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Acceptance and Commitment Therapy: An Introduction for SLPs

Acceptance and Commitment Therapy: An Introduction for SLPs
William S. Evans, PhD, CCC-SLP
February 22, 2024

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Editor's Note: This text is a transcript of the course Acceptance and Commitment Therapy: An Introduction for SLPs, presented by William S. Evans, PhD, CCC-SLP.

Learning Outcomes

After this course, participants will be able to: 

  • Describe the core theory of Acceptance and Commitment Therapy.
  • List example therapeutic techniques from Acceptance and Commitment Therapy.
  • Describe how to apply Acceptance and Commitment Therapy concepts to case scenarios of patients with communication disorders.

The agenda includes a brief discussion on how counseling relates to the scope of practice in speech-language pathology (SLP), followed by an overview introduction to Acceptance and Commitment Therapy (ACT). We will discuss case scenarios and apply ACT concepts and techniques to communication and related disorders within various areas of SLP scope of practice.

Counseling and the SLP Scope of Practice

As many of you are aware, counseling falls within our scope of practice, as outlined in the 2016 Scope of Practice Statement. SLPs engage in counseling by offering education, guidance, and support to individuals, their families, and caregivers. This counseling addresses acceptance, adaptation, and decision-making concerning communication, feeding, swallowing, and related disorders.

Within the counseling process, SLPs address emotional reactions, thoughts, feelings, and behaviors stemming from communication disorders, feeding and swallowing disorders, or related conditions. Adjustment counseling related to communication disorders is explicitly stated within our scope of practice.

However, a significant challenge lies in the fact that many SLPs feel unprepared to work in this area due to the lack of training and support. Surveys indicate that only about 40% of US graduate programs offer a dedicated counseling course. If you find yourself less comfortable in this aspect of our scope, rest assured that you are not alone. Nonetheless, it is imperative that we integrate counseling into our practice.

The Need for Counseling in CSD

Communication disorders frequently exert a significant negative impact on the mental health of our patients, clients, and their families. For instance, in my clinical practice and research expertise area focusing on stroke survivors with aphasia, there is a notable disparity in mental health outcomes compared to stroke survivors without aphasia.

Research indicates that stroke survivors with aphasia are at a considerably higher risk for mental health difficulties, such as major depression and anxiety, when compared to those without aphasia. For instance, within three months post-onset, 93% of stroke survivors with aphasia reported experiencing high levels of psychological distress, in contrast to only 50% of stroke survivors without aphasia. This example underscores how communication deficits can significantly exacerbate mental health challenges.

In my journey and exploration of counseling, my interest peaked during my clinical fellowship at Mass General Hospital. During this time, I predominantly engaged in outpatient treatment, focusing on higher-level cognitive rehabilitation. Working closely with patients, I emphasized patient-centered goals and implemented metacognitive strategy training. 

It became increasingly apparent to me that effectively assisting these individuals with their reasons for referral required a comprehensive, whole-person approach. Addressing their beliefs regarding communication or cognitive-communication deficits, evaluating their level of motivation, and considering their overall mental health were crucial components. These personal factors intertwined with their impairments, environmental demands, and overarching life participation needs.

It is imperative that we integrate counseling techniques and approaches into our practice if we aim to deliver whole-person, patient-centered care across all domains of practice. Moreover, it's worth noting an additional reason for this integration. It's quite common to observe how communication deficits and mental health factors can mutually influence and exacerbate each other. 

Many of you may have encountered or observed these vicious cycles within your caseloads. Consider, for instance, the scenario where communication difficulties contribute to or worsen depression and anxiety. These mental health challenges, in turn, may prompt avoidance behaviors and social isolation, ultimately diminishing opportunities for practicing and generalizing the therapeutic strategies implemented during treatment sessions.

In turn, this may result in diminished recovery, deteriorating mental health, and exacerbation of communication difficulties, thus perpetuating this common vicious cycle. The question remains: What steps can we take to better comprehend and address these relationships frequently observed in clinical settings?

Acceptance and Commitment Therapy

Today, I'll discuss the Acceptance and Commitment Therapy (ACT) framework as an approach we can utilize to understand and address some of these recurring cycles. ACT represents a modern form of third-generation psychotherapy, and it is considered a variant of cognitive behavioral therapy (CBT) due to its emphasis on understanding thoughts and cognition, as well as facilitating behavioral change.

However, unlike other forms of CBT, such as Cognitive Therapy, ACT possesses its unique approach, which includes mindfulness practices, a distinct theoretical framework, and its own methodology for addressing the interplay between behavior, belief, and emotion. Central to the ACT model is the enhancement of Psychological Flexibility, a core construct aimed at promoting mental health and psychological well-being.

ACT seeks to create a willingness to accept and engage with uncomfortable experiences when necessary, enabling individuals to lead meaningful and fulfilling lives. While it's natural for individuals to avoid pain or discomfort, avoidance can impede the ability to pursue a meaningful life or navigate challenges effectively.

The ACT approach to addressing these issues incorporates mindfulness training, an emphasis on present-moment awareness, educational components, and the encouragement of individuals to identify and align their actions with their personal values within the context of their lives.

ACT Premises

In ACT, the experience of suffering is considered a common human phenomenon, affecting everyone, albeit to varying degrees and in diverse ways. A fundamental principle of ACT is that suffering itself is a normal aspect of psychology. One of ACT's frequently cited principles is that clients are not deemed broken; suffering is not seen as pathological but rather as a state of being "stuck." Additionally, a premise I highly value in my patient-centered approach with individuals coping with aphasia is that the counseling relationship is one of equals.

I'm not an expert in emotions, adaptation, and recovery; I'm human too. We all experience suffering and strive to find meaning in our lives despite our struggles. As a clinician, I may offer perspectives and assist you in your journey of growth and discovery. I might help you see things that are hard to discern alone, but I'm on this journey too. We're all humans who struggle and suffer, trying to figure it out together, and I deeply appreciate the egalitarian aspect of this therapy.

Another aspect that's particularly beneficial and sometimes goes against intuition is that individuals typically seek counseling because they're experiencing suffering, struggling, or dealing with mental health symptoms, correct? ACT takes a somewhat counterintuitive approach to this. Instead of solely focusing on reducing symptoms, which is a commendable starting point but often encounters limitations, ACT aims to change the relationship with symptoms and struggles so they no longer impede living according to one's values. The objective in ACT isn't to feel happy constantly and avoid struggle altogether because that's an unrealistic aim. If I could feel that way, I'd choose it in a heartbeat. It's simply not within the realm of human possibility.

Instead, the aim is a fulfilling, meaningful life, even amidst painful thoughts, feelings, and sensations. By trying to alter our relationship with unwanted experiences, mental health symptoms often diminish as a secondary effect. However, even if symptoms persist, individuals still have the capacity to progress and lead a profound, purposeful life, even amidst ongoing struggles. What I particularly appreciate about this model, especially for us as SLPs, is that most of the individuals we work with are dealing with chronic conditions such as developmental disorders and acquired brain injuries. For many of them, these are core issues and struggles that are lifelong. Therefore, having a model that can assist them without relying on the premise of eliminating those struggles provides them with a multitude of pathways forward.

An Example ACT Question

Here's a question example you might ask in ACT. If you're applying the ACT model to your own life, which is always part of core trainings, you must reflect and apply it to yourself. So, considering what's important to me, what am I willing to do and experience at this moment to move in a direction I value? Am I ready to endure discomfort to connect or support someone I love?

Core ACT Concepts

We'll cover some core ACT concepts because thoroughly understanding the model can greatly aid in case conceptualization. When working with a client or patient, you may find yourself wondering why they're experiencing such significant challenges. It may seem related to mental health or their responses to situations. Having frameworks and terminology for diagnosis can be helpful in these situations. So, we'll discuss psychological inflexibility, related challenges like cognitive fusion and experiential avoidance, the ACT method for enhancing psychological flexibility, and the fundamental concept of making things workable and finding what suits them best.

Psychological Inflexibility. Psychological inflexibility refers to a dominant, rigid psychological reaction to negative internal experiences, which broadly encompass anything discomforting or negative. These experiences may include negative thoughts, emotions, or physiological sensations such as pain. When individuals experience significant psychological inflexibility, their behavioral response options become limited, often leading to actions that perpetuate or worsen their emotional distress. This dynamic resembles the vicious cycle I mentioned earlier. For instance, individuals might resort to emotional avoidance or control strategies, even when such behaviors contradict their values or life objectives. This persistent and inflexible response makes things harder and harder.

Cognitive Fusion.  Another concept that contributes to the notion of psychological inflexibility is cognitive fusion. This entails being entirely entwined with one's internal experiences, caught or trapped within one's thoughts. Individuals fused with their internal experiences may see no distinction between their thoughts and their sense of self. They might believe that their thoughts are their truth and reality, requiring unwavering attention and compliance. Additionally, they may feel that their interpretations of events are inherently correct and must be followed without question. When individuals become fully fused with negative thoughts or experiences and are consequently very rigid, it becomes challenging to create movement and flexibility or lead a meaningful life.

ACT seeks to establish distance between thoughts and self to help patients. Rather than promoting fusion, it encourages individuals to "defuse" or step back from internal experiences where they might otherwise feel "stuck."

Experiential Avoidance. Another pivotal concept that contributes significantly to this inflexibility is experiential avoidance. This refers to efforts to control, avoid, suppress, or eradicate unwanted internal experiences, even when doing so results in behaviors and outcomes that contradict an individual's values and life objectives. A common example seen in communication disorders is social withdrawal, where individuals attempt to avoid certain experiences, leading to various additional consequences. Other examples include substance abuse or addiction. The challenge with experiential avoidance is that the pursuit of emotional control can become a problem in itself, compounding the initial core experience.

ACT relies heavily on metaphors and analogies because many of its concepts can be rather abstract. For instance, one might liken the additional struggle caused by experiential avoidance to playing tug of war with a monster who relentlessly pulls you closer to a pit, or being trapped in quicksand where the more you struggle, the deeper you sink. However, in moments of panic, it's challenging to slow down, relax, and allow oneself to float and find a way out. The instinct is often to fight harder, exacerbating the situation.

Russ Harris, known for his accessible ACT trainings, encapsulates this idea in his quote: "Instead of encouraging clients to use more clever ways to fight and win this war against their own thoughts, feelings, and sensations, ACT helps clients step out of this war altogether." The realization is that this struggle can often worsen matters. While there's nothing inherently wrong with employing control strategies—for example, taking time off or engaging in activities to lift one's mood—these are natural responses. In fact, much of what we aim to achieve in our caseload involves empowering individuals with a sense of control, which is good.

ACT becomes particularly relevant when individuals engage in patterns of experiential avoidance that prove to be costly. These behaviors often entail negative consequences, consuming significant resources such as money, time, or effort, and ultimately proving ineffective. Despite the substantial effort invested, these strategies tend to yield poor results and can significantly distort one's life.

For instance, consider someone struggling emotionally who finds temporary relief through gambling. While it may offer momentary solace, the long-term costs can swiftly become life-altering. It's important to acknowledge that seeking control over pain and unwanted experiences is commendable. However, it's crucial to recognize the point at which these efforts become counterproductive. For example, taking breaks when needed is healthy, but if the break consumes the majority of one's life, it becomes detrimental and distorting.

Our role is not to determine these boundaries for individuals but rather to support them in their journey toward self-discovery. They must determine, on their own terms, what constitutes excessive cost or life distortion.

Psychological Flexibility.  In addressing inflexibility issues like cognitive fusion and experiential avoidance, the essence of ACT lies in promoting psychological flexibility. There are several ways to conceptualize the core model of psychological flexibility.

The original creator, Steven Hayes, proposed a six-point framework. However, Russ Harris has simplified this into a three-point framework. According to Harris, individuals are most flexible when they can open up, be present, and determine how to do what matters in the present moment. ACT incorporates treatment processes that support each of these aspects.

"Open up" therapy processes.  To help individuals open up and become more flexible, ACT incorporates processes that promote acceptance. This involves accepting what's happening and what one is feeling, allowing for the presence of uncomfortable thoughts, feelings, and sensations without unnecessary avoidance or defense mechanisms.

One important aspect is assisting individuals in "diffusing" from fused thoughts. These could be words, stories, or impressions passing through our minds. They may or may not be true, and they're certainly not orders, nor necessarily wise. With a bit of perspective-taking, individuals can refrain from reacting impulsively to situations, such as becoming angry, defensive, or feeling unintelligent due to communication difficulties. They can take a step back from these thoughts and still navigate the situation effectively.

Therapeutic approaches aimed at helping clients open up include experiential exercises and discussions centered around metaphors like the quicksand analogy. Treatment processes also focus on helping clients be present.

"Be present" therapy processes.  And being present is pivotal; it's the mindfulness aspect of this contemporary psychotherapeutic approach. Processes are aimed at assisting clients in truly engaging with the present moment. This involves being nonjudgmentally aware in the moment, just as it is. Alternatively, it can involve the study of self as context. Instead of identifying solely with thoughts and interpretations of events, seeing the self as the context or space where all those thoughts occur is emphasized.

So, using a metaphorical analogy, one might ask, "Am I the weather, or am I the clear sky?" Thoughts are likened to weather—passing through, sometimes gentle, sometimes a downpour. Or perhaps the individual is more like the sky, the space where all these thoughts happen. This perspective helps people be more flexible because they have space; they can be present, open up, and diffuse.

"Do what matters" therapy processes. The third aspect involves treatment processes that assist clients in aligning their actions with what truly matters to them. This entails helping them identify their values. In the ACT model, values represent what individuals most aspire to stand for in life, often expressed in simple terms like love, kindness, integrity, respect, or independence. What's particularly insightful about ACT's approach to values is that they're not viewed as goals but rather as aspirations—directions in life that individuals strive to move towards.

This perspective proves especially helpful for our clients and caseloads, many of whom must adapt significantly to changed life circumstances. For instance, if someone valued being responsible and loving as the breadwinner for their family but experiences a brain injury that alters their capabilities, there may be alternative ways for them to live out these values within their new reality.

The approach might not be the same as before; they may need to explore different tactics or goals. This is where the notion of committed action comes into play. It involves considering what actions individuals can take right now, today, or this week, that align with their values. Therapeutic activities in this realm primarily focus on helping individuals identify their values and then establish concrete, actionable goals that enable them to live out these values in their daily lives.

Workability. Another key concept from ACT that I find incredibly helpful is the notion of workability. Essentially, individuals are encouraged to consider if what they are working on currently contributes to making their lives rich and meaningful. If the answer is yes, then it's considered workable, and there's no immediate need for change. However, if the answer is no—if their actions aren't fostering richness and meaning in their lives—then it's deemed unworkable. In such cases, the focus shifts towards exploring more flexible approaches and considering alternatives that might yield better results. The overarching goal of ACT is to help individuals discover workable approaches to living a meaningful life, thereby avoiding the cycle of repeating unworkable patterns.

What I particularly appreciate about this framing is its inherent kindness. Instead of framing actions as right or wrong, or labeling individuals as good or bad, the focus is solely on whether the approach is effective in achieving a rich and meaningful life, as defined by the individual. If it's not working, it doesn't imply that you are broken; rather, it suggests that adjustments are needed to find a more workable approach. This framework can prove immensely beneficial in our interactions with clients and patients who may feel stuck. It empowers us to help them explore and discover workable approaches to their recovery journey.

ACT: Excellent Theoretical Support and Evidence

One reason I became interested in ACT in my own area of research, and why I'm currently dedicated to it, is its robust theoretical support and substantial evidence base. As I mentioned, the core construct of psychological flexibility—aiding individuals in opening up, being present, and doing what matters—is firmly rooted in the literature. It serves as a modifiable psychosocial factor with excellent psychometric support, indicating that individuals can learn to be more flexibility. Moreover, in the treatment literature, there's a well-established causal mechanism of action associated with ACT interventions.

Studies have shown that individuals undergoing ACT treatment experience improvements in measures of psychological flexibility. Importantly, this enhancement in psychological flexibility correlates with improved functional outcomes. For those of us who appreciate clear models and mechanisms, this evidence on the counseling side of things is particularly relevant to our practice.

Furthermore, ACT boasts a robust evidence base more broadly. While it hasn't gained as much traction in our area yet, efforts are underway, including collaborations with colleagues, to strengthen its presence in the research community.

ACT: Evidence Base

There are over a thousand randomized control trials conducted to date using ACT in various populations, addressing conditions such as depression, anxiety, and PTSD, with consistently strong and positive findings overall.

Additionally, there's promising preliminary research in related areas. For instance, a significant study conducted by Beilby et al. combined ACT with compensatory training and demonstrated substantial improvements in psychosocial functioning among people who stutter. Pilot studies have also indicated reduced depression in stroke survivors through group-based ACT approaches, as well as decreased psychological distress in individuals with severe traumatic brain injury (TBI).

In my own work, which we'll delve into later, we've been adapting acceptance and commitment therapy specifically for stroke survivors with aphasia, yielding promising preliminary results

Rationale for Using ACT to Improve Functioning 

The rationale behind using ACT to improve functioning for people with communication disorders is multi-faceted. Communication disorders involve changes and psychological experiences that are inherently challenging to accept, given their profound impact on individuals' lives. It's understandable that those we seek to assist are struggling with genuine and significant challenges. Moreover, the reaction to the impairment itself can often exacerbate the difficulties faced by individuals.

Many of the interventions and strategies we offer require considerable psychological flexibility to effectively implement in day-to-day life. Therefore, the motivating aim in both our discussion and the work I'm engaged in is centered on improving psychological flexibility. By combining this focus with our specialized interventions tailored to the scope of practice, we anticipate a synergistic effect. Bringing these elements together has the potential to yield outcomes that are more than the sum of their individual parts.

Case Scenarios Applying ACT

Now, I can delve into some case scenarios that illustrate the application of ACT concepts and techniques to communication disorders within our scope of practice. It's important to note that my area of expertise and research focus primarily revolves around aphasia, particularly post-stroke aphasia.

The initial scenarios I'll discuss are credited to students who contributed them as part of my Communication for Counseling for Communication Disorders course at Pitt. Students in this course encounter a wide range of caseloads, allowing for collaborative exploration of how these concepts translate into clinical practice.

Case 1: Adolescent Who Stutters

Case History and Presentation. The first case discusses an adolescent who stutters, with scenario credit attributed to former student Emily Hood. Here's the case history and presentation:

Anthony is a 15-year-old male who presents with stuttering for the past 12 years and receives treatment at a private practice. He resides at home with both parents and his younger sister. Anthony's stuttering primarily consists of part-word repetitions and blocks, often accompanied by physical tension. His most common secondary behaviors include clenching his fists and widening his eyes, particularly during blocks. Notably, there is a family history of stuttering, with both his grandfather and a cousin affected, yet Anthony has strong familial support. During conversations, his family ensures he has the time and space to articulate his thoughts and ideas.

Relevant Thoughts, Emotions, and Behaviors. Considering relevant thoughts, emotions, and behaviors experienced by Anthony in relation to his stuttering, several patterns emerge. In an effort to avoid stuttering, Anthony often opts for alternative words or phrases if he anticipates stuttering. This avoidance behavior extends to situations like dining out, where he may choose a different menu item to avoid potential stuttering. Additionally, he expresses a preference for sitting at the back of the classroom to avoid being looked at if he has to participate in class.  

At school, Anthony actively avoids answering questions, engaging in group work, and speaking during group presentations. His parents note that he tends to withdraw from social interactions and doesn't have many friends. Furthermore, Anthony admits to struggling with low self-esteem and confidence, harboring negative perceptions about his stutter. He finds his stutter embarrassing and believes that others judge him and perceive him as unintelligent when he stutters.

Applying ACT Concepts. As we reflect on the ACT concepts discussed thus far, several seem pertinent to Anthony's case. In actual practice, we always need to confirm our conjecture.  If we think something is occurring, we are going to have a conversation with the person and ask questions such as, "I am wondering when you do X, does it feel this way?"  So, I am going to provide what I believe is happening with Anthony. 

Experiential avoidance. I'm observing signs that could indicate experiential avoidance — distinct control and avoidance strategies aimed at avoiding the painful experience of stuttering in front of others. Instances include circumlocution, altering menu choices, and social withdrawal. Based on his expressed sentiments, these approaches likely prove unproductive for him and hinder his ability to lead a fulfilling life. While they may offer temporary relief, they ultimately yield long-term adverse effects by perpetuating a cycle of struggle and exacerbating his difficulties.

Cognitive fusion. Additionally, in this case, there appear to be instances of cognitive fusion where Anthony seems to be fused with distressing beliefs about fears of judgment and his self-worth tied to his stuttering. When one becomes fused with these thoughts, fully subscribing to them, it restricts flexibility, limiting the range of options and alternatives for responding to such feelings. This likely feeds the development of rigid and unworkable responses, such as avoidance behaviors.

ACT Informed Treatment. What can we do to help somebody like Anthony? Stuttering is an area of practice where we have direct evidence to draw upon. For instance, Beilby et al. present an example of an evidence-based ACT intervention specifically tailored for stuttering treatment. When considering our own practice, there are various options to explore. One approach could involve pursuing ACT treatment directly, potentially collaborating with or referring to a mental health professional, or integrating ACT elements into our existing services. The idea would be to help Anthony learn to open up, be present, and do what matters, even in painful moments of stuttering. Through this process, we aim to gradually shift Anthony's relationship with his experience of stuttering over time.

Instead of focusing solely on symptom elimination, Anthony can find pathways to lead a meaningful life even in the presence of these symptoms. This shift in focus is a way to disrupt these unproductive feedback loops. Over time, individuals who can increase their flexibility in navigating unwanted and painful experiences can gradually sever these unwanted feedback loops. 

Stuttering can then become something that Anthony has the skills and tools to manage. Sometimes I know when to apply them and when to let things be. I understand they won't always work perfectly, and specific strategies for my stuttering may or may not be effective. If they don't work now, perhaps that's acceptable. I've discovered ways to continue interacting, engaging, and accepting those challenging experiences. This could be a valuable long-term goal for someone like Anthony.

Case 2: NICU Pediatric Dysphagia

Case History. Moving to a very different area of practice, it's important to consider not only the patients or clients but also their families. We aim to support everyone affected by communication or swallowing disorders. Let's explore some ACT concepts in the context of NICU pediatric dysphagia.

This case is a three-month-old female under SLP care in the NICU with hypoplastic left heart syndrome. She underwent several heart surgeries and is now transitioning back to oral feeding after responding well overall. However, reevaluation revealed aspiration on thick liquids during MBSS, and she shows aversion to bottle feeds. It was recommended she be given 20 milliliters of thin liquids twice a day to facilitate the transition, along with feeding tube support. However, the recommendation to continue using a feeding tube during the transition was not well-received by the patient's parents.

Related Problematic Scenarios. The parents are struggling to come to terms with the necessity of a feeding tube for their daughter's nutrition. Upon receiving the recommendation, they reacted with anger, expressing sentiments like, "That'll just slow her down. If you and the rest of the hospital staff were working harder, she wouldn't even need it." They strongly believed that a feeding tube would be detrimental for their daughter at this stage. Additionally, their infrequent visits are compounded by their responsibilities at home and their full-time jobs. When asked about it, they expressed, "But it's not just the scheduling. It's so hard to see her like this. We feel so helpless."

Applying ACT Concepts. Let's consider how we can apply some of these core ACT concepts and therapeutic skills.

Cognitive fusion.  It's apparent that these parents are experiencing understandable cognitive fusion amid their grief process. They seem fused with the beliefs that the feeding tube is harmful to their daughter and that she needs to regain health and normalcy as swiftly as possible. This fusion appears to impede their ability to consider alternatives and understand current treatment recommendations and rationale.

Experiential avoidance. Furthermore, there are indications of experiential avoidance behaviors. The infrequent visits might be an attempt to avoid the overwhelming sense of helplessness. If so, this avoidance is probably hindering their ability to act in alignment with their values as caring and loving parents.

ACT-Informed Response. This scenario underscores a natural response, albeit one that might be getting in the way of a rich and meaningful life aligned with their values. Let's consider how to support parents during this challenging period using an ACT-informed approach. It's worth noting that regardless of the specific counseling methodology employed—be it ACT, CBT, motivational interviewing, or solution-focused brief therapy—it is grounded in fundamental counseling skills such as active listening and expressing empathy. In this situation, employing active listening techniques for adjustment and grief counseling can create a space where these parents feel heard and understood amidst their turmoil.

Being able to slow down, inquire about their feelings of helplessness, prompt them to discuss their values as a parent, their hopes for their daughter, and discuss their thoughts and beliefs about feeding tubes - acknowledging that there's a way to validate their feelings - can model acceptance and diffusion from difficult emotions, especially if we're not reacting by becoming upset because they're upset. Demonstrating supportive and open-ended discussion about workability in this context. If we could do this for them in this moment, it's likely to help parents diffuse from their beliefs instead of just fighting or disputing with them. And I hope this is something you've all experienced in your lives - that when somebody truly listens to you, is there for you, and demonstrates empathy for the situation you're going through, it's really hard to fight with them.

In those moments in my life where I've felt this, I've experienced this opening up of possibilities, acknowledgment of grief, improved flexibility, and opportunity to progress. And this is something we can offer even in those three-minute conversations. We need to find that space within ourselves to slow down and be present. Then, depending on how that discussion went, considering a mental health referral for grief counseling or coping with stress might be incredibly beneficial for these parents right now.

Case 3: ACT for Aphasia

Now I'll address a third case, which represents a vastly different area within our scope of practice. I'm going to discuss an example from our ACT for Aphasia treatment project.

This stems from an ongoing pilot study that my colleagues and I are conducting, which is funded by the NIH. Here, we're endeavoring to develop and pilot a combined counseling and communication strategy training intervention for aphasia based on ACT principles. Our underlying hypothesis, which probably isn't surprising given the context I've discussed thus far, is that ACT for aphasia will improve flexibility and resilience during stroke recovery. It will also improve communication participation, psychosocial adjustment, and overall quality of life. We believe that by integrating ACT with communication strategy training, the effects will be synergistic and greater than the sum of their parts.

Why? Because ACT enhances psychological flexibility. Therefore, providing this intervention should increase the willingness of individuals with aphasia to utilize strategies in their daily lives, especially in challenging situations such as conversing with strangers in a store. This demands a high level of willingness and the ability to manage discomfort, which they might initially feel more comfortable doing with you in the clinical setting. Additionally, by emphasizing communication strategy training that improves functional communication and incorporating ACT as a form of talk therapy, we aim to ensure that most people with aphasia have access to this type of intervention. Moreover, many activities that align with one's values in life necessitate effective communication. If we can improve functional communication, we can assist individuals in pursuing what truly matters to them. Therefore, the combined approach should yield synergistic effects.

Preliminary ACT for Aphasia Therapy Manual

The version of the manual we developed is based on a modified ACT training manual utilized within the Veteran Affairs System. We've been piloting a 10-session intervention that incorporates mindfulness training and extensive efforts to assist patients in identifying their core values. We discuss various ACT concepts and metaphors using materials tailored for individuals with aphasia. We help them construct a personalized communication toolbox consisting of individualized strategies. All of these components are used to help them determine their weekly "bold moves" – actions they can take to participate in their lives, communicate effectively, and live in accordance with their values in their life right now. Data collection was completed this fall, and although the results are preliminary, we have gathered most of the data to date, and it's showing great promise.

I'm genuinely excited about this approach for aphasia. We're observing good study feasibility and treatment acceptability, as indicated by patient reports, along with promising outcomes reported by patients. Although these findings are yet to be published, we're observing medium to large effect sizes in improving psychological flexibility, reducing emotional distress, and enhancing overall stroke and aphasia-related quality of life.

Case History.  Let's look at a case of someone who underwent this treatment intervention. The patient, a 75-year-old female, was four months post-onset aphasia resulting from a left hemisphere ischemic stroke. She exhibited mild to moderate expressive and receptive aphasia across spoken and written modalities, with an overall fluent profile.

Before her stroke, she was retired but actively involved in leading her church community. However, at this juncture, only four months post-stroke, she finds herself back home experiencing significant social isolation. Living alone, her son provides support, but he resides more than an hour away and cannot be present at all times. While she can use the phone, communication proves challenging due to her aphasia. Residing in a rural area with poor internet service, coupled with her lack of interest in technology, further limits access to additional resources or treatment options. Additionally, she is unable to drive, as her son, who owns the car she used, is not yet comfortable with her driving again so soon after the stroke, despite medical clearance.

Patient-Identified Values. In working with this patient and applying ACT for aphasia, she identified her core top three values as faith, independence, and connecting with others. One significant scenario where these values came into play was her church community. Church served as her primary social network, supporting her deep faith and providing opportunities for connection with others. However, since her stroke, she had not returned to church. She cited her inability to drive there and expressed emotional pain at the thought of returning. She harbored fears about how she would be perceived and doubted her ability to meet the expectations associated with her previous leadership role. Despite her desire to reconnect with her faith community, she struggled with feelings of inadequacy and said she wanted God to take away her aphasia so she could return to church and regain that sense of connection. This was very distressing for her. 

Applying ACT Concepts. It appears that there are clear patterns of experiential avoidance in her situation, particularly in her avoidance of the painful experience associated with returning to church. Unfortunately, this avoidance seems to be hindering her ability to live in accordance with her values related to faith and connecting with others. Additionally, she appears to be strongly fused with beliefs about needing to fully recover before she can consider returning to church, as well as being certain about how she would be perceived if she did return.

Therapy Outcomes. Using this 10-session treatment approach with mindfulness approaches, identifying values and bold moves, let's discuss these different concepts, such as psychological flexibility, and how she could apply them in her life. 

Here are the results for this particular participant. Building up her communication toolbox involved practicing various strategies through bold moves. She began by asking for repetition when she didn't understand, reading aloud to monitor errors, and creating an aphasia advocacy card that explained aphasia and provided communication strategies on the back. This card was helpful for facilitating communication with new acquaintances. She also used circumlocution strategies to aid in communication. Regarding mindfulness approaches to intervention, it's essential to meet the individual where they are, especially when striving for patient-centered care.

One interesting aspect with this patient was that while mindful meditation practices resonate well with some individuals, they may not be accessible to others due to their beliefs and cultural background. In her case, the meditation practices we initially offered did not resonate with her. Therefore, we sought to find what would be workable for her within the therapy framework. Eventually, we discovered that contemplative prayer, a specific approach to meditating through repetitive prayer, aligned well with her preferences. This alternative approach proved to be highly effective for her, and she embraced it wholeheartedly, making it her own and fully engaging with it.

Examples of value-based bold moves that we worked with her to identify and implement in her life included creating an aphasia card and using it with her friends to fulfill her value of connection. She also initiated conversations with her son about resuming driving, aligning with her value of independence. However, one of the most significant moves was her decision to attend a new church where she could easily get a ride from a nearby friend. This decision allowed her to live out her values of connection and faith in a practical and manageable way.

Reflecting on this journey, I initially envisioned a Hallmark movie moment where she would return to her old church, be embraced, and come to terms with her aphasia, moving forward triumphantly. However, her approach proved to be much more effective for her given her circumstances. Instead of overwhelming herself with the idea of returning to her old church, she found a practical solution that allowed her to honor her values of connection and faith without undue pressure.

Here, I truly appreciate this aspect—it's like my little wake-up call. To truly adopt a patient-centered approach, you have to follow their lead. You must give them the space to discover their bold moves, to discern how they can manifest their values in their lives because often, they will conceive something far better than what we might envision for them.

Regarding outcomes, we conducted a post-treatment interview with her, inquiring about her experience with the treatment in the study. When asked if the treatment addressed her needs, she responded, "I think it really did in the end. From the beginning of the stroke to today, there's a difference in my mindset because, for me, going into a stroke and this whole thing was like I'm waiting for a miracle." She admitted that she was essentially waiting for God to remove her aphasia before she could move forward with her life. However, she then expressed, "And now I realize I'm happy and good where I'm at. I can still do good things. I've learned a better way of being free. Every day is mine."


So, these are the kinds of changes we are trying to make possible for individuals where the communication strategy training is straightforward and practical. What seemed to facilitate her ability to implement these strategies was an increase in willingness and flexibility. Each of these three cases illustrates these concepts across different areas of practice.

Reflecting on the overall conclusions and takeaways, ACT offers a valuable set of frameworks and therapeutic approaches for assisting patients, clients, and families within our appropriate counseling roles. If this approach resonates with you, I would encourage you to pursue additional training. There are numerous online trainings and in-person boot camps available. Additionally, efforts are underway to develop speech-language pathology-specific evidence-based practices, which will allow us to incorporate these approaches more directly into our scope of practice.

Additional Training Resources

Steven Hayes:
  • https://stevenchayes.com/workshops/
  • https://www.praxiscet.com/trainers/steven-c-hayes/
Russ Harris:
  • https://psychwire.com/harris/act-beginners
  • https://www.youtube.com/channel/UC-sMFszAaa7C9poytIAmBvA/videos

Questions and Answers

This approach sounds very similar to avoidance reduction therapy for stuttering from Vivian Sisskin.

Absolutely. Again, when you're talking about counseling, there are many different recipes, often with the same core ingredients. So find an approach that you can wrap your head around and that resonates with you, and try to use that with clients. There are many different ways to get there.

Can you explain more about the mindfulness activity on slide 39?

We did our model by starting sessions with a mindfulness form activity. These were a type of guided exercises like environmental awareness (i.e., being aware of where you're in the environment). Noticing the breath would be a guided breathing exercise. Noticing sounds is being in the present moment and noticing what you hear. Eating a raisin is focusing on the sensation of taste. Most of these are guided exercises that then we talked about and connected to practice. A couple of good resources are two apps offered for free by the VA - Mindfulness Coach and ACT Coach. Both have some very similar guided auditory exercises that anybody can use for free.

Can you give more information about how a client identifies their core values?

Yeah, so one example would be doing a values card sort. You take a set of cards of values and go through the deck with the person. Have them pick the ones that resonate with them the most. For example, being loving, pursuing knowledge, environmental responsibility, et cetera.  Then maybe have them cut the deck down again so you can get them to the point of selecting their top 3-5 values. You might have many values, but finding a few core ones to act on is really helpful.

What has been your experience applying this practice with those who have developmental disability, cognitive decline, or brain damage?

We've only been using it in terms of stroke survivors, but some of them have obviously had concomitant cognitive deficits there as well. There are some good models and resources for modifying cognitive behavioral therapy in these populations where the idea is that the more cognitive disability you have and the more difficulty somebody has with abstraction, the more support you provide. Most of these modern therapy approaches have at their core this idea of doing what matters and making bold moves. That's the ACT version of behavioral activation. So, doing meaningful activity, right? That's usually a component that you could focus on. Even if these pretty obscure metaphors don't land, you can still help people identify simple values such as being loving, finding meaningful activity, and supporting things that way.

What patient-reported outcome measures did you use?

We use a specific measure of psychological flexibility called the Acceptance and Action Questionnaire. There is also a measure of emotional distress, anxiety, and depression called the K6. 

Is there any evidence for using this successfully with clients with TBI?

Yes, especially because this is a major intervention and use in the VA in the Department of Defense. My collaborator Eric Meyer has done a lot of work in that area as well, so there's a lot more evidence there. 

If you're working with caregivers, do you have them identify their values or values that you like to promote and their child?

Absolutely. It's just trying to figure out these conversations. The thing I like about this values model is that it is a level separate from goals. We can talk about goals. What goals do you have for treatment or therapy? Why are these your goals? If a person is setting goals that aren't reasonable at the moment, this is a way to step back and ask, "What's the value here? What are their hopes for their child? What are their hopes as a parent? Well, what are their values as parents?" As soon as you move to these core, simple one-word values, you can come up with new goals that are much more reasonable.

This approach sounds like it'll take a fair amount of time, given the need to really connect with a patient and dig into things that are most important to them. Any insight into how to facilitate this approach if the patient's payer source isn't providing many outpatient visits or LTC and SNF settings?

How do we make this practical? I teach this in my Counseling for Communication Disorders class, not because we can be trained in ATC from webinars or a few lectures. It's more about understanding the core concepts to inform how you're going to respond to somebody. And so it's a lot easier to do these kinds of core moments of authentic listening counseling. So, if you go back to the slides and look at some of the recommendations for working with those parents who have the child in the NICU, those are kind of much more basic counseling recommendations that are really informed by the concepts of ACT.

Another simple place is finding space for mindfulness, getting people to slow down, pause, and elicit relaxation responses during moments of therapy and giving them that space diffusing. Noticing these natural moments where somebody's getting stuck and starting to beat themselves up. Catching those teachable moments and responding to them in an ACT-informed way is a really powerful way to work it out. That's separate from giving a course on ACT and billing for it. I think those are just places to start.


Evans, W.S. (2024). Acceptance and commitment therapy: an introduction for SLPs. SpeechPathology.com. Article 20650. Available at www.speechpathology.com

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william s evans

William S. Evans, PhD, CCC-SLP

William S. Evans, PhD, CCC-SLP, is an associate professor at the University of Pittsburgh in the Department of Communication Science and Disorders with a joint appointment in the Clinical and Translational Science Institute. He completed his undergraduate and graduate training at UMass Amherst and Boston University in the areas of psychology, linguistics and speech-language pathology, and has practiced clinically at Mass General Hospital and the Pittsburgh VA. At the University of Pittsburgh, he directs the Language Rehab and Cognition Lab and is a member of the multi-PI Pittsburgh Translational Aphasia Research Initiative. He teaches graduate coursework in the areas of counseling, aphasia and cognitive-communication disorders, and his federally-funded aphasia clinical trial research is focused on counseling, therapeutic games and adaptive computer-based interventions.

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