Non-linearity of treatment

Flexible dance through the Hexaflex process

Unlike other manualized protocols that require following a rigid order (Session 1: Psychoeducation, Session 2: Relaxation, etc.), ACT functions as a nonlinear model.

The six Hexaflex processes (Acceptance, Defusion, Present, Self Context, Values, Action) are all interconnected, and the system can be entered through any of them.

The therapist should be like a jazz musician, able to improvise and move from one note to another as the situation requires in real time.For example, a therapist may have planned to work "Values" into a session.

However, the client arrives in a state of acute panic because he has had an argument. At that point, insisting on talking about values would be useless and disconnected.

The therapist must pivot flexibly toward "Contact with the Present Moment" and "Acceptance" to anchor the client.

Minutes later, if the client starts saying "I'm a mess, I always mess everything up", the therapist fluidly moves into "Defusion" and "Self as Context".

There is no preset correct order; the correct order is dictated by the barriers the client presents here and now.

This flexibility requires the therapist to know the model well so as not to get lost, allowing him or her to dance with the client's resistance rather than trying to force it into a rigid schema.

The danger of premature outcome assessment

Because ACT works by undermining the client's habitual control strategies (creative hopelessness), it is not uncommon in the early stages of treatment for the client to feel confused or even experience a temporary increase in discomfort.

By removing the crutches of avoidance (such as stopping drinking to calm down or stopping avoidance of social situations), the underlying emotional pain surfaces more strongly before the new acceptance skills have taken hold.

For this reason, it is critical to avoid premature assessment of outcomes based on symptom reduction.

If we judge therapy in session 3 based on "do you feel happier?", the answer might be "no, I feel more anxious because I am now facing things I avoided before".

The therapist must psychoeducate the client about this learning curve: just as cleaning a deep wound hurts more before it begins to heal, or as tidying a closet involves taking everything out and creating more chaos temporarily, acceptance therapy often involves "feeling more" in order to "live better."

Eva