defined as attention to the present external and internal world in a manner that is flexible, fluid, and voluntary (Hayes et al., 2012). 210

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A common practice in ACT is to cultivate contact with the present moment through mindfulness. Though ACT did not emerge explicitly from Buddhism (Wilson, 2006), mindfulness is associated with Eastern practice (Zen), which may lead to skepticism and resistance from some Christian clients. Using words other than mindfulness to describe mindfulness practice might help some Christian clients enter into the present moment. Christians throughout the centuries have emphasized present-­moment awareness through spiritual disciplines (e.g., practicing the presence of God, simple prayer, centering prayer, Lectio Divina, meditation, the sacrament of the present moment; Foster, 1998). Similarly, Christian mystics have described something akin to mindfulness. For example, Quaker mystic Thomas Kelly (1941/1992) affirms the practice of dwelling “in immediacy with him who is the abiding Light behind all changing forms” (p. 16). Contemporary movements within the Christian church have also reawakened the importance of the inward spiritual experience (see Foster, 2011; McLaren, 2008; Rohr, 2009). ACT-­infused, faith-­based counseling will likely involve contemplative exercises that explicitly call for contact with the present moment in the context of a relationship with God (Garzon, 2013; Larkin, 2007). Not all faith-­based therapists choose to use sacred texts in counseling, but some do (McMinn, 2011). Regardless of the counselor’s preferences, sometimes clients bring up passages from sacred texts and the counselor then must choose whether to enter into those conversations or not. Various biblical passages may help Christian clients connect with the present moment, though they ought to be approached with caution because the same passages might easily lend themselves to cognitive fusion. For example, in his letter to the church in Philippi, the Apostle Paul writes, “Fix your thoughts on what is true, and honorable, and right, and pure, and lovely, and admirable. Think about things that are excellent and worthy of praise” (Philippians 4:8). This passage has often been used in Christian adaptations of second wave CBT to suggest that we should better control our thoughts. A more ACT-­consistent alternative is to recognize that various thoughts will come and go, because brains do what brains do, but we have some choice about where we allow our mind to dwell. This nonjudgmental awareness of the present reduces potential cognitive entanglement and struggle (e.g., “That’s a bad thought!”). ACT-­consistent interpretations are not as readily apparent with some other biblical passages. For example, the Apostle Paul instructs believers in Corinth to “destroy every proud obstacle that keeps people from knowing God. We capture their rebellious thoughts and teach them to obey Christ” (2 Corinthians 10:5). This militaristic language lends itself to a fused and judgmental view of religious doubts and struggles. Still, the skilled ACT therapist can help clients honestly explore the nature of “rebellious thoughts” and “proud obstacles” and approach thinking in a flexible, nonjudgmental way. Indeed, ACT encourages contact with deeply held values and allows them to speak into the present-­moment awareness of choice. A complementary 211

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metaphor used in ACT is “passengers on a bus” (Hayes & Smith, 2005), wherein thoughts are viewed as passengers on a bus. There is no attempt to kick the unwanted passengers off the bus, though they may exit on their own. Neither is there an attempt to get all the passengers to agree on the route the bus takes. Rather, they are simply passengers who do not get to drive. Some of the passengers may be “rebellious thoughts” and “proud obstacles,” but the driver (i.e., the client) is the one who chooses where to go and what values to pursue.

Self-­as-­Context Self-­as-­context facilitates psychological flexibility by reminding us that we are not merely the sum of our thoughts, feelings, and histories. Self-­as-­context sees the individual as the continuous, unchanging context within which thoughts and feelings occur, and histories are written and unfold to bring us into particular present moments. Metaphorically, self-­as-­context is the bowl rather than the fruit in the bowl, or the chessboard rather than the pieces being played upon it. Self-­as-­context attends to the one who notices (i.e., context) more than what is noticed (i.e., content). Thoughts are noticed more for what they are than what they say they are. Emotions are not self-­defining (e.g., “I’m a depressed person”) but are noticed as the “fruit in the bowl.” A troubling past is part of an ever-­moving, ever-­ changing string of events occurring in the context of a self that transcends particular thoughts, feelings, and behaviors. In a general sense, spirituality itself promotes self-­as-­context. Spirituality assumes the numinous—­that something or someone is bigger than me. This in itself promotes the possibility of noticing oneself from a distance. As discussed previously, prayer also promotes a contextual view of self. Christianity offers freedom from thoughts, feelings, and personal histories, especially because of the New Testament emphasis on transformed identity. The Bible teaches that a new understanding of self is possible because of the saving work of Jesus and the continuing work of the Holy Spirit. This idea of a transcendent, continual, unchanging, spiritual self is coherent with the fundamental notion of self-­as-­ context (Hayes, 1984). Indeed, God’s forgiveness, notions of repentance (turning away, and turning toward), and our new identity in relation to God are all congruent with a flexible, transcendent sense of self (Zettle, Barner, & Gird, 2009). The faith-­based counselor may find utility in self-­as-­context in that it promotes freedom to behave differently in the present than one has behaved in the past. Those who believe they are defined by past failings may find it difficult to act in new ways. In the aftermath of an extramarital affair, one might say, “I’m a terrible husband, and I have ruined my chance to be the husband I wanted to be.” Guilt, shame, and 212

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hopelessness follow. From a self-­as-­context perspective, the client may learn to notice these thoughts and feelings, and to observe how he desires to be in his marriage. There is flexibility in this way of thinking because behaving is in the present, and distinct—­at least to a certain extent—­from the past. A possible tension is that the Bible contains various words describing Christians, which appear to foster self-­as-­content (i.e., “I am a…”) more than self-­as-­context. These words include “children of God” (Romans 8:14), “joint-­heirs with Christ” (Romans 8:17), “God’s workmanship” (Ephesians 2:10), and “a new creature in Christ” (2 Corinthians 5:17). Indeed, the term “Christian” itself is a self-­as-­content description. Two points may lessen this tension. First, these biblical identities don’t appear to create any problematic psychological rigidity. Second, the majority of these words refer primarily to God’s nature and character more than to the believer’s nature and character. How the therapist understands and responds to self-­as-­content statements related to religion and spirituality can help guide clients toward greater awareness of self-­as-­ context. For example: CLIENT:

I want so badly to be a good Christian, to be the sort of person God wants me to be, but I just can’t do it.

COUNSELOR: L  et’s take a moment and look at that statement. Consider this in terms of how you want to be rather than who you want to be. Just observe it for a moment. Notice that the counselor feels no need to refute the client’s thought or to help the client find evidence that is consistent or contrary with the thought. Rather, the task is simply to view it apart from self-­as-­defined-­by-­content. Over time, the client develops a more contextual view of self, allowing for greater contact with deeply held values. Preconceived notions of who the self is (such as I am lazy, selfish, sinful, unfaithful, and so on) can be noticed for what they are—­thoughts—­while the values that one choses to drive behavior (such as acting lovingly, kindly, or patiently) can be attended to and lived out.

Defining Valued Directions ACT’s explicit focus on values frees counselors who have felt restricted in their ability to involve spirituality in the treatment of religious clients. ACT therapists seek to aid clients in being open to their experience, in being fully present, and in behaving in a values-­consistent manner. In this way, values give a sense of purpose and serve to direct behavior (Dahl, Plumb, Stewart, & Lundgren, 2009). Similarly, faith systems tend to assume a mission and purpose to life beyond feeling good. 213

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The word “values” may be an area of potential miscommunication between the ACT therapist and religious clients. Fortunately, words are only words (see previous cognitive fusion section), and the ideas conveyed with ACT’s values focus can be perceived as quite compatible with religious systems. We offer four examples of potential miscommunication and resolution. First, values are positively focused in ACT. In contrast, many religious values are prohibitions or proscriptions. While this may appear at first to be an area of conflict for religiously-­committed clients, it can actually become a way of increasing psychological flexibility and perspective. For example, the first commandment is, “you must not have any other God but me” (Exodus 20:3). This is worded as a prohibition, but with some creativity it can easily be converted to an ACT-­consistent value: “I choose to keep God in the center of my vision, to consider how God would want me to live, and to follow.” Second, in ACT, values are “freely chosen, verbally constructed consequences of ongoing, dynamic, evolving patterns of activity, which establish predominant reinforcers for that activity that are intrinsic in engagement in the valued behavioral pattern itself” (Wilson, 2009, p. 66). For some Christians the idea of “freely chosen” values might be disconcerting. Are not values prescribed in the Bible and by church tradition? To some extent, this issue has been complicated and politicized with terms such as “family values” or “Christian values.” This tension can lead to meaningful conversations about the essence of faith and free will. Even devoutly religious individuals can choose whether they endorse the values commonly held in their faith communities. Third, some Christians might react to a view they perceive as inherently subjective and having little to say about objective truth. This is also an unnecessarily dichotomous point of view. One can choose values whether they are based on subjective perceptions or some ultimate truth. Again, recognizing the role of choice, even in values deemed to be absolutistic, can enhance psychological flexibility. Fourth, some Christians may object to the idea of freely chosen values due to their understanding of humans as being in a state of total depravity. In this theological tradition, even our best thinking has been contaminated by the broken state of this sin-­stained world. And if humans are indeed in this state, then how can they choose values (or be free at all for that matter)? Rather than becoming embroiled and fused in doctrinal nuance, it seems important in this case to acknowledge the concern while also noting that whether depraved or not, we continually at least have the perception of choosing. Whether that perception is partly illusory or utterly real, we can sit in the driver’s seat (see the bus metaphor in being present, above) and steer the best we can. This then leads to greater awareness of committed action.

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Committed Action Many clients enter into therapists’ offices with a similar perspective to the one Bilbo Baggins related to Frodo in The Lord of The Rings: “It’s a dangerous business, Frodo, going out of your door,” he used to say. “You step into the Road, and if you don’t keep your feet, there is no telling where you might be swept off to” (Tolkien, 1994, p. 72). ACT therapists are fond of saying that we eventually must “vote with our feet” by stepping in a valued direction. Committed action can be defined as “a values-­based action that occurs at a particular moment in time and that is deliberately linked to creating a pattern of action that serves the value” (Hayes et al., 2012, p. 634). When we continue to engage with our freely chosen values, we build larger patterns of meaningful behaviors. In ACT, committed action is “value-­in-­action,” rather than a construction of self (self-­as-­content). As we do what is important to us, this is an end in itself, and not primarily about us becoming something. This focus of ACT is likely to be embraced enthusiastically by religious clients. Much of Christian scripture calls believers to be filled with meaningful action. James (2:14), the brother of Jesus, writes, “What good is it, dear brothers and sisters, if you say you have faith but don’t show it by your actions? Can that kind of faith save anyone?” Matthew (7:15–­16) records Jesus saying, “Beware of false prophets who come disguised as harmless sheep but are really vicious wolves. You can identify them by their fruit, that is, by the way they act. Can you pick grapes from thorn bushes, or figs from thistles?” Committed action is so central to religious life that faith-­based ACT therapists are unlikely to experience any consistent areas of tension while working with religious clients on this core process. If there are areas of apparent tension, it is likely based on a misunderstanding of committed action. In those situations, it is helpful to find common descriptors that are used both in ACT and in religious settings. One such descriptor is “integrity,” which describes a sense of wholeness and completeness and is often used in faith communities. ACT therapists also value the notion of integrity: “Committed action is a step-­by-­step process of acting to create a whole life, a life of integrity, true to one’s deepest wishes and longings” (Luoma, Hayes, & Walser, 2007, p. 158; italics added).

Conclusion In his Christian translation of ACT, Sisemore (in press) writes, “In all my years of practicing, teaching, and writing, no secularly rooted model of therapy has seemed to 215

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offer such a readily apparent ‘fit’ for Christians as ACT, both in terms of its ends and its means” (p. 6). Given the areas of congruence described here, especially with regard to views of suffering and committed action, we concur that ACT is an excellent fit for faith-­based counseling. Still, we have noted five areas of real or perceived tension in using ACT to work with religious clients. First, for many religious clients a radical acceptance of present realities is possible, in part, because of a belief in an afterlife. It is important to respect and accept the possibility of a religiously informed telos in faith-­based counseling while recognizing that focusing overly much on the future can be a means of experiential avoidance. Second, religion often promotes particular behavioral standards that sometimes lead to a sort of behavioral fusion: “I am what I do.” While understanding and communicating the doctrine of grace can go a long way in resolving this tension, especially for Christian clients, it is nonetheless important to recognize how deeply intertwined behavior is with faithful expressions of religious belief. Third, faith-­based ACT will sometimes require sensitive language around issues of faith. For example, the word “mindfulness” may trigger some negative reactions with Christian clients, but the idea of mindfulness is highly compatible with Christian practice. Fourth, some biblical language may promote self-­as-­content interpretations, but with thoughtful exploration these interpretations can often be shifted toward increasing psychological flexibility. Fifth, the word “values” may cause some tension in faith-­ based counseling, so we have offered four examples for how this might be approached by faith-­based ACT therapists. Perhaps the best summary of how to approach ACT in faith-­based counseling comes from the triflex language of ACT itself: open up, be present, do what matters (Harris, 2009). Remaining open to clients’ experiences of faith may call for some creative adaptations of a traditional ACT approach, and at the same time ACT may cause clients to look at their faith in new and fresh ways. Mutual transformation, where ACT may change as a result of faith and faith may change as a result of ACT, requires therapists to be open and adaptable while encouraging the same in their clients. It is also important to be present and in-­the-­moment when doing faith-­based counseling, participating fully in the counseling relationship. In many faith-­based counseling settings, there may be overt and covert pressures to move toward categorical thinking and verbal sparring. Effective faith-­based ACT therapists observe this tension and find ways to stay in the present moment, helping clients observe themselves as the contexts in which these categories and tensions occur. Finally, one of the most natural and encouraging areas of confluence between religious faith and ACT is the desire to do what matters by identifying and remaining committed to core values. In this area in particular, there is the potential for faith-­based counselors to employ ACT to go beyond just improving their clients’ psychological functioning into addressing issues of both profound and practical spiritual significance. 216

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References Clinebell, H. (1984). Basic types of pastoral care and counseling. Nashville, TN: Abingdon Press. Dahl, J., Plumb, J., Stewart, I., & Lundgren, T. (2009). The art and science of valuing in psychotherapy: Helping clients discover, explore, and commit to valued action using acceptance and commitment therapy. Oakland, CA: New Harbinger Publications. Delaney, H. D., Miller, W. R., & Bisonó, A. M. (2013). Religiosity and spirituality among psychologists: A survey of clinician members of the American Psychological Association. Spirituality in Clinical Practice, 1, 95–­106. Foster, R. J. (1998). Celebration of discipline: The path to spiritual growth (Revised ed.). New York: HarperCollins. Foster, R. J. (2011). Sanctuary of the soul: Journey into meditative prayer. Downers Grove, IL: Intervarsity Press. Garzon, F. L. (2013). Christian devotional meditation for anxiety. Faculty Publications and Presentations. Paper 74. Retrieved from http://digitalcommons.liberty.edu/ccfs_fac_pubs/74. Harris, R. (2009). ACT made simple: An easy-­to-­read primer on acceptance and commitment therapy. Oakland, CA: New Harbinger Publications. Hayes, S. (1984). Making sense of spirituality. Behaviorism, 12, 99–­110. Hayes, S. C., & Smith, S. (2005). Get out of your mind and into your life: The new acceptance and commitment therapy. Oakland, CA: New Harbinger Publications. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). New York: Guilford. Hook, J. N., Worthington, E. L., Davis, D. E., Jennings, D. J., Gartner, A. L., & Hook, J. P. (2010). Empirically supported religious and spiritual therapies. Journal of Clinical Psychology, 66, 46–­72. Jones, S. L., & Butman, R. E. (2011). Modern psychotherapies: A comprehensive Christian approach. 2nd ed. Downers Grove, IL: IVP Academic. Kelly, T. (1941/1992). A testament of devotion. New York: HarperCollins. (Original work published in 1941). Larkin, E. E. (2007). Christian mindfulness. Review for Religious, 66, 230–­247. Luoma, J. B., Hayes, S. C., & Walser, R. D. (2007). Learning ACT: An acceptance & commitment therapy skills-­training manual for therapists. Oakland, CA: New Harbinger Publications. McLaren, B. D. (2008). Finding our way again: The return of the ancient practices. Nashville, TN: Thomas Nelson. McMinn, M. R. (2011). Psychology, theology, and spirituality in Christian counseling (revised ed.). Wheaton, IL: Tyndale. McMinn, M. R., & Campbell, C. D. (2007). Integrative psychotherapy: Toward a comprehensive Christian approach. Downers Grove, IL: IVP Academic. McMinn, M. R., Ruiz, J. N., Marx, D., Wright, J. B., & Gilbert, N. B. (2006). Professional psychology and the doctrines of sin and grace: Christian leaders’ perspectives. Professional Psychology: Research and Practice, 37, 295–­302. McMinn, M. R., Snow, K. N., & Orton, J. J. (2012). Counseling within and across faith traditions. In L. Miller (Ed.), The Oxford handbook of the psychology of spirituality (pp. 255–­270). New York: Oxford. McMinn, M. R., Staley, R. C., Webb, K. C., & Seegobin, W. (2010). Just what is Christian counseling anyway? Professional Psychology: Research and Practice, 41, 391–­397. Rohr, R. (2009). The naked now: Learning to see as the mystics see. New York: Crossroad Publishing. Rolheiser, R. (1999). The holy longing: The search for a Christian spirituality. New York: Doubleday.

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Sisemore, T. A. (in press). Acceptance and commitment therapy: A Christian translation. Christian Psychology. Smith, E. (2004). Theophostic prayer ministry: Basic seminar manual. Campbellsville, KY: New Creation Publishing. Tan, S. (1994). Lay counseling: A Christian approach. Journal of Psychology and Christianity, 13, 264–­269. Tolkien, J. R. R. (1994). The fellowship of the ring: Being the first part of the lord of the rings (2nd ed.). Boston: Houghton Mifflin. Wilson, K. G. (2006). Is ACT merely rehashed Buddhism? Retrieved from http://contextual science.org/is_act_merely_rehashed_buddhism. Wilson, K. G. (with DuFrene, T.) (2009). Mindfulness for two: An acceptance and commitment therapy approach to mindfulness in psychotherapy. Oakland, CA: New Harbinger Publications. Worthington, E. L., Jr., Johnson, E. L., Hook, J. N., & Aten, J. D. (2013). Evidence-­based practices for Christian counseling and psychotherapy. Downers Grove, IL: IVP Academic. Zettle, R. D., Barner, S. L., & Gird S. (2009). ACT with depression: The role of forgiving. In J. T. Blackledge, J. Ciarrochi, and F. P. Deane (Eds.) Acceptance and commitment therapy: Contemporary theory, research and practice (pp. 151–­174). Sydney, Australia: Australian Academic Press.

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CHAPTER 14

Using ACT in the Context of Health Care Chaplaincy Jason A. Nieuwsma, PhD Duke University Medical Center VA Mental Health and Chaplaincy

Joe McMahan, MDiv, BCC, ACPE Supervisor VA Southern Oregon Rehabilitation Center

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T

he receipt of modern health care services is among the most unnatural of human experiences. Needles, knives, and numerous otherwise dangerous objects are often purposefully directed at one’s body; pharmaceuticals are frequently employed to alter one’s physical and emotional states; and total strangers are commonly allowed to examine the most intimate, nonpublic, and personal aspects of one’s self. It goes without saying that there are good reasons for all of this, and being as we have observed modern health care advances to accompany astounding benefits—­such as the 30-­year increase in life expectancies over the last century (NCHS, 2011)—­we for the most part willingly tolerate the alienating, frightening, unnatural aspects of health care. Yet they remain unnatural. They remain at times even dehumanizing. Health care delivery, and the illnesses that motivate us to seek it, can take from us so much of our sense of self and sense of identity. The landmark turn-­ of-­ the-­ century Institute of Medicine (2001) report, “Crossing the Quality Chasm,” addressed this very issue by noting the lamentable absence in contemporary heath care of “patient-­centered care”—­or care that respects the individual characteristics and values of the person receiving it. Of all those employed by contemporary health care systems, this gap in health care may be no better addressed than by the profession of chaplaincy. Chaplains serve as a bridge to the familiar, to the divine, to community, and to a fuller sense of one’s identity and humanity beyond what is portrayed in the medical record. Chaplains remind us of the “bigger picture.” They remind us of our existence and lives outside of the role of being a patient. They remind us of our values, desires, meaning, and purpose in life. And, of course, they remind us of our relationships to God, the universe, and spiritual truths. The clinical chaplain traverses more territory across more boundaries than almost any other health care professional. There is scant a unit or service in the hospital where a chaplain might not tread or be requested. The potential reach of a chaplain’s care is extensive—­spanning from cancer to cardiovascular, pediatrics to palliative, even patient to provider—­making the chaplain in a very tangible way responsible for holding, honoring, and respecting the fullness of entire health care systems. No doubt this can be a taxing job, but also a sacred job. There is a palpable sacredness to being invited into the most vulnerable and intimate moments of patients’ lives, from birth to death and everywhere in between, and to care not only for patients but for health care professionals as well. When this responsibility is taken seriously, when it can be appreciated for what it is amidst the busy demands and noise of health care systems, it points to a sort of transcendence. Not some sort of happy transcending quality or a transcendence divorced from reality, but instead a transcendence that is derived and rooted (as paradoxical as it is to root transcendence) in being fully present to and attentive to the pain, joy, suffering, sadness, relief, triumph, defeat, and many other experiences embedded in health care systems. More than

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anyone else, it is the chaplain who is entrusted with the safekeeping of these varied experiences. Clinical chaplains understand this. For many, it is the reason that they entered into their profession. Being willing to hold and represent this transcendence day in and day out is nonetheless a significant challenge, one that requires chaplains to remain closely connected to their faith traditions. In addition to and in harmony with reliance on their religious and spiritual practices, we propose that there are tangible and synergistic ways that health care chaplains might further thrive in addressing the challenges of their profession via incorporation of principles and practices from acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 2012). This chapter will examine opportunities for incorporating principles from ACT into the work of health care chaplaincy. The practice of chaplaincy in health care settings has evolved and in many respects has come into its own as a profession over the past century. Before delving into some of the contemporary clinical opportunities for chaplains to use ACT, it is worth briefly touching on seminal moments in this developmental trajectory over the years in order to better understand how ACT can uniquely complement and contribute to the ongoing growth and development of chaplaincy as a health care profession. Following this brief look at some of health care chaplaincy’s history, we will explore specific synergies between ACT and the practice of health care chaplaincy—­particularly complementarities that ACT has with the practice of pastoral presence, the development of genuine relationships, the capacity to encounter spiritual/religious struggle, and the fostering of meaning and purpose in patients’ lives. Next we will examine how ACT can intersect with the work that chaplains do in mental health care settings and in traditional medical settings. Finally, in the tradition of clinical pastoral education, we will conclude the chapter with a sample verbatim highlighting ways that a clinical chaplain might use ACT with a patient.

Clinical Chaplaincy in Historical Context While religion has long been intertwined with health care and has often provided a basis for health care provision, the development of chaplaincy as a health care profession is relatively recent. This is not to assert that until recently chaplains were absent from health care settings. To the contrary, chaplains’ presence in health care settings can be traced back hundreds of years to the earliest semblance of hospitals (Swift, 2014), but it is in the early 20th century that the pedagogical paradigm for the training of contemporary health care chaplains has its roots. Two personages in particular are most often credited with the creation of the modern chaplain training paradigm: Anton Boisen, who, while serving as a chaplain at Worcester State Hospital, a mental hospital 40 miles west of Boston, instituted a clinical training program for theology students; and Richard Cabot, a physician and ethicist who taught at Harvard 221

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University and who significantly influenced many of Boisen’s ideas and the eventual development of Boisen’s approach to chaplain training (Asquith, 1980). Boisen is widely credited as the founder of clinical pastoral education (CPE), which since its inception under Boisen at Worcester State Hospital in 1925 has grown into the dominant model for training clinical chaplains. Many health care systems now require that their chaplains have a certain number of units of CPE (often four units, with a unit equaling 400 hours of combined training and hands-­on clinical experience). Boisen’s approach to chaplain training was profoundly influenced by his personal experience with mental illness (Boisen, 1960). Throughout his life, including before and during his time as a hospital chaplain, Boisen experienced multiple psychotic episodes. He had lengthy inpatient stays at mental hospitals during these episodes, which he experienced as providing religious insights and which largely motivated his desire to more closely integrate religion and medicine. Although many important factors have undoubtedly contributed to the development of CPE as it exists today, Boisen’s personal experience with mental illness birthed two prominent commitments within CPE that are as central to CPE training today as they were nearly a century ago. One is a deep empathy and respect for the patient’s experience, including a commitment not to persuade patients to certain ways of thinking. CPE-­trained chaplains aim to journey alongside patients, offering a nonjudgmental “pastoral presence” in the midst of someone’s suffering. The other is the abiding commitment in CPE to self-­exploration. CPE has come to rely heavily upon the use of verbatims—­ word-­for-­word recollections written by the CPE chaplain student recording encounters with patients (an example is provided at the end of this chapter). Processing verbatims with CPE supervisors and fellow CPE students is intended to prompt chaplain trainees to carefully analyze their personal reactions to patients and the contributors to those reactions. CPE training presumes that in order to be an effective chaplain, the chaplain must first be self-­aware. These commitments in CPE training have naturally aligned chaplaincy more closely with some psychotherapy models than others. CPE has long valued psychological theory—­indeed, the Association for Clinical Pastoral Education (ACPE) requires those who go through the full training process to become CPE supervisors to develop their own integrative models for assimilating theories from theology, education, and psychology. The psychological approaches that have historically been leaned toward within chaplaincy include psychodynamic, humanistic, and existential psychotherapeutic modalities (Doehring, 2015)—­with notably less attraction toward cognitive behavioral perspectives. Given the importance ascribed in CPE to nonjudgmentally respecting the patient’s experience, it makes sense that humanistic and existential perspectives would resonate with chaplaincy. Psychoanalytic and psychodynamic approaches, which would have been prominent during the early developmental stages of CPE, entail a commitment to self-­exploration that also resonates with CPE. 222

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Cognitive behavioral approaches, by comparison, are far less likely to encourage self-­ exploration on the part of the therapist, and they can have a colder, more clinical feel than Carl Rogers’s humanistic approach or the existential therapy of Viktor Frankl. Although cognitive behavioral approaches are certainly not shunned by clinical chaplains—­many chaplains absolutely make use of this modality—­the general inclination toward other psychological models has aligned many chaplains with psychotherapeutic perspectives that are diminishing in their prominence within professional mental health care. Cognitive behavioral approaches easily have the largest base of empirical evidence demonstrating their effectiveness (Chambless & Ollendick, 2001), a crucial determinant of treatment uptake in today’s evidence-­based health care systems. With clinical chaplains increasingly feeling the pressure to demonstrate their value in an evidence-­based culture, finding psychotherapeutic models with empirical backing is likely going to become ever more important. ACT offers particular promise here. It is an evidence-­based psychotherapy born out of the behavioral tradition that nonetheless prizes many therapeutic elements from earlier psychological approaches. In fact, the therapeutic elements perceived by some chaplains as missing from traditional cognitive behavioral therapy, which have prevented many chaplains from warming to that model, have been intentionally recaptured in ACT. This includes the two above-­noted commitments from CPE: a therapeutic stance, or pastoral presence, that is willing to be nonjudgmentally present to suffering; and an attention to and awareness of self. ACT’s commitments to these therapeutic elements are differently embodied than in, for example, psychodynamic or humanistic approaches. Awareness of self in ACT is not about exploring the deep-­seated influences of one’s childhood and one’s unconscious motivations, as is part of the self-­ exploratory exercise in psychodynamic approaches, but is instead about noticing and being in contact with one’s present-­moment experiences of life, including things like one’s thoughts, emotions, desires, values, and reactions to the external environment. The willingness to be present to suffering in ACT requires the therapist to practice sincere empathy (perhaps even a form of love) and has certain parallels to what in humanistic therapy might be termed “unconditional positive regard.” However, ACT is unique in intentionally tying empathy and acceptance practices to cultivating an ability within patients to be present to their values and to possibilities for moving in the direction of those values (all the while being willing to bring pain along for the ride). Of course, awareness of self, willingness to encounter suffering, and empathy are all inextricably linked. This is evident in Boisen’s biography, with his psychiatric suffering contributing to and motivating much of the development of CPE. Perhaps not coincidentally, this is also evident in the biographies of leading ACT developers, who have attributed significance to how their experiences with mental health problems (such as panic attacks and substance abuse) contributed to the development of the ACT therapeutic approach. Relatedly, ACT is critical of dichotomizing between the 223

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“well clinician” and the “ill patient,” a distinction which diminishes shared dimensions of our humanity. In addition, the ACT approach is skeptical of certain artificial boundaries that are sometimes erected to separate care-­ providing professionals. Although the primary developers of ACT have been psychologists, those psychologists have consistently insisted that ACT principles can be used well beyond prototypical psychotherapeutic settings. Taken together, each of these aspects opens the door wide for clinical chaplains interested in ACT.

Connecting ACT with Chaplaincy Practices For a number of years, the first author of this chapter has introduced and taught ACT to various groups of health care chaplains. These workshops have often begun by having attendees complete a basic questionnaire asking them what kinds of psychotherapeutic models they are familiar with and which ones they incorporate into their chaplaincy practice. Without fail, responses to the first half of this questionnaire generally indicate that chaplains make the most use of widely known psychotherapeutic traditions like psychodynamic therapy, humanistic therapy, family systems, and even cognitive behavioral approaches. A much smaller proportion indicates being familiar with or making any use of ACT (even if they voluntarily signed up for an ACT workshop). However, the second part of this simple questionnaire uses a modified version of the Acceptance and Action Questionnaire—­II (AAQ-­II; Bond et al., 2011) to assess the degree to which chaplains are already inherently making use of ACT practices, even if they do not label what they are doing as ACT. These few modified questions derived from the AAQ-­II ask chaplains to indicate the degree to which they do things like helping patients “accept that they cannot control every aspect of life” and “live a life they value despite painful experiences and memories.” On these items, there is strong, across-­the-­board agreement from chaplains indicating that they frequently encourage these kinds of processes in their patients. In other words, the processes and outcomes that are being encouraged in ACT are highly aligned with preexisting practices and commitments in chaplaincy. The theory, structure, and particular therapeutic practices in ACT offer to chaplains practical opportunities for improving and deepening their care practices in a manner that is consistent with preexisting core priorities. We examine four particular areas of synergy below, providing brief examples within each for practical ways that the chaplain might use ACT principles in clinical situations.1

1 All case examples have been de-­identified. The authors wish to thank Chaplain Gretchen Hulse and Chaplain Ronald (Cliff) Vicars for sharing clinical experiences that contribute to some of the included case examples.

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Pastoral Presence Pastoral presence, or a ministry of presence, has become a centerpiece of what contemporary chaplains provide, particularly those operating in health care settings. Pastoral presence, as with many activities of the chaplain, escapes simple definition. In her book A Ministry of Presence: Chaplaincy, Spiritual Care, and the Law, Winnifred Fallers Sullivan (2014) describes “ministry of presence” as: Religion naturalized. Religion without code, cult, or community. Religion without metaphysics. It is religion for a state of uncertainty. As is typical of American religion, it both resists specific theological elaboration and is deeply rooted in a specifically Christian theology of the Incarnation. (p. 174) As rooted in the Christian tradition, an incarnational approach to pastoral presence means that chaplains represent to those they serve the continued presence in the world of Jesus—­God made flesh, God with us, God among us. More broadly construed, this representation of the divine in the present moment resonates with chaplains from a diversity of religious traditions. It further resonates for chaplains aiming to serve patients across a varied religious landscape. Thus, in the religiously diverse and frequently secular contexts where many health care chaplains operate, a ministry of presence entails non-­coercively inviting patients to take notice of the divine and the sacred. Beyond this, though, pastoral presence is about “being with,” which can be easily connected to incarnational origins but which also is intended to be a very practical embodiment on the part of the chaplain. Particularly in health care contexts, the chaplain is willing to be with patients in the midst of their suffering. As Sullivan (2014) points out, this kind of presence, or being with, contains paradox: it is a presence to absence—­a presence to loss, to aloneness, to unfulfilled hopes, desires, and expectations. In this respect, pastoral presence dares to tread terrain that is often avoided by both contemporary health care and by many religious communities (Rambo, 2010), which in their own respective ways can be afraid to tolerate a persistence of human suffering. A parallel can be drawn here between the ways in which certain paradigms of religious healing are challenged by a ministry of presence and the ways in which paradigms of psychological healing are challenged by ACT. Both the practice of pastoral presence and ACT assume that human suffering is inevitable, expectable, and in fact natural. Suffering is certainly not to be sought after or reveled in, but neither is it to be excessively avoided—­because it cannot be avoided. Although the specific practice of being present as understood in ACT is not tied to theological underpinnings in the way that a ministry of presence is, there are significant and strong synergies between ACT and chaplain philosophies of care and approaches to manifesting these

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philosophies. Instead of being tied to incarnational theology, presence as understood and practiced in ACT is frequently tied to mindfulness. Mindfulness has been described as nonjudgmentally paying attention, on purpose, in the present moment (Kabat-­Zinn, 2012). In any given moment, there are literally thousands of things that one could be mindful of: one’s breath, the air temperature, the feel of clothing on one’s body, thoughts, feelings, emotions, other people—­the list goes on. Mindfulness certainly involves being present to whatever comes along, yet there is also a degree of intentionality that can be introduced with mindfulness, especially as practiced in clinical contexts. Patients can be encouraged to be mindful of particular things. In ACT, this directing of a patient’s attention is done with an inviting and gentle spirit and with an expectation that attention is likely to wander, at which times a gentle redirecting of attention may be introduced. Case conceptualizations and psychological theory help to drive the sorts of things that are selected for the patient to be mindful of in ACT. Often, the avoidance of painful topics serves to constrict patients’ lives and can potentially contribute to psychopathology. Thus, ACT frequently encourages patients to be mindful in precisely these painful areas. The willingness to be present to such pain then serves to increase psychological flexibility and capacities for living a values-­driven life. The following example illustrates the use of pastoral presence in an ACT-­consistent manner, resulting eventually in helping the patient move forward in his life.

Case Example Jim Phillips is a 35-­year-­old married white male who was paralyzed from the waist down following a work accident 11 months ago. He has been rehabilitating as an inpatient on a long-­term care unit for the past nine months, during which time his wife of three years has visited him with decreasing regularity. Mr. Phillips makes excuses for his wife’s absence, stating that she is busy with work and school, though it is evident from her behavior that she wants to escape the marriage and associated responsibilities of caring for her husband. A devoted Baptist, Mr. Phillips has developed a close relationship with the unit chaplain. During one of their conversations, Mr. Phillips uncharacteristically confessed to how hurtful his wife’s absence has been, and then quickly changed the subject to something more benign. The chaplain had long suspected that Mr. Phillips was reluctant to voice this pain for fear of being seen as unlovable. The chaplain responded by saying, “I really appreciate you sharing your feelings about your wife. From the look in your eyes when you talked about her just now, I can tell this is really important to you. But then you changed the

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topic. Is this something you try to avoid thinking about?” Mr. Phillips confirmed that he tries to avoid thinking about the topic, to which the chaplain replied, “With me here right now, I wonder if you’d be willing just to notice the feelings that come up for you when you think about your wife.” Mr. Phillips agreed to try. He began to talk, but then stopped and started to cry. The chaplain placed his hand on Mr. Phillips’s shoulder and remained silently with the patient as he continued to cry for a number of minutes. Eventually, Mr. Phillips turned to the chaplain and said, “Thank you. I think I needed that.” The chaplain asked if he could pray with Mr. Phillips, and the patient agreed. Over the next number of weeks, Mr. Phillips became more willing to talk about the pain in his relationship with his wife and came to the point where he was able to compose a letter to her honestly stating his feelings and concerns. In this example, the ACT-­ consistent principles employed by the chaplain include: identifying avoidance as a possible stuck point; attending to the present moment (particularly to avoided painful emotions); orienting toward values (e.g., with the prayer); and eventually fostering values-­consistent behaviors (e.g., writing the letter).

Genuine Relationships Closely related to practicing a ministry of presence is the chaplain’s commitment to cultivating genuine relationships. Attesting to this, the Association of Professional Chaplains (2009) Standards of Practice begins with the following preamble: Chaplaincy care is grounded in initiating, developing and deepening, and bringing to an appropriate close, a mutual and empathic relationship with the patient, family, and/or staff. The development of a genuine relationship is at the core of chaplaincy care and underpins, even enables, all the other dimensions of chaplaincy care to occur. It is assumed that all of the standards are addressed within the context of such relationships. (p. 1) Genuine relationships are risky. While all health care providers presumably strive to demonstrate empathy in their practice, chaplains go further than this. They aim not just to be empathic toward patients but to develop relationships with them (as well as with families and hospital staff), relationships characterized by mutuality and genuineness. Importantly, this relational mutuality is grounded in shared humanity, and perhaps in shared faith, while yet preserving those responsibilities attendant to the roles of patient and spiritual care provider. For instance, mutual here does not 227

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imply that the chaplain and patient spend equal amounts of time talking about their respective personal struggles and providing equivalent forms of spiritual care to one another. It does mean that the chaplain is humble and vulnerable enough to not just practice spiritual care on somebody but to practice spiritual care in the context of relationship with a person. The fostering of genuine relationships is a major focus in CPE. Many CPE supervisors use the verbatim method to press students to attend to their own intrapersonal reactions that arise during interpersonal interactions with patients. A chief intended result of these reflections is an increased capacity to be present and genuine during patient encounters. Formation of a trusting therapeutic relationship is of course core to all psychotherapies. However, ACT is noteworthy in the degree to which it emphasizes developing genuine therapeutic relationships and in how it approaches fostering such relationships. ACT’s primary focus on fostering psychological flexibility, rather than primarily focusing on psychiatric symptom reduction, inherently places the patient and provider on more common ground. Rather than emphasizing the dichotomy between ill patient and well provider, ACT invites both patient and provider to strive toward greater psychological flexibility. Indeed, the six core processes in ACT are presumed to be operative not just for the patient but also for the provider. This can be observed in the midst of an encounter with a patient. For instance, a provider may decide to accept a feeling of anxiety in dealing with a particularly difficult patient and might use cognitive defusion techniques during a session to deal with personal thoughts of inadequacy or frustration. These thoughts can be recognized as distinct from the sense of self that is able to observe them (self-­as-­context) and is able to choose to be present to the patient. Motivated by the value of providing compassionate care, the provider is then engaging in therapeutic committed actions in this relational context with the patient. For the practiced ACT provider, there is a highly dynamic interplay between ACT processes that are ever informing one another and are at once operative in the patient and the provider throughout the therapeutic encounter. The following example demonstrates how ACT-­consistent principles might be used within chaplaincy to meaningfully deepen genuine relationships with patients and their family members.

Case Example Ms. Lucia Guardia is a 76-­year-­old Latina female with cervical cancer who was admitted to hospice two weeks ago with a prognosis of four to eight weeks left to live. This prognosis came as a relative shock to Ms. Guardia, who until a month ago was optimistic about her chances for remission. The chaplain assigned to Ms. Guardia was a CPE student who had lost her own

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mother to cancer a year earlier. After their first time talking, Ms. Guardia and the chaplain felt an immediate and close connection with one another. Nonetheless, working with Ms. Guardia evoked considerable feelings of anxiety and sadness in the chaplain, which she explored with her supervisor. Through conversation with her supervisor, the chaplain was able to further clarify why working in a hospice setting with patients like Ms. Guardia was so important to her and was able to become more present in the relationship that she cultivated with Ms. Guardia. By being aware of the various thoughts and emotions evoked during her work with Ms. Guardia, the chaplain was able to become more genuine in her relationship with the patient. Ms. Guardia was open with the chaplain about her fear of death, her sadness about the things she would be losing, her sadness about her family’s loss, her gratitude for the full life that she had lived, her satisfaction for various meaningful accomplishments, and her hopes for how she might be remembered. The chaplain further developed close relationships with a number of the patient’s family members. Following Ms. Guardia’s death, the family requested that the chaplain help lead the memorial service. In this example, the ACT-­consistent principles employed by the chaplain include: being present to discomfort in order to carry out values-­driven actions (e.g., experiencing anxiety in the midst of caring for a loved patient); making space for the patient to experience a full range of emotions, hopes, fears, and memories; and using genuine relationships to orient care for the patient and family members (e.g., leading the memorial service).

Spiritual Struggle For many patients, religion is a major source of support in times of illness. At the same time, illness can be a catalyst for spiritual struggle. Illness can cause patients to question the fairness of life, whether God cares, whether their suffering is merited, and what is of ultimate meaning in life. For chaplains in health care settings, operating amidst these questions can serve as a catalyst for the refinement of their personal theodicies—­or beliefs about how God exists and functions in the midst of suffering. Given that chaplains are uniquely formed through their own religious training and typically serve under the auspices of an endorsing religious body, these theodicies are likely to be refined in relation to (if not always in keeping with) the teachings of the chaplain’s respective faith group. At the same time, contemporary chaplaincy has emerged as a secularized professional practice wherein chaplains from various faith

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traditions are all trained together under the CPE model and are expected to provide spiritual care to all patients regardless of patients’ belief systems and religious traditions (Craddock Lee, 2002). To do this work well necessitates varied and nuanced approaches to addressing patients’ spiritual struggles. It frequently necessitates a willingness to tolerate and even embrace uncertainty with patients, while simultaneously embodying hope, comfort, and peace in the middle of chaotic and frightening circumstances. The capacity to do this skillfully can make clinical chaplains a unique resource among clergy: patients who do not belong to a faith community and might otherwise never receive spiritual care can be ministered to in an accepting, respectful, and meaningful way by the clinical chaplain. They can voice to the chaplain spiritual struggles that they perhaps have never voiced to a spiritual care provider before. They can receive spiritual care and comfort in a safe context and at their deepest moment of need. In much the same way, religious patients too may find in the clinical chaplain a distinctively safe and trustworthy spiritual care provider with whom to share struggles that they may not feel comfortable voicing to those in their regular faith community. The dynamic shifting between acceptance and commitment processes in ACT provides the clinical chaplain with a useful way to further conceptualize and approach spiritual struggle. ACT of course does not formally propose a certain theodicy and is not inherently in contradistinction to any particular theodicy. If ACT has anything to contribute in this sphere, it would be the suggestion that the experiential motivators prompting individual theodicies not be too quickly avoided or dismissed in the rush to resolve probing life questions. Much as clinical chaplains are willing to be with patients when patients feel that God is not there, so too is the ACT provider willing to withhold impulses to hurriedly solve patients’ problems in order to first be present with individuals in the midst of their pain. The impulse to find quick solutions is often very strong, for both patients and providers. It can be hard to tolerate uncertainty. One approach to tolerating uncertainty in ACT is termed “creative hopelessness.” This involves first assisting patients in confronting their past failed attempts to avoid pain and solve problems, which can engender a certain sense of hopelessness. However, acknowledging and attending to the futility of previous approaches to problems invites an uncertainty for what to do next, and in this uncertainty is the potential for creativity, for new ways of being. Creative hopelessness exemplifies the balance between acceptance and commitment processes—­creating room to accept and be present to uncertainty, and in so doing also creating room to be present to one’s values and adopt new approaches for engaging with others and the world. The example that follows serves to demonstrate how chaplains might use ACT-­consistent practices to address spiritual struggle.

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Case Example Mr. Patrick O’Donnell is a 28-­year-­old war veteran who was admitted to the inpatient psychiatric care unit after attempting to cut off his hand. During examination in the emergency room, Mr. O’Donnell cited the Bible passage about cutting off one’s hand if it causes a person to sin. After a full psychiatric evaluation, the chaplain for the psychiatry unit was called in to talk with the patient about the scripture he had mentioned. Mr. O’Donnell was glad to have a chaplain to talk with, and he was clearly experiencing profound guilt and shame. The patient told the chaplain that he has been unable to sleep since returning from deployment approximately two years ago, as he has nightmares about things that he witnessed in combat. While he was reluctant to share specifics at first, the patient eventually told the chaplain that he was particularly troubled by memories of having shot two children. He suspected the children were suicide bombers, but this was never confirmed. This, he said, is the reason that he was attempting to cut off his trigger hand. Mr. O’Donnell had been a practicing Catholic before joining the military, and he expressed to the chaplain a desire to confess his sins to a priest. After conferring with the interdisciplinary team about Mr. O’Donnell’s case, it was agreed that the patient was psychiatrically stable and that the chaplain could foster bringing a Catholic priest onto the unit to provide the sacrament of confession to Mr. O’Donnell. The patient reported to the chaplain that this was helpful but that he still felt guilty. In the spirit of creative hopelessness, the chaplain helped the patient be experientially present to his feeling of guilt, to feeling trapped by his actions, and to feeling like nothing he could do would “make it right.” The patient then told the chaplain that he wanted to hold a funeral service for the two children. After again conferring with the interdisciplinary team, the chaplain accommodated this request. The chaplain reserved the hospital chapel for one hour, and only the chaplain and the patient were in attendance at the service, which had a major influence on Mr. O’Donnell. Although the patient continued to feel guilty for what occurred, he was more able after this experience to identify things that he wanted to live for. The chaplain explored with Mr. O’Donnell how forgiveness can be understood as a “giving of what went before.” This helped the patient in identifying certain values of previous importance to him, and he was able to begin constructing purposeful intentions for his life after discharge from the hospital. In this example, the chaplain used specifically religious practices as well as integrating a number of ACT-­consistent principles, such as using creative hopelessness; fostering acceptance of unpleasant thoughts 231

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and feelings (e.g., allowing room for guilt, and not viewing guilt as the enemy); identifying values (e.g., using forgiveness and “giving what went before” to identify earlier life values); and supporting committed actions in line with values.

Meaning and Purpose Chaplains provide spiritual care. Spiritual care and spirituality probably strike most people as intuitively self-­explanatory concepts. However, operationally defining these terms for scientific purposes has proved anything but straightforward, with definitions varying markedly and being subject to dispute. Even so, nearly all definitions of spirituality include some focus on life meaning and purpose. Although it has been asserted that spirituality as measured in the scientific literature is frequently confounded with measures of good mental health (Koenig, 2008), it is also the case that clinical psychology has tended to focus more on alleviating diagnosable mental health problems than on helping people realize meaning and purpose in life. The latter is a tricky endeavor, fraught with subjective notions of what is meaningful and worthwhile in life. Making room for such subjectivity can feel uncomfortable in a culture of evidence-­based health care. This subjectivity can feel as though it does not belong, perhaps should not belong, in medicine. However, for medicine to be patient-­ centered in the manner prescribed by the Institute of Medicine (2001), as alluded to at the beginning of this chapter, subjective patient variables must play a central role. Principal among these patient variables are perceptions of meaning and purpose in life. A study of veterans with post-­traumatic stress disorder (PTSD) underscores this point. The study, conducted by Alan Fontana and Robert Rosenheck (2005), sought to determine what most motivated veterans with PTSD to seek care from the Veterans Health Administration. The authors found that while PTSD symptom severity and social isolation were motivating factors, veterans were even more motivated to seek care because they had lost meaning and purpose in life. If patients are turning to health care systems because they are seeking to renew life meaning and purpose, health care systems need to structure care provision accordingly, and as the authors of the veterans study assert, chaplains are going to be a very relevant part of this care for many patients. In ACT, meaning and purpose are viewed less as abstract concepts and more as the concrete stuff of life. Being rooted in behaviorism, ACT leans heavily toward action and the living out of values in highly practical ways. Life meaning and purpose are not so much feelings and cognitions as they are actionable mission statements for how to live. The clarification of values in ACT is for the purpose of being able to put

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clarified values into action. For that matter, the acceptance-­based processes in ACT are also largely for this purpose—­helping people develop a willingness to experience internal stimuli (such as thoughts and emotions) in order for individuals to simultaneously choose to put their values into action. Chaplains devoted to practicing a nonjudgmental, non-­coercive form of pastoral presence may sense a possible tension here, insofar as it seems that patients are being encouraged to move in a particular direction. Note, however, that the ACT practitioner is not aiming to move a patient in a direction chosen by the practitioner; rather, the patient is being encouraged to move in the direction of values that she has articulated. These values become verbs, and meaning and purpose become adverbs: to purposefully love one’s spouse; to meaningfully interact with one’s children; to meaningfully contribute at work; to purposefully read a good book. Chaplains who seek to assist patients to “live into their values” in this manner are not coercing them. Instead, chaplains are inviting patients to open their eyes and be aware of, attend to, and live into their own lives—­ much in the same way that chaplains are attempting to be present to the patients that they serve. The following example illustrates one way that ACT-­based principles can be used to address issues of meaning and purpose.

Case Example Jane Johnson is a 43-­year-­old African-­American female whose mother died unexpectedly five years ago; since then, the patient has been persistently grieving and has exhibited some depressive symptoms. Ms. Johnson has two teenage daughters who were both very close with their grandmother. The patient feels that she ignores her daughters much more than before, as she is now consumed with grief and feelings of depression. Recognizing this only further depresses her and leads her to ruminate about all the things she misses about her own mother, including all of the ways that her mother used to care for her and her daughters. The patient has, on occasion, referenced all of the kind things that were said about her mother at the funeral service. The chaplain has been able to see Ms. Johnson on an outpatient basis over a series of weeks and has worked with the patient to create a safe, trusting, empathic relationship and to help Ms. Johnson be present to her feelings of grief and inadequacy. Following up on the patient again mentioning the remembrances from her mother’s funeral service, the chaplain invited Ms. Johnson to consider how she would like to be remembered someday. Ms. Johnson said that she would like to be remembered for many of the same things that her mother was—­being a loving mother, being a trusted confidant, and being involved in the

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community. The patient was even able to name a number of things she would like to do along these lines, like volunteer at the middle school and at her church. The chaplain asked Ms. Johnson if she could imagine volunteering in one of these contexts, even while continuing to experience her feelings of grief and loss. The patient agreed to try. Over the next number of weeks, Ms. Johnson became increasingly engaged in activities at her church and at her daughters’ school, and though she continued to feel the loss of her mother and experienced discomfort at times integrating into her volunteering activities, she was able to tolerate this discomfort, reported a significantly increased sense of purpose to her life, and felt like she was even honoring the memory of her mother as well. In this example, the ACT-­consistent principles employed by the chaplain include: being present to emotions (e.g., grief); clarifying values (ACT practitioners sometimes use an imaginal “attending your own funeral” exercise, but this patient’s remembrances of her mother accomplished similar purposes); and carrying out committed actions (e.g., volunteering).

ACT in Different Health Care Settings There are a myriad of ways to divide and subdivide the health care system into its different components, and it is likely that any classification system of this sort will contain numerous places where roles for chaplains exist or could be justified. For the purposes of this chapter, it is particularly useful to consider the comparison between how chaplains might use ACT in mental health settings compared to general medical settings.

Mental Health Specialty Care Settings In many settings where clergy operate in a pastoral counseling capacity, they provide not only spiritual counsel but may be the primary or sole source for mental and emotional care. This is not the case for chaplains working in mental health care settings. Even so, chaplains in mental health settings can serve similar functions as clergy in other settings. For instance, persons on inpatient mental health units may be there against their will or at someone else’s suggestion and therefore may be reluctant to accept care. As in other settings, the chaplain working with such an individual can serve as a trusted personage who can help to explain care services and destigmatize mental health care. That said, this role can be particularly delicate for chaplains working with mental health care teams, as these chaplains may feel 234

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pressured by mental health providers to get the patient to comply with treatment. ACT processes may be of assistance here. By focusing on values, chaplains can assist patients in aligning their personal objectives with the objectives of mental health care teams (e.g., both might value reconnecting the patient with his family), which may or may not result in compliance but should help to foster more fruitful dialogue between the patient and providers. Additionally, it may be useful for the chaplain to clarify to the broader interdisciplinary team some of the values of chaplaincy (e.g., nondirective, nonjudgmental pastoral presence) and how these values guide chaplain care and the ways that chaplains can optimally contribute to a team. For chaplains who use ACT and interact with mental health professionals, there may be need for discussions around professional roles. In the first author’s experience disseminating ACT principles to health care chaplains, it is often the case that mental health professionals respond positively to chaplains who employ methods from ACT. Many of these mental health professionals see benefits in having a chaplain with whom they may be able to use some common language, work toward shared goals, and root their joint care in evidence-­based modalities. However, some mental health professionals may feel uneasy about chaplains using ACT. In these cases, it is important to remember two things. First, using ACT does not cease to make a chaplain a spiritual care provider. Chaplains who use ACT should be prepared to articulate how ACT principles intersect with the spiritual care they provide. As already noted in this chapter, chaplaincy has a long history of integrating psychological principles into pastoral care practices, and this history of integration ought to help pave the way for utilization of contemporary evidence-­based psychotherapeutic approaches. Second, health care teams should always have quality patient care as their primary focus. The demarcation of roles is going to vary depending on the particularities of a given context but should always be in service to this objective of providing patient-­ centered care.

General Medical Care Settings In non-­specialty mental health care settings—­i.e., the general medical care settings in which most clinical chaplains do most of their work—­it is often the case that the chaplain is not only responsible for the religious and spiritual needs of the patient but may also be one of the primary sources on the health care team for psychosocial care. In inpatient medical settings, psychiatrists and psychologists are not typically part of the health care team; doctors and nurses on these teams are hopefully practicing good bedside manner that is mindful of the psychosocial aspects of the patient, but these professionals are understandably primarily focused on the patient’s presenting medical problems; and social workers, should they be part of the picture, are 235

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frequently so occupied with the critical tasks of coordinating discharge planning and follow-­up care that little time remains to provide much in the way of focused psychotherapeutic care. And so the health care chaplain is left as one of the few professionals, perhaps the only professional, who is unencumbered by attending to the patient’s pressing medical needs and can devote primary attention to psychosocial-­spiritual care. That is, at least in principle. Amidst the pressure to provide metrics and prove value to health care systems, chaplaincy has frequently become caught up in efforts to generate numbers for health care administrators, such as through seeing large quantities of patients. This of course can spread chaplains quite thin and can limit their ability to provide more intensive psychosocial-­spiritual care for those patients most in need. In fairness, there are multiple and complex factors that contribute to the structuring of health care chaplaincy in this way—­to include, for instance, interpretations of various accrediting and organizational mandates to provide all patients with access to spiritual care—­but the fact remains that many clinical chaplains can find themselves nearly as harried as the rest of the health care team and without the bandwidth to provide the more in-­depth psychosocial-­spiritual services which may be of most benefit to patients. ACT is by no means a panacea for this problem, but it has some things to offer for these chaplains as well as for the patients to whom these chaplains are providing psychosocial-­ spiritual care. First, ACT can be used by chaplains to help themselves and their patients to slow down and relieve stress in the midst of overwhelming and chaotic situations. Mindfulness practices and self-­as-­context exercises may be of particular use in this respect. Obviously, prayer fits in wonderfully for these purposes as well. Slowing down in a manner that allows patients to better tolerate unavoidable distress should also help patients be more present to comprehending medical information and making values-­based medical decisions. Second, ACT can help patients to evaluate their priorities, commitments, and lifestyle choices at a critical point in their lives. Being in the hospital can prompt honest soul searching about what is important in life. The chaplain is an ideal member of the care team to explore these issues with patients in a thoughtful way that helps them better articulate values and begin to make concrete behavioral commitments moving forward in their lives. Third, ACT can help to inform chaplains’ spiritual assessments. For example, patients might be conceptualized in terms of where they fall on continuums for the six core ACT processes (e.g., avoidant vs. accepting). Utilizing elements such as this from ACT could help enhance spiritual assessments so that they provide useful information to the health care team and indications about targeted areas for follow-­up care. Importantly, all three of these approaches to integrating ACT into chaplaincy practice can be adopted in brief encounters with patients. Chaplains frequently do not have the

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luxury of seeing patients for multiple “sessions” in medical contexts, and so it is important that ACT can be used even when time with patients is limited.

Case Example: Verbatim2 Mr. James Esteves is a 60-­year-­old divorced Latino male whose clinical diagnoses include borderline personality disorder, bipolar disorder, and alcohol dependence. His chart indicates periods of homelessness and a past suicide attempt. As a resident at a substance abuse rehabilitation facility, he has been attending a grief class led by the chaplain for five weeks and has come to the chaplain’s office for an individual visit. This is the chaplain’s second one-­on-­one visit with Mr. Esteves. The patient discusses the recent death of his brother, his mother’s recent death, and his estrangement from his daughter—­events that have all occurred in the past few months. Following is a verbatim of the encounter (C = Chaplain; P = Patient). In keeping with the verbatim tradition, the verbatim and subsequent reflections from the chaplain are presented using first person pronouns. C1:

Tell me about your brother.

P1:

After his son committed suicide, he went on a huge binge, and when he quit drinking, it was such a shock to his body that he had a heart attack and died. I was in a rehab program when it happened. In fact, I was in my counselor’s office when the phone call came in. My counselor must have been able to tell it was an emergency call, and he handed me the phone and I was told.

C2:

You were close with your brother.

P2:

Yes, and then Mom died just a few months after that celebrating her retirement dinner.

C3:

That’s a lot to hold.

P3:

Yeah, and then after my brother’s funeral, my daughter cut off all communication with me. That really hurts. [He starts to sob. There is a feeling of grief and hopelessness.]

C4: [Silence] That is a lot to carry with you. [Pause] Holding the feelings, as you are, is the place to start. 2 The verbatim and reflections are based on clinical experiences of the second author. As with all clinical examples in this chapter, details have been altered to protect the patient’s identity.

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P4:

Thanks… [Tearful]

C5:

[Silence] How have you grieved these losses?

P5:

I made it to my brother’s funeral. I couldn’t go to Mom’s. I wanted to remember her as she was. But, my daughter cutting me off is what hurts the most.

C6:

In the steps there is a time for making amends. [The residential program the patient is in makes use of the twelve steps from Alcoholics Anonymous.] Have you thought about what that might look like?

P6:

I’m just afraid it will be more rejection.

C7:

I can see that seems like too big of a risk for you right now, and I can see how much this has affected you. I can imagine how hard it would be to want to be in relationship with your daughter, but she won’t acknowledge you. [Silence, allowing patient to be present to his pain. During this time, I am intentionally aware of both the patient’s pain and my own sense of isolation from my son, who is autistic. While these are different pains, I nonetheless feel a meaningful empathic connection with the patient. I notice that his countenance is weighed down by all the pain in his life. I think about how far we have come in the past few weeks, and I am impressed by his willingness to accept and be present to the pain in his life. I begin to think about the fusion in his story and attempt to illustrate it through my language—­e.g., “a lot to carry with you,” a heavy weight that was him, and he was it.] What if you did not have to carry it all, all of the time? What if God could help you carry it?

P7:

What do you mean?

C8: Are you open to trying something with me? P8:

Sure.

C9:

[We get up and leave my office to go into the chapel where there is some space.] I need to use my belt to illustrate something. [I hand him one end, while I hold the other.] Let’s pretend that this belt represents all of the pain and grief that you are holding onto. Let’s give it all of the characteristics that you are experiencing in the heaviness of the grief in your life. So, it is very heavy.

P9:

Okay.

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C11: Are you holding it the way you hold the weight of your grief? [I test by tugging on it. He holds on more firmly.] So imagine, in between us, a cavern that stretches through here. You are on one side, the weight of your cares stretches across, and I will represent God. [I tug a little more adamantly. He instinctively pulls back.] Hold on to it! [With lightheartedness] What do you want to do with all the things you have been holding? P11: I want to let them go. [His grip is relaxed; I tug and instinctively he holds on tighter.] C12: What would it be like if you could let it go and let God hold it for you? [I hold the belt taut.] P12: I don’t know. I’ve never tried letting it go before like this. C13: So, if you let go of the belt it won’t go away. It will still be here, but I will be holding it—­just as if you let God have your pain. It may not go away, but someone who is able to carry it will be holding it. Are you ready to let it go, or do you want to hold it? [I tug on the belt.] P13: I want to let go. C14: Are you sure? P14: Yes. [I tug and hold it taut. He lets it go. I notice something happen physically in his countenance, and because we are in a traffic area, I return to the office.] C15: So, the idea this exercise illustrates is how God desires to be our burden bearer. Here it is, “Psalm 68.19, Praise be to the Lord, to God our Savior, who daily bears our burdens.” [Knowledge from previous visits suggests that he would be open to a scriptural illustration. I tell him briefly about modern-­day burden bearers who take goods into the old city of Jerusalem.] God wants to carry the load of your pain and grief…I noticed that when you dropped the belt something shifted in your body. What were you aware of? P15: For the first time, I felt that things were going to be alright.

Theological Reflection on Verbatim The story of this patient brings to mind the story of Elijah. As recorded in I Kings 19, Elijah has run into the wilderness to escape a death threat. He is so distraught that he prays to God to take his life. All seems hopeless, and Elijah is grasping for a way out. In the midst of this desperation, Elijah is ministered to, first with physical 239

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nourishment provided from an angel and then eventually by the presence of God in the form of a gentle whisper. This whisper provides Elijah with comfort, courage, and direction to “go back the way you came” and reengage with the call that God had on his life. From an ACT perspective, Elijah can clearly be understood to be initially engaging in avoidance and escape behaviors. He is so fused with his feelings of fear and hopelessness as to be passively suicidal. But then Elijah’s encounter with the divine unburdens him, creates hope amidst a hopeless situation, and allows him to return to the present with a new sense of purpose to move forward in action. While the patient in the above verbatim is not being chased by a physical enemy in the same way as Elijah, he has been running from a metaphorical enemy, using alcohol as a way to escape from emotional pain. In turning to alcohol, he has dodged his feelings, not allowing himself to experience their fullness as a means of moving forward into action. Spiritually, he has tried to numb himself, which has had the effect of cutting him off from both spiritual pain and spiritual resources. It is spiritually significant that Elijah found a place of comfort and rest. In the life of the patient, he has found a place of rest in the provision offered through the residential program. In the Psalm (C15) was the opportunity to reinforce a confidence in a God who is present and able to carry his burdens.

Psychological Reflection on Verbatim In the course of ACT, the importance of building rapport with the client is paramount (Harris, 2009). Further, there is a powerful understanding in ACT of the psychological significance of assisting the patient to experience feelings (Williams & Kraft, 2012). Having built trust and rapport with the patient in previous meetings, this encounter presented the opportunity to invite the patient to open up to his feelings. The objective was to foster an acceptance, or willingness, on the part of the patient to experience some of the pain that he had long been attempting to avoid with the aid of substance abuse. In some ways, the invitation for the patient to have God carry some of his burden could be interpreted as yet another form of avoidance. However, in this patient’s case, the metaphor illustrating how God can help to carry the patient’s burdens was a means of allowing the patient to be present to both his emotional pain and to the presence of a God who cares enough to help hold that pain. In nontheistic therapeutic encounters, the ACT therapist is a very important person in this respect, as one who is willing to be present with the patient and jointly hold the patient’s pain, just as the chaplain can be. For this patient, I was able to introduce a third presence who is willing to help hold his pain—­God. Back in my office, we discussed further that turning to God does not mean that the patient will cease to have pain, noting that life contains suffering. For this patient, 240

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having a loving God who is willing to help shoulder his burdens appeared to enhance his willingness to encounter the pain in his life rather than attempt to numb it away through alcohol. Additionally, from an ACT perspective, the belt exercise helped to encourage processes of acceptance, cognitive defusion, and present-­moment awareness. Acceptance was fostered through encouraging the patient to willingly encounter, name, and not run from the various emotional pains in his life. Cognitive defusion was subtly at work in helping the patient to think of his “burdens,” including painful thoughts and emotions, as embodied in the belt (and therefore distinct from himself). Present-­moment awareness in this exercise involved helping the patient be aware not only of how heavy his burdens felt but of God’s presence, love for the patient, and desire to create a place of peace and rest for the patient. Mindfulness of the spiritual reality for the patient proved very powerful.

Pastoral Analysis of Verbatim This situation challenged me on an emotional level. I have experienced loss of persons, positions, place, and have stared down the face of rejection. I felt deep sadness as I experienced his story. And I recalled the moments when all I was able to do with someone was be open about my own painful experiences. Additionally, I recognized the moments when I was inflexible, wanting to somehow numb away the pain of grief. My personal experiences enabled me to sit with this patient’s pain, to hold both space and hope, to be as suggested in the hymn “The Servant Song” (Gillard, 1977): I will hold the Christ-­light for you in the night time of your fear. I will hold my hand out to you, speak the peace you long to hear. My primary work was to stay present to the patient’s experience. As we came to a place where it seemed like a logical break for inserting an exercise, I changed my stance. Wonderfully, the belt exercise provided the means to initiate various ACT processes (the exercise used in the verbatim is a variant on an exercise known in ACT as the “tug-­of-­war;” Hayes, Strosahl, & Wilson, 1999, p. 109). Though the patient expressed a sense of peace and hope, I was careful not to set up the expectation that this would be a once-­and-­for-­all moment for the patient. Also after returning to my office, I checked with the patient about his values in an effort to find a way to move forward and to explore actions he could take to live his values. However, he was not quite ready for that discussion and it was determined that exploration of values would probably be best saved for our next encounter. The goals moving forward were to continue to remain in a pastoral relationship that was

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genuine and present, to further encourage processes of the patient opening up to avoided experiences, and to further foster the discovery of a sense of self in the present moment from which the patient could choose to enact new modes of behavior in line with his values.

Summary As the preceding verbatim and case examples illustrate, clinical chaplains can find numerous ways to integrate ACT principles into the care they provide to patients, even in very difficult situations. Indeed, clinical chaplains offer crucial spiritual care to persons in the midst of life’s most challenging circumstances. From its inception and throughout its evolution, clinical chaplaincy has had close ties with psychology. There has been some reluctance among chaplains to fully adopt contemporary evidence-­based psychotherapeutic approaches, in part because these approaches may not seem to resonate as well with core chaplain commitments. ACT provides exciting new possibilities in this respect, having grown out of the behavioral tradition with strong commitments to empiricism yet also embracing numerous principles and practices that are highly synergistic with chaplains’ values. In ACT, chaplains can discover ways to enhance existing commitments to practicing a ministry of presence, developing genuine relationships with those they serve, journeying with individuals as they encounter spiritual struggles, and fostering meaning and purpose in patients’ lives. Chaplains can use ACT across a variety of health care contexts, including in brief encounters with patients. There is much promising work yet to be done in further fleshing out different ways that chaplains can integrate ACT with the spiritual care that they provide. We hope that this chapter has stimulated some ideas in that regard.

References Asquith, G. H. (1980). The case study method of Anton T. Boisen. The Journal of Pastoral Care and Counseling, 34, 84–­94. Association of Professional Chaplains. (2009). Standards of practice for chaplains in acute care settings. Association of Professional Chaplains. Boisen, A. (1960). Out of the depths. New York: Harper & Brothers. Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., et al. (2011). Preliminary psychometric properties of the Acceptance and Action Questionnaire-­II: A revised measure of psychological inflexibility and experiential avoidance. Behavior Therapy, 42, 676–­688. Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685–­716.

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Craddock Lee, S. J. (2002). In a secular spirit: Strategies of clinical pastoral education. Health Care Analysis, 10, 339–­356. Doehring, C. (2015). The challenges of being bilingual: Methods of integrating psychological and religious studies. In E. A. Maynard & J. L. Snodgrass (Eds.), Understanding pastoral counseling (pp. 87–­100). New York: Springer. Fontana, A., & Rosenheck, R. (2005). The role of loss of meaning in the pursuit of treatment for posttraumatic stress disorder. Journal of Traumatic Stress, 18, 133–­136. Gillard, R. (1977). The servant song. Scripture in Song/Maranatha! Music (ASCAP). Harris, R. (2009). ACT made simple: A quick-­start guide to ACT basics and beyond. Oakland, CA: New Harbinger Publications. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press. Hayes, S. C., Strosahl, K., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed). New York: Guilford Press. Institute of Medicine (US), & Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, D.C.: National Academy Press. Kabat-­Zinn, J. (2012). Mindfulness for beginners: Reclaiming the present moment—­and your life. Boulder, CO: Sounds True. Koenig, H. G. (2008). Concerns about measuring “spirituality” in research. Journal of Nervous and Mental Disease, 196, 349–­355. National Center for Health Statistics (NCHS). (2011). Health, United States, 2010. Hyattsville, MD: US Government Printing Office. Rambo, S. (2010). Spirit and trauma: A theology of remaining. Louisville, KY: Westminster John Knox Press. Sullivan, W. F. (2014). A ministry of presence: Chaplaincy, spiritual care, and the law. Chicago: The University of Chicago Press. Swift, C. (2014). Hospital chaplaincy in the twenty-­first century: The crisis of spiritual care on the NHS. Burlington, VT: Ashgate Publishing Company. Williams, R. E., & Kraft, J. S. (2012). The mindfulness workbook for addiction: A guide to coping with the grief, stress and anger that trigger addictive behaviors. Oakland, CA: New Harbinger Publications.

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CHAPTER 15

ACT for Military Chaplains William C. Cantrell, MDiv, BCC VA Mental Health and Chaplaincy US Navy Reserve

Jason A. Nieuwsma, PhD Duke University Medical Center VA Mental Health and Chaplaincy

ACT for Clergy and Pastoral Counselors

T

he United States military, like many armed forces, functions as a cultural and socioeconomic melting pot for the nation. Although, like most militaries, the US military’s makeup relative to national demographics skews toward being composed of younger men, there is nonetheless considerable diversity with respect to race, ethnicity, gender, education, socioeconomic status, and familial and cultural backgrounds. Achieving such diversity is in fact a priority for the Department of Defense (DoD), as is apparent from the military’s stated strategic planning objectives: An all-­ volunteer force must represent the country it defends. We will strengthen our commitment to the values of diversity and inclusivity, and continue to treat each other with dignity and respect. We benefit immensely from the different perspectives, and linguistic and cultural skills of all Americans. (DoD, 2012, p. 4) Out of this diversity, the military seeks to bring together a single force that expresses shared commitments, values, and purpose. For years, militaries across the globe have looked to the chaplain as the most tangible embodiment of a spiritual center to unify and minister to the diverse components of armed forces. The military chaplain’s job in this respect can be daunting. Chaplains must balance commitments to their personal faith tradition and endorsing body while simultaneously taking into account the values and beliefs of the institutions they serve and the individuals to whom they provide care. For military chaplains, diversity presents challenges, opportunities, and dynamic real-­world situations in which to meaningfully live out pastoral and spiritual care. Against this multifaceted, vibrant, and diverse backdrop, acceptance and commitment therapy (ACT) presents military chaplains with promising ministry possibilities. This chapter explores these possibilities, beginning first with an overview of the type of ministry that military chaplains do and moving from there to considering three particular areas of synergy for applying ACT in the military context. These areas include applying ACT to address: 1) psychosocial stressors common among military personnel, 2) resiliency, and 3) moral injury. Brief case examples are provided in each of these three domains. Of note, this chapter focuses less on roles of military chaplains that are covered elsewhere in this book—­in particular, functioning in health care contexts, pastoral counseling settings, and parish ministry—­in order to devote more attention to topics unique to the military context.

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Chaplains in the Military Chaplains who serve in the US Armed Forces have dual roles as representatives of their faith traditions and as military staff officers. While they have a distinct role of supporting and protecting the government’s obligation to provide opportunity to each citizen to exercise his or her freedom of religion (i.e., First Amendment rights), this actually makes up a small portion of the chaplain’s most common activities. While at sea, on the flight line, in the desert or mountains, in schools and training commands, in hospitals, and in other distant places across the globe, military chaplains provide service members and their families with counseling, guidance, moral support, education, and worship. Many of them serve as advisors to their leadership on morale, religious affairs, and ethics. They often function as teachers training service members in a variety of areas, such as combat and operational stress, suicide prevention, resiliency, pre-­and post-­deployment preparation and adjustment, marriage and finance, and others. As they are promoted to more senior positions, chaplains frequently have greater supervisory and directing roles. And, of course, they provide religious support through teaching, study groups, leading worship services, and providing for or facilitating access to faith-­specific needs for those from various religious traditions. They provide a visible reminder of the presence of God and offer hope during the most difficult times that military members face. Chaplains represent well over one hundred different faith groups, and they commit to facilitating care for all service members, providing a safe place for them to turn without concern for fear or judgment. The different branches of the military have unique ways in which they articulate the aspects of confidentiality in chaplaincy, but they all emphasize that those who turn to chaplains for care have the privilege of confidentiality unless the service member decides otherwise. Being a confidential resource affords chaplains optimal opportunity to minister to service members in the context of relationships that can be honest and genuine. While military chaplains commonly engage in and have received training to provide the array of services just mentioned, chaplains in the military have not always been optimally prepared to address some of the issues that they see most frequently. In particular, although chaplains are specially trained in their respective faith traditions, they are unevenly trained in being able to attend to the various psychosocial needs that they so frequently encounter. A large-­scale study conducted jointly by DoD and the Department of Veterans Affairs (VA) provides evidence of this point (Nieuwsma et al., 2014; Nieuwsma, Rhodes, et al., 2013; Nieuwsma, Meador, et al., 2013). In a survey of active duty military chaplains and full-­time VA chaplains, the study found that chaplains were best equipped to care for problems of a religious or spiritual nature (e.g., struggle with religious belief system, difficulties with forgiveness) but that the problems they actually saw most frequently were psychosocial in 247

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nature. Among the military chaplains, the top problems from a list of 32 items that they endorsed as seeing most frequently were: 1) relationship/family stress, 2) work stress, 3) anger, 4) anxiety, and 5) depression. Furthermore, the study found that 79% of DoD chaplains perceived that service members with mental health problems commonly sought help from the chaplain instead of a mental health provider. According to these respondents, the most common reason for turning to the chaplain was a desire for confidentiality. Other reasons for turning to chaplains included reduced stigma, more flexible availability, shared worldview, and comfort with clergy as natural supports within a community. Importantly, life stressors and mental health problems cannot be easily disentangled from related spiritual problems. While this study from DoD/VA indicates the centrality of chaplains in attending to service members’ mental health needs, it is critical to remember that the provision of psychosocial care can and often should be intricately related to the provision of spiritual care. Hence, the chaplain’s identity as a spiritual care provider is important to maintain amidst efforts to better equip military chaplains to appropriately attend to mental health needs. Since most of those who serve in the military enter when they are young adults, their mental health needs are often related to experiencing the challenges and transitions of military life simultaneous to the challenges common for their stage of life—­ challenges such as developing relationships, building personal identities, reordering relationships with former friends and within their families of origin, integrating sexuality in their life, choosing to marry, living both independently and with significant constraints perhaps for the first time, developing meaning in their work, and developing a spiritual life. Although the military provides structure helpful to carrying out the institutional mission, these more personal life challenges often leave those in early adulthood wanting for some guidance, structure, and support from time to time. If they continue in the military for many years, they are likely not only to experience the common challenges of life, but to experience these challenges compounded by long and sometimes unpredictable separations, by frequent moves, by disruptions of friendships and social support, by sometimes imposing financial difficulties, and of course by living with the risks of combat and intense training environments. For these service members, military chaplains are well positioned to support, intervene, and often mitigate the potential for negative consequences. Given the right tools, chaplains have a good chance of helping many whose problems, if addressed early enough, may never require formal treatment by a mental health professional. At the same time, chaplains equipped with the right tools may be better able to recognize when the care of a mental health professional is necessary. While by no means is it the only tool that can help in these regards, ACT has a number of attributes that make it especially well-­suited for the military chaplain’s toolbox.

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ACT can prove of particular use to the diverse work of military chaplaincy because of its flexibility, values-­centric approach, use of metaphors, non-­reliance on models of psychopathology, focus on the present moment, and nonjudgmental stance. These attributes are not only of significant therapeutic value but are highly compatible with most pastoral care approaches. As a psychotherapy that is not “disorder based,” ACT looks at people not as problems to be fixed but as human beings to be admired—­perhaps as one might admire a unique sunset (Wilson & Dufrene, 2008)—­ and assisted in their journeys to live fuller, more meaningful lives. ACT is more of a general approach and orientation to caring for those who suffer than it is a psychotherapy with a set protocol dictating a certain sequence of techniques over a particular number of sessions (although numerous ACT protocols and methods do exist and can serve as useful guideposts). Because of this, ACT is well suited for the diverse situations encountered by military chaplains. Like most helpful tools that chaplains have to offer, ACT too invites those who use it to apply its principles and exercises in their own lives. Those who do so will find that they then get more traction out of ACT when using it in their attempts to help others. Using ACT invites the chaplain to embrace a certain openness to being personally challenged in healthy and insightful ways. It also invites chaplains to look for theological and philosophical parallels to truths from their faith traditions and to consider how these parallels might be valuable in counseling sessions or in other contexts. To use ACT effectively in chaplain ministry, chaplains need to make room for the diversity of persons they serve while also finding ways to be authentic in the integration of ACT practices with their pastoral identity. The remainder of this chapter will present some of the specific ways in which ACT can intersect with the work of military chaplaincy.

Status Viatore: Providing Care Along the Way There is a Latin phrase in the Christian tradition that alludes to the living faithful as pilgrims on a journey: status viatore. Literally, this phrase refers to the state of being on the way. The phrase can be juxtaposed against status comprehendes, or the state of knowing. As humans, we naturally yearn for this later state, and yet we find ourselves in the state of being on a journey, of being unsure about the future, of being “on the way.” For Christians, there is an understanding that this impermanent and at times nebulous state of status viatore inevitably characterizes our existence on earth. As Paul writes, “now we see through a glass, darkly” (1 Cor. 13:12, King James Version). To live a flourishing life amidst the uncertainties of human existence requires both an acceptance of uncertainty as well as faith in what is not yet known, what is unseen.

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In the military, this notion of “being on the way” has a definite resonance. As already noted, many members of the military are in the early phases of their adult lives, perhaps even having joined the military as a vehicle to help them find “a way” in life. The feeling of being a transient pilgrim on a journey can certainly ring true for many service members. At any point during one’s military service, and particularly so during times of conflict, there is a very real and physical transience to military life. Members of the armed forces are often literally “on the way” from one point to another, with the palpable understanding that their location on any given day is temporary. Yet in the midst of such impermanence, some things can remain consistent. Ideally, the military can help to provide a larger sense of purpose, direction, and community that serves to orient and guide service members along the way. Of course, this is not always the case, and the journey can grow difficult. The metaphor of being a pilgrim “on the way” fits nicely in ACT; indeed, a number of commonly used ACT metaphors entail some reference to being on a journey. ACT’s focus on the present moment fosters awareness that one is on a journey. Taking notice and becoming mindful of thoughts, feelings, and one’s broader contextual surroundings in the present moment can help not only in understanding one’s place within a larger journey but also in allowing one to be more intentional about the next steps in that journey. In this way, the metaphor of a pilgrim is quite appropriate and might be juxtaposed to that of a wanderer. An aimless wanderer can be mindful in the present moment but is without direction, whereas the pilgrim’s mindfulness is ultimately in service to finding a way forward along the journey. In ACT, there is plenty of room for the pilgrim to be unsure of next steps, to experience anxiety about present circumstances, and to doubt the way ahead. The pilgrim is not expected to always be sure-­footed and confident. However, ACT is not content with mindfulness of one’s location as a final objective. Rather, ACT seeks to help pilgrims accept the inevitable uncertainties of the present moment in order to identify a direction forward and move along it. The following example illustrates one way that this might be done during a brief encounter with a service member.

Case Example 1 Lance Corporal Benson is a hard-­charging young marine respected by his peers. He enlisted into the Marine Corps both to serve his country and to grow personally. He is the only one of the children in his immediate family who has avoided drugs and jail time. He does not know his father, and his mother has worked hard all her life, 1 The case examples in this chapter are based in part on experiences from the first author’s over 20 years of service as a Navy chaplain. As with all examples in the book, details have been changed to protect actual identities.

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living day-­to-­day. Lance Corporal Benson handles high explosives in an intense setting. His job is routine, but safety is a high priority. His head needs to be in the game. While making rounds in the field, the chaplain checks in with Lance Corporal Benson’s company commander and the first sergeant. They ask the chaplain to meet with Benson, as he has been showing significant signs of stress that they believe are increasing the potential risk for a mishap during the live fire exercises. The first sergeant introduces the chaplain and marine, and the two of them take a seat under camouflage netting at the end of the firing line. The marine is clearly distraught, breathing rapidly, and a little shaky as he begins to explain that just as he started feeling like he was pulling his life together (becoming a marine, embarking on a military career, getting engaged to be married), it is now all falling apart. His brother was recently convicted for murder and sentenced to 30 years in prison, leaving a newborn baby with no parents behind. Benson believed he was the only logical choice to raise this child, not seeing adoption or foster care as favorable options. He had a deep sense of wanting to be responsible, unlike how he perceived his family members to be. He was fearful of not being a good husband, a good father, and a good marine all at the same time. He was overwhelmed and afraid that his fiancée might have doubts about moving forward now that a child was part of the picture. He was on a course to not repeat what he saw while growing up as significant mistakes in his own family, and now he had been derailed. After empathically listening to his story, the chaplain invited him to pay attention to his breathing and to mindfully take some long, slow, deep breaths. They worked together on his breathing for a few minutes. As the marine began to relax, the chaplain asked him to describe the thoughts and feelings that arose when telling the story he had just recounted. He described fear, anger, frustration, anxiety, and despair. He talked about how he couldn’t even envision how he could do all these things. He had never planned for this, and he had worked so hard and planned so carefully. Then the chaplain asked him to keep breathing and begin to notice or recall any bodily sensations that came up. He described his chest tightening, having headaches, and feeling boxed in. After attending to these thoughts, feelings, and bodily sensations with the marine, the chaplain led him into the following exercise (adapted from Russ Harris’s “ACT in a nutshell” metaphor; see Harris, 2009). Chaplain: I would like for you to do an exercise with me. Is that okay? Benson:

Yes sir.

Chaplain: Y  ou did a good job of identifying your thoughts, feelings, and bodily sensations. But then you said you wanted to get rid of them and get

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back to normal. I have to ask you before we begin if “getting rid of them” has been working very well. If it has, we probably don’t need to do the exercise. Benson:

No sir, I guess that’s why I’m talking to you.

Chaplain: O  kay then. Sit up and get in a comfortable position and remove your Kevlar [marine removes helmet]. Now, I want you to hold your helmet in your hands with the open side facing your face, as if you were getting reading to put it on. Now I want you to take the feelings, thoughts, and sensations you described and place them in the helmet. Now raise the helmet to your face, just a few inches from touching your face. I am going to place my hands against the top of your helmet and I want you to describe what you can see—­how aware you are of your surroundings. Benson:

Well, of course I can’t see much.

Chaplain: O  kay, now it is hard to be part of what is going on around you when you can’t see it, right? Now I want you to begin applying pressure, pushing your thoughts, feelings, and sensations away from your face to increase your visibility, increasing the pressure as you go. [Stopping a few inches further from his face] How is it now? Benson:

It is better, but still somewhat blocked.

Chaplain: O  kay. Now I am going to remove my hands and I want you to slowly and gently place your helmet in your lap, open end up. How about now? Benson:

Well sir, I can see normal.

Chaplain: I f trying to push away or avoid your thoughts, feelings, and sensations only seems to make it harder, I want you to consider another possible approach. What if you could take them, and rather than resist or fight them, just allow them to be there, to make room for them, to hold them—­but then move forward with your life? I don’t mean to oversimplify, but the struggle for most people comes mainly from the temptation to avoid, withdraw, stop, or diminish their feelings, thoughts, and sensations, and it usually has the outcome of making things worse. The pain of these things is real and difficult to control, but the struggle is voluntary. Does this make sense? Benson:

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Chaplain: Y  ou have a lot on your plate. And you will have some tough decisions and demands that may force you to take on responsibilities ahead of your plan, but you have already proven what you are capable of when you are committed. Tell me a little about the things that are most important in your life, what you value, what gives meaning and purpose to your life. Benson went on to describe his relationship with his fiancée, the significance of his family despite their troubles, and the importance of being a good husband, father, and marine. The chaplain began to work with him to identify some small steps to focus on a few of these areas and decide on actions he could take to live in harmony with his values. The chaplain encouraged the young marine to focus on the things he can control, such as his decisions and committed actions to live in accordance with what gives his life meaning and purpose, even if it means having to take along for the journey some of the feelings and thoughts that come with the ongoing challenges that he is likely to experience. Appearing calm and collected with expressions of renewed hope, they prayed together and the chaplain gave him a blessing. The entire conversation and exercise took about 35 minutes. Benson indicated he was more clear and calm and could concentrate on his duties. He had some homework to consider, but he was present and able to safely resume doing a job he loved, with people he cared about. When working on acceptance, it is often important to emphasize the difference between resignation and acceptance. Where resignation is a giving up or an act of submission, acceptance is more a willingness to experience the thoughts, feelings, and bodily sensations without reacting to them by fighting them, avoiding them, or withdrawing from them. It is about a willingness to make space for them to occur, to hold them lightly, recognize them for what they are, and move on to choices and behavior that lead toward what gives life meaning and purpose. In making room for his reactions to his challenges, the marine seemed to also make room for the possibilities of moving forward in his life. Of note, chaplains too can be tempted to be unwilling and unaccepting of difficult content that may arise in working with service members. Some interesting questions for chaplains to ask themselves in this regard are presented by Kelly Wilson in his book Mindfulness for Two (Wilson & Dufrene, 2008). Wilson invites counselors to consider: 1) What are the biggest things I avoid in session? 2) What behavior repertoires do I use to keep these hard things away? 3) What have the consequences of these choices been? Seriously considering these questions can assist chaplains in identifying areas in which they may benefit themselves and those they serve by working on acceptance processes.

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Resiliency At times, the field of clinical psychology has been accused of adopting a rather negative view of human psychosocial functioning (Snyder & Lopez, 2009), devoting much attention to all of the ways that things can “go wrong” psychologically. The positive psychology movement has in many ways developed as a contrasting reaction to this view of humans, instead focusing on psychological strengths (Snyder & Lopez, 2009). Amidst this climate in psychology, there came to be a growing interest in the topic of resiliency. Resiliency has been defined in a number of ways. At their root, definitions of resiliency all share two elements: 1) being exposed to adversity, and 2) adapting effectively (Bates & Bowles, 2011). The Office of the Chairman of the Joint Chiefs of Staff (2013) for the US military has adopted a similarly pithy definition, understanding resiliency to be “the ability to withstand, recover, and grow in the face of stressors and changing demands.” Though lengthier, the below definition from Michal Ungar (2008) offers some further insights into how resiliency might be conceptualized: In the context of exposure to significant adversity, whether psychological, environmental, or both, resilience is both the capacity of individuals to navigate their way to health-­sustaining resources, including opportunities to experience feelings of well-­being, and a condition of the individual’s family, community and culture to provide these health resources and experiences in culturally meaningful ways. (p. 225) Ungar, who developed this definition out of his work with youth, offers a conceptualization of resiliency that clearly extends beyond an individual’s capacity to be resilient on his own to a view of resilience that incorporates surrounding, culturally meaningful social structures. For members of the armed forces, the military is such a culture—­a culture that embodies a larger sense of community as well as aims to foster common understandings about values and virtues. The military is sometimes described as having a warrior culture. This has meant different things across different times and places (French, 2005), but often includes a type of honor code. Such codes frequently include common understandings about the value of good discipline, self-­ sacrifice, loyalty, and courage. These values, to use terminology from Ungar’s definition of resilience, can serve as “health-­sustaining resources” that are “culturally meaningful.” For chaplains, it may be useful to explore how values, as discussed within the context of ACT, also have parallels with the cardinal human virtues of prudence, justice, temperance, and fortitude. These virtues—­extolled in the Christian tradition (e.g., Catechism of the Catholic Church), while also foundational in various faith traditions and traceable all the way back to Plato’s discussion of them in the

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Republic—­are similar in many ways to the core values to which service members are taught to aspire. As understood in many moral, philosophical, and faith traditions, these virtues are considered foundational and constant, able to be dependably relied upon for guidance and direction. Training, exercising, eating, sharing quarters, and fighting together while learning and adapting to all the boundaries, rules, and commands in the military reinforces the importance and influence of behaviorally committing to certain shared values and virtues—­both on an individual level and on a communal level. ACT does not espouse that individuals should all adopt particular virtues. It does, however, seek to help people find ways of being motivated by their values so as to live more consistently in line with these values on a moment-­by-­ moment basis. Since chaplains are often in the situation of ministering to large groups of people who may not necessarily be in the midst of a crisis, the following example suggests ways that ACT can be used to help engage a group of service members with their values and thereby foster resilience.

Case Example During an intense exercise in the desert of southern California in the heat of July, thousands of marines were training in a series of live fire exercises. They were hot, exhausted, and losing pounds daily as they strived to stay hydrated. Many, for the first time, were being exposed to the chaotic characteristics of war. They had people screaming at them to push them to their limits, directing them to complete the training mission. While a group of them were resting and downing water and electrolytes, the chaplain came by. Chaplain: How are we doing, marines? Marines:

[Red faced and about to fall over] Oorah! Sir!

Chaplain: I t’s pretty hot out here with the mid-­July sun beating down. I’ve been watching all of you going hard day and night for weeks now. Why are you doing this? Why are you subjecting yourself to this misery? Marines:

[Look perplexed]

Chaplain: D  id you all volunteer? [Given that there was no draft in place, of course they all had, but the question was challenging them to think about why they volunteered and potentially about their values.] Marines:

Yes sir!

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Chaplain: S  o what did you expect to get out of this? I have to say, from the outside looking in, someone might think you are a little crazy! Marines:

[Laugh and smile]

Chaplain: So okay, tell me why you really do this. One at a time, they began to share a list of reasons that were grounded in meaning and purpose for their lives, reasons that reached beyond themselves and beyond personal self-­fulfillment. There was a kind of kinship they were establishing, perhaps one that borders on family and might someday be even stronger than family. Shared suffering with shared victories makes powerful bonds. Their descriptions were reflective about aspects of growth and discovery of aspects of themselves they might have never known had they chosen another path. They were discovering that which they had not known existed before, hope they had not trusted or felt before, and charity they had not learned before. Their new freedoms as young adults were being tested against lessons of prudence, temperance, and fortitude. Of course, they did not use these words, but their reasons for doing what they did resonated with these virtues. Many of them were discovering what life could look like when they were not at its center, and most of them liked it. Though their suffering and pain was often deep, their sense of comradery, accomplishment, joy, and belonging to something greater than themselves appeared for many of them to be at least as powerful and deep. They were finding ways to make room for the breadth of experiencing both the negative and positive. They were learning resilience. From an ACT perspective, they were growing in their psychological flexibility by making space for a range of challenging as well as rewarding thoughts, feelings, emotions, and bodily sensations. The preceding example illustrates how individual and communal values can promote resilience in the face of a highly challenging training exercise. Notably, the intense hardships of this training were nonetheless contained in a relatively safe environment and can therefore be understood as representing comparatively minor adversity up against the traumas and unpredictability that some service members experience in combat. Even in the face of intense traumas, values can promote resilience, resulting in post-­traumatic growth rather than injury. However, we must be extremely cautious of fostering a culture that seeks to promote quick and easy forms of resilience. Trauma and other types of adversity can cause profound emotional, psychological, and moral distress. On its face, these distress reactions may not look anything like “resilience.” Yet this distress is often entirely appropriate and normal, and it can also be of moral and spiritual value. Traumas experienced in combat, as will be discussed further in the next section on moral injury, can present a serious affront to one’s values. Distress, including moral distress, is important to listen to, and chaplains most of all should not be aiming to summarily dismiss such distress in 256

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service of a kind of resilience that simply aims to put individuals “back in the fight.” Rather, resilience ought to be conceptualized as a longer term objective that seeks to provide meaningful, sustainable contexts in which individuals can be heard and can connect to and live out their values. ACT can help to promote this latter kind of resilience rooted in the bigger perspective of their life, rather than focused on a moment or event in time.

Moral Injury Chaplains who work with service members and veterans have by this time likely encountered the term “moral injury.” While the experience of moral injury is no doubt as old as warfare itself, the term moral injury is a useful addition to a nomenclature that has largely focused on psychiatric symptomology. Mental health professionals have offered somewhat different definitions of moral injury to date. Johnathan Shay has described moral injury as resulting from someone with authority betraying what is right in a high-­stakes situation (Shay, 2014). In his books Achilles in Vietnam and Odysseus in America, he provides numerous examples of veterans who found themselves in morally compromised situations and felt betrayed both by their immediate leadership and by their country’s leadership (Shay, 1994, 2002). More recent definitions of moral injury have focused on broader violations of morality. Brett Litz and colleagues describe moral injury as resulting from perpetrating, failing to prevent, witnessing, or learning about events that transgress moral beliefs (Litz et al., 2009). Despite differences in specific definitions, moral injury can be broadly understood as resulting from a violation of morality in the context of war. ACT may offer particular promise in the care of those with moral injury (Nieuwsma et al., 2015). ACT approaches human suffering in a manner that allows moral suffering and moral questioning to be both sincerely engaged and “lightly held,” making room for individuals with moral injury to find new ways of reengaging with important moral beliefs, commitments, and values. Further, while treatment from a mental health provider can be helpful to someone with moral injury, the nature of this unique injury also clearly fits in the chaplain’s domain. Shame, guilt, anxiety, and anger are common for someone struggling with moral injury, and these experiences and emotions are of course familiar to chaplains. Many of these emotions are intertwined with issues of forgiveness—­both of self and of others—­another familiar area for chaplains. Importantly, the forgiveness process for someone with moral injury is likely to be just that—­a process; forgiveness is not likely to be a quick fix. ACT offers some practical approaches to engaging this process in a meaningful way, as the below example illustrates.

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Case Example Dan McConnell was a 25-­year-­old sergeant who had been a soldier for seven years at the time of his second deployment to Iraq. He was known as a strong leader and good example. At the time of his deployment, he had been married for six years and had two children, ages three and six. While standing watch at a checkpoint in Iraq, one of the other soldiers noted a car advancing toward the checkpoint. There were signs in several places warning drivers about the checkpoint and the need to stop. However, despite excessive signaling from guards to the vehicle to stop, it did not slow down. The driver seemed to ignore their warnings. Adrenaline flowing, and the rules of engagement flashing through his mind in a millisecond, Sergeant McConnell fired his weapon. The vehicle swerved and rolled gently to a stop. Upon approaching the vehicle, the soldiers discovered the driver was a woman and there was also a child inside. The woman was dead, and the child was wounded. There were no weapons in the car. Four years later, after separating from the military, Mr. McConnell stopped into the VA chaplain’s office after a medical appointment at the hospital. The veteran had come to develop a relationship with the chaplain over the past year, informally checking in with the chaplain around once a month. The chaplain in this time had learned some about Mr. McConnell’s war zone experiences, including the incident described above. Although the veteran had avoided going into much detail about the event, it was evident to the chaplain that Mr. McConnell was haunted by it. The veteran brought up the incident that day with the chaplain, noting that he had been feeling especially troubled by it lately. He noted that he had been drinking more lately—­two or three beers a day, up from only one or two per week. After talking for around 20 minutes, the veteran became quite honest and vulnerable about his moral injury. Veteran:

 omewhere over there is a kid without a mom. I have no idea what S happened to that kid. For all I know, he’s an orphan. Hell, some terrorist group probably took him in under their wing. All this kid knows is that an American shot his mom while she was just innocently driving her car. Why wouldn’t that kid want to fight back? Of course he would—­I would. I signed up to defend my country, and all it amounts to is me killing an innocent woman in front of her child and probably creating another terrorist in the process. It’s really screwed up.

Chaplain: That’s a lot to carry. Veteran:

Yeah, yeah it is.

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Veteran:

I try not to. Whenever I think about it, I just go to a really dark place, so I try to avoid it.

Chaplain: How? Veteran:

 onestly? [Chaplain nods empathically.] Lately with alcohol. [Pause] H And my kids—­I find myself withdrawing from them. When I’m around my kids, I find myself thinking about that Iraqi child, thinking about what I took from him. It feels wrong somehow that I should be with my kids, like I’m a hypocrite or something.

Chaplain: I can sense just how heavy that guilt feels for you. Veteran:

 eah…I’ve asked God to forgive me, but I don’t know that I’m Y forgivable. I figure I’ll probably go to hell when I die. I’ve kind of accepted it.

Chaplain: Is that really what you believe God will do with you? Veteran:

 ell, I know God is supposed to be able to forgive anything, so I guess W I don’t really believe that, but I just feel like I deserve to be punished for what I did.

Chaplain: Y  es, I can tell you’ve felt this way for some time. [Pause] Are you willing to consider something with me? [Veteran nods.] What values did you feel you’d violated when you found out that you had shot a woman? Veteran:

I don’t know, really, like all of them. [Pause] I guess I’d say protecting innocent people. That’s why I joined the military in the first place. First there was 9/11, and then I kept seeing on the news all these innocent people over in the Middle East being killed by terrorists. I wanted to help. I wanted to protect them. I wanted to stop the bad guys. And then I feel like I just ended up being one of the bad guys myself.

Chaplain: S  o there’s the value of protecting innocent people. And protecting children in particular, yes? Especially with you having kids of your own. Veteran:

Yeah, boy did I screw that up.

Chaplain: C  an I ask you to do something again, to notice something with me this time? [Veteran nods.] Every time your mind gives you a thought like that—­“I screwed up,” “I can’t be forgiven,” “I deserve to be punished”—­ what happens to your values?

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Veteran:

What do you mean?

Chaplain: S  o say you’re with your kids and these thoughts come up, what happens? Veteran:

I leave. I walk off.

Chaplain: And so this value of “protecting”—­what happens to it? Veteran:

You mean, like, protecting my kids?

Chaplain: Yeah, you would say that’s a value for you, right? Veteran:

 eah, definitely. I mean, I suppose I’m not really protecting my kids by Y walking off. I’m certainly not being with them in the way I’d like to be, in the way that I feel like they deserve. I’d like to teach them good life lessons and things like that, and I definitely don’t feel like I’m doing that.

Chaplain: S  o it’s like you’ve found yourself in this hole, this deep guilt. And whenever you approach a situation where you might be able to climb out of the hole some, to live your values again, like with your kids, your mind starts saying all this stuff to you and you go back deeper into the hole. Veteran:

Yeah, it really feels like that—­just like that, like a dark hole.

Chaplain: I wonder if next time you sense yourself in this kind of a situation—­ where you feel like you’re barely peeking out of the hole at the possibility of embracing your values (being with your children in this case), and your mind starts saying all of those negative things to you about deserving to be punished, being a bad person, and all that—­I wonder if there’s a way to just make room for your mind to say those things. I wonder if you might just allow those thoughts to be there without avoiding them, and go ahead and climb out of the hole anyway. Perhaps to go ahead and stay there with your kids for a while, even while your mind insists on saying whatever it has to say. Can you consider that, accepting the costs if it means reconnecting with your children who you value? Veteran:

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 m, huh. Wow, I guess I never really thought about it that way. I might U be able to try. How do I even do that?

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In response, following this exchange, the chaplain led the veteran through a brief cognitive defusion exercise, encouraging him to just observe the different thoughts that came into his mind. After the exercise, the chaplain discussed with the veteran how this kind of exercise might be used when the veteran is with his kids and starts to experience guilty thoughts and the impulse to withdraw. They discussed how becoming practiced in the use of cognitive defusion and in growing more willing to take a stance of acceptance can facilitate recognizing the rewards of living a life of meaning and purpose. In this example, the chaplain was able to use ACT to help the veteran reconnect to important life values. Issues of spiritual significance, including forgiveness, were of importance in future meetings with the veteran.

Summary As illustrated in the different case examples in this chapter, chaplains who work with service members and veterans can integrate ACT into their ministry in myriad ways. As a values-­based approach, ACT invites chaplains and the people they serve to meaningfully consider how spiritual, religious, and moral values can help to guide their lives. This chapter focused on how chaplains can use ACT to address the topics of psychosocial stressors common among military personnel, resiliency, and moral injury. Chaplains of course attend to a number of issues beyond these topics and function across an array of contexts. Many military chaplains function in the roles of a congregational minister, a pastoral counselor, or a health care chaplain—­roles considered separately in other chapters in this book. Given the many different hats that military chaplains assume over the courses of their careers, they need tools that are correspondingly adaptable. ACT is such a tool.

References Bates, M. J., & Bowles, S. V. (2011). Review of well-­being in the context of suicide prevention and resilience. Proceedings of the NATO human factors and medicine panel HFM-­205-­symposium on “Mental Health and Well-­Being across the Military Spectrum,” 11–­13 April 2011. Chairman of the Joint Chiefs of Staff. (2013). Chairman’s total force fitness framework. CJCSI 3405.01. Washington, DC. Department of Defense (DoD). (2012). Department of Defense diversity and inclusion strategic plan: 2012–­2017. Washington, DC. French, S. E. (2005). The code of the warrior: Exploring warrior values past and present. Lanham, MD.: Rowman & Littlefield Publishers. Harris, R. (2009). ACT made simple: A quick-­start guide to ACT basics and beyond. Oakland, CA: New Harbinger Publications.

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Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., et al. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695–­706. Nieuwsma, J. A., Jackson, G. L., DeKraai, M. B., Bulling, D. J., Cantrell, W. C., Rhodes, J. E., et al. (2014). Collaborating across the Departments of Veterans Affairs and Defense to integrate mental health and chaplaincy services. Journal of General Internal Medicine, 29, 885–­894. Nieuwsma, J. A., Meador, K. G., Rhodes, J. E., Cantrell, W. C., Jackson, G. L., Lane, M. B., et al. (2013). The intersection of chaplaincy and mental health care in VA and DoD: Expanded report on VA / DoD Integrated Mental Health Strategy, Strategic Action #23. Washington, DC: Department of Veterans Affairs and Department of Defense. Nieuwsma, J. A., Rhodes, J. E., Jackson, G. L., Cantrell, W. C., Lane, M. E., Bates, M. J., et al. (2013). Chaplaincy and mental health in the Department of Veterans Affairs and Department of Defense. Journal of Health Care Chaplaincy, 19, 3–­21. Nieuwsma, J. A., Walser, R. D., Farnsworth, J. K., Drescher, K. D., Meador, K. G., & Nash, W. P. (2015). Possibilities within acceptance and commitment therapy for approaching moral injury. Current Psychiatry Reviews, 11, 193–­206. Shay, J. (1994). Achilles in Vietnam: Combat trauma and the undoing of character. New York: Scribner. Shay, J. (2002). Odysseus in America: Combat trauma and the trials of homecoming. New York: Scribner. Shay, J. (2014). Moral injury. Psychoanalytic Psychology, 31, 182–­191. Snyder, C. R., & Lopez, S. J. (Eds.). (2009). Oxford handbook of positive psychology. Oxford; New York: Oxford University Press. Ungar, M. (2008). Resilience across cultures. British Journal of Social Work, 38, 218–­235. Wilson, K. G., & Dufrene, T. (2008). Mindfulness for two: An acceptance and commitment therapy approach to mindfulness in psychotherapy. Oakland, CA: New Harbinger Publications.

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CHAPTER 16

ACT for Clergy and Pastoral Counselors: Addressing Spiritual Self-­Care Sky Kershner, MSW, DMin Kanawha Pastoral Counseling Center, Charleston, WV West Virginia University, Charleston Division

Jacob K. Farnsworth, PhD Denver Veterans Affairs Medical Center Eastern Colorado Health Care System

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lergy and pastoral counselors face numerous obstacles to personal well-­ being (Proeschold-­Bell & McDevitt, 2012). On perhaps the most observable level, clergy typically work long hours serving the needs of their congregations, often without adequate funding, resources, or facilities. It can be rare that this work fits neatly into the standard 40-­hour workweek; usually it requires clergy members to be on call around the clock to respond when their services are needed. Being constantly “on call” can take its toll on mind, body, and spirit. Yet the work of clergy members extends far beyond investments of time and physical energy. As spiritual figures within their religious communities, clergy are also sought out to receive and bear witness to the emotional burdens of their parishioners. In their role as religious confidants, clergy are presented with accounts of tremendous suffering, unspeakable cruelty, and agonizing doubts from the lives of their congregation members. Due to the need to preserve the trust and anonymity of their parishioners, these emotional burdens generally rest exclusively on the clergy member’s shoulders with few, if any, avenues for sharing the load. A brief search of articles related to clergy stress and self-­care reveals a number of reviews and studies, discussing everything from compassion fatigue and clergy burnout to growing concerns about how stress is affecting clergy health (Lewis, Turton, & Francis, 2007; Roberts, Flannelly, Weaver, & Figley, 2003; Weaver, Larson, Flannelly, Stapleton, & Koenig, 2002; Weaver, Koenig, & Ochberg, 1996). Furthermore, the esteem and social status conferred upon clergy often comes with a hidden cost. Although clergy are revered and honored for their religious stations, worshippers may find it difficult, if not impossible, to see them as people separate from their titles. Clergy members may thus sometimes feel both socially rewarded and confined by their titles; not allowed to exist simply as imperfect people. Evidence suggests that such stressors are having a negative impact on clergy health. An article by Proeschold-­Bell and McDevitt (2012) indicates that at one time clergy were some of the more healthy people in the US. While there was significant stress-­related disease, this was offset by clean living: “What clergy have historically been good at is good behavior: fewer accidents, fewer suicides, and less syphilis” (p. 177; as cited in King and Bailar, 1969). However, the overall position of clergy as the healthiest professionals in the US has started to wane, with chronic diseases such as obesity and hypertension taking a significant toll (Proeschold-­Bell & LeGrand, 2010). Given these and other potential challenges inherent in the role of clergy, it is evident that increased attention to the psychological and physical self-­care of clergy members is warranted. To help address this need, the following chapter draws from the clinical and theoretical framework of acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 2012) to explore how this psychological intervention can also support clergy members’ well-­being in the course of their religious and

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spiritual responsibilities. ACT’s model of psychological well-­being is first reviewed, followed by a discussion of how the six core processes of ACT may be applied to clergy members in their efforts to engage self-­care. Before we begin, we would like to make a brief note that this chapter speaks largely from the perspective of the North American religious context, focused primarily on religions based in the Abrahamic traditions (Islam, Judaism, and Christianity). It is recognized that many other religious traditions exist with their own context and that future discussion is warranted to explore how ACT can best support their religious leaders’ compassionate self-­care.

What ACT Has to Offer: Psychological Flexibility Broadly speaking, the ACT model of individual well-­being is based on the concept of psychological flexibility, which can be defined as the ability to adapt behavior to varying contexts and situations in the pursuit of one’s core values (Hayes et al., 2012). The term “psychological flexibility” itself alludes to the illustrative metaphor of bending without breaking. Just as flexibility in tree branches allows for growth in the midst of fierce winds, the opposite condition, rigidity, creates brittleness, which can cause branches to snap in the course of resisting environmental forces. Although the term itself was coined by psychologists in recent years, the principles of psychological flexibility are evident in the great spiritual traditions of humankind. Some of the most noted examples of psychological flexibility come from the Buddhist traditions of eastern Asia. For instance, in the Jataka (Buddhist literature), Buddha said, “Bend like a bow and be as pliant as bamboo, and then you will not be at odds with anyone” (Dhammika, n.d.). As well, Buddhist tradition encourages such notions as pliancy with respect to rules, appropriately changing them to fit the context, and detachment from rigidly held views and opinions (Dhammika, n.d.), the latter obtained through meditation. Meditation has also been studied more recently with findings suggesting those who practice have greater cognitive flexibility—­or the ability to think about multiple concepts simultaneously or switch more readily between concepts (Moore & Malinowski, 2009). This latter kind of flexibility has implications for well-­being in that having the ability to readily switch or hold multiple ideas simultaneously provides greater opportunity to pursue a variety of paths when experiencing difficulties or frustrations, rather than being locked into one way of moving forward. Likewise, psychological flexibility is suggested in several of the teachings of Jesus Christ. For example, when sending his followers out two by two, He recommends a 265

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number of flexible ways to behave. In Jesus’s instructions to his disciples in Mark (“Take nothing for the journey except a staff” NIV, 1985), this idea of flexibility is central. The Message version of Mark 6:9–­11 captures this well: “Don’t think you need a lot of extra equipment for this. You are the equipment. No special appeals for funds. Keep it simple.” He adds in Mark 6:10 (The Message 2004), “And no luxury inns. Get a modest place and be content there until you leave,” and in Mark 6:11 (The Message 2004) He states, “If you’re not welcomed, not listened to, quietly withdraw. Don’t make a scene. Shrug your shoulders and be on your way.” Note here that Jesus is not reported to say, “If you’re not welcomed by the townspeople, build a bunker, get a loudspeaker, and broadcast day and night. It’s really important that these people get the message.” Rather, as excited as the disciples were to be spreading the message of their teacher, Jesus cautions them to be flexible in their approach. In the remaining portions of this chapter, a similar proposition is made to clergy members regarding issues surrounding self-­care: namely, that adopting a flexible approach to their own identities and duties as religious leaders will render them ultimately better able to perform those duties and care for themselves along the way.

A Walk Around the Hexaflex In ACT, psychological flexibility is divided into six interrelated yet distinct processes that are sometimes referred to as the ACT hexaflex (Hayes et al., 2012). These processes include acceptance, contact with the present moment, defusion, self-­ as-­ context, values, and committed action. Each process helps provide clarity as to how the overarching goal of psychological flexibility can take shape in day-­to-­day life. In the following sections, each of two of the core ACT processes will be explored together, linking them to the overarching goal of creating flexibility. These processes will also be explored through stories, exercises, and the experiences of the authors. Readers are invited to listen and consider how each process might apply to their own circumstances and pursuit of well-­being.

Acceptance and Contact with the Present Moment The ACT processes of acceptance and contact with the present moment each pertain to how we choose to relate to whatever we are currently experiencing (Hayes et al., 2012). On the one hand, contact with the present moment asks, “What am I aware of right now, in this moment?” In taking a present-­oriented focus, the past and future are temporarily set aside and attention is nonjudgmentally directed to observe 266

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one’s moment-­by-­moment flow of experience. On the other hand, acceptance asks a separate but related question, “Can I be open to whatever I am experiencing right now?” In other words, acceptance refers to acknowledging and validating the reality of one’s experience without attempting to minimize or defend against it. Thus, in ACT we may choose to accept that something is happening, even when we do not like or agree with it, and we can be open to this experience, whatever it is, in the here and now. The following examples can help provide some guidance as to how these two processes relate to clergy self-­care. In doing so, it is first useful to consider the opposite of acceptance and contact with the present moment, namely, avoidance.

Ministers, Avoidance, and Running Away As we, the authors, have looked back on our lives thus far, it is easy to see how many decisions we have made along the way that were based on a strategy of avoidance. However, we can also see that the more we avoided difficult things, the less we were able to tolerate the feelings that we were trying to escape. During author Sky Kershner’s first year in seminary studying the Christian New Testament, it was suggested that the Christian apostle Mark had left a little hint of his own identity in his gospel, which includes the verse, “A young man, wearing nothing but a linen garment, was following Jesus. When they seized him he fled naked, leaving his garment behind” (Mark 15:51, New International Version). Ironically, running away seems to be, for some clergy, part of the journey to ministry. During one period of Sky’s pastoral education, a fair amount of his time was spent running away from his duties as a student chaplain. Terrified, he was especially good at avoiding his clients, believing that he had nothing of value to offer them. Feelings of anxiety, insecurity, unworthiness, and fears of being seen as a phony all plagued him, and because of the strategy of avoidance, he had less and less experience pushing through them. The fear was exhausting and his avoidance of uncomfortable moments did little to calm his dread. Although painful, Sky’s experience may be far from uncommon. In his book The Confidence Gap, Russ Harris (2011) argues that fast-­paced, industrialized nations like the North Americas may have things backward. Many of us have the idea that if we just felt more confident we could do whatever we think is important for us to do. So we wait, and wait, for the feeling of confidence to arrive, meanwhile slowly sinking into bogs of despondency and inaction. In contrast, Harris makes the case for something that now, with the benefit of time and experience, seems obvious to us: confidence is not a feeling that just comes when you want or need it; it is a conviction that is based on action. At this point in his career, Sky did not have confident thoughts and feelings about working with clients who were in hospital stays or other serious 267

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settings; indeed, he had no experience with this or other experience from which he could draw upon. Over time, the confidence to act came only from trial and error, making mistakes and learning from them, watching, reading, studying, and trying again—­it didn’t come through “feelings of confidence.” Although the avoidance seemed a relief at the time, with the gift of hindsight he can now recognize that his avoidance early in his career only prolonged his suffering. Generally, and to the point of self-­ care, avoidance is problematic. Rather than waiting for a particular feeling to come (such as feeling like doing it, or feeling that you have things under control or that you are now confident in your work so you can take care of yourself), it is possible to take steps toward caring for oneself in the here and now.

DON’T CRY Another way in which clergy may practice avoidance is by trying to argue with or solve negative emotions. During a training role-­play, a student pastor was doing a great job giving empathy until the congregant burst into tears. At this point, the student panicked and all of his reflective listening skills went out the window: “Now don’t do that, don’t cry. It will get better. Where is your faith?” he pleaded. Without experience sitting with and opening up to intense, painful emotions, we are prone, like this student pastor, to regard them as dangerous and destabilizing. However, scientific studies have suggested that attempting to avoid feared emotions can become a self-­defeating process (Kashdan & Steger, 2006; Wenzlaff & Wegner, 2000). In a recent study, it was observed that those who feared specific emotions tend to experience those emotions more often and more intensely (Hughes, Gunthert, Wenze, & German, 2015). The truth about emotions is that they do not kill you and they do not last forever. Just keep breathing. They too shall pass. In fact, research indicates that the ability to validate and compassionately regard one’s own painful emotions is associated with greater psychological well-­being and fewer symptoms of depression and anxiety (Raes, 2010). The sheer volume and intensity of painful negative emotions encountered directly or indirectly by clergy necessitates that they are provided time and space to develop these skills of self-­care (for an excellent self-­directed volume addressing the development of greater self-­compassion around painful emotions, see Germer, 2009). Another aspect of acceptance is the willingness to hold several views, perspectives, or feelings simultaneously, rather than trying to evaluate or judge some as good and some as bad, or some as better than others. In listening to those who have endured tragedy or hardship, a common theme is conflicting emotions and wishes. In reflecting these experiences, clergy might say, “So you feel sad that your mother has passed, and at the same time relieved that your mother is no longer suffering,” or “So you feel lucky to have survived, and at the same time guilty that others did not.” Yet 268

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in reflecting these apparent discrepancies, clergy should not overlook their own areas of internal conflict. Deep spiritual impressions of feeling called by God may coexist with perceptions of inadequacy or doubt; love and respect for congregation members may flow alongside desires to avoid accompanying social pressures and the interpersonal tension that accompanies leading groups of people. When internal discord caused by these conflicting positions appears, the natural inclination of humans is to try to avoid the discomfort by rational argument or through strategies of escape. As an alternative, ACT encourages us to allow for all of our thoughts, emotions, associations, memories, and sensations to exist together. There is no exclusion. Instead, internal struggles are themselves offered mercy and compassion and are regarded not as failings, but simply as a normal and expected part of being human.

A Second Piece of Showing Up The ability to accept the emotions that we are feeling requires that we first be in touch with our own experience. This requires spending time practicing noticing these experiences in the here and now. Many prayer traditions include such time in the quiet now; prayer that is away from words, but is quiet, reflective, and just noticing. This kind of presence builds the capacity to be aware of your emotions, thoughts, and sensations; and this capacity can be useful to you as well as others. Staying in contact with the present moment is embedded within the old wisdom noted by Theodore Roosevelt, “People don’t care how much you know until they know how much you care.” Specifically, it is hard to show up in an authentic, caring way for another if you are not fully in the present moment yourself. Likewise, if one goal of spiritual self-­care is to help clergy learn to be there for others, it stands to reason that they must also learn to routinely step back from their active labors and take the time necessary to turn their attention inward and sit with their own needs. In the Christian tradition, Mary and Martha may assist us in seeing this virtue of simply being in the present. In one story, Martha is consumed by what she perceives needs to be done next and has a fairly strong resentment toward those who are not working. Mary, meanwhile, is content to rest in the presence of her Lord, to be with Jesus in the now. Just as Jesus praised Mary for recognizing and paying attention to “the good part” (Luke 10:42, King James Version), clergy too may need to recognize that in the midst of their important duties, there is virtue in taking time to stop and simply be with themselves. This being present with ourselves is all the more important when we are experiencing personal struggles. When the character of God visits the much-­afflicted character of Job in the Hebrew Bible, He seems offended when Job asks what seems like a natural question, “Why did this happen to me?” It can be admitted that for much of 269

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his clergy life, Sky has been privately disappointed, and at times even embarrassed, that the character of God seemed to show Job no empathy or compassion. Then recently he heard a priest friend in a clergy group point out something about the character of God that he had not noticed: “At least God shows up,” he said. That, at least, is something, and may at times be enough for even the most difficult of hardships. Just as showing up in all of your humanity to what is happening in the life of clients, patients, and parishioners is a key to good service, honestly and authentically showing up to yourself is a key to spiritual self-­care.

Defusion and Self-­as-­Context In contrast to acceptance and contact with the present moment, which ask us to draw near to and value our present experiences, the ACT processes of defusion and self-­as-­context allow us to create a healthy distance from aspects of our minds that may serve as barriers to self-­care. In ACT, fusion occurs when people see words as reality itself (Hayes et al., 2012). Alternatively, defusion refers to the psychological process of separating words from the actual things they represent. Through defusion, we see that many of the verbal conventions we routinely use are not helpful when treated literally. For example, telling someone to “get over” distress as if it were a track hurdle actually provides very little useful information about how to deal with emotional pain. Defusion undermines the artificial constraints created by such unhelpful verbiage, thereby freeing us to see things as they are, without preconceptions. The ACT process of self-­as-­context (see Hayes et al., 2012) takes this same skill and applies it to our own sense of self. In discovering a sense of self-­as-­context, we learn to separate our many roles, identities, and attitudes from basic consciousness. When this is achieved, what remains is a form of pure awareness that enables us to experience ourselves as we are, without judgment or qualification. In the following section, examples will be used to expand upon these definitions and demonstrate how they can be applied to the goal of spiritual self-­care.

BREAKING THE RULES The skill of defusing from words is often useful when we experience strong beliefs or rules that lead us down unhealthy paths. In Carmen Berry’s When Helping You Is Hurting Me (2003), the author suggests that many clergy have fallen into the “The Messiah Trap,” which involves two primary beliefs: Belief #1: No one else is willing to do what needs to be done. Belief #2: No one can do it as well as me. 270

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If regarded as literally true, these beliefs can exercise powerful control over clergy members’ behavior. They may feel unable to delegate tasks or seek help, convinced that they are destined to carry their burdens alone. One response to such beliefs may be to debate or disprove them by appealing to reason or more benevolent interpretations of sacred texts. Although at times these approaches may be helpful, in many other instances our very attempts to stop thinking or believing a thought only make it more available to our minds (Wegner & Schneider, 2003; Wegner, 1989). To see how this works, take a few moments and do everything in your power not to think about vanilla ice cream (Walser & Westrup, 2007). You may think about whatever you wish, as long as it is not vanilla ice cream. You can even try to substitute an “X” for vanilla ice cream. Start now: don’t think of vanilla ice cream. Were you successful? We suspect not. This is because whereas our minds are very good at adding information, they are not well designed to intentionally forget information. After all, in order to intentionally forget, you have to first remember what it is you want to forget! The good news is that rather than trying in vain to erase thoughts from our minds, we can defuse from our thoughts by seeing them as they are, simply words floating in our minds. With this psychological distance in place, we are then put in a position to decide whether the words we are hearing ourselves say are in fact the ones we really want to be following. Defusion can be particularly helpful when overly general rules limit our potential. A pastor Sky talked with recently told him a story of how he had “broken the rules” with a parishioner. The parishioner was feeling suicidal and saying that no one understood her. The pastor, who confided in Sky that he himself had been suicidal at times, shared with the parishioner that he had struggled with depression most of his life and that some days it took all he had just to get out of bed. The pastor reported to Sky that in this case the parishioner seemed surprised and genuinely helped by his sharing of his humanity with her. At the end of their conversation, Sky asked the pastor what rule he had broken. “I don’t know,” he said, “I wasn’t sure if it was okay for me to be so personal.” Such rules may be part of the trap that clergy find themselves in from time to time. They are expected to be safe, empathetic, and helpful, and yet in seeking to fulfill these expectations they may cut themselves off from one of the primary healing forces for both themselves and others—­who they are as people. In this instance, by choosing to follow his gut sense rather than the formulaic rules he had been taught in his training, this pastor was able to connect more fully to his parishioner and to himself.

Stuck in Limiting Self Stories Finding flexibility in roles seems to be an area of major difficulty for many clergy. In an article written by M. Collette Nies (2010), she reported on a survey conducted 271

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in 2008 (see The Clergy Health Initiative website: http://divinity.duke.edu/initiatives-­ centers/clergy-­health-­initiative) that found two major sources of stress for clergy. First, the work-­life balance of many respondents was out of kilter. According to these findings, the culprits of imbalance were reported as being “difficulty in balancing multiple roles; feeling guilty about taking time to exercise; disregarding needed health care because of time demands, struggling to achieve overall work-­life balance” (p. 35). Second, the authors reported that the existential burdens of ministry also added stress by leading clergy to feel obligated to carry “others’ emotional and spiritual burdens; being overwhelmed by others’ needs; and feeling expected to solve the unsolvable” (p. 36). These stressors indicate a theme of being overstretched and overwhelmed and suggest that the ministerial roles that clergy feel expected to take on may actually discourage them from using adequate self-­care strategies. In contrast to this conception of what it means to be clergy, the idea of self-­as-­ context asks the person (note here that we are talking about a human being and not just a role or a title) to gently let go of her identities and develop an attentive awareness of her own sense of consciousness. When this is achieved, roles and identities can be examined, much like you would inspect an outfit after taking it off and hanging it up in a closet. Like clothing, sometimes roles and identities become ill-­ fitting to our natures or ill-­suited to our environment. When this happens, we feel constrained by them and unable to move and perform the work we cherish most. If this has occurred for clergy members, developing awareness of self-­as-­context would encourage them to ask the following question: “What would you need to do to develop more flexibility in terms of how you see your role as a clergyperson?” Exploring and reimagining our identities and roles and the way we engage in them can be helpful in reducing the stress of ministerial work if it relieves the unrelenting burden that comes from believing one must be all things to all people, all the time.

What’s in a Name? When we have facilitated a group, we have asked participants to introduce themselves, using only first names as a model. “My name is Betty,” the next person might say, and so it goes around the room. It is sometimes a telling moment when a group member who is clergy introduces him-­or herself by saying, “My name is Pastor Bill” or “My name is Pastor Karen.” Unless our first name really is “Pastor,” we might consider, just for a moment, developing the flexibility to be just “Bill” or just “Karen” without identifying ourselves by the roles we play. Sky has even known some clergy who use their official title in everyday situations (e.g., the Very Reverend Father Smith). To us, this sounds exhausting! How about trying, “The Usually Reverend Father Smith,” or how about “The Occasionally Reverend Father Smith”? By being 272

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careful how and when we use our labels as clergy, we can begin to have flexibility with ourselves around them. Engaging with labels in this way allows the freedom to “visit” other roles and identities that one might wish to engage, like the role of “healthy” or “well-­rounded.” Let’s take a closer look with an exercise.

I Am Not This As a sense of self-­as-­context is not a skill commonly taught in many cultures and traditions, it can be helpful to use exercises designed to create distance between what we perceive and our sense of ourselves as perceivers. In college, Sky met a Franciscan monk who taught him an interesting meditation practice. The practice is called “Who am I?” In this exercise, which we have adapted slightly to enhance a sense of self-­as-­context, you begin with your eyes closed and take several slow breaths to help quiet your mind. It then follows as so: 1. Ask yourself the question, “Who am I?” 2. Whatever answer your mind comes up with, in the next slow breath, give the response: “I am not this. Who am I?” 3. No matter what your mind comes back to you with, always give the same response: “I am not this. Who am I?” 4. Do this until the question is no longer important. Doing these kinds of exercises can help you let go of the selves that your mind has conceptualized for you and assists in recognizing that there is another self beneath them all—­a fresh and unadorned self; very much like a newborn child that has yet to swallow whole the expectations and identities presented to him by life. By not clinging too tightly to any one sense of ourselves, stress is reduced and we no longer feel compelled to surrender our physical and emotional health to a particular role. Rather, we can allow time and room to wear other roles and identities that enhance our well-­ being and, if needed, make appropriate alterations to our clergy role to include reasonable self-­care routines.

Values and Committed Action We believe the best reason for developing psychological flexibility is that in doing so, we become better able to do what we want to do and go where we want to go. For all its emphasis on acceptance, being in the present moment, and loosening our grip on labels and identities, ACT is actually a framework dedicated first and foremost to 273

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meaningful change. The two remaining ACT processes, values and committed action (Hayes et al., 2012), provide, respectively, the why and what of how this is accomplished. Values are, quite simply, the principles we choose to act on because they intrinsically bring us vitality and purpose. For many clergy members, values such as service, love, compassion, or duty inspire them to devote their lives to their religious callings. In doing so, there is no guarantee from day to day of any particular outcome. Living the value itself is motivation enough. This is not to say that living our values is without effort. We are often called to sacrifice time, resources, and energy in order to pursue our values. Hence, in ACT, these efforts to live values are not just called actions, but committed actions. In other words, they are actions that, albeit sometimes timid and anxiety-­filled, are nonetheless taken with conviction because they are reflections of what we truly value most. On this point, the words of the prayer/poem “Do It Anyway”1 may be instructive: People are often unreasonable, irrational, and self-­centered. Forgive them anyway. If you are kind, people may accuse you of selfish, ulterior motives. Be kind anyway. If you are successful, you will win some unfaithful friends and some genuine enemies. Succeed anyway. If you are honest and sincere people may deceive you. Be honest and sincere anyway. What you spend years creating, others could destroy overnight. Create anyway. If you find serenity and happiness, some may be jealous. Be happy anyway. The good you do today, will often be forgotten. Do good anyway. Give the best you have, and it will never be enough. Give your best anyway. In the final analysis, it is between you and God. It was never between you and them anyway. Values and committed action are not about success, failure, or social approval. Rather, they are two sides of the same coin that reflect what we will stand for in life: what we truly value will inform our actions and our actions will in turn manifest what it is that we truly value. The goal in self-­care is to, as you would for another, value personal health and well-­being. 1 While this version of the prayer has at times been ascribed to Mother Theresa, the original inspiration for it appears to come from a 1968 pamphlet by Kent M. Keith entitled “The Silent Revolution: Dynamic Leadership in the Student Council.”

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Being the Best Me I Can Be ACT emphasizes the importance of consciously choosing values in a way that is free from external constraints or fear of punishments. A set of values should ultimately be chosen because the choosing person sees them as being intrinsically valuable and not simply means to an end. In this way, living values represents a purely authentic way of being. Lying on his deathbed, Reb Zusya was very upset and crying, tears streaming down his face. His students asked with great concern, “Reb Zusya, why are you upset? Why are you crying? Are you afraid when you die you will be asked why you were not more like Moses?” Reb Zusya replied, “I am not afraid that the Holy One will ask me ‘Zusya, why were you not more like Moses?’ Rather, I fear that the Holy One will say, ‘Zusya, why were you not more like Zusya?’” (Cited in Tales of the Hasidim by Martin Buber, 1947, p. 251). From these few words we can surmise that as he approached the remainder of his days, Zusya felt a great longing to have lived in more accordance with some of his values. Committing to living one’s values in the present moment can thus help to inform an approach to self-­care that is not only concerned for the well-­being of the clergy member’s body, but is also concerned for the well-­being of the clergy member’s conscience.

SABBATH As part of their role as spiritual and religious figures, clergy are naturally set apart from those non-­clergy who have not made similar commitments to a spiritually-­ oriented lifestyle. As noted previously, the values often associated with clergy emphasize kindness and service toward humanity, but somewhat ironically less often include themselves as a member of that all-­encompassing human category. The tragedy in this form of selflessness is that in choosing to serve and value humanity, clergy members sometimes neglect the one human that they are with 24 hours a day, seven days a week—­themselves. Rather than being a reflection of greediness or egotism, acts of self-­care can instead be understood as a more complete rendering of service to the members of the human family. Sky’s first experience of clergy self-­care was 30 years ago when he was fresh out of seminary and his local denominational leadership was in turmoil. Three out of four clergy leaders had entered divorce proceedings the previous year. Wisely, one of the responses of the denomination was for clergy members to take a mandatory five-­ day retreat. The retreat was exactly what they needed. The retreat’s leader instructed Sky and his colleagues that the most important thing they could do for themselves during their stay was to take as many naps as they could. If at any time they felt tired, he told them not to fight it, but to just go and take a nap. Sky took him up on this, napping twice a day for the first three days. Midway through the week he felt 275

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wonderful and better prepared to resume his role with his congregation. Thus, rather than being self-­indulgent, such acts of self-­care may actually enhance clergy members’ ability to serve others selflessly. This principle can be observed in the Hebrew understanding of Sabbath. In the Hebrew book of Genesis, God created the world in six days and then rested on the seventh, from then onward setting that day of the week apart for humankind as a day devoted to rest and reflection. It is not hard then to see how the principle of Sabbath overlaps with that of self-­care. In his book Sabbath, Wayne Muller (2013) writes, “Once people feel nourished and refreshed, they cannot help but be kind; just so, the world aches for the generosity of a well-­rested people” (p. 11). Even periods as brief as several minutes at a time can create a sacred space wherein clergy can practice attentively and compassionately, attending to their own stress and burdens. In developing such routines, clergy may do well to remember that Sabbath is not dependent upon our preparedness to stop. We do not stop because we are finished. We do not stop when we complete our phone calls, finish our project, get through this stack of messages, or get out this report. We stop because it is time to stop and rest. The spiritual principle of Sabbath requires surrender. If we only stop when we are finished with all our work, we will never stop—­because our work is never completely done. Rather, the principle of Sabbath calls clergy members to listen, heed the needs of their own finite bodies, and honor their cries to rest from their labors for a time.

Conclusion This concludes our brief walk around the ACT hexaflex in the service of clergy self-­ care. We hope that this brief tour of ACT has been interesting, and, more importantly, useful. Perhaps it will encourage your curiosity in exploring acceptance, contact with the present moment, defusion, self-­as-­context, values, and committed action in your work with your clients, and in your own personal journey. Self-­care is fundamental to good service. Engaging the ACT processes in a life that is open, aware, and engaged may offer just the right tools for supporting you in that service role.

References Berry, C. R. (2003). When helping you is hurting me: Escaping the messiah trap. New York: The Crossroads Publishing Company. Buber, M. (1947). Tales of the Hasidim: The early masters. New York: Schocken Books. Dhammika, B. S. (n.d.). Guide to Buddhism A to Z. Retrieved from http://www.buddhisma2z. com/content.php?id=137 Germer, C. K. (2009). The mindful path to self-­compassion: Freeing yourself from destructive thoughts and emotions. New York: Guilford Press.

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Harris, R. (2011). The confidence gap: A guide to overcoming fear and self-­doubt. Boston, MA: Shambhala Publications. Hayes, S. C., Strosahl, K., & Wilson, K. G. (2012). Acceptance and Commitment Therapy: The process and practice of mindful change (2nd ed). New York: Guilford Press. Hughes, C. D., Gunthert, K., Wenze, S., & German, R. (2015). The subscale specificity of the Affective Control Scale: Ecological validity and predictive validity of feared emotions. Motivation and Emotion. Retrieved from http://link.springer.com/article/10.1007/s11031– 015–9497–7#page-1, doi: 10.1007/s11031–­015–­9497–­7. Kashdan, T. B., & Steger, M. F. (2006). Expanding the topography of social anxiety: An experience-­sampling assessment of positive emotions, positive events, and emotion suppression. Psychological Science, 17, 120–­128. King, H., & Bailar, J. C. (1969). The health of the clergy: A review of demographic literature. Demography, 6, 27–­43. Lewis, C. A., Turton, D. W., & Francis, L. J. (2007). Clergy work-­related psychological health, stress, and burnout: An introduction to this special issue of Mental Health, Religion and Culture. Mental Health, Religion & Culture, 10, 1–­8. Moore, A., & Malinowski, P. (2009). Meditation, mindfulness and cognitive flexibility. Consciousness and Cognition, 18, 176–­186. Muller, W. (2013). Sabbath: Finding rest, renewal, and delight in our busy lives. New York: Random House Publishing Group. Nies, M. C. (2010). Clergy health and wholeness. New World Outlook, November/December, 35–­36. Retrieved from http://www.gbophb.org/assets/1/7/NWO_nov-­ dec10_clegy_health_article. pdf. Proeschold-­Bell, R. J., & LeGrand, S. H. (2010). High rates of obesity and chronic disease among united Methodist clergy. Obesity, 18, 1867–­1870. Proeschold-­Bell, R. J., & McDevitt, P. J. (2012). An overview of the history and current status of clergy health. Journal of Prevention & Intervention in the Community, 40, 177–­179. Raes, F. (2010). Rumination and worry as mediators of the relationship between self-­compassion and depression and anxiety. Personality and Individual Differences, 48, 757–­761. Roberts, S., Flannelly, K. J., Weaver, A. J., & Figley, C. R. (2003). Compassion fatigue among chaplains, clergy, and other respondents after September 11th. Journal of Nervous & Mental Disease, 191, 756–­758. The Prayer Foundation (n.d.). Mother Teresa: Do it anyway. Retrieved from http://prayerfounda tion.org/mother_teresa_do_it_anyway.htm Walser, R. D., & Westrup, D. (2007). Acceptance and commitment therapy for the treatment of post-­ traumatic stress disorder and trauma-­ related problems. Oakland, CA: New Harbinger Publications Weaver, A. J., Koenig, H. G., & Ochberg, F. M. (1996). Posttraumatic stress, mental health professionals, and the clergy: A need for collaboration, training, and research. Journal of Traumatic Stress, 9, 847–­856. Weaver, A. J., Larson, D. B., Flannelly, K. J., Stapleton, C. L., & Koenig, H. G. (2002). Mental health issues among clergy and other religious professionals: A review of research. Journal of Pastoral Care and Counseling, 56, 393–­403. Wegner, D. M. (1989). White bears and other unwanted thoughts: Suppression, obsession, and the psychology of mental control. New York, NY: Viking Adult. Wegner, D. M., & Schneider, D. J. (2003). The white bear story. Psychological Inquiry, 14, 326–­329. Wenzlaff, R. M., & Wegner, D. W. (2000). Thought suppression. Annual Review of Psychology, 51, 59–­91.

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Jason A. Nieuwsma, PhD, is associate professor in the department of psychiatry and behavioral sciences at Duke University, and serves as associate director of the Mental Health and Chaplaincy program at the Department of Veterans Affairs. Nieuwsma has led multiple projects, authored numerous articles focused on improving the ­integration of mental health and spiritual care services, and trained hundreds of chaplains and mental health professionals in the application of acceptance and commitment therapy (ACT). Robyn D. Walser, PhD, is associate director of the National Center for PTSD Dissemination and Training Division and associate clinical professor in the department of psychology at the University of California, Berkeley. As a licensed clinical psychologist, she maintains an international training, consulting, and therapy practice. Walser is developing innovative ways to translate science into practice, and is responsible for the dissemination of state-­of-­the-­art knowledge and treatment interventions. Walser has coauthored three books, including Learning ACT, The Mindful Couple, and Acceptance and Commitment Therapy for the Treatment of Post-­Traumatic Stress Disorder and Trauma-­Related Problems. Steven C. Hayes, PhD, is Nevada Foundation Professor in the department of psychology at the University of Nevada. An author of forty-­one books and nearly 600 scientific articles, his career has focused on analysis of the nature of human language and cognition, and its application to the understanding and alleviation of human suffering and promotion of human prosperity. Among other associations, Hayes has been president of the Association for Behavioral and Cognitive Therapy, and the Association for Contextual Behavioral Science. His work has received several awards, including the Impact of Science on Application Award from the Society for the Advancement of Behavior Analysis, and the Lifetime Achievement Award from the Association for Behavioral and Cognitive Therapy. Foreword writer Siang-­Yang Tan, PhD, is professor of psychology at the graduate school of psychology at Fuller Theological Seminary in Pasadena, CA, and senior pastor of First Evangelical Church Glendale in Glendale, CA. He has authored or coauthored numerous articles and books, including Lay Counseling, Disciplines of the Holy Spirit, Rest, Coping with Depression, Full Service, and a major textbook, Counseling and Psychotherapy. He is a licensed psychologist, ordained pastor, and Fellow of the American Psychological Association.

Index A

about this book, xv–­xvii absorption, 98 acceptance, 86–­95; ACT core process of, 49, 50, 62, 151; change and, 86–­87, 88, 89, 107; Christian examples of, 166–­ 167, 169–­170, 198; clergy self-­care and, 266–­267, 268–­269; definition of, 151; defusion and, 100, 101, 105; experiential, 26–­27, 34; faith-­based approaches and, 208–­209; gratitude and, 89–­90; Islamic teachings on, 141–­142; Judaism and, 151–­152; mindfulness and, 27, 34; paradoxical findings about, 15; permission related to, 88; present-­moment awareness and, 71–­72; problem of control and, 93–­95; religiously unaffiliated people and, 180–­181; resignation distinguished from, 253; willingness and, 65, 89, 90–­93, 95; wisdom related to, 88–­89 Acceptance and Action Questionnaire (AAQ-­II), 224 acceptance and commitment therapy (ACT): ACT acronym used in, 36; adaptive leadership and, 192–­193; applications of, 56–­57; Buddhism and, 129–­137; Christianity and, 163–­172; clergy and, 185–­201; committed action in, 112; congregational leadership and, 190–­196; core processes of, 48–­52, 61–­62, 65–­66, 136–­137; evidence-­ based paradigms and, 13–­16; faith-­ based counseling and, 203–­216; FEAR

acronym used in, 35; health care chaplaincy and, 219–­242; “hold and move” summation of, 4–­5; human suffering and, 25–­38, 54, 186–­188; Islam and, 139–­148; Judaism and, 149–­160; military chaplains and, 245–­261; mindfulness employed in, 34; pastoral care and, 186–­190; pathological processes defined by, 135–­136; philosophical origins of, 44–­47; psychological flexibility in, 27–­28; relationship to pain in, 15–­16; religion/spirituality and, 1–­2, 42, 52–­57, 127–­128; religiously unaffiliated people and, 173–­181; research on effectiveness of, 43; self-­care and, 198–­201, 264–­276; values explored in, 112–­114; worship leadership and, 196–­198 ACT acronym, 36 actions: practical survey of, 200. See also committed action adaptive leadership, 191–­193 agnostics, 176 American Psychological Association (APA), 12 American Psychologist (journal), 22 antidepressant medications, 21 Association for Behavioral and Cognitive Therapies (ABCT), 9 Association for Clinical Pastoral Education (ACPE), 222 Association of Professional Chaplains (APC), 227 atheists, 176 avoidance. See experiential avoidance

ACT for Clergy and Pastoral Counselors

awareness, 62, 64–­66, 83; conscious, 64–­65, 74; practice of mindful, 69–­74; self-­as-­context as, 74–­75, 77–­82; therapeutic process of, 187, 194. See also present-­moment awareness

B

behavior: fusion with religious, 216; rigid or inflexible, 47, 50 belt exercise, 241 Berry, Carmen, 270 Biblical counseling, 205 blaming others, 103 bodily sensations, 93, 100–­101 Boisen, Anton, 221, 222, 223 Bonhoeffer, Dietrich, 20, 25, 28–­38 boundlessness, 53–­54 Bowen, Murray, 190 breath, mindfulness of, 42, 251 Buber, Martin, 275 Buddhism, 129–­137; ACT processes and, 135–­137; core teachings of, 132–­134; five faculties in, 131, 136–­137; Four Noble Truths in, 133–­134; loving-­ kindness and compassion in, 131–­132; mindfulness meditation in, 130–­131; psychological flexibility and, 130, 265; teaching method used in, 132; Twelve Links of Dependent Origination in, 134–­135 burnout, clergy, 199–­200, 264

C

Cabot, Richard, 221–­222 Cantrell, William C., 245 centeredness, 36, 37 change and acceptance, 86–­87, 88, 89, 107 chaplaincy. See health care chaplaincy; military chaplains cheap grace, 29 chessboard metaphor, 78

282

choice and willingness, 92–­93 Christian psychology, 205–­206 Christianity, 163–­172; ACT processes related to, 165–­171, 198; being present in, 165–­166, 168–­169; conscious awareness described in, 65; distress endurance related to, 24; faith-­based counseling in, 205–­206; mindfulness-­ like practices in, 211; opening up described in, 166, 169–­170; pastoral presence in, 225; Paul’s life and teachings in, 164, 168–­171; Peter’s life and teachings in, 164, 165–­167; psychological flexibility in, 265–­266; self-­as-­content statements in, 213; suffering from perspective of, 20, 21–­23; valued living described in, 167, 170–­171 clergy, 185–­201; congregational leadership and, 190–­196; pastoral care and, 186–­190; self-­care for, 198–­201, 264–­276; stress and burnout of, 199–­200; worship leadership and, 196–­198 clinical chaplaincy. See health care chaplaincy clinical pastoral education (CPE), 222 cognitive behavioral therapy (CBT): empirical studies based on, 10–­11; therapeutic focus of, 140 cognitive defusion. See defusion commitment: ACT support for, 65; Buddhist faculty of, 136 committed action: ACT core process of, 49, 50, 158–­159; barriers to, 122–­124; biblical example of, 198; Christian examples of, 167, 170–­171; clergy self-­care and, 273–­276; faith-­based counseling and, 215; Islamic teachings on, 147; Jewish faith and, 159–­160; religiously unaffiliated people and, 179–­180; values and, 112–­114, 122–­124

Index

commonsensical truth, 132–­133 communal and interpersonal practices, 197 community-­based living, 37–­38 compassion: Buddhist tradition and, 131–­132; religiously unaffiliated people and, 180 concentration, 69 conceptualized self, 75–­76, 77, 136 condemning others, 103 confidence, 267–­268 Confidence Gap, The (Harris), 267 conflict, congregational, 193–­196 congregational leadership, 190–­196; adaptive leadership and, 191–­193; case study illustrating, 194–­196; conflicts in congregations and, 193–­196; congregational systems theory and, 190–­191 congregational systems theory, 190–­191 conscious awareness: self-­as-­context as, 74; in spiritual/religious traditions, 64–­65 consciousness, 52, 74, 77 consciousness examen, 200–­201 contacting the present moment. See present-­moment awareness contextual cues, 45 contextualist worldview, 14 contrition and sorrow, 200 control, problem of, 93–­95 Cost of Discipleship, The (Bonhoeffer), 29 costly grace, 29, 30, 36, 39 countercultural messages, 183 creation story, 31–­32 creative hopelessness, 230

D

defilements in Buddhism, 133, 135–­136 defusion, 95, 98–­102; acceptance and, 100, 101, 105; ACT core process of, 49, 50, 62; Christian examples of, 170, 198;

clergy self-­care and, 270–­271; faith-­ based counseling and, 209–­210; forgiveness and, 103–­105; Islamic teachings on, 143–­144; making moves toward, 101–­102; religiously unaffiliated people and, 181; righteous indignation and, 102, 103; thoughts of risk and, 99; true/false thoughts and, 98–­99; value of practicing, 100–­102; verbal dominance and, 97, 98, 100, 107 deictic relational frames, 51 derived relational responding, 45 destinations vs. directions, 116–­119 disillusionment, 136 distorted thinking, 13–­14 distress endurance, 24 “Do It Anyway” prayer, 274 Drescher, Kent D., 185

E

Easterlin, Richard, 4 “Easterlin Paradox,” 4 Ellis, Albert, 10 emotions: acceptance of, 268–­269; values contrasted with, 123 empathy, 223 Emre, Yunus, 140 engagement, 36 enlightenment, prayer for, 200 ethical will, 156 eulogy/tombstone exercise, 121 evidence-­based psychotherapy: ACT and the refining of, 13–­16; contemporary ascent of, 10–­11; religion/spirituality and, 9–­10 examen prayer, 200–­201 experiential acceptance, 26–­27, 34 experiential avoidance: ACT description of, 26–­27, 48, 152–­153; clergy and the problem of, 267–­269; Jewish rituals discouraging, 153–­154 experiential knowledge, 45–­46

283

ACT for Clergy and Pastoral Counselors

F

faith: human suffering and, 22; language issues around, 216; mature characteristics of, 24 faith-­based counseling, 203–­216; acceptance in, 208–­209; ACT core processes and, 207–­215; committed action in, 215; defusion in, 209–­210; empirical support for, 206; explanatory overview of, 204; present-­moment awareness in, 210–­212, 216; self-­as-­ context in, 212–­213; two dimensions of, 207; values in, 213–­214, 216; varieties of, 205–­206 Farnsworth, Jacob K., 109, 263 FEAR acronym, 35 feelings: Buddhist view of, 134, 135. See also emotions feet willingness, 90 Fontana, Alan, 232 forgiveness: ACT perspective on, 55; asking for, 160; defusion and, 103–­105; mental health benefits of, 12; reconciliation and, 106; self-­as-­context and, 82 Four Noble Truths, 133–­134 Frankl, Viktor, 223 Freud, Sigmund, 10 Friedman, Edwin, 190 functional contextualism, 44, 140, 146, 147 functional cues, 45 fusion, 26, 48, 98

G

Gandhi, Mahatma, 121 genuine relationships, 227–­229; case example of, 228–­229; explanation of, 227–­228 God’s will, 25, 30, 35, 36–­37

284

Goff, Brian C., 203 grace: Christian doctrine of, 164, 166, 168, 169, 172, 210; costly vs. cheap, 29; faith-­based counseling and, 210 gratitude, 89–­90

H

happiness: money and, 4; pursuit of, 23–­24, 184 Harris, Russ, 267 Hayes, Steven C., xvii, 41, 128, 173 healing the world, 156–­158 health care chaplaincy, 219–­242; connecting ACT with, 224–­234; explanatory overview of, 220–­221; genuine relationships in, 227–­229; health care settings for, 234–­237; historical context for, 221–­224; meaning and purpose viewed in, 232–­234; pastoral presence in, 225–­ 227; psychological approaches used in, 222–­223, 224; spiritual struggle in, 229–­232; verbatim in, 222, 237–­242 heart willingness, 90, 91 heartfulness, 70 Heifetz, Ronald A., 191 Heschel, Abraham, 159 Hitler, Adolf, 28 “hold and move” consideration, 4–­5 Holy Longing, The (Rolheiser), 208 hopeful resolution, 201 human nature, 13–­14 human suffering, 20–­23; ACT and, 25–­38, 54, 186–­188; Buddhist teachings on, 133–­134; language and, 26; mental health and, 21; religious perspectives on, 20, 21–­23; research on religion/spirituality and, 22–­23; values related to, 119–­121; willingness to encounter, 223

Index

I

I/here/now perspective, 51, 83 Ignatius Loyola, 200, 201 images, mental, 93, 100 impermanence, 137 inflexibility, 47, 50 insight, Buddhist faculty of, 137 Institute of Medicine, 220, 232 integrationist approach, 205 integrity, 215 interconnectedness, 54 Internet-­based pastoral care, 178–­179 inward practices, 197 irrational thinking, 13–­14 Islam, 139–­148; acceptance in, 141–­142; ACT model related to, 141–­147; cognitive defusion in, 143–­144; committed action in, 147; general overview of, 140; present-­moment awareness in, 144–­145; self-­as-­context in, 145–­146; values in, 142, 146–­147

J

Judaism, 149–­160; acceptance in, 151–­ 152; committed action in, 159–­160; ethical will in, 156; experiential avoidance and, 153–­154; idea of repairing the world in, 156–­158; mourning rituals in, 153–­154; present-­ moment awareness in, 155; repenting process in, 159–­160; values in, 156–­158 Jung, Carl, 189

K

Kabat-­Zinn, Jon, 64, 131 Kahneman, Daniel, 13 Kelly, Thomas, 211 Kershner, Sky, 263, 267 King, Martin Luther, Jr., 159 Knabb, Joshua J., 19

knowledge: double-­edged sword of, 38; problem of human, 32–­33; verbal vs. experiential, 45–­46 Kohlenberg, Barbara S., 149 Kumano, Hiroaki, 129

L

language: ACT view of, 45; conceptualized self and, 75; defusing from, 107; how it works, 95–­96; human suffering and, 26; inadequacy of, 2; RFT account of, 44; verbal dominance and, 96–­98 leadership: congregational, 190–­196; worship, 196–­198 Leadership Without Easy Answers (Heifetz), 191 Leibniz, G. W., 186 Lennon, John, 91 Life Together (Bonhoeffer), 37 Litz, Brett, 257 love, ACT-­based values and, 37 loving-­kindness, 131–­132

M

Mark (Apostle), 266, 267 Matthew (Apostle), 164, 165, 166, 167, 188, 198, 215 McCartney, Paul, 91 McMahan, Joe, 219 McMinn, Mark R., 203 Meador, Keith G., 19 meaning and purpose, 232–­234; case example of working with, 233–­234; viewed in clinical chaplaincy, 232–­233 medical care settings, 235–­237 medical chaplaincy. See health care chaplaincy medical model, 21 medications, 21 meditation: definition of, 64–­65; mindfulness distinguished from, 67

285

ACT for Clergy and Pastoral Counselors

Meehl, Paul, 10 mental health: human suffering and, 21; religion/spirituality and, 6–­9, 52–­53, 232; specialty care settings for, 234–­235 Messiah Trap, 270–­271 metamorphosis, 170 metaphors: chessboard, 78; passengers on the bus, 212; two-­sided coin, 32; willingness, 91 military chaplains, 245–­261; case examples of work by, 250–­253, 255–­ 256, 258–­261; challenges specific to, 246; functions performed by, 247–­249; moral injury encountered by, 257–­261; providing care along the way by, 249–­253; resiliency promoted by, 254–­257 mind, poisonous states of, 133, 134, 136 mindfulness: acceptance and, 27, 34; benefits of, 69; Buddhism and, 67, 130–­131; definition of, 131; faculties related to, 131; meditation distinguished from, 67; mental/physical health and, 53; presence in ACT related to, 226; present-­moment awareness and, 67–­72, 154, 211; religiously unaffiliated people and, 181; research studies on, 68–­69 Mindfulness for Two (Wilson), 253 ministry: ACT in the context of, 188–­ 189; faith-­based counseling and, 206 Ministry of Presence: Chaplaincy, Spiritual Care, and the Law, A (Sullivan), 225 money and happiness, 4 moral expectations, 116–­117 moral injury, 257–­261; ACT approach to, 257; case example of working with, 258–­261; definitions of, 257 Mother Teresa, 123–­124 Mourning and Mitzvah (Brener), 153 mourning rituals, 153–­154

286

Muller, Wayne, 276 mutual adaptation, 207 mutuality, relational, 227–­228

N

Naradevo, Phrayuki, 129 Niebuhr, Reinhold, 86, 87 Nies, M. Collette, 271 Nieuwsma, Jason A., xvii, 2, 3, 41, 173, 184, 219, 245 “nones” (no religious affiliation). See religiously unaffiliated people Nouwen, Henri, 189

O

observer perspective, 74, 78 opening up: Christian examples of, 166, 169–­170; therapeutic process of, 187, 194, 216 Ord, Ingrid, 163 Oswald, Roy, 199 outward practices, 197

P

pain: ACT approach to, 15–­16, 23, 54, 183, 187; sacred, 120; values related to, 119–­121. See also human suffering panic disorder, 14–­15 paradoxes, 14–­15 parish clergy. See clergy passengers on the bus metaphor, 212 pastoral care, 186–­190; human suffering and, 186–­188; Internet-­based, 178–­179; ministry and, 188–­189; wounded healer and, 189–­190 pastoral counseling, 205 pastoral presence, 225–­227; case example of, 226–­227; explanation of, 225–­226 patience in Islam, 142 patient-­centered care, 220

Index

Paul (Apostle), 164, 168–­171, 198, 208, 209, 211, 249 peer-­to-­peer stance, 189 permission, acceptance and, 88 perspective, sense of, 50–­52 perspective taking, 56; self-­as-­context as, 83; transcendence related to, 180; verbal dominance and, 97, 98, 101 Peter (Apostle), 164, 165–­167 poetry, listening to, 96 positive psychology, 254 positive thinking, 70 post-­traumatic stress disorder (PTSD), 232 prayer: faith-­based counseling and, 210; steps of the examen, 200–­201 present-­moment awareness, 67–­74; acceptance and, 71–­72; ACT core process of, 49, 62, 66, 154–­155; case example of session on, 72–­74; Christian examples of, 165–­166, 168–­169, 198; clergy self-­care and, 266–­267, 269–­270; faith-­based counseling and, 210–­212, 216; Islamic teachings on, 144–­145; Judaism and, 155; mindfulness and, 67–­72, 154; religiously unaffiliated people and, 180 pressure cooker theory of upset, 102 psychological flexibility: Buddhist tradition and, 130, 265; Christian teachings and, 265–­266; cultivating through ACT, 27–­28, 49–­50; Islamic teachings and, 141, 146; self-­awareness and, 83 psychology: Christian, 205–­206; derivation of word, 56–­57 psychotherapy: health care chaplaincy and, 222–­223; mindfulness related to, 69; religion/spirituality integrated with, 9–­13, 56–­57 PsycINFO database, 6 purpose. See meaning and purpose

R

Rambo, Shelly, 22 rationality, 13–­14 receptivity, 136 reconciliation, 105–­106 reflective thanksgiving, 200 relational frame theory (RFT), 44, 51, 96 Relational Frame Theory (Hayes, Barnes-­ Holmes, and Roche), 75 relationships: cultivating genuine, 227–­ 229; theological view of, 38. See also therapeutic relationship relaxation exercises, 71 religion/spirituality: ACT and, 1–­2, 42, 52–­57, 127–­128; Buddhism and, 129–­137; Christianity and, 163–­172; committed action and, 122–­124; community and, 37–­38; continuum related to, 57; history of science and, 1; human suffering and, 21–­23; Islam and, 139–­148; Judaism and, 149–­160; mental health and, 6–­9, 52–­53; mindfulness related to, 69–­70; people unaffiliated with, 174–­181; psychotherapy integrated with, 9–­13, 56–­57; values related to, 111–­112, 113, 114–­121 religious and spiritual values, 111–­112, 114–­121; ACT approach to, 113, 214; case study illustrating, 110, 115, 124–­125; committed action related to, 122–­124; destinations vs. directions and, 116–­119; goals distinguished from, 117; Islamic teachings on, 142, 146–­147; protection vs. pain and, 119–­121; rules vs., 114–­116 religiously unaffiliated people, 173–­181; ACT processes and, 179–­181; challenges presented by, 178–­179; demographics describing, 175–­177; general characteristics of, 177; national growth of, 174–­175, 177

287

ACT for Clergy and Pastoral Counselors

Remen, Rachel, 157 repenting process, 159–­160 research: on effectiveness of ACT, 43; on faith-­based counseling, 206; on religion/spirituality and mental health, 6–­9, 22–­23 resignation vs. acceptance, 253 resiliency, 254–­257; case example of fostering, 255–­257; definitions of, 254; values related to, 254–­255, 256 righteous indignation, 102–­103 rigidity, 47, 50, 265 risk: defusing from thoughts of, 99; reconciliation related to, 106 Robb, Hank, 85 Rogers, Carl, 10, 223 roles: applying ACT in different, 183–­184; finding flexibility in, 271–­272; self-­as-­ context vs., 78–­79 Rolheiser, Ronald, 208 Roosevelt, Theodore, 269 Rosenheck, Robert, 232 rules vs. values, 114–­116, 171 Rumi, Mevlana C., 146

S

Sabbath, principle of, 276 Sabbath (Muller), 276 sabr, 141–­142 sacred pain, 120 Saperstein, Daniel M., 185 science and religion, 1 scrupulosity, 115 self: conceptualized, 75–­76, 77, 136; limiting stories about, 271–­272; transcendent sense of, 180, 212 self-­as-­content, 75, 213 self-­as-­context, 74–­82; ACT core process of, 49, 50, 62, 66, 77; Buddhist faculties and, 136, 137; Christian example of,

288

198; clergy self-­care and, 270, 272, 273; conceptualized self vs., 75–­76; as conscious awareness, 74; exercise for experiencing, 273; explanation of, 74–­75; faith-­based counseling and, 212–­213; Islamic teachings on, 145–­ 146; practice of, 77–­82 self-­as-­process, 75, 144 self-­awareness, 83, 180, 223 self-­blame, 103 self-­care of clergy, 198–­201, 264–­276; acceptance and, 266–­267, 268–­269; ACT hexaflex and, 266–­276; committed action and, 273–­276; contemporary need for, 264; defusion and, 270–­271; present-­moment awareness and, 266–­267, 269–­270; psychological flexibility and, 265–­266; retreat and Sabbath for, 275–­276; self-­as-­context and, 270, 272, 273; values and, 273–­276 self-­concepts, 75–­76 self-­condemnation, 103 self-­exploration, 222–­223 selfing function, 135 self-­knowledge, 68 selflessness, 275 “Servant Song, The” (Gillard), 241 shame: psychopathology and, 33–­34; theological view of, 34–­35, 36, 39 Shay, Johnathan, 257 shiva ceremony, 154 simple action, 29 single-­minded obedience, 30, 35, 37, 39 Smith, Clinton J., 203 social support systems, 55, 178 socialization process, 75 spirit, derivation of word, 42 Spirit and Trauma: A Theology of Remaining (Rambo), 22 spiritual self-­care. See self-­care of clergy

Index

spiritual struggle, 229–­232; case example of, 231–­232; explanation of, 229–­230 spirituality. See religion/spirituality Spirituality in Clinical Practice journal, 12 status viatore, 249–­250 Stern, Chaim, 150 stress: clergy burnout and, 199–­200, 264; major sources of clergy, 272 suffering. See human suffering Sufi tradition, 145 suicidality, 178 Sullivan, Winnifred Fallers, 225 support systems, 55, 178 symbolic relating, 45

T

taiki-­seppo, 132 Tales of the Hasidim (Buber), 275 Tan, Siang-­Yang, xii tawba, 144–­145 telos, religious, 209, 216 teshuvah, 159–­160 theodicy, 186–­187 Theory of Mind skills, 52 therapeutic relationship: genuineness in, 227–­229; human suffering explored in, 54; peer-­to-­peer stance in, 189 “third wave” therapies, 12–­13, 43 thoughts: Christian view on, 170; control problem with, 94–­95; definition/ description of, 93; defusing from, 100–­102, 271; fusion with, 26, 48, 98; irrational, 13–­14; Islamic teachings on, 143–­144 tikkun olam, 156–­158 Tippett, Krista, 157 tombstone/eulogy exercise, 121 transcendence, 53, 180, 212 transdiagnostic therapy, 189 trees of life and knowledge, 31–­32 Twelve Links of Dependent Origination, 134–­135

two banners exercise, 92–­93 two-­sided coin metaphor, 32, 34

U

ultimate truth, 133 Ungar, Michal, 254

V

valued living: importance of, 15–­16; theological view of, 25, 29–­31, 35; therapeutic process of, 187, 194 values: ACT identification of, 27, 49, 50, 112, 155–­156; Buddhist tradition and, 137; Christian examples of, 167, 170–­171; clergy self-­care and, 273–­276; committed action related to, 112–­114, 122–­124; destinations vs. directions and, 116–­119; emotions contrasted with, 123; faith-­based counseling and, 213–­214, 216; goals distinguished from, 117; Islamic teachings on, 142, 146–­147; Jewish teachings on, 156–­158; meaning and purpose related to, 232–­233; protection vs. pain and, 119–­121; religious and spiritual, 111–­112, 113, 114–­121, 198, 214; religiously unaffiliated people and, 179; resiliency related to, 254–­255, 256; rules vs., 114–­116, 171 verbal dominance, 96–­98; breaking the spell of, 98; defusing from, 97, 98, 100–­102, 107; external vs. internal, 97–­98; perspective taking and, 97, 98, 101 verbal knowledge, 45 verbatim, 222, 237–­242; case example of, 237–­239; pastoral analysis of, 241–­242; psychological reflection on, 240–­241; theological reflection on, 239–­240 virtues, 254–­255

289

ACT for Clergy and Pastoral Counselors

W

Walser, Robyn D., xvii, 41, 62, 63, 173 waswasa, 143 Web-­based pastoral care, 178–­179 well-­being and mindfulness, 68 wheel of life, 134, 135 When Helping You Is Hurting Me (Berry), 270 “Who am I?” practice, 273 willingness: acceptance and, 65, 89, 90; banners exercise on, 92–­93; Buddhist faculty of, 136; metaphor for exploring, 91; personal values and, 92; problem of control and, 95; reconciliation and, 105–­106; two kinds of, 90–­93, 105–­ 106; wanting related to, 91–­92

290

Wilson, Kelly, 253 wisdom, 88–­89 workability, 103, 189 World Happiness Report, 23 worship leadership, 196–­198 wounded healer, 189–­190 Wounded Healer (Nouwen), 189

Y

Yavuz, K. Fatih, 139 Yom Kippur (Day of Atonement), 159–­160

Z

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