Working with ‘common’ mental health disorders

Ahead of our intermediary workshop ACT for anxiety and depression with Russ Harris, we are looking at these so called ‘common disorders’. We might call them our bread and butter, as therapists. Whether we label them diagnostically or view them as symptoms of anxiety or low mood, we frequently engage with individuals facing these issues. Indeed, lifetime prevalence rates for depression are estimated at 17%, with 3.8% of UK adults reporting depression in 2020 according to the office of national statistics (ONS). Globally, estimates suggest 8.4% of adults in the US reported at least one major depressive episode over the preceding year (National Institute of Mental Health). Comorbidity of these has been estimated as high as 50% (National Institute of Health). In therapy, therefore, we must be equipped to work with both, regardless of the referral/primary concerns.

Common practitioner problems

Despite these areas encompassing huge amounts of our clinical work, clinicians often report ongoing difficulties, particularly with entrenched clients. Here are some of the common difficulties we typically see in supervision, and experience ourselves:

• Not setting up session goals effectively – e.g. emotional rather than behavioural goals (“I want to feel better”, rather than “I want to be a better parent”)
• Finding their sessions are not experiential enough, i.e. talking about ACT, instead of doing it
• Inconsistencies in the process, e.g. slipping into cognitive challenging
• Trying to ‘fix’ the client
• Focusing on listening instead of doing and avoiding the tricky uncomfortable experiential/process work
• Trying to convince/persuade/debate with the client
• Excessive focus on one process and neglecting the others, for example, focusing on committed action (behavioural activation) but neglecting values driven behaviours and breezing over cognitive defusion.
• Lack of understanding of the theoretical underpinnings – functional contextualism and behaviour analysis

How do we approach these ‘common’ experiences in therapy?

Although these experiences maybe common is it important to acknowledge that they do present on the range of issues and therapy that can make them very difficult to work with having said that there are few central points are worth to consider that apply across the most people presenting with either anxiety or depression.

One key point in to working with anxiety and depression is starting with normalisation. Given the above statistics, we can see how common this is at a clinical level, even more so when we break down the common experiences of anxiety and depression that many of us will experience at one time or another in our lives.

When we consider the overlapping aspect of both conditions, withdrawal is central. From an anxiety perspective, this can be more focussed on avoidance of the anxiety provoking situation, high threat arousal and a fear – relief cycle from avoidance. From a depression perspective, we might see avoidance due to feelings of hopelessness, lack of energy or loss of interest, amongst a plethora of other reasons.

These two areas are merely touching the surface of the work involved with these conditions, but we can already see the utility of an ACT approach. Normalisation is a part of acceptance and addressing withdrawal shows the power of the behavioural approach. This, alongside the rest of the key processes in ACT, can help to shape and effective intervention for these clients. For example, when we consider the utility of accepting that anxious thoughts, or self-critical thoughts show up, we can then work towards using defusion to step back or distance from these thoughts. Getting clients moving (committed action) in line with their values, even to a small degree, helps build the buy in. Using that committed action to shape hierarchies in an ACT consistent manner (i.e. stepping away from distraction methods and leaning into the hierarchy), further enhances the therapeutic effectiveness. Finally, self-as-concept and present moment focus can help to ground our clients and step away from their conceptualised selves connecting with the past and the future predictions.

So, practically, what do we do?

1. Gain a solid grasp of the fundamental theoretical principles, including an understanding of RFT. For more insights on RFT, check out our upcoming workshops.
2. Implement experiential sessions to practice what we advocate during therapy.
3. Embrace challenging aspects without hesitation. Establishing a strong therapeutic relationship lays the groundwork for essential work.
4. Remember, your role is not to ‘fix’. Shift focus from convincing or debating to fostering understanding and laying the groundwork for clients to initiate changes.