ACT 1: Clean vs Dirty Discomfort

Sometimes the most lasting injuries to our mental health come not from negative emotions, but our response to them. Acceptance and Commitment Therapy, or ACT, has an interesting perspective on how we can improve on this. Discomfort is inevitable in life, but it doesn't have to be self-inflicted.

What is Acceptance and Commitment Therapy?

Acceptance and Commitment Therapy (ACT) is a branch of psychological treatment that has been developing in prominence over the last twenty years. Evidence consistently supports ACT as an effective therapeutic treatment for a range of clinical disorders ranging from depression and anxiety, to disorders such as insomnia, hoarding, eating disorders, and suicidal thoughts (1 - 7). ACT has also been found to improve wellbeing in "non-clinical" populations (individuals without any diagnosable mental health conditions) (6). Under the ACT framework, low mental wellbeing is thought to come about because of two things: processing our negative emotions in unhealthy ways, and living our lives in a way that is distanced from our most important values (which are different from person to person). Improving our mental wellbeing is at the forefront of ACT, with a focus on making choices that move us towards healthy mental functioning, or our “valued life”, as opposed to other forms of therapy that focus on reducing symptoms of illness. This is one of the reasons that ACT is really useful for self-care for the general population, as well as treating individuals with mental illnesses.

The component of ACT that we will be focusing on today is their perspective on healthy and unhealthy ways of processing negative emotions. Our second ACT article, ACT 2: Values, will focus on incorporating a values-oriented framework into our daily decision making.

Clean vs Dirty Discomfort

When it comes to accepting negative emotions, a key concept in ACT is the differentiation between “clean” and “dirty” psychological discomfort. Clean discomfort is any natural emotional response to a negative event. Dirty discomfort comes about from our attempts to avoid these emotional responses, and can take several different forms.

The current coronavirus epidemic is a very relevant example. This is a confusing, unpredictable, and stressful time for a lot of people, and it’s completely natural to not feel 100% all of the time. That is clean discomfort. However, sometimes our response to clean discomfort is to try and bargain with these emotions, and convince ourselves that we have no right to feel them - as if doing so would actually erase the clean discomfort in the first place. This is not the case, and such attempts at bargaining (dirty discomfort), only serve to increase and complicate our negative emotions.

Bargaining can take different forms. Say we were experiencing a low, listless mood due to a coronavirus lock down (clean discomfort), and so we responded to this by berating ourselves for not being as productive as usual, in an attempt to force ourselves to cheer up and get on with things. This inevitably might make us only feel worse and in the long run we only end up feeling increasingly out of control of our productivity.

Another common form of dirty discomfort is comparing our situation to others in worse situations, and trying to convince ourselves that we therefore don't have any right to experience negative emotions. Let's say we were on lockdown at home, and felt a bit sad and lonely because we couldn't see our friends. An example of this negative comparison might be telling ourselves that we have no right to feel upset about having to stay at home, because people in the world are dying and we are relatively much better off.

Gratitude and perspective are incredibly useful things, and at times can be very beneficial for our wellbeing - we'll touch on this in a later article. However, the ACT model finds that when we are feeling overwhelmed by intense negative emotions, invalidating our experiences in this way is unkind and unhelpful. If you accidentally knocked yourself out with a dumbbell at the gym, you wouldn't call it physical exercise. The logic here is the same - while you have all the right self-care pieces, using them in the wrong way can occasionally lead to injury.

To get around this, ACT recommends practicing clean approaches to discomfort. One approach is to name our emotions and their origin in as simple and factual a way as possible. For example, “[X] has happened, so I am experiencing feelings of [X].” Drawing from our earlier scenarios: “I am on lockdown in my house because of a dangerous virus, and as a result I am feeling pretty down right now,” or, “I might not see any of my friends for a while, so I'm experiencing feelings of loneliness.” Then, try following this up with an accepting statement, such as “These feelings are natural, and it’s ok to struggle sometimes.” This technique won’t “fix” our negative emotions, but it can allow us to view them clearly and not get so overwhelmed. While unpleasant to experience, negative emotions are a guaranteed consequence of being alive, and not something that we can always control. What we can control is our response to these emotions, and allow ourselves the space to process them in a healthy way.

A valid criticism of this clean vs dirty pain exercise is that accepting your negative emotions cleanly still doesn't do anything to resolve them, other than adopting a "wait and see" attitude. This is where the second key component of ACT comes in: Committed positive action (Equalling our total: Acceptance AND Commitment Therapy). The scientific literature on ACT shows us that wellbeing is best targeted by a combination of these two together, rather than either component purely on its own (6). Committed positive action can be anything as simple as going for a walk to clear your head, to deeper exercises that can help us reconnect with meaningful goals in our lives. If you want to learn more about this subject, we recommend having a look at our second ACT-based article to obtain a more holistic understanding of using this therapeutic framework to improve your wellbeing.

References:

1. Churchill, R., Moore, T., Furukawa, T., Caldwell, D., Davies, P., Jones, H., Shonohara, K., Imai, H., Lewis, G., & Hunot, V. (2013). 'Third wave' cognitive and behavioural therapies versus treatment as usual for depression. Cochrane Database of Systematic Reviews,10, No. CD008705. Doi: 10.1002/14651858.CD008705.pub2

2. Ducasse, D., Jaussent, I., Arpon‐Brand, V., Vienot, M., Laglaoui, C., Beziat, S., Calati, R., Carriere, I., Guillaume, S., Courtet, P., & Olie, E. (2018). Acceptance and Commitment Therapy for the management of suicidal patients: A randomized controlled trial. Psychotherapy and psychosomatics, 2018, 1‐12. Doi: 10.1159/000488715

3. Fogelkvist M, Gustafsson SA, Kjellin L, & Parling T. (2020). Acceptance and commitment therapy to reduce eating disorder symptoms and body image problems in patients with residual eating disorder symptoms: a randomized controlled trial. Body Image, 32, 155 - 166. Doi: 10.1016/j.bodyim.2020.01.002

4. Hunot, V., Moore, T., Caldwell, D., Furukawa, T., Davies, P., Jones, H., Honyashiki, M., Chen, P., Lewis, G., & Churchill, R. (2013). 'Third wave' cognitive and behavioural therapies versus other psychological therapies for depression. Cochrane Database of Systematic Reviews, 10, No. CD008704. Doi: 10.1002/14651858.CD008704.pub2

5. Kanter, J., Baruch, D., & Gaynor, S. (2006). Acceptance and Commitment Therapy and behavioural activation for the treatment of depression: Description and comparison. The Behaviour Analyst, 29(2), 161 - 185. Doi: 10.1007/bf03392129

6. Levin, ME, Krafft, J, Hicks, ET, Pierce, B, & Twohig, MP. (2020). A randomized dismantling trial of the open and engaged components of acceptance and commitment therapy in an online intervention for distressed college students. Behaviour research and therapy, 2020, 126. Doi: 10.1016/j.brat.2020.103557

7. Ruiz, F., Pena‐Vargas, A., Ramirez, E., Suarez‐Falcon, J., Garcia‐Martin, M., Garcia‐Beltran, D., Henao, A., Monroy‐Cifuentes A., & Sanchez, P. (2020). Efficacy of a two-session repetitive negative thinking-focused acceptance and commitment therapy (ACT) protocol for depression and generalized anxiety disorder: A randomized waitlist control trial. Psychotherapy, 2020 (02). Doi: 10.1037/pst0000273.