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Mindfulness in Acceptance and Commitment Therapy

As mindfulness has become increasingly well known among the general public, and in the world of therapy and mental health care, it has also begun to gain something of bad reputation. Increasingly, there are accusations of 'McMindfulness' made about the way mindfulness is used and these have begun to taint the reputations all clinical mindfulness interventions. Much of the criticism is that mindfulness has been divorced from both its historical and cultural roots and, stripped of context, sold as a panacea. Often clients will complain, rightly, that they have been recommended mindfulness, without any clear understanding of how it will help them. There is truth to some of these criticisms so it's worth looking at how mindfulness is used as a core component within Acceptance and Commitment Therapy (ACT).

It's important to start by acknowledging that there is no single agreed upon definition of mindfulness. There are many different approaches which can both compliment and conflict with one another. Many point to Buddhism as the source of the practice, and indeed many western practices draw from Buddhist traditions, but the history of mindfulness extends much further back in history to at least 4000 years. Although some ACT practitioners may utilise some of these other approaches, ACT itself has found its own way to mindfulness through scientific enquiry. But, as Steve Hayes, PhD, the co-creator of ACT, has said, the fact many approaches have found their way through the woods to the same place by different routes, tells you there is probably something important about that place.

So, to understand what mindfulness is when used in ACT, let's start by noticing what it is not. Mindfulness is not synonymous with meditation. Of course, there are mindfulness meditations, but formal meditation is not a necessary part of ACT. Part of the reason for this is pragmatic - expecting people to sit and meditate for long periods each day tends to result in being less mindful, not more, because they do not do it, for various reasons. The second reason is that many people struggle with formal mindfulness, especially if they have a trauma history, and so, formal meditation without appropriate training and guidance, can cause them more problems than it solves. Thirdly, it's unnecessary for our purposes in ACT, and ACT is all about doing what works, not what we think *should* work. Instead, mindfulness in ACT is intended to bring the skills involved (more on this shortly) to everyday life, in the here and now, not simply whilst engaged in formal meditation.

Next, in ACT, mindfulness is not a relaxation technique or tool for reducing stress. Often, even among clinicians, this is how mindfulness is 'sold' to clients, but it is inconsistent with the ACT approach. It is true that for some, mindfulness can lead to temporary stress reduction and relaxation, but those thoughts, feelings, and physical sensations, can bounce back again soon afterwards. In ACT, the intention is bringing our attention to these experiences, without any direct attempt to change them in the moment, so that we can gain a greater ability to choose what we do next. When mindfulness is used specifically to escape feelings of stress in the moment, the result is a narrowing of responses, not the widening we are aiming for.

Mindfulness in ACT is not about emptying the mind of thoughts. There are meditative techniques where this is the focus, but they sit outside of ACT and mindfulness. In ACT the aim is not to rid the mind of thoughts, but instead to pay them attention with curiosity and compassion, otherwise we can quickly end up back in the very cycles of experiential avoidance ACT is aiming to help us step out from.

So, what is mindfulness in ACT? It is the combination of all the ACT processes - defusion, acceptance, self as context, and contacting the present moment - and any and all of the tools and techniques we use to build and reinforce these processes. As we can see, mindfulness in ACT is not just one thing but the result of engaging several processes that facilitate the psychological flexibility that ACT aims to develop. At any given time in therapy, we might be using mindfulness techniques to encourage or reinforce any or all of these processes.

Mindfulness, as used in ACT, distinguishes thinking from attention. Mindfulness here is the process of paying attention to thinking rather than being caught up in the thinking itself. A common metaphor in ACT is learning to look *at* thoughts instead of *from* thoughts. Mindful attention is intended to be flexible so that we can attend to the various parts of our experience, in the present moment, by choice, depending on what is most helpful to us.

Mindfulness, as used in ACT, is intentionally open and curious, even towards experiences that are painful and unpleasant. It is also kind and compassionate, rather than cold or clinical, and certainly not judgmental or critical, in order to reduce the additional needless suffering, we can add to our own experiences and promote the psychological flexibility which enables us to choose a range of responses beyond simply struggling with, or attempting to escape, our experiences.

Watching any ACT session, you will be certain to hear the therapist encourage their client to notice a given aspect of their experience in the moment. That may be a thought, feeling, physical sensation, urge, posture or anything they are aware of through their senses. This may be part of a more formal mindfulness exercise or simply, and commonly, using mindfulness 'on the fly' to direct and focus attention to an aspect of the experience in the here and now. Using mindfulness in this way is both useful in the session to bring the client's attention to potentially important parts of their experience and to help the client develop mindfulness skills they can use practically in their daily life, in any given moment.

Mindfulness in ACT is the use of attention to engage with, and reinforce, the core ACT processes of psychological flexibility. Every mindfulness intervention should be engaging at least one, if not more, of these processes and clients are encouraged to take these practices and use them flexibly as an integral component of their day-to-day life, rather than as a standalone stress management/relaxation technique.

Given the variety of definitions and practices that fall under the term mindfulness, and the very specific way it defined in ACT, we may wish to decide how useful the term is for any client that may already have developed a negative view of the term from previous experiences. We can instead speak to the specific processes we are addressing and, of course, there is far more to ACT than mindfulness, not least the importance of committed action in service of values. Regardless of the terms we use, it is an essential part of the work to connect the core processes we are building and reinforcing through mindfulness to the client's values and goals. In doing so we make the explicit link between the practice of everyday non-meditation mindfulness with measurable changes to their lives.

Christian Hughes is a Psychotherapist, and former military clinician, specialising in Acceptance and Commitment Therapy, Compassion Focused Therapy & CBT, with expertise in trauma & PTSD and a special interest in Moral Injury.

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