The ACT of grieving; when the pain won’t go away, and life seems pointless
Dr Ray Owen, Consultant Clinical Psychologist (Cancer & Palliative Care)
Alina’s husband Pete died of prostate cancer 8 months ago. She describes the weeks immediately after his death as a blur. For the last few months, though, she says her life has settled into a constant cycle of sadness and tears, replaying his last weeks in her mind and avoiding activities or people that remind her of him, bringing new waves of pain and loss. Alina says she doesn’t know what she’s for any more, so can’t find the motivation to do anything. And when she thinks of years more of this life, she’s beginning to wonder whether it’s worth carrying on.
The nature of the problem
Everyone who works with grief will recognise situations like that of Alina (a fictional person, but based on so many real ones I’ve met). And these problems are familiar enough that we all have our ways of approaching them, making sense of them, trying to help.
Yet this stuff is always difficult, and it’s worth reminding ourselves of some of the reasons why:
- This emotional pain is intense, is entirely understandable (we might even say ‘deserved’), and we know it’s probably not going away anytime soon
- So much of an individual’s identity and purpose may have been tied up in the person who died: it becomes hard to see what to aim for in life now
- And sometimes, our own losses may make our clients’ pain hurt us, or make us feel helpless in the face of their suffering
When anyone grieves, it’s not just the emotional pain of grief – the sadness, anger, fear, guilt – it’s how we react to the pain that gets us into more trouble; the withdrawal, the dwelling on the past, the over-busy-mustn’t-let-my-mind-start-thinking, even the use of alcohol or other drugs to numb the pain.
Though any of these might have the desired effect in the short-term, not only will they fail to change things in the longer term, they’ll also make it harder to start moving towards that ‘new life’ that well-meaning friends will increasingly talk about.
What’s more, all of this is takes place against the background of a society that tends to view human suffering as a problem to be fixed, or worse an illness to be medicated. And that grief is some set process or a state to be ‘got over’.
Acceptance & Commitment Therapy – a way of helping
Different models of how to support grieving people will address these matters in different ways (or sometimes don’t).
One approach to this – a psychological model called Acceptance and Commitment Therapy (or ‘ACT’, always pronounced as the word, not separate letters) – doesn’t see the pain, the response to the pain, or even the (sometimes unhelpful) actions of other people as symptoms, complications or pathology; but rather as fundamental to how we humans learn about the world, understand it and react to it. And those ways are both our greatest strengths and our greatest vulnerabilities. So, this approach it isn’t just about grief responses, but all forms of distress and suffering.
ACT is a ‘third-wave’ therapy – at heart it’s a form of behaviour therapy which puts a huge emphasis on acceptance, mindfulness, compassion and values-driven behaviour. In the 20 years or so that it’s been around, there have been thousands of scientific studies of its various parts, and over 150 major treatments trials (randomised controlled trials or RCTs) published in academic journals showing its effectiveness across a surprising range of conditions. These include the usual mental health conditions (anxiety, depression, PTSD, delusions, hearing voices, anger control amongst others), coping with physical health problems (chronic pain, cancer, diabetes, other long term conditions) but also areas that aren’t usually seen as clinical problems, such as dealing with stigma and prejudice, learning new skills or even encouraging use of safety equipment on building sites! All the details are on the main ACT website www.contextualscience.org .
ACT sees many of our difficulties as arising from our attempts to control, challenge or remove naturally occurring thoughts and feelings, rather than learning how to pursue a fulfilling life even with them present some of the time. And that’s true for all of us, not just those seeking help.
To turn things around, ACT encourages us to be more AWARE, OPEN, and ENGAGED
- AWARE; able to notice what’s going on both inside our heads, hearts and bodies, and in the world outside us, and develop the ability to return to the here-and-now rather than being lost in the past or future, or ruled by rigid rules and stories about ourselves. ACT overlaps with mindfulness-based approaches in this way.
- OPEN: responding to those thoughts and feelings with recognition of what they are, rather than letting them control all of our choices and actions. Be willing to experience them, if that’s what it takes to move forward. And develop the ability to ‘let them be’ without taking unhelpful steps to reduce them.
- ENGAGED: to become clearer about our values – what matters to us, how we want to be in this world (different people value different things – mine include ‘being helpful’, ‘being kind’, ‘being curious’,’being creative’) and then base our actions on those rather than the (understandable) urge to reduce unwanted thoughts and feelings. And finding ways of doing that even when our circumstances have changed – as in bereavement.
While those are the changes that ACT promotes, it also puts great emphasis on how that’s done, through
- Being clear that what is causing difficulty is not illness or pathology, but the natural consequences of how our minds work
- As such, it applies as much to the therapist as to the client. To model this, ACT therapists will use more self-disclosure than is found in many counselling or therapy models
- Focussing less on what is absolutely ‘true’ for this client or the world in general, and more on what works to give them a more fulfilling life
- Actively doing and experiencing things – within sessions and between them- rather than exclusively talking and listening
So what would be an ACT approach helping Alina, whom we met at the beginning of this piece?
Well, the first thing to say would be that (hopefully) it would have many things in common with any other caring and effective form of support; not least, showing compassion, respect, a genuine interest in the other’s experience and a willingness to allow their story to be properly heard.
The ACT practitioner might also be spending time on:
- Helping Alina notice in detail the thoughts and feelings that show up for her, when they do, and what she tends to do next (e.g. avoiding seeing people)
- Understanding why we naturally react this way, such as the urge to reduce or move away from strong unpleasant feeling (known as ‘experiential avoidance’). Emphasising that it is not a sign of being ‘ill’ or ‘broken’, yet noticing that it might not be working well for her in the long term
- Encouraging her not to struggle against the thoughts and feelings when they show up, yet neither to get drawn into prolonged rumination and reflection if it doesn’t help
- Helping her to return to the here-and-now when her mind begins to spiral into her memories, without unhelpful patterns of suppressing thoughts or needing constant distraction
- Noticing the presence and the impact of rules and beliefs about herself, especially those that define her in terms of being (for example) a wife and a carer
- Establishing the values that matter most to Alina; look how they have been impacted by her loss and the pain that creates (“inside your pain, you’ll find your values”)
- Without giving a message of ‘rushing’ or ‘moving on’, look at new ways of living by those values in a life where Pete is no longer around. So, gradually developing a sense of purpose and meaning distinct from the specific roles she has lost while maintaining continuity with the things that mattered most about how she was with Pete (examples for her might have been acting caringly, loyally, honestly)
- Helping to understand that in moving forward she will be carrying many of her difficult thoughts, memories and feelings with her – life cannot wait until they are all resolved (because they never fully are)
- Helping her develop any new skills necessary to do these things
And what might I want for Alina at the end of this work? That her memories and feelings relating to Pete – both the wanted and unwanted ones – are still there, but they do not control her as much anymore, and that she is no longer scared of them. And most importantly, that she is beginning to experience a life that has meaning, fulfilment and pleasure in it, even in the presence of her grief.
Of course, Acceptance and Commitment Therapy isn’t the only way to help someone achieve this.
But I’ve certainly found it to be one very powerful way.
Taking it further
As with any different model of counselling or therapy, some of those specific approaches will take a bit of learning, but some key parts (e.g. working with Values) needn’t require a massive amount of training.
If you are interested in learning more, then I’d recommend starting with a self-help book written by Dr Russ Harris (2012) The Reality Slap – how to find fulfilment when life hurts (Robinson Press). Indeed, that author’s writings and youTube videos are definitely one of the best ways into this field, and his website www.actmindfully.com.au has lots of good stuff on it.
If you prefer to read something more academic, then Hayes, Strosahl & Wilson (2012) Acceptance and Commitment Therapy (2nd edition- Guildford Press) is very thorough and will give you a sound understanding of the principles underlying the approach.
There is a wide range of ACT courses available, many of them listed at the main ACT website www.contextualscience.org .
If you’d like to learn more about ACT specifically for Grief, I’m delivering a 2 hour webinar in April 2017; here’s the link if you’re interested:
Dr Ray Owen, July 2016