Acceptance and Commitment Therapy (ACT) 101

Margaret: [00:00:00] I think actually taking the cliche into yourself and applying it to your life and seeing like the truth, the truth, maybe behind the cliche is, is harder, or at least it takes more time, right? 

Preston: Yeah. Or like when that prophecy in Kung fu Panda said that Tai Long would escape prison. You remember that 

Margaret: patient?

Hello guys, and welcome to episode 40 of How to Be Patient. Preston, how does it feel to be 40 episodes old? 

Preston: Hey, thanks for having me. You know, um, when I first went through this middle podcast crisis, I was thinking about a lot of things. Do I buy a new microphone like I did last month till I get a new car?

Or, or maybe we could just talk about what Margaret wants to talk about. You know, it's about time we heard a woman's voice on this podcast, you know, what they 

Margaret: say about microphones 

Preston: to give them to men. Yeah. I mean, I mean it's, it's, it's a, it's a dangerous occupation these days to podcasting. Be a man with the podcast.

Yeah. 

Margaret: But yeah, it is. I [00:01:00] mean, listeners, we are, uh, filming this on Friday, September 19th. Um, we, there's so many jokes we could make that we won't make. Yeah. So if President Trump is listening to our podcast, 

Preston: we think that Brendan Carr is an upstanding individual and he would never censor anyone 

Margaret: and they love free speech.

Um, today's episode is about acceptance and commitment therapy, and it is the other main type of therapy that I do. It is one that we've gotten questions on the therapy episodes and also in our question box that people would like to know more about different therapy types. And so what better way to spend a Friday night Preston than learning about the theory of a therapy?

Preston: I'm ready to commit. 

Margaret: I'm ready to both accept you and commit. Um, but first, for our icebreaker today. We, I sent Preston a quiz that, it's not a quiz, it's [00:02:00] like a, you pick quiz one you care about more, uh, on values or it's like the values assessment. And I had to do this, actually, the background story is I had to do this in college for this theology class.

I took, and let's just say that this test was interesting to compare to like my friends and my like boyfriend at the time because like, I feel like my friends who I'm still friends with, we had the exact same values and other people, and I did not. And, and it was interesting to be like, wait, this is what you value.

And like, I don't, that was 50 on my values list, uh, to which Preston texted me and said, I don't wanna share. 

Preston: Yeah, I came around, I'm gonna share them Now 

Margaret: you're like, I had to lie a little bit. Like, oh, 

Preston: I'm feeling a little vulnerable here. 

Margaret: So the reason we're starting with the values assessment, part of this is, I, Preston does not know this, I'm going to ask each of us to bring a small, not that personal problem into how we talk about ACT today.

And so the first part of it is values. And these values might not [00:03:00] apply to the problems we bring up, but, um, so the, the assessment goes through and gives you your top five or you can pay more to learn more about where the other ones fall. But I didn't, I neither to Preston. So in ACT we use our values to kind of align our action despite the internal emotional states.

And so Preston, what were your values? 

Preston: Okay, so first I wanted to say a little bit about this quiz situation. So it wasn't like, uh, here are all these values and why don't you rack 'em and stack 'em. It would like always compare two. So I, I felt like it was Tinder, but for like virtues. So it was like, swipe left or swipe right on, like accountability or pleasure or enthusiasm or, um, discipline.

And like some of them, it, it was like the same or mm-hmm. That's how I felt it. I was like, yeah, okay. How do I compare, like obedience and, or, sorry, discipline and accountability. Like they are, those are so intertwined. So I had trouble swiping on these, but this is, this was the product of all of them no 

Margaret: matches.

Preston: My, my top five. Yeah. This is, this is who [00:04:00] I matched with and we're going out later this week. 

Margaret: Um, Hey Jason, can we get, can we get a sound effect after his each rally? 

Preston: You know, I was looking at one of, will you do it 

Margaret: Family Feud style, where you start with number five and go up to one? 

Preston: As long as it's not copyright.

Because we, we'll be like, Jason, can you play the Titanic music? And Jason's like, we cannot afford that license. 

Margaret: He's like, do, do, do. It's not, 

Preston: it's not happening guys. I'm sorry. Which, which is why I'm learning the harmonica. You know, you, you, that's why you gotta make, Hey, so my top five or I've never 

Margaret: heard someone under 65 say the phrase make, Hey, okay.

Preston: Health, 

Margaret: health is my number one, is number five. 

Preston: Mm-hmm. So wellbeing, fitness, not being sick is what? That's very fair. Sums medicine. Well, yeah, life aligned. So it, I was always comparing health with other like virtues, like pleasure, but I was like, I feel like I can't have as much pleasure if I don't have health.

Like I saw health as like a [00:05:00] means to achieve all these other, um, different values. Wealth was my next one for actually a similar reason. So like I, a lot of the things that I want to do or that I wanted to experience that were also on the values list, you like needed wealth to achieve those things. I think I like recoiled a little bit because it, you know, it's had material goods, luxury lifestyle, things that I think I, I bristle when I, I think about being associated with them because it makes me seem superficial and materialistic.

But at the end of the day, I understand that wealth is, money is power and it's power to do the things that we want to do. So that's, that's how I rationalized it at least. Yeah. Okay. The next one was accountability. I hear a lot about being responsible and dependable and. Actually, I don't like that word.

So just being in the military, accountability gets thrown around so much like mm-hmm. They call it accountability formation when you have to like show up and like do like a headcount and they take [00:06:00] roll call and everything. So. So I actually have a pretty negative association every time I saw it, but I was trying to say like, okay, how does this value actually like relate to my life, you know?

Mm-hmm. And the results kind of speak for themselves. Like I do a lot of very disciplined things and I'm constantly need to be responsible and dependable in my job and my families for my pets, for my plants, like podcast, the things that are value important to me in my life. This is like a central piece of that, despite how much I like hate the word.

And then I think that makes 

Margaret: sense though, that it also bothers you in your like military context, but also your life is filled with things about being accountable. So I feel like there's also maybe. It's a good value for you and also maybe a value that can kind of overtake all the other values sometimes.

Preston: Mm-hmm. Yeah. So sometimes that feels like all my life is just accountability, honestly. Mm-hmm. Like you could, you could, uh, go to the moon and back just doing online trainings to say, up to date with [00:07:00] your various EHRs and, and, uh, that's true military taskers and all that's under the umbrella of accountability.

Okay. Uh, then challenge, that one was actually pretty easy for me. Um, I think I, I both liked identifying with it and, and felt that it was, um, stood its own against some of the other values. So like challenge versus pleasure. I'm like, I've always chosen challenge throughout my life and like, I don't think there's ever been a time where I picked like the pleasurable easy way over, like the challenging way.

It's just so, and I did find it like ironic or strange because I do find pleasure in challenge. Mm-hmm. So then it also made it hard to differentiate them. Then finally, uh, excitement. 

Margaret: Excitement is number one, which is interesting. Related to So pleasure didn't make it on there? 

Preston: No, it didn't. I guess not. I was thinking it would 'cause I, I remember I swiped, swiped right on pleasure several times.

Margaret: Mm-hmm. 

Preston: But just not enough I guess. So sum it up. I had make it into [00:08:00] your life, health, wealth, accountability, challenge and excitement. Those are mine. 

Margaret: And how did you feel when you got all five of them? Like, does it feel accurate to you? 

Preston: I think it does. Um, when I was, when I knew that wealth was winning for a while, was when I texted you like, Hey, I don't want to share this.

I don't wanna do this. I'm like, I don't want people to think I'm a materialistic. Like there's no way. But then like when I, when it, when it was all in context, you know, like health, wealth, accountability challenge, excitement. I was like, I feel like that's, that's well-rounded. Um, 

Margaret: yeah. You 

Preston: know? 

Margaret: Yeah. Life, 

Preston: liberty and the pursuit of property.

That's really property. What my values are. That old John Locke.

Margaret: Okay. Um, I was, after I did it, I was like, Preston's gonna, Preston's gonna be like a fucking course. These are your answers on here. Um, you's just like, 

Preston: it's bad is one virtue Art is another virtue. Every day is the other Virtue Daily. I'm like, how are you even [00:09:00] getting these? Like they were the 

Margaret: test. I dunno, it just, it just told me my number five was actually pleasure.

So mine did make it on there because I'm not trying to suffer all of my life. I feel like, I feel like if you had asked me this though, like when I did it five years ago, that was not number five. Or like when I did in college. Mm-hmm. I guess a decade ago that was not number five. That would've been like what it would've been like.

Responsibility would've been five. Um, number four is wisdom. I feel like wisdom and curiosity were kind of battling it out on mine. And Wisdom One, because I like integration of systems and like. Theology and poetry with like medicine and science. And I feel like that's kind of wisdom to me. Um, and then three was creativity, which goes with the bad art every day.

Mm-hmm. Of course. And the podcast. Yeah. These, these are all so 

Preston: predictable. Tone. What is not, not that you're No. In like a good way. Okay. Not, and not that like makes you mundane, that you're a predictable person, but like it's, these are all ego [00:10:00] syntonic. 

Margaret: That's true. Um, my number two is trust. I feel like, I think I've said this in the podcast before, like in friendship and dating and even my family, like, I feel like I am, the negative part of this is probably I'm someone that holds a grudge, but like if I'm like with someone until the day we die, like I've been a bridesmaid like so many times.

Mm-hmm. And I feel like I. The shadow side of this is I can't really see negative about people until it's too late. And so many things have built up that I'm like, oopsies. Haha. Was it 

Preston: loyalty? One of them? 

Margaret: Yeah. 

Preston: So trust made it for loyalty, but for some reason the word 

Margaret: trust resonated with me more because I feel like loyalty can be like loyalty despite like, like nonsensical loyalty, whereas trust mm-hmm To me is like I will turn it off eventually.

Preston: Loyalty can be blind. Obedience. 

Margaret: Yeah. 

Preston: And loyalty can be an influenced by [00:11:00] trust, but not always. 

Margaret: I think also these filling these out that some of it is, there are values and they're aspirational. So I think I also try to be more trusting despite my sometimes cynical underside. Mm-hmm. I see. My last one was love.

Sorry. I dunno what? Oh, it's 

Preston: so beautiful. 

Margaret: Well, like, I dunno, like I, and I feel like that. Mm-hmm. I feel like I love a lot of. People and things and places and memories. Mm-hmm. And so I, it is, I don't know. 

Preston: And love, love is pleasure. So, so pleasure, wisdom, creativity, trust and love. Those are your 

Margaret: five. Mm-hmm.

No responsibility in sight. 

Preston: Yeah. Not, not a single no challenge overlap between us. It's interesting. 

Margaret: Mm-hmm. 

Preston: And yet we're fo we're both look at us both here on a podcast 

Margaret: and here we go. Well, when you asked me this, you did say, we'll be good, like opposites of each 

Preston: other. So Yes. This, this was intentional chat.

It was, so if, [00:12:00] if you are listening this morning and you're, you're kind of curious about your own personal values. The website we used was personal, VALU es. So if you just type that into your, um, search bar, it should bring you to the same values assessment we took. And you can take the free thing and find out your top five.

Margaret: So we are going to take. A very quick break and when we get back we're gonna talk about why we talked about values, because values are kind of one of the core principles within acceptance and commitment therapy, which from here on out I will be referring to as act, which is how people in the field say it.

It is not a CT, um, which I did call it a CT for the first six months of my training. Okay. Act and we'll be back.

Okay. So Preston? Yes. What do you know about act? 

Preston: I know that acceptance and commitment therapy is, it's on the branch of like cognitive behavioral therapies and it's kind of like, all I've really heard [00:13:00] about it is that it's a way to kind of change CBT and apply it to people that can't necessarily alter their situation.

So a lot of CBT. Her cognitive behavioral therapy is acknowledging that you have some of these like maladaptive thought patterns and then kind of untwisting them, but also changing the way you behave. That puts you into those maladaptive thought patterns. But sometimes you can't change your environment at all.

Um, like one example could be like, my mom, um, she's in a wheelchair, so if a lot of her cognitive distortions come from her, like inability to do things because she's paralyzed well, doesn't help to say like, have you tried not being paralyzed? What have you really 

Margaret: thought about it? 

Preston: Yeah. Like, oh man, the CBT zone is not, well talk 

Margaret: like I, I'm is a lot 

Preston: more thorough than that.

But there a lot of it, the conversation shifts to, okay, how do we accept the primary stressor that is [00:14:00] unchangeable, but still find ways to function, live our life the way we want to. That's all I like. So I know like philosophically like kind of what it accomplishes. I know nothing else about it or like how, how you operated it, it, how, feel, 

Margaret: how, what, why, who, when, 

Preston: what parts exactly where.

Margaret: Yeah. So, okay. So my background with ACT is, so I've been training in IT for two years and how to supervisor at my residency and did half day of ACT clinic for the last two years. So had like two or three ACT patients once weekly. Um, so ACT is, you were right on this, that it is sort of a branch of CBT.

It's technically third wave like behavior therapy first and like is a descendant of Skinner, but is also developed from the fact that CBT in the like seventies, eighties, nineties was the thing that was being the most researched post DSM three in terms of how we think about. Categorizing mental illness and then [00:15:00] trying to develop therapies and medications.

But for this episode, therapies that can systematically address it and be studied via like randomized control trials and CBT was the best one at being able to manualize itself. Psychoanalysis, though I love her, was, did not do as well with that. And also a little bit, didn't believe in it for a while, like how do you measure what we do, which kind of valid.

But, um, one of the problems, as you were saying though, with CBT or at least CBT when it was practiced seventies, eighties, nineties, was this kind of focus in the model of cognitions or thoughts, behaviors, and then emotions, right? That is the CBT triangle, but kind of confronting thoughts, doing thought logs where you kind of.

Argue against yourself and use the Socratic method to kind of pull up the thought and see if it's really true or see if it's a logical fallacy or you know, all, any number of things that you're overvaluing it or catastrophizing it. [00:16:00] And act somewhat puts that cognition's part out of the way in terms of what we're actually doing in sessions.

And like you said, it is very helpful for cases where you can't reappraise the kind of painful stimuli, um, or you can't make the pain go away. Or maybe you've tried. Often people will try the kind of CBT way of things and they're still left with either overwhelming pain and chronic pain disorders, overwhelming anxiety or rumination and OCD, things like that.

And so, act as it is now tends to not focus on finding out or duking it out with the truthfulness of your thoughts. 

Preston: And a lot of them are like, already true, and there's no point in debating that. Yeah. 

Margaret: The other part of this, so I'm gonna tell you a little bit about the kind of like theory and philosophy behind act.

So the philosophy behind it is, you know, a quote unquote pragmatic philosophy, um, which is [00:17:00] functional contextualism, which is basically just like not, there's not just like one stimuli and then one response. There's everything that goes into a single person's emotional state and behaviors is very dependent on when, why, who, what, all of these things that happened and shape it.

Preston: Functional, functional, contextualism functionalism. So in the context of my life, or given everything that's in my circumstances, how do I function? 

Margaret: Yeah. And I think also like. With that, from that philosophy comes the idea, and this is true for other behavioral therapies as well, that it's not so much trying to figure out like what is the core truth or the real story underneath this.

Mm-hmm. It is, is this working for you? Mm-hmm. Which you can see how that ties very directly to this idea of not spending as much time trying to restructure thoughts or reframe. Mm-hmm. It's more kind of like the thoughts don't actually [00:18:00] decide what reality is in a way that matters pragmatically for your, uh, kind of behaviors.

Preston: Yeah. So CBT is more of the who, why, and this is more of the what, how 

Margaret: a little bit. Yeah. I mean, and they do, they do overlap, right? Mm-hmm. And there are some branches of CBT that have kind of worded things similarly. There's a paper I'll cite in the show notes that talk that Steven Hayes wrote that talks kind of about what act is and where it can overlap.

Um. Actually that's Steven Hayes didn't write it. It's a different, it's an article in a book that's called The Encyclopedia of CBT and there's a chapter on act that compares them. But yeah, basically that is the first part of it. And then the theory within it is something that we're not gonna go into.

'cause we could probably spend a whole episode on this. And I don't think people want that. And I don't think that I could spend a whole episode accurately describing the theory. But it is relational frame theory. And basically this is the idea that [00:19:00] language in enact the idea applying this is kind of language is part of how we shape and relate to stimuli.

So it's not just, you know, if we go all the way back, it's not just like for humans, it isn't as simple as like bell means food. So you start salivating when you hear bell. Mm-hmm. It's like our thoughts and understanding of a narrative also are part of how we understand. So that's relationship 

Preston: frame theory.

Relational frame theory. Okay. So how, how I frame my relationship with my objects and experiences. 

Margaret: Or, or that the framing matters and impacts how you are feeling, behaving, suffering, or having mental illness. 

Preston: As in like, if I anticipate that it's gonna be painful, it's gonna be more painful, versus if I anticipate that, that it's serving some other thing.

Margaret: I think it, yes, in, in that, anticipating is like something your mind is creating. It's not, it's that like our thoughts and words and internal feelings and imaginings [00:20:00] impact the way that we respond to the stimuli. It's not just things outside of us. 

Preston: Yeah. I'm, I'm picturing like, hot wax being an example of that boring, like, 

Margaret: I feel like why, 

Preston: like if I pick up a candle, I'm like tilting it or something.

As I'm walking with this hot wax drips on my hand, I'll be like, ow. Like, I'll be surprised I'll be hurt. I'm not expecting any of it, but like, I don't know, maybe, maybe you got some hot wax dripped on your back in like A-B-D-S-M scenario. You're like, what? This doesn't hurt as bad as I thought. May, maybe it actually would give you pleasure, and that's, that's one of your core values.

Margaret: Can you not be a freak for one episode? Can you not sexualize something for one episode? 

Preston: Well, it makes it stick. Like I, I always had to use like those, like sexual acronyms in med school to, to memorize things. So I'm like, okay, relation, relational frame theory. I'm just going straight to hot wax now. The narrative we have around candles.

Margaret: So, but I just wanna say it's different than like the [00:21:00] ccbt necessarily reframe. Mm-hmm. And like, this theory is mainly just that like, there is a relationship between our thinking and putting words and language to something and how we actually experience it. Yeah. So before you go back, agree that makes sense into your, your cave of candle wax and stuff 

Preston: recedes into the dark.

Margaret: Um, one of the ways they say it in this chapter from CBT is that act as an intervention approach designed to bring language to heal as in to a heel like a dog, not heal as in to heal and make better so that it can become a tool to be used when it is useful rather than an unseen process that consumes the humans that host it.

Preston: Mm, that makes sense. 

Margaret: Which will make more sense as we talk about some of the processes, I think. 

Preston: Mm-hmm. 

Margaret: Um, one of the other ways they said in this book chapter was that act cares more about context over content compared to regular CBT. So again, less about like moving the, the kind of details and syntax and words in sentences around more [00:22:00] about like, well, what are you doing when you leave therapy?

Like, it's great if we like rearrange these thoughts and make you think better, but does it actually make your life better? Mm-hmm. Um, okay. Does all of that make sense? There's one other thing I guess with this I wanna say, which is that Steven Hayes, who is like credited as the main creator of content creator, you know, scientist and creator of, uh, act.

Preston: I mean, it is, if, if you think about it, it is content. 

Margaret: It is content. Just that it's PubMed as your platform even. 

Preston: It's like, yeah, I post a lot on PubMed. 

Margaret: Yeah. I'm a PubMed influencer. Not, not a big deal. I just wanna say the other thing is that for the last, uh, like seven, eight years, he has been moving more towards this idea of process based therapy.

So he still is very ProAct, but it has made him want to, now he's proactive. No. So process based therapy. I know you said 

Preston: he was like, ProAct. I was making a pun. 

Margaret: That one didn't, didn't hit [00:23:00] quite the same. Okay, 

Preston: gotcha. Just just forget I said anything. I'm gonna Jason cut 

Margaret: that out. Um, he won't now. 'cause I said that, um.

Process-based therapy is more of this idea of taking a step back and actually asking like, what are the factors in different therapies that are therapeutic? Like what is actually impacting people so that we don't keep ending up with more of this alphabet soup of different therapies, but can say, are there consistent things and good psychodynamic therapy and good DBT and good act and dah, dah, dah, dah, dah.

Mm-hmm. And if you're a real nerd about this, you can also hear there's a panel that he and like Marsha Lenahan were on at one point, um, that he talks about, uh, that they were both like, yeah, I call it this in DBT and he calls it this an act. And maybe they call it this in CBT, but is this the same thing And we're just describing it differently.

So 

Preston: yeah, I can really feel the, the pragmatics coming through in, 

Margaret: in 

Preston: their kind of priority system. Like, how are we making anyone better? What are you doing after you leave? How do we use words to like improve your life? Like, let's not get caught in this [00:24:00] like tide pool of other kind of Bs. 'cause, 'cause the, it's basically saying you don't have the luxury.

To sit around and scratch your chin and think all day about where does this come from? You, you need to get better. 

Margaret: Yeah. Yeah. I think, um, okay, so that being said, let's talk a little bit about how act, so ACT is trans diagnostic. So it's meant to be used across different diagnoses and can be helpful for a lot of different diagnoses, whether it's an addiction or chronic pain, depression, anxiety, OCD, um, there have been eating disorders even.

Are there emerging studies there? And it's partially probably because in act they, the main goal they have is increasing psychological flexibility to be able to have a life and actions that make that life that are more in line with your values. 

Preston: And you have to start with your values. To make things more in line with that.

We 

Margaret: actually usually, well, we usually, yes. Yeah. In general, [00:25:00] that's the goal. Sorry. You are right. Um, my act supervisor just popped into my mind of being like, you don't actually do values until you're like a number of sessions in and you actually know the person because da, da, da. But yes. Yeah. Ideally that's the end goal.

Um, so how would you think about it, like when you have someone in your clinic, either for CBT or psychodynamic, you can do either for this exercise, what would you say is the hypothesis of a CBT therapist or a psychodynamic therapist when it comes to what the, the will fix AKA, what's broken? Like what are the problems that CBT is trying to fix?

Preston: Um, it's often trying to fix a self-concept. 

Margaret: Mm-hmm. 

Preston: Ultimately, like there's somewhere deep down, there's this maladaptive core belief, a label you've put on yourself like, I am unlovable, or I'm worthless. And. You try to disentangle that while also working to change how you react [00:26:00] to a lot of the kind of downstream effects of this self-concept you have.

Mm-hmm. So ultimately, like the whole therapy can kind of live and die in just talking about how you feel about yourself. 

Margaret: Mm-hmm. And I will say probably some of the CBT folks would, would raise a hand at that and say, we do exposures and we do behavioral things. But yeah, I think you're right that there is a pushing back and forth on this like conception of self and at the very least kind of fixed cognitions around how the world is and how that will impact you.

Um, yeah. 

Preston: And then, and then I think psychodynamic is, it's similar really in that regard. I think psychodynamic addresses, like how you became who you are. 

Margaret: Mm-hmm. 

Preston: Like almost like it's the story of how my five values came to be. 

Margaret: Mm-hmm. I think that's right. Yeah. And how you force those values onto mm-hmm.

Everything in the room now. 

Preston: Yeah, exactly. That's psychodynamic. 

Margaret: Um, [00:27:00] yes, we are oversimplifying to the stalwarts of the other camps who are listening to this podcast, but um, 

Preston: yeah, we're, we're trying guys. Okay. 

Margaret: Maybe you should have an act mindset and just accept that we're gonna be wrong. Yeah, exactly. 

Preston: We're, we're trying to pragmatic about this.

Say no, you want for the purpose, purpose of the podcast. We're gonna, we're 

Margaret: gonna be wrong. That's the podcast t-shirt. We're just, I'm just a baby except for I'm not, I'm now a toddler and you're a baby still training wise, but problems. Okay. So the problems in an act view is kind of threefold. So it's, we're wanting to increase psychological flexibility to be able to live more of a life that, based on your values, but, well, I'll say three things.

One is you can't be like the person that is coming for ACT therapy. We would hypothesize you can't be present to the here and now. Like you can't notice what's happening. Around you, in you, outside of you, in a way that you can like, select and direct your attention. Secondly, you are stuck, ruled by, or fused to a certain emotion, thoughts, or [00:28:00] sensation, whether that be infused to it as in ruminating, stuck on it, can't move beyond it or fused to it as you're so avoidant of that, that it becomes the main driver of your life by driving you away from anything mildly related to it.

And thirdly, you're not living, your actions are not matching your values. And what would be a meaningful life for you as you see it now? So those are the three problems. 

Preston: Hmm. So, so you can't be present. There's a dissonance between how you're living and how you want to live. And I'm kind of blanking on what the middle one was.

Margaret: Um, you are like fused or avoiding heavily a certain emotion thought, internal experience, or sensation. 

Preston: Okay. So. 

Margaret: Those are the kind of an overview of the problems and what we talk about in ACT is being process-based and that there are six core processes that we're working on on any given time. Mm-hmm. [00:29:00] Um, and before we talk about that, I am going to give us something to think about on the break and you two listeners and when we come back we're gonna talk about those processes and Preston and I will share a small, not that personal, not that vulnerable life problem, uh, that we each have and see if we can apply each concept to how we might help ourselves or a patient with it.

And you can think along with us. So we will be right back.

Welcome back guys. We are still talking about ACT and we are gonna talk about the six core processes that an ACT therapist will like teach to you and then. You'll come back to iteratively as you try to work on different aspects. So Preston and I have both thought about problems that we are actually experiencing in our lives that are small and not that vulnerable for us to talk about.

Um, my problem is that I feel like my, I never get to [00:30:00] bed on time and like, it's like I come home from work and I'm really tired and I like, just wanna like scroll and turn my brain off, and then I need to do my dishes and laundry and other stuff, and I just like don't, and then I like go to bed and everything's still kind of messy, but then I wake up the next day and it's like, things are messy and it pisses me off and I'm kind of tired, like, and I avoided going to bed on time too, whatever.

So that's, that's my problem that I would like to think about through the lens of these six processes of what I'm doing. Coming up against or avoiding Preston. 

Preston: Um, I would say my problem is my screen time. So I think, and I've made this like my New Year's resolution in the past where I want to be more present and not necessarily present for other people, but just experience the world around me in a way that feels active and lucid.

Because there were times where at the peak of me posting and [00:31:00] making a ton of content where I was like always refreshing and checking comments or making new content or editing where it would feel almost like I lived in my phone and I would check the real world, and I hated that. Mm-hmm. And now, even if it something isn't being witnessed by an audience, I still want to like, feel present in the room and be like, oh, I just did this 

Margaret: thing.

Mm-hmm. 

Preston: And so that's, that's been hard for me and I've been trying to like cut my screen time down, but I think it, you know, used to be around like six or seven hours a day. And I think that's worst was like eight or nine hours a day. And I was like, dang, I'm, I was like awake for 15 hours. 

Margaret: Mm-hmm. So 

Preston: like, most like majority of my time today was on my phone.

Ugh. Like I hated that. So I guess it's both like not failing to be present with my environment or being able to pay attention to things around me and also like incongruent with how I wanna live my life. 

Margaret: Mm-hmm. So, so with our values, you're already connecting them. Okay. So one of the things before we say any of the processes, I'll say that there is, [00:32:00] every modality of therapy has kind of an archetype or stereotype, I guess orientation of the type of therapist that does it.

And so like the classic one, right? Is an analyst, a classical analyst is very much a blank slate. Doesn't, isn't super responsive to the way and like, up to and including the way they set up the room, right? Like that is, there is a way an analyst. Interacts, there's a, like CBT, you people associate with having exposures for homework, having to do thought logs, having a kind of Socratic leaning, you know, with patients.

And for act. What you'll notice with people who do act and like this is encouraged within the method is that they tend to use a lot of metaphors. Um, there tend to be experiential exercises. So not just exposure, but like when talking about a concept, they'll often use metaphors. Or one of the common ones we'll do is [00:33:00] talking about diffusion from a thought.

And we'll, the exercise will be like, okay, I want you to hold your hand, let's say your hand. Or is your like thought that you're worrying about, like, put it here. What can you see? Put it out here. What can you see? Oh, you can still see most things, but your arm hurts. Like, what if you just rested your hand in your lap and it's like, it's still there.

You know, it's there but it's not taking over things. So that is both a metaphor and kind of a something that can help. Make, I think some of these concepts a little stick. Here's a live 

Preston: action metaphor. 

Margaret: Yeah, exactly. Um, so they tend to do that a lot. Uh, and then they tend to, and this is where I think there can be similarities with DBT or dialectical behavioral therapy, they talk about logical paradoxes.

So kind of two things being true, um, and things like as they are in the world, which is when we try to only feel happiness, we often feel less happiness. When we try to get rid of our anxiety, we paradoxically increase our anxiety, things like that. Um, and then lastly, they do values assessments and [00:34:00] they constantly are kind of bringing you back to that and asking how this applies in that pragmatic way.

Preston: Mm-hmm. Yeah. That, that's, that's so true that the pursuit of something often leads, uh, to like the loss of it. The detriment of it. Mm-hmm. People that people that hope to live with no regrets end up paralyzed, not making decisions, and are regretting more things. 

Margaret: Yeah. Yeah. I think there's a lot of examples like that, um, that we've all heard as cliches, but I think actually taking the cliche into yourself and applying it to your life and seeing like the true, the truth maybe behind the cliche is, is harder or at least it takes more time, right?

Preston: Yeah. Or like when that prophecy in Kung fu Panda said that Ty Long would escape prison. You remember that? That movie. So they sent, seen that movie. So they sent the duck to go tell them to, to double all the guards. I've seen that movie. What? That movie you haven't seen Cookie Panda movie. Oh my gosh. Seen that movie.

Well, anyways, the duck shows up and his feather spoilers falls down. [00:35:00] Yeah. Guys, if spoil goofy panda for you, if you think 

Margaret: kung fu panda. Yeah. 

Preston: So they were trying to make things more secure by tell having his duck go, you know, tell them to secure the palace. But then his feather slips out and it falls over by the prisoner and he uses that feather to pick the lock to his own handcuffs that escapes because of it.

Margaret: Oh, 

Preston: so actually Kung fu Panda is Act. Pill Act. 

Margaret: Act. 

Preston: Yeah. And they, they know about these logical paradoxes 

Margaret: honestly, though, act similar to DBT has some relationship with kind of like Zen Buddhism, things like that, like philosophy that is not very western. So there is something in a lot of martial arts that it feel like includes paradox of like gentleness is strength and I don't know anything about kung fu or kung fu panda.

So that's where I'll stop. But like that the use of the, in like strength for its own self is weakness and dah, dah, dah. 

Preston: All just things. Yeah. You have to, you have to eliminate [00:36:00] desire. No. To eliminate pain or pleasure. 

Margaret: Yeah. And, and I don't go that far as an act therapist, as you can see by my values list.

Well, so that's just, you're not 

Preston: the dragon warrior. 

Margaret: Okay. Well you're not anything. I'm not either. That's okay.

Um, okay. So with those things in mind, the first one that I often start with, with people is the idea of diffusion, which is process one, diffusion. We know what it means literally. It's also in technically called cognitive diffusion, but it's the idea of distancing yourself from kind of internal sensations, thoughts, things like that.

Mm-hmm. And so it's not the idea of like, let me distance myself and not feel sadness when I feel sad, or let me try to like push this away and pretend it's not there. And that's where we get into this metaphor of like, okay. How much does this get in your way? If you, [00:37:00] if this is the thought and it's right here.

Okay. A lot gets in your way. What if you like hold it all the way out here? Well, then my arm starts to hurt after two minutes, like so. Mm-hmm. It's not to obliterate it and try to never feel anxiety. It's also not to hyper fixate on it, but to hold it in this distance that is the idea of cognitive diffusion.

So having space from your automatic thoughts or feelings or prior kind of schema. 

Preston: Okay. I can do that. My, I'm staring on my phone right now. I'll just, I'm just gonna distance myself from that. I'm gonna put it over here. 

Margaret: So like, one thing I'll often ask people is kind of like when they bring something into there they wanna work on, so Preston, you wanna work on using your phone less.

Mm-hmm. What are the internal things that happen that make you, when you've tried in the past to use it less and it's not worked out as well? What are the kind of internal feelings, thoughts, stories, automatic things that come up that you feel like have gotten in your way or made you start 

Preston: using it 

Margaret: again?

Preston: [00:38:00] So, um, it's a couple. One will be like boredom. So boredom is exists in like my world. Like I don't let myself be bored. So I, I, I don't like the feeling of boredom, so I try to do something to eliminate boredom and very easy thing to do. Most mindless thing to do is to pull my phone out and check it. So that, so that's one.

Another one will be like seeking pleasure or seeking an emotion. Like, I know if I scroll for a little bit, like I'll feel, maybe I'll find something that makes me laugh or makes me think about something, or that I enjoy at least catches my attention. So there's somewhat of a reward path there. You, you're both like, you relieve the punishment of boredom, then you're rewarded by opening up your phone.

The other thing that's been tough for me actually is like. I can see those and I can say like, oh, that's not right. Like, like you should deal with the board of Preston. Like, I can recognize that, but then I have these fears like that I'm gonna get canceled or something. Like, I don't think [00:39:00] I'm doing anything to get canceled.

Clarify. 

Margaret: So you, well now and now you have me in your life and you texting. 

Preston: Yeah. But like I'll, I'll post a video, you know, and I'll gain some traction and I'm like, oh, that's nice. The video's going well and I, I've like woken up and had videos get like a million views overnight, which is mm-hmm exciting.

But it can also be scary 'cause you don't want like it to have gotten a million views because it's now on like the cover of like NBC and they're like, look at this terrible person who, who has this awful opinion and we should all shame him. You know? So I'm like, I'm like that could happen. So I feel like compelled to check because of that.

But then the problem is once I check and discover that I'm not canceled in 0.2 seconds, then now I'm in my phone. I'm sucked in doing other things. Yeah, 

Margaret: yeah. So there's the anxiety and uncertainty about something. Hasn't necessarily happened to you before, but that you have had, as we talked about on the podcast before, like consequences for different people, like in med school, not liking your videos.

Mm-hmm. So I also think it's informed by the past hi experience of having [00:40:00] had negative things happen if a video was seen widely or seen by someone who was like, cancel him. 

Preston: Yeah, exactly. Like a successful video is both like pride inducing and fear inducing. 

Margaret: Yeah. Yeah. Okay. And so diffusion from that or being able to take distance, let's say from, I think that last one is kind of the most potent.

I mean, I think the others are common, but you have insight into them. What diffusing, what would it look like when that thought comes up that you're like, I have to check this to make sure I'm not. Canceled. Even though I know if we were doing CBT, we might challenge it by being like, it's illogical. It's happened this time, and if it does happen, we're checking it all the time, blah.

Mm-hmm. That would be the ccbt approach act though. The wi thing, I, my patients are sick of me saying is we're gonna drop the rope. The rope being the tug of war with examining the thought and ruminating on it. And also would be like, not checking your phone. And so this is where there's also the [00:41:00] overlap with like exposure and response prevention, right?

Mm-hmm. Um, so it might be diffusing might be in that moment when the urge comes to notice that it's there to name it what it is, and then to give yourself something that is three to 10% more challenging than giving into it right away. 

Preston: Hmm. Well, I, I could acknowledge that I'm worried that my post is a little bit controversial.

That's why I want to check. But this is mostly like anxiety driven hypotheticals and I don't have evidence that it is doing poorly right now and poorly in the sense of like it's getting negative traction and I guess I could always check on my computer or my laptop instead. And those platforms are much less likely to kind of just like suck me in.

Margaret: Yeah. Thoughtlessly. I think that second part is kind of [00:42:00] diffusion in the internal before you do anything else though it's, it's not noticing like why it might be wrong as much as it is like noticing, and this is related. So the second part of the second process that is very related to diffusion is self is context.

So in this example, it's noticing that that thought is occurring and it's occurring along the backdrop or it's a leaf in the river of self that you are, which sounds very highfalutin, but is basically just. The orientation and act as a therapist and a patient is like recognizing that this does not necessarily, this is something that thoughts are something that happened in me and my brain is good at creating thoughts, but not necessarily like accurate thoughts.

And so I can ignore them. Mm-hmm. Or that's an option. I can step back and not say, this thought and emotion dyad I'm feeling is automatically correct in who I am and requires this behavior. Yeah. 

Preston: Not every thought. My brain [00:43:00] constructs is an exact reflection of me and my values. 

Margaret: Right. And the way we often will do this for the like metaphor experiential thing is like, have someone do this stroop, like word color test and be like, all right, tell me what, like, like we're gonna do this really fast.

Tell me like what each word says. And they'll say the color and accident. And they'll be like, okay. So your brain was like, is good at coming up with something. Mm-hmm. But not necessarily the something that is the correct or like intended task that you send to it. Mm-hmm. The other thing we can we'll do is like, hold it up like a piece of paper that's like red on the front and green on the back.

And then be like, so what color is this? And I'll be like, red. And then you flip it around, you're like, so you're wrong. Your brain doesn't know everything. Say you're wrong. Okay. You don't say it like that. If my ex supervisor ever hears this, that's not what I would say. 

Preston: Yeah, that reminds me of it is like that.

If you should include that Charlie Kirk video where he's like, he shows him the photo and he's like, so, you know, beyond a shadow doubt that this is a human. And he's like, yes. And he's like, [00:44:00] this is a dolphin fetus. 

Margaret: I've seen that. I have seen that. Um, so yeah, so that's one of the core things, and if we go up to that definition, but it's the idea that our brains are made to come up with solutions quickly and to survive.

And that that is great in a lot of ways, but not necessarily great in being like all of these are automatically correct. Which again is kind of a cliche, but to actually live as if your brain is kind of like. AI where it's like, this might be right and it could be a good start, but it may be hallucinating or just like confabulating things together.

Preston: Yeah. And your brain, your brain really does hallucinate. 

Margaret: It does. And so recognizing that, and then so the self context part of that, that is where we will do the meditation. That's like, no, put your thought on a leaf and let it go on the stream and sit by the stream and put your feet in the stream and watch the leaf float away and know the leaf will float back if you need it.

But it's a leaf and it's not you. And there's [00:45:00] many leaves in the stream right now. Mm-hmm. And you're laughing and you couldn't do mindfulness. And that's why I suggest that maybe you need it. 

Preston: Yeah. That's funny. No, I was actually thinking about how like all of your metaphors have to do with like summer camp, you're playing tug of war, you're going down to the stream, you're watching leaves.

And I was thinking like, how would I make these metaphors work for like a finance bro? That's true. So, so, so bro, like what's the return on investment for this thought that you have right now? What's run the numbers on 

Margaret: the earth Finance bros. Okay. Rights for finance. Bros been on the earth before. Famously, I advocate for rights for finance bros.

Uh, that brings us to present moment, which is mindfulness, basically, right? Mm-hmm. So the ability to direct your attention, which I think is related to yours, and I'm also focusing on your problems. Otherwise, the episode's gonna be super long, and I think mine has to do with my screen used to. So I'm just doubling down and making this for both of us.

It's two 

Preston: people. The same problem, really. Two 

Margaret: people, same problem, different values. Um, so present [00:46:00] moment is present moment awareness is all the many different ways. And we've done the mindfulness episode, so I will not belabor this right now, but that you can direct your attention to different stimuli other than just what your, your thought hallucinating machine is.

Helpfully or not helpfully coming up with. So the ability to notice that you are stuck in rumination around a topic, you always worry about the ability to notice that, oh, here's this sensation again of wanting to check my phone because I'm kind of unsettled by the idea that this, I don't have certainty around if a video isn't gonna get canceled.

Mm-hmm. That is in mind for, I think for my, like going to bed on time related to phone stuff. It's kind of like, well, I don't wanna go wash my dishes that are kind of gross. And I, my like, maybe I'll just find another good thing on the phone. And then the feeling of motivation will come. That's, that is my, like where I get stuck is like, I wait for the feeling to change.

Mm-hmm. But do nothing to change the feeling. And so the mindfulness is the ability to move the attention. [00:47:00] So there's one thing of noticing, but if we just had diffusion, it was like, okay, I know I'm not that thought, and then we didn't include anything else. Then you're kind of just like. Okay. Like, what am I then, 

Preston: if not my thoughts, what am I 

Margaret: And what I mean, this is like the abyss, that squidward zone, not one, the nothing abyss.

Um, and so the, the way that this pairs together is I'm noticing this anxiety. I checked this an hour ago, I don't need to check it again. That's not in line with how I wanna live my life and I'm okay with this level of risk I'm taking by posting a video. So can I move my attention 50% to the paint my numbers I'm trying to do instead?

Or 

Preston: yeah, 

Margaret: the cat sitting on my lap. 

Preston: So for finance president sitting up, be your risk tolerance, you know, we, we'll move, move to Preston 

Margaret: to a risk practice for finance host platform. 

Preston: Yeah. It's like my Preston's boutique therapy where I just only work with Goldman Sachs. Actually, I think those people [00:48:00] exist.

Margaret: They they do, they're like business coaches. I feel like they're like people who did train as therapists. They're like executive. Coaches. So we have diffusion and self context, which are related, and then we have the mm-hmm. Present moment awareness. And then the last one is where we get the name, which is acceptance.

And I prefer using the word willingness. Why are you squeezing your hand? Like 

Preston: I'm accepting, I'm, I'm hyper accepting. 

Margaret: You look constipated. You're like, I am working on a bowel movement. I'm bearing down right now I'm working on my pelvic floor. Yeah. 

Preston: I'm bearing down 

Margaret: on that. Accepting I have a pelvic floor.

That's where our, our listeners who've heard every episode so far. Uh, so acceptance. But I use, a lot of people now use the word willingness 'cause acceptance can have the connotation of like, just accept that the world is bad or just like, accept this injustice. And obviously that is kind of fucked up.

Preston: Yeah. I, I think acceptance, um, underscores or like implies a level of agreement. [00:49:00] 

Margaret: Yes. 

Preston: Whereas willingness, you can be willing to do something that you don't agree with. 

Margaret: Right? Like, I'm willing for you to weirdly talk about your hot wax addiction, but I don't 

Preston: agree. But you don't openly accept it. I 

Margaret: don't accept it.

And so, yes, exactly. Willingness is less. And I think 

Preston: if you, yeah, if you talk about acceptance, you can get that tug of war about whether or not it's fair. Yeah. And ultimately it doesn doesn't matter that it's not fair. It just matters what you're willing to do. 

Margaret: Mm-hmm. And I think willingness is also good because I often will say, you know, this is act, you know, the type of therapy we're doing, the A comes for acceptance.

But I like using the word willingness because acceptance does, like we're saying, mean all these 

Preston: things just doesn't sound as good. Willingness and commitment therapy. Ah. 

Margaret: And then say we will, like, the acceptance does not mean saying if someone's in a horrible relationship or in a job that is like they're [00:50:00] getting yelled at every day.

That is not what we are accepting When there's any chance we can change something. But the willingness part comes in to things like you mentioned, like being in a wheelchair or I think a lot about my patients with chronic pain or my patients who have eating disorders who are going through recovery and have a lot of like abdominal pain and recurrent negative thought like body thoughts and urges that those will get better over time, but they will not go away, at least in the foreseeable coming months.

Mm-hmm. And so there has to be a level of willingness or allowing is also another word I'll use so that we can apply our skills and make the best of what we kind of have right now. Mm-hmm. But I do think that this is one of them that I don't necessarily start with as much as you get your way there in the therapy.

It can be super invalidating if you kind of come at it early or you miss the validating and compassion and rapport building parts of the [00:51:00] therapy and know, like you need to be willing to 

Preston: Yeah. It's, it's almost like, who are you to tell me? 

Margaret: Yeah. 

Preston: That I need to be willing to do anything. That's actually probably, and this is true for a lot of different therapies, I think probably the biggest thing I've learned in now, I guess a year and a half of doing therapy is to not skip the validation and like supportive psychotherapy phase.

Like I'm, I'm truly understanding why it's like a tree that starts with supportive psychotherapy then moves into other things. Because I think before I usually I'm like, I'm like, cool, you got thoughts. Let's challenge 'em. You know, back and forth. 

Margaret: You do, you do love a challenge. 

Preston: And now I'm like, and excitement.

Yeah, exactly. I'm like, this is this be challenging and exciting and I'm holding you accountable. Like I'm just, I'm knocking off my list without yours. Wait, ready? What were the other ready to rock and roll? 

Margaret: What were the other two values? 

Preston: Oh, health and wells. 

Margaret: You're like, I'm, well, you're not getting paid very well.

Preston: Yeah. So now I'm like, oh, I first three sessions, like, just tell me about yourself. [00:52:00] You know, you're, you're afraid. Let's, let's get to know each other a little bit. First, 

Margaret: I'm afraid to tell you, you're not beating the man discovers empathy allegations. What? This one, 

Preston: dude, 

Margaret: you're not, you're, this is bad.

Imagine, 

Preston: imagine me saying this out loud in supervision, and every other co-resident in my supervision is a female. And they were just like, Hmm, okay.

Margaret: Well maybe you listen. I was like, guys, guys, you 

Preston: just, you don't jump in to the maladaptive core belief like 30 minutes in. You realizing that? And they're like, ye yes. Preston, are you 

Margaret: clocking this? Are you clocking? Did you guys know about this? You like, I just did some mushrooms last weekend and I thought.

I bet other people have feelings 

Preston: because you should validate someone before you, like try to tell 'em how to change their life. 

Margaret: Isn't that crazy? It's so crazy. You know, I even though you know better than them on how to run their life. 

Preston: Yeah. I, it's just so sarcastic. I, a supervisor tell me that all therapy is, is [00:53:00] convincing someone that what you think is wrong with them is wrong with them.

That's 

Margaret: like a very evil view of therapy. 

Preston: I know it's evil. 

Margaret: That's like not what I would describe therapy as. That's not, I mean, maybe it is, maybe that's the shadow I can't recognize. Um, but yeah. Okay. So the other two, um, so those four are thought of as like the mindfulness kind of diffusion whatever parts.

And then the other core part are value. So finding what is meaningful as well as assisting people with discernment that like there are many people who will, if you ask them off the cuff, like, what do you value? We'll say one thing, but it's really something that they sort of value or that they think they should value or they have the reaction like you did to taking the test as like, oh, I shouldn't value this one thing I put, so I'll put something else.

Yeah. So that is part of the values work is getting to know someone in this relationship and hearing some of their like history and stories Right. [00:54:00] And getting a little bit more existential by tapping into what is has depth for them. Um, especially 'cause a lot of people that you treat with ACT have anxiety or OCD, so they can have a lot of shame and kind of morality hangups around what they should value.

Mm-hmm. Yeah. I think a lot of 

Preston: people pre-filter what they say that they value. Yeah. Yeah. And I, I, I felt myself even doing that when I was taking the test. I was like, what do I want to value? And then I had to like really rewind and be like, okay, my actions and my decisions show what I value. So I, I tried to go off of, rather than what I thought about it with like, what does my life show that I do?

Margaret: Yeah. Yeah. Um, and it's interesting because I think part of me wishes I valued responsibility more. Like, I don't know, like I, I think it's interesting because I think mine is reflective of me, but it's, it's interesting the ones when you like look through it and you're like, I kind of wish I was someone who was super motivated by this, that, or [00:55:00] the third thing, you know?

Mm-hmm. 

Preston: Yeah. Like I'm kind of mad that I didn't have like creativity or wisdom on there. I was like, yeah, like I'm surprised I didn't value them higher, but I think I want to want to value them. Like I wanna do creative things, but then I end up just going on another run. 

Margaret: Well, you can see though how people like do something like the values thing and like people always say like, relationships are more, they're less about like direct compatibility in terms of like interests and like likes and dislikes and more about like priorities and values.

And you can see how. I feel like I knew someone who had to take this test before they, like when they were doing pre-K in the Catholic church marriage counseling before marriages, uh, called Pre-Cana and they had to do this and I think them and their partner had the like, exact same ones except for one.

And they were like, we're knocking it outta the park. We're, we're crushing it. They're like, it's gonna suck when it's like trash day though. 'cause neither of us. 

Preston: Yeah. The accountability one. Yeah. [00:56:00] 

Margaret: Um, the last one is committed action of these processes. So this is where all of your other skills, behavioral activation, um, other things can kind of be slotted into these processes from other therapies if it applies.

But committed action is helping people and patients like I, I find this is where like kind of acting together as two frontal lobes in the room to get creative and figure out how do we apply these values despite these kind of hangups and obstacles that you're getting stuck on. Mm-hmm. And also. Where is the rigidity and not being psychologically flexible, making you try to change us in such a like rapid way that you end up in this cycle of failure.

Preston: Interesting. It, it's, um, intriguing to me how the first, like majority of these steps are really like establishing a base of mindfulness and then it very quickly just goes into, okay, now, now what are your values and how do we commit to action? 

Margaret: Yeah. But they're not, [00:57:00] but, but it's, I guess it's not quick, like I'm giving you the processes, but act is not a linear therapy.

Mm-hmm. So like, you could see how you could spend a year just working on willingness and talking about like, all the stories that come up around why they shouldn't have to be mm-hmm. Be willing to accept this or why all the ways that like using their brain prior has protected them to like keep them safe.

And that willingness can't be true or. Trying to like let this thing be makes them feel like they're gonna have a panic attack. Mm-hmm. And then how do we work on diffusion there as well as like present moment awareness? So there's a lot of stories that come up in those first four and, and the values and committed action.

And I think one of the things that I really like in ACT is that from a structural standpoint, I think it kind of toes the line between psychodynamic or insight therapy and like CBT or DBT where there mm-hmm. Is [00:58:00] a process that you exist within. There is this container, but instead of being like, uh, like a, a running track that is a circle with like lines and this is where you must run.

It's like an, a field enclosed with a fence, but psychodynamic is just like entire world. And there there's 

Preston: daisies and there's a stream. Yeah. There's You run over to a wall section. Yeah. I'm 

Margaret: sorry, what is the finance version of 

Preston: this ACT Camp? Yeah, I like it. Act 

Margaret: camp. Yeah. I would. Like, uh, there's an, a place I worked at called the OCD Institute at McLean Hospital, and it is kind of like ACT camp like, like there's memes on the wall about like not falling for your compulsions.

And like all they do is like act exposure and response and like compassion based mindfulness. And it's just like we're doing this, we're doing a, like a ses, a group therapy where all of us imagine something we're the most afraid of. That's like the thing in Harry Potter when they like have to see a Bogart and it transforms and then they learn through the ridiculous spell.

It is like literally [00:59:00] like that. It was very effective. 

Preston: Yeah. I had a a, um, an attending one time who she would a apply some act type, um, I guess philosophies to her treatment of patients. She worked with the eating disorders and so Dang she would have us eat, um, a cockroach or not cockroach a grasshopper.

Like, you know how they, they like sell those at like some of the like international supermarkets Oh yeah. And stuff. Yeah, so, so the purpose of it was to like expose yourself to an unpleasant experience while having like mindfulness through it. Mm-hmm. The purpose that she did with us as trainees was to like, have empathy for patients who feel this way about eating almost every food.

Like our food. Yeah. Yeah. So like this, this might be a strawberry to your patients, but like to you it's like a grasshopper that that's repulsive to you. Yeah. 

Margaret: Oh, that's, I love that. 

Preston: Yeah. So I, I thought it was, it was a fun exercise. 

Margaret: This is also why I think one of the psychological components, and I don't just think this, there are papers on this like talking about it, but like [01:00:00] why exercise can be a really great thing for people and it's a skill that can lateralize not just in like having something new or community you belong to, but also inducing a manageable, unpleasant experience.

Preston: Mm-hmm. 

Margaret: And your knowledge, and people always talk about this, so exercise like for finance 

Preston: bros is called microdosing discomfort.

Margaret: You can check out Preston's Bright. Well, he can't have a private practice yet, but 

Preston: coming soon. 

Margaret: Coming soon to a, a zoom near you. Um, but yes teams, but yeah, our components is again, acceptance or willingness, diffusion self as context, present moment awareness, values making and meaning making and committed action.

Mm-hmm. So those are our components. And so let's come back to our problems because then I know we're, we're running to the end of the episode right now. Um, so we talked a little bit about diffusion and self context. What, [01:01:00] for me, I think willingness for, for me would sound like reminding myself or like having reminders and connecting frequently.

Just to remember that like I don't feel like getting up and starting to like do dishes and get ready for bed. I'd rather stay on my phone 'cause I like. Feels good to be distracted, 

Preston: to make a small, but being, being willing to do it tired, being willing to do it when you don't want to. 

Margaret: I think being willing for me to trust that if I, I have enough experience, knowing that if I just get up and tolerate it for the first five minutes, then I enjoy it and I'm glad to be up and moving around and feel much better, go to sleep better and wake up better.

And so the willingness to not to push again, I think I always arbitrarily use three to 10% hard because I think otherwise you keep avoiding if you're like, just push through it. So saying, all right, get up and clean for five [01:02:00] minutes and if it, you really hate it still at the end of the five minutes. I mean, this is why I have that like avoidance diary series on TikTok is like mm-hmm.

Just truly this idea in action over and over again. Um, but the willingness to trust that this current sensation. The willingness and then also the trust and self is context that this current sensation, even though it feels like I'm just gonna keep feeling like it and I wanna do this other thing, is actually going to change quite drastically in five minutes of doing the feared or like avoided action.

Preston: Yeah. And that's very true for running actually. 

Margaret: Mm-hmm. 

Preston: Um, it takes like six weeks of running continuously before like your first run doesn't suck. 

Margaret: I feel like the first mile always sucks. 

Preston: Yeah. And it can, like, you have to know that like, okay, this discomfort that I'm feeling for like the first eight minutes, nine minutes, 10, 11, 12, I don't know how fast you run a mile, but it's, well, 

Margaret: I'm chilling.

Yeah. It's not, but it's not gonna last forever. I'm yogging as me and my friend would say in med school, [01:03:00] we gonna, ya, and, 

Preston: and if you get through that first mile, you're like, oh, is this kind of nice, you 

Margaret: know. 

Preston: You, you, you start getting like good runs and you start to feel in shape and then, then you start to get positive like center for Marathon.

Marathon, yeah. Then you say, I must 

Margaret: do the, I must be responsible for this challenge. 

Preston: It's, it's a natural pipeline really. 

Margaret: So my commit, my values would be, I think for me as Preston, as you know, I started teaching 6:30 AM Pilates classes today. And I do it twice a week. And I enjoy it when I have slept well and wake up to an apartment where I've actually like made coffee the night before.

Mm-hmm. Stuff like that. Mm-hmm. And I would like to continue to enjoy that. And that's a value for me of showing up well and joined that part of my life as well as just exercising in general. So my committed action, I think, maybe not tonight 'cause it's already, what is it? What time is it? Seven 15. Well, I guess tonight it would be something, but more importantly like Sunday before I teach on Monday [01:04:00] morning would be.

Keeping in mind that five minute timer idea of when it hits seven o'clock, I'm not gonna feel like getting up from whatever I'm watching or, or leaving my friend or doing whatever. Mm-hmm. But trying to diffuse, notice my values, do the action, I said I would, and notice the self context and be like, I'll feel differently in five minutes and feel better overall for the next 24 hours.

Because what I think of it as act with this kind of thing is like, this is actually pleasure maxing for me and like this five minutes of like being distracted on my phone. 'cause the inertia is not better than the next 24 hours of me being pissed because I stayed up too late, made myself tired. Mm-hmm.

Everything's a mess and I'm like anxious and overwhelmed. 

Preston: Mm-hmm. Um, that's good. I like those. Those are good commitments and I think, I think you'll find a way to balance both pleasure and a clean apartment. [01:05:00] Um, thank you for belief me and my, my commitment action is, I think it's, it's probably actually gonna be to like, find more ways to distract myself.

I think I, I can be present and do things in my house without like forcing myself to be bored, but like, if I have that feeling of boredom, I'm gonna commit to finding a way to extinguish that boredom without checking my phone. So I'm bored, but let me go do my paint. I paint by numbers instead or something.

And then I think I can also commit to spending more time on the computer to like kind of check the status of my posts. Mm-hmm. And alm and namely, because I'm acknowledging that as like intentional time that I'm using for it. And it's not something that's secondhand capturing my attention. It's a place where I'm willing to spend my attention.

Yeah. So those are my two commitments. 

Margaret: And when the. The urge comes up to not wait till you can check your [01:06:00] computer. How might you use self as context or some of these ideas of like, diffusing from the intense thought or feeling? Mm-hmm. 

Preston: Um, I think I'll, I'll kind of like say intentionally like, I'm only gonna go to this app and I'm only gonna check one thing.

Mm-hmm. And then I'll like set it down afterwards. Right. But you're 

Margaret: talking about actions. How do you diffuse, oh, how do you know, like what is something that if, if, let's slip this. If you were observing like your brain and thoughts coming up this urged check and kind of worry of like, what if I canceled comes up?

What would you say to another person who's 

Preston: experiencing that? It's very unlikely. And while the risk is always there, you're gonna have to tolerate that risk to live your life in the way you want to. 

Margaret: Yeah. Or so that's kind of a CBT. So I'm sorry, I'm doing the thing where I test you on this. Um, so. Just noticing like that is a thought I have, [01:07:00] which may or may not be true.

That is not me. 

Preston: Okay. Yeah. It's, it's always more simple. 

Margaret: Yeah. The fusion is less about disproving or kind of fighting the thought or coming up with a mm-hmm. New solution as much as it's just being like, and that's there, that's a leaf on the river. 

Preston: Mm-hmm. And, and that, that's, that's a thought that I will think.

Margaret: Yeah. 

Preston: And I thought it Okay. And you thought it, 

Margaret: the last thing I'll say that we just didn't mention is, um, we talked about this in the mindfulness episode, but practicing mindfulness is like, practicing is like doing a bicep curl. You, some people are taught mindfulness as this thing that's gonna make anxiety go away.

But mindfulness as it's studied in stress reduction and in act, is about building the ability to move your attention and to notice where it's at and try and refocus it somewhere else. Mm. So some people will experience mindfulness and have someone say like, oh, if you're having a panic attack, just try to like notice your breathing.

And they'll say, [01:08:00] that's actually worse. And I just was even more aware of my panic attack. Mindfulness is something you build over time, not something that is built the moment you need it. Um, so, so in act with like willingness and present moment awareness, often my ACT sessions with my patients will start with five minutes of me leading them through a mindfulness exercise.

Mm-hmm. Because we are just trying to get reps in, of being able to move your attention despite boredom, despite it wandering somewhere else and to gently diffuse and come back. So I do not recommend to my patients who have not done mindfulness to try mindfulness for the first time, mid panic attack or like flashback with PTSD that may just, will likely just worsen things.

Mm-hmm. Okay. So we covered a lot about ACT today. 

Preston: Yeah, we did. I feel like I learned a lot. Good. I got, I got through all the, the stages. I mean, I still try to do CBT at the end. 'cause that's, that's okay. Hey, hey. It's a thought that my mind had, they're related and I, and I went [01:09:00] to it, you know? Right. I, I tend to, I tend to, you, it think Ccbt like, yeah, 

Margaret: you love ccbt, but, 

Preston: but that is or isn't me, you know?

Margaret: Um. Let us know if you guys like these kind of therapy explainer, uh, episodes. We can also do more act episodes or we can, I, I do think one of the things with learning different forms of therapy or just even getting to know it and experience it, is some of the like, role plays we do, um, where you get to see it being kind of played out in a session.

We talked a little bit about our own stuff now, but it's kind of more, it's easier to understand when you can experience it happening in like a faux session as we've done mm-hmm. With different fictional characters on prior episodes. So let us know what you like, dislike about any of these so we know.

What you would like more of. 

Preston: Yeah, and we, and we could do whole episodes of just like even the same characters, but maybe through like different lenses of therapy or something. That would be fun to see how they fun, how they compare. [01:10:00] Yeah. 

Margaret: I still need to watch The Sopranos. 

Preston: That would be interesting. Well, um, if you ever wanna leave any of these comments, you can always come chat with us and the Human Content Podcast family.

We're on Instagram and TikTok. We have a How to be Patient Instagram that's growing. We have I think like 2,800 or so. Loyal followers these days. Uh, keep sending us messages. We'll do our best to reply. You can also contact the team directly at how to do patient pod.com. 

Margaret: Leave reviews 'cause they do help us in the Apple Podcast store and 

Preston: and they also help us like learn more about what do you think, which is, and we read 

Margaret: them and we screenshot them and send them to each other and say, yep, 

Preston: we do.

Hey. It's like our main form of communication is like through you guys reviewing stuff. 

Margaret: Yeah. You're like our, like child after divorce. 

Preston: You can always see more from me and Margaret, um, at our own separate accounts. So Margaret's at separate our everyday, our 

Margaret: separated account. 

Preston: I am on YouTube at its Preo Margaret's, uh, at Badar everyday on Instagram and TikTok.

Shout out to any of our new [01:11:00] listeners. Um, I think we have people all over the world, so I saw people listen from Australia, New Zealand 

Margaret: tour, Sweden, 

Preston: Germany, the uk. Yeah, so thanks for being here. That's all. I didn't realize, realize that we have like an international presence, so you guys are the best.

Thanks again for listening. We're your host, Preston Roche and Margaret Duncan. Our executive producers are Preston Roche, Margaret Duncan, will Flannery, Kristen Flannery, Aaron Corny, Rob Goldman and Shahnti Brooke, our editor and engineers. Jason Portizo. Our music is Bio Benz v. To learn more about our program, disclaimer and ethics policy submission verification, licensing terms, and our HIPAA release terms, go to how to be patient pod.com or reach out to us at how to be patient@humancontent.com with any questions or concerns.

How to be patient is a human content production.[01:12:00] 

Thank you for watching. If you wanna see more of us or if you wanna see, this is lilac. She's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac Point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They, they probably exist for real.

But in the meantime, I'm just gonna pet lilac and then I'm gonna go dance in the [01:13:00] background.