Wednesday, August 24, 2016

Acceptance and Commitment Therapy (ACT)

Steven Hayes starts his book “Get Out of Your Mind& Into Your Life” with the questions: “Why is it so hard to be happy? Why is life so difficult? Why do humans suffer so much? And what can we realistically do about it?”
He states that Acceptance and Commitment Therapy (ACT) has some profound and life-changing answers to these questions.
In April, my colleague Kathleen and I participated in an introductory  workshop on ACT, which is officially pronounced as the word “act” and not as the initials, to emphasize that as a behavioral therapy at its core, it is about taking action, taking effective action guided by our deepest values, in which we are fully present and engaged.
What is ACT?
ACT is a fairly new, empirically supported behavioral therapy that is based on Relational Frame Theory (RFT). It was developed by Steven Hayes in 1986 and is closely related to other third-wave behavioral therapies such as Mindfulness Based Cognitive Therapy (MBCT) or Dialectical Behavior Therapy (DBT).
Unlike most Western psychotherapy, ACT does not focus on reducing symptoms, but does this as a by-product. Clients come to therapy to get rid of their depression, anxiety, urges to drink, traumatic memories, low self-esteem, fear of rejection, anger, grief and so on. In ACT, there is no attempt to try to reduce, change, avoid, suppress or control these private experiences and feelings. Instead, clients learn to reduce the impact and influence of unwanted thoughts and feelings through the effective use of mindfulness. This is based on the view that ongoing attempts to get rid of symptoms actually create a clinical disorder in the first place.
The goal of ACT is to transform our relationship with our difficult thoughts and feelings, so that we no longer perceive them as symptoms. Instead, we learn to  perceive them as harmless, even if uncomfortable, transient psychological events.  
Clients learn to stop fighting with their private experiences—to open up to them, make room for them, and allow them to come and go without a struggle. And the energy we previously invested in trying to control these unwanted feelings we now invest in taking effective action guided by our personal values to change our life for the better.
Therapeutic Interventions
ACT offers clients an alternative to Experiential Avoidance (EA) through a variety of therapeutic interventions. It focuses on two main processes:

1.      Developing acceptance of unwanted private experiences that are out of personal control. 
  1. Commitment and action toward living a valued life. 
At the foundation of these processes are the six core principles of ACT, which are organized in a so called “Hexaflex”.

  • Defusion (Watch your thinking)
  • Acceptance (Open up)
  • Contact with the present moment (Be here now)
  • The Observing Self (Self-as-context – Pure awareness)
  • Values (Know what matters)
  • Committed action (Do what it takes)

The model shows that these processes are all connected and support each other.

There is no correct order for focusing on these processes, but their application is the ultimate goal of ACT: psychological flexibility. Increasing psychological flexibility involves helping clients to disentangle themselves from the cycle of EA and cognitive fusion.

Clients are taught to focus on the things that they have influence over, like their behavior, depending on what the situation affords, in order to move towards what they value, instead of trying to control experiences over which they have no influence, such as their emotions and thoughs.

Each principle has its own specific methodology. These include metaphor, paradox and experiential exercises that aim to undermine the power of EA and cognitive fusion.

Experiential Exercises
One exercise we did in our workshop was on Defusion.* We had to bring back to mind an upsetting and recurring negative self-judgment to form a sentence in our head  like: “I am stupid“ or “I am incompetent” and were asked to hold that thought for several seconds and try to believe it as much as we could and observe how it affected us. Then we were asked to now change the sentence to: “I am having the thought that ….I am stupid or incompetent” and were asked to hold that thought again for several seconds and to notice how that would feel.
Most of us noticed a distance from the thought, with much less impact on our emotions. This exercise demonstrated also that there was no attempt to get rid of or change the thought – only the relationship with the thought had changed, seeing the thought as just words.
This was just one of the exercises we did in the workshop but there are many more. For example, to deal with an unpleasant thought, we might simply observe it with detachment; or repeat it over and over, or say it out aloud, until it just becomes a meaningless sound; or imagine it in the voice of a cartoon character; or sing it to the tune of “Happy Birthday”; or silently say “Thanks, mind” in gratitude for such an interesting thought.
In contrast to CBT, not one of these cognitive defusion techniques involves evaluating or disputing unwanted thoughts.
What to treat with ACT?
ACT has proven effective with a diverse range of clinical conditions, like depression, OCD, chronic pain and other health conditions, anxiety, PTSD, and substance abuse.
Critics say that ACT is not really based on new theory and is also borrowing interventions from other therapies, but I must say that I really enjoyed working with this complete model. It is easy to understand and work with, it is very flexible as you can start at any point of the hexaflex, the interventions are very illustrative and it is also really fun to use. A  key ingredient of ACT is definitely humor, demonstrated also by the facilitator Aline Kruit from the U-Center in Maastricht, a clinic that provides “Compassionate Care and Clinical Excellence” in the assessment and treatment of co-occurring disorders (see This workshop was given to counsellors, but reading through the books and materials and doing some of the exercises, I can see people also using ACT as a self-help guide.

Book recommendations
Steven Hayes, Get Out of Your Mind & Into Your Life, 2005
Russ Harris, The Happiness Trap, 2007
                                                                                                   Nicole Drinkwater

Friday, July 1, 2016

Expat issues: culture shock

When individuals who developed  in one cultural context try to rebuild their lives in a different one, there is always a psychological impact. Ambiguity, lack of certainty and unpredictability are to a certain degree experienced by anyone entering a new culture; even the most prepared ones. Anyone who attempts to live and work in a strange culture can expect to experience culture shock.  

Culture shock, a term introduced by Kalevo for the first time in 1960 refers to the depression and anxiety experienced by many people when they travel or move to a new social and cultural setting:

culture shock  is precipitated by the anxiety that results from losing all our familiar signs and symbols of social intercourse. These signs or cues include the thousand and one way in which we orient ourselves to the situations of daily life: when to shake hands and what to say when we meet people, when and how to give tips, how to make purchases, when to accept and when to refuse invitations, when to take statements seriously and when not. Now these cues which may be words, gestures, facial expressions, customs or norms are acquired by all of us in the course of growing up (…) When an individual enters a strange culture, all of most of these familiar cues are removed. He or she is like fish out of the water.(Kalevo Oberg, 1960)”

To minimise the effect of culture shock it is important to acknowledge the existence of it, and to know and pay attention to the symptoms. Some of the typical symptoms of culture shock are:

  • Sense of loss, confusion, disoriented
  • mood changes, feeling depressed, anxious, withdrawn, irritable,
  • ready to cry, exhausted, panic, fatigued, feeling vulnerable,
  • Anger, animosity towards other people
  • Feeling overlooked, rejected, unaccepted, inadequate, different
  • Boredom, loneliness, self-doubt
  • General unease with new situations
  • Irrational fears
  • Obsession with own health and feeling sick or nauseous
  • Allergies, pain
  • Insomnia, excessive need of sleep
  • Identification with and idealisation of home culture
  • Trying to absorb everything within the new culture too fast
  • Difficulty solving even the most simple problems
  • Feeling insecure, frustrated, angry, resentful, unable to concentrate
  • Development of stereo-types in the new culture, need to complain
  • Strong longing for family and friends back home 

Such stress reactions cannot be avoided when people leave their familiar environment and are exposed to a foreign one, but over time individuals will acquire understanding and coping skills appropriate to the new culture, regaining confidence and an increased sense of well-being. Having recovered from the negative stress of culture shock the person can relax defences and participate within the new culture. 

How long this process will last is not fully predictable because how people react to moving internationally and how wll they will adjust during resettlement varies from person to person and depends on a number of variables such as perceived support, personal resiliance and cultural intelligence. 

In many cases people have the coping skills to go through and overcome the difficulties that arise during cross-cultural transition. However, when living and working in a new country becomes overwhelming, finding the right support is vital to expatriate and his or her family. 

                                                                                                                                                  Paola Gobbi

Resources: Colleen Wars, Stephen Bochner, Adrian Furnham, (2001) The Psychology of Culture Shock, Routledge

Friday, May 6, 2016

Mindfulness - Paying attention and functioning fully


We spend much of our lives on automatic pilot; carrying out daily activities with minds elsewhere.  Perhaps we are dwelling on something which has upset us or worrying about what might happen tomorrow, next week, next year---  The past and future occupy much of our mental space, leaving us less available to experience the present moment and allow us to function fully.

The consequences are that we can feel disconnected from ourselves, as if we are on a fast train through life, with no opportunity to stop off to reconnect with who we are and what’s important to us.  We are in a constant state of doing.

Mindfulness is about a way of being.  It is a 2500 year old Buddhist practice which is increasingly finding a place in modern psychological research and practice.  The original secular Mindfulness program was developed by Jon Kabat-Zinn in a clinical setting over 30 years ago.  This is called Mindfulness Based Stress Reduction (MBSR) and is still the most widely practiced. 

The benefits of mindfulness practice are supported by research findings. Being fully aware can help us disengage from rumination - absorption in unhelpful thoughts-  and feelings of stress.  It allows us to act with calmness and clarity, even in stressful situations and make more informed and conscious choices.  It has been shown to increase energy, decrease stress, improve mood and general well-being and boost the immune system.

So what is Mindfulness?  According to Kabat-Zinn, Mindfulness is about paying attention, in a particular way: on purpose, in the present moment and non-judgmentally.  Mindfulness or attention training  involves practices such as meditation, body scanning and simple yoga exercises which develop the ability to focus attention and increase awareness of internal processes.

How does it work?  Attention plays a central role in interactions with our surroundings. It is commonly regarded as a naturally occurring capacity, yet our experience is that paying attention is not so easy.  Instead our attention is so often distracted by thoughts of what we need or want to avoid.  Why is this?

The key role of attention is to increase awareness of our internal and external environment related to threats to having our needs met.   This can be about safety -monitoring for physical danger - but is frequently concerned with needs such as relationship, status and power.  Attention constantly wanders to internal thoughts which form an ongoing commentary about ourselves, others and the world generally.  We constantly, worry, compare, judge, regret and plan.  The sensations associated with threat-based thinking will be constriction, tension and a general sense of unease.  Excessive rumination can underpin real mental suffering, such as in anxiety and depression.

Mindfulness helps to develop awareness of how mental processes create and maintain distress.  Our inner world is often perceived as an undifferentiated amalgam. Through paying close attention to it we learn to differentiate experience into thinking, sensing and feeling components.  For example, feeling anxious in social situations might be associated with fearful thoughts such as “I never know what to say”. In this way mindfulness helps us to tune in to our feelings and the thoughts which maintain them.

It also develops the ability to calm ourselves when emotionally aroused or stressed. Paying attention to breathing is central to all Mindfulness practices.  It is our ever present anchor to the here and now.  “Awareness of the breath” provides access to a calming experience to which one can redirect attention from distressing thoughts or feelings. 

Another beneficial aspect of mindfulness is developing the ability to “decenter”.  This is about recognising that the components of experience are simply events occurring in awareness. We become observers of our experience rather than becoming absorbed in it, recognising that we are not our experience.  I may fail at something, have thoughts and feelings about this, which will pass but I am not my failure.  We also learn to accept what happens rather than continuously making judgements about whether it is good or bad, pleasant or unpleasant, to be engaged in or avoided.

The compelling message of Victor Frankl, psychotherapist and concentration camp survivor, was it is not what happens to us in life which defines our experience but our attitude to it.  Mindfulness is concerned less with the content of experience but how we relate to its elements.   We can allow our attention to wander passively and take up residence in thoughts and feelings which create and maintain our distress.  Mindfulness practice teaches us that there is another possibility.  Through consciously paying attention to what is, in the present moment, we can be more at ease even when challenged by what life throws at us.


Carmody,J., “Reconceptualising Mindfulness”(2016), Handbook of Mindfulness p 62-75.

Kabat-Zinn, J., “Full Catastrophe Living”

For Mindfulness training see and




Thursday, April 14, 2016

When your daughter or son is leaving an international school to start university, are you concerned how she or he is going to manage the change?

International schools create their own cultural environment. For children who attend an international school and move to university the process may be a bit more daunting.

When my own twin kids left home 2 2 years ago,  I was of course not sure whether they were ready to face the challenges away from their protected little world, which was greatly defined by their school and family. Today, I know they have both managed the transition well in their own way.
Recently, my daughter came to Holland together with two other international students from Bristol University for the Families in Global Transition (FiGT) conference to introduce their Third Culture Kid Society—a society at their university that addresses the needs of kids with a similar background. The goals are to provide a community, expand the group to other universities, work towards accepting their diverse identity and, rather than “assimilating” in a culture, to simply come together and get to know one another.

Third Culture Kids (TCK) is a term that describes people who spend a substantial part of their formative years in cultures different from the one of their passport or parents’ home country. It applies to a substantial number of international-school students.

During the stay of my daughter and her friends, I had the opportunity to observe a new generation of TCKs. Something that all three students shared, despite their completely different roots and upbringing, was an awareness of their situation, being very realistic about its benefits, but also their struggles.

Although they do not feel completely comfortable with the label TCK, they use the term TCK because of lack of a better one to describe their very unique experience. As one of the girls mentioned, the focus on labelling them as TCKs during school felt uncomfortable and elitist to her; she was dismissive towards this term and at the beginning also towards the Third Culture Kid Society.

What is common among Daria (born to a Polish mother and Lebanese father, growing up in Kuwait and attending the international school there), Charlotte (born to a Thai mother and English father, growing up in Thailand and attending the international school there) and Anna (born to Greek parents, growing up in Holland and attending the American school in The Hague)? The answer is that when they meet and introduce themselves, they do not need much to explain to each other.  

Since Ruth van Reken and David Pollock published their book “Third Culture Kids: Growing up Among Worlds,  a lot has changed for this group of kids. Schools have picked up the subject and have raised awareness among parents, teachers and students. I personally have benefited from such a program at the American School of The Hague, where I have learned to better understand my own expatriate experience. I studied in Germany, and one of my struggles was that I suppressed many aspects of my personality in order to fit in. Thanks to the transition program of the international school, my daughter did not need to hide herself; on the contrary, she was able to go out there together with her friends, create a place for them and others in a similar situation, without getting isolated from their environment. This shows the self-confidence of this generation TCKs.

During breakfast time (in the aftermath of the conference), I wanted to explore how they view their future. I was wondering, if they had the choice, would they choose to move around the world or to settle down?

All three of them seem to consider some moving around because of feelings of restlessness, exploring themselves and the world, as well as work opportunities. Yet in the end, they would like to settle down.

Most telling of how they feel about their situation was when I surprised them with a direct question: do you like being a TCK? The silence that followed showed how emotional they became. Their answers revealed their dilemma: appreciation of the opportunities they have had and a longing for a place to put down their own roots.

Being TCK you have an inherit open-mindedness to go out, see, do things rather than assume things. It is a privilege because we can get exposure to the world around us and be adaptable. What I don’t like about being TCK is the sense of “Who am I?” It is difficult to connect with people that have no idea of what TCK is.

A TCK can be a lot more open to arguments, cultures, differences, looking critically and objectively at how people deal with their emotions. There is a feeling of not fitting in, which can bring anxiety. No country feels completely like home, which is fine, yet confusing, since Western values are very different from the Eastern culture.

We can empathize with everyone in different environments. Nevertheless I have felt completely alienated and left out in certain situations.

I am sharing this experience without the intention to give specific advice on how to help your child to manage the next step after graduation. I just wanted to document my experience because in the face of those three girls I saw a very promising future for the next generation of TCKs. The progress of the last decades in raising awareness among parents, students and teachers starts meeting the needs of the coming generations. They seem to be better equipped with self-confidence and resilience to manage their experiences in different cultures. This does not mean that individual students won’t experience difficulties in managing their process of change. However, imagine if more and more of these kinds of initiatives were developing among students themselves, how much they would be benefited.

My last thought however was that it will remain an individual challenge: how to resolve the dilemma of embracing change and creating a feeling of belonging.

 Lamprini Kiosse

Wednesday, March 9, 2016

Therapies – how to choose the best one

As with any other aspect of life, therapies and therapeutic approaches are subject to time – be it the contemporary developments of science and research, the newest fad, the current focus of society and what has become more important for people at any given time.

Recently something started to change, in a very gradual way, until it became very visible. Psychoanalysis started to be taken seriously, again. Not that Freud ever faded from our collective memory. His iconic image, the typical jokes about him (usually involving repressed memories about caregivers or sexual innuendos, or both), and the global image of the ‘hm-hm’ therapist who simply sits there, are still all over books, movies, TV shows, memes, gifs, you name it.

Not only in popular culture have Freudian ideas been present, but also in scientific research. From time to time it’s possible to find articles that still aim to either prove or disprove Freud, especially in the neurosciences. But psychoanalysis is not merely Freud, and a lot has evolved since his early ideas about people, the mind and relationships; a lot has changed since the 1800s, and that includes psychoanalysis itself, obviously. To try to hold on to those early steps of a theoretical body and to try to disprove it by, for example, scanning the brain to find physical proof of the psychic apparatus (super ego, ego and id – which are concepts and not actual parts of the brain), seems to be a waste of time.

Earlier this year several articles posed the question: Are there still things to learn about psychoanalysis? This shift might have occurred because research is showing that if we consider improvements over the long term, some more (modern) empirically based therapies are not as effective as once thought and psychodynamic therapies do look better, particularly when you’re not thinking short term and you aim for a deeper understanding and lasting effects. If we really think about it, psychotherapy isn’t easy for anyone, so it makes sense to make it really worthwhile and just dive deep.

Interestingly enough, researchers are also coming to the conclusion that the most important factor for effective change in therapy is mainly linked to the quality of the relationship established between client and therapist, and not so much the techniques or theoretical approach. That makes sense. When dealing with painful things, change is much more likely to occur if it happens in a safe, caring environment.

So, more than choosing a specific approach, it might be better to choose the therapist you feel most comfortable with, who eventually gives you clues that she/he actually cares for your well-being and progress and is trying her/his best, even if she/he is not perfect.

Lea Pereira