ACT Therapy for Negative Schizophrenia

International Journal of Existential Volume 3, Number 1
Psychology & Psychotherapy January, 2010

Exposition in existential we defend the appropriateness of accep-
terms of a case of “Negative tance in problems of an existential nature,
Schizophrenia” approached at the same time as arguing for situating
by means of Acceptance and people’s difficulties in a vital more than
Commitment Therapy purely psychological framework.
Key words: Existentialism, Acceptance
José M. García-Montes* and Commitment Therapy, schizophre-
Universidad de Almería nia, identity.
Marino Pérez-Álvarez
Universidad de Oviedo 1.Introduction.
Acceptance and Commitment Therapy
*Corresponding author: José M. García- (Hayes, Strosahl & Wilson, 1999) constitutes
Montes. Universidad de Almería. Depar- one of the most recent developments of radi-
tamento de Personalidad, Evaluación y cal behaviourism in the treatment of diverse
Tratamientos psicológicos. La Cañada de San problems presented by outpatients (Dougher
Urbano s/n. 04120-Almería. Spain. & Hayes, 1999; Kohlenberg, Hayes & Tsai,
Phone number: +34 950 01 50 92. 1993). Briefly, it can be said that the objective
Fax: +34 950 01 54 71. of the therapy is twofold. On the one hand,
E-mail: jgmontes@ual.es the aim is for clients to accept those aspects
of their experience that they have been trying
unsuccessfully to modify (anxiety, obsessions,
sadness, etc.); on the other, it is attempted to
avoid this paralyzing the person’s life, so that
Abstract he or she can aim for those goals that are of
personal importance (social relationships,
The present work attempts to show, work relationships, etc.) even while experi-
through a case study, the possibilities of encing anxiety, obsessions or any other situa-
Acceptance and Commitment Therapy tion that has acted as a block up to that point.
(ACT) applied from existential thought. As it can be seen, with respect to classical
First of all we describe the symptoms re- cognitive-behavioural approaches, Acceptance
ferred to by a patient diagnosed as suffer- and Commitment Therapy (ACT) represents
ing from “negative schizophrenia”. These a change of therapeutic focus. Intervention
symptoms are then analyzed in existential is no longer aimed at eliminating or reduc-
terms, with special emphasis on the no- ing the psychological symptoms, but sets out
tion of “personal identity”. This is fol- rather to achieve a distancing of the person
lowed by a description of the intervention with respect to those symptoms, so that, for
carried out applying the techniques and example, anxiety does not represent an im-
principles of ACT, and an account of the pediment to speaking in public (if this goal is
patient’s evolution over two years. Finally, important in the patient’s life).
www.ExistentialPsychology.org 1
Bearing in mind the above, ACT proposes six perspective. We shall first present the case of
goals that should be covered over the course a client diagnosed as “negative schizophrenic”
of the intervention (Hayes, Strosahl & Wil- and his situation at the time of coming to us
son, 1999): 1) To break the client’s precon- for therapy. Subsequently, we shall analyze
ceptions about the therapy, creating a kind of the client’s symptoms in existential terms,
desperation about the solution he is seeking; with the emphasis on personal identity as a
2) To make him see that, in part, the problem concept that can articulate the patient’s prob-
is precisely the attempts to control the symp- lem and the search for a solution. This will be
toms; 3) For the client to accept that which followed by a brief exposition of the inter-
cannot be changed or which it is considered vention and its results. Finally, we shall draw
valuable to have; 4) For him to distinguish some tentative conclusions on the basis of the
between “I” and “me”, or, to put it another case treated. In this regard, we might already
way, between the person and his behaviour; 5) point out that these conclusions are in a
To take the client’s values as the framework similar direction to those of Kvale and Gren-
for acceptance of the experiences that are to ness (1967), who argued for a development of
be changed; and 6) To establish a commit- radical behaviourism (in our case, ACT) from
ment to work in line with these values. a phenomenological-existential perspective.
As regards the techniques used in order to 2.Exposition of the case and its symptoma-
fulfil these objectives, prominent among them tology.
are the use of paradoxes and metaphors, the
review of linguistic conventions and the use At the time of consulting us, E. was 28 years
of experiential exercises, in addition to con- old and lived in a central neighbourhood of a
ventional behavioural therapy techniques town in northern Spain with his mother and
(exposition, shaping, etc.). grandparents. Over the previous 11 years, he
had received a wide variety of diagnoses, the
Recently, the second author highlighted the most common being that of “schizophrenia”.
theoretical and technical affinities between Likewise, he had been prescribed a consider-
ACT and traditional clinical approaches able range of treatments of all kinds, includ-
such as psychoanalysis, strategic therapy and ing more than 20 types of drugs, among them
existential therapy (Pérez, 1996, 2001). In various antipsychotic products. There had
any case, the similarities between ACT and been equal variety as regards other types of
existential psychotherapy would be deep- treatment or intervention, which even includ-
rooted, and, could in some way be traced back ed an exorcism, practised on the client with
to the conceptual coincidences between the no success whatsoever.
work of B. F. Skinner and phenomenological-
existential thought (Day, 1969; Fallon, 1992; E.’s parents were divorced when he was six
Kvale & Grenness, 1967). The present work years old, after which his father moved to
is intended as a practical exploration of such another province, where he now lives with his
coincidences, and of the possibilities offered new wife and E.’s four stepbrothers and step-
by an ACT intervention from an existential sisters. Thus, E. grew up with his mother and
his grandparents. It is difficult to establish the and outpatient psychiatric attention. Despite
point at which E.’s problems began. Until he being advised to continue his studies, E. lost
was 17 he had been a diligent student, a keen all interest in them, as well as his “ability to
reader and good at sports. However, in the concentrate”. As he himself recounts, in these
eyes of E., things were already not right. As three years he lived a totally “unproductive”
he told us, “I’ve lived in hell at all times and life. His only interest was music, to which he
in very different ways at the different stages devoted a great deal of his time.
of my life, from my earliest memories until
now.” Even so, E., acknowledges a certain On giving up the psychiatric treatment, at
change on reaching age 17, since, until that the age of 20, he spent a few months during
age, he had the idea that everyone was like which he remained in his darkened room for
him “inside”. Indeed, E.’s complaints focused, whole days, hardly eating and immobilized
from the start, on his “private world”, or, as he by the unease produced by the sensations he
would say, on his “sensations”: “My inside,” he experienced. When these sensations stopped,
told us, “changes constantly and rapidly, espe- he began to feel something that he claims he
cially when I try to do something on my own had never had before: positive thoughts about
initiative. Doing something on my own ini- the future. Little by little the “positive” days
tiative, for me, is equivalent to trying to break began to outnumber those on which E. stayed
down the barrier between my world and that shut away in his room. This encouraged him
which I believe there is outside”. According to go on holiday with his father to a nearby
to what he told us, he often found himself village, where he met his first girlfriend. E.
deprived of his knowledge and abilities as recalls that “it all went well, but I felt anxiety
though by magic. These symptoms appeared as well as pleasure”. That made him feel like
without warning and in some way increased a fraud, “a psychotic with a double life”, to
his confusion and insecurity. Likewise, from use his own expression. After that summer,
the start, E. saw that his peace of mind de- he decided take up his studies for the third
pended to a large extent on the view he felt time. Everything went well until before the
others had of him as a person: “I don’t see Christmas holidays he had another crisis. In
others, I don’t have the right to judge them, his words, “I lost control of my body, fused
but others do have the right to judge me,” with other people and immersed in continu-
he said. This dependence on other people’s ous paranoia, totally helpless. At that mo-
criteria leads him to continual self-reproach ment I saw channels inside my body through
and profound isolation: “I cannot express my which there circulated an energy that ‘burnt’
resentment against this cruel, mediocre and me if I stayed still; I could bear it with a kind
limited outside world, and I accept my role of internal ‘muscles’ (located in my head) if I
without being able to avoid it”. was lying down on my back”. Tired of these
types of “sensations” and of “fighting” them,
As indicated above, these symptoms began to he decided to take his own life by getting
manifest themselves publicly when E. was 17 into the bathtub with a hairdryer in his hand.
years old. From then until age 20, E. received Having failed in this suicide attempt, he spent
various types of pharmacological treatment three weeks trying to starve himself to death,
which led to his being forcibly admitted to a dence upon other people and the experience
psychiatric hospital and prescribed a strong of his own body.
dose of antipsychotic medication. After be- We shall begin by looking at the first aspect:
ing discharged from hospital, E. again tried “condemnation to freedom”. This concept
to commit suicide, this time by consuming a was identified simply and brilliantly by the
massive dose of drugs that he had obtained by important Spanish philosopher José Ortega y
“saving up” week-by-week those prescribed by Gasset:
the psychiatrist. This new attempt to take his
own life led to another forcible admission to Life is given to us, since we find ourselves
the psychiatric unit. After being discharged, in it without knowing how or why; but that
E. spent two entire years without leaving the which is given to us, life, is not given to us
house, at the end of which he began to go ready-made. Rather, we have to make it,
out compulsively: “at first I didn’t even get each one his own. Life is a task, and it gives
undressed to go to bed, and I spent all day us a lot to do! (Ortega y Gasset, 1979/1996,
walking or at relatives’ houses, until I began p. 98).
to bore them. I was at the disposal and at
the mercy of everyone, with the idea that the But this doing is always multiple, so that, on
solution to my unease might appear at any choosing one thing as opposed to another or
moment, and that I shouldn’t turn down any others, people define themselves both posi-
invitation”, he told us. During this time he tively and negatively. To use the words of
continued to take antipsychotic medication Ortega once more:
until, six months before coming to see us, he
decided to stop it. E. came to us in search of Each instant and each place opens up
a new remedy for his “bodily sensations”, for before us various paths. From any circum-
his “fusion” with people and, in general, for stance, even extreme ones, avoidance is
the “useless pain” he felt in his life. possible. What cannot be avoided is that
we have to do something, and that we have
3.Re-exposition of the case in existential to do what is, in the end, the hardest thing:
terms. to choose, to prefer. How many times have
people said they would prefer not to prefer?
So far we have aimed to give as clear and (Ortega y Gasset, 1957/1995, p. 52).
objective an account as possible of E.’s life up
to the time we met him. However, we should In any case, it seems clear that freedom (or
like to go further and ask ourselves whether choosing, if you will) produces fear (Fromm,
there is any possibility of making sense of the 1987) in that it implies the construction of
problems this client presents. In our opinion, one’s own being. It is appropriate here to
such an explanation would involve under- consider Jean-Paul Sartre’s (1943/1993) as-
standing that E. attempts to deny certain sertion that, for human reality, being is choos-
constituent aspects of the construction of his ing oneself. Therefore, while the person does
identity, specifically, the “condemnation to not choose (or, rather, plays at not choosing)
freedom”, his relationships with and depen- s/he is not (or, rather, plays at not being). For
indeed, s/he who has chosen nothing is po- self ”. For example, in reference to the area of
tentially everything, even though s/he may de “friendship” he wrote: “I don’t see much to do
facto be nothing. The case of E. could be seen, with friendship. It’s difficult for me to do so.
then, as an obstinate attempt at non-being; I don’t exist in society”. Although his descrip-
that is, a way of trying to elude his necessary tions of other areas are fuller, we feel it im-
freedom of action, and thus his construction portant to highlight the fact that, throughout
as a person. In this regard, it should be under- the evaluation, he used expressions of the type
lined that, as mentioned above, until the age “I see myself ”, “one of the visions that comes
of 17 E. adjusted perfectly to the normative to me,” etc. It can be observed, then, that E.’s
models of his cultural context: good student, use of language is characterized by avoid-
sportsman, keen reader, etc. These types of ance of responsibility for his values – thus
behaviour for which, we should remember, E. creating a scenario in which they come to
did not feel ultimately responsible, may shape him ready-made, and are not chosen by him.
what Laing (1960) has called a “false self ”. As Added to this is E.’s frequent recourse to his
Laing (1960) stresses, this bending oneself to private states (feelings, emotions, thoughts,
the norms or expectations of others is in part etc.), citing them as the cause of his actions.
a betrayal of one’s possibilities, but it is also a In Sartrean terms we would be talking about
technique for concealing and preserving one’s “bad faith” behaviours (Sartre, 1943/1993,
“true” possibilities, that is, a way of playing at 1946/1999). For if we have defined man’s
not being that which one does. situation as one of free choice, without ex-
cuses and without help, anyone who hides
Another form of trying to escape from the behind the excuse of their passions, anyone
“condemnation to freedom” could be seen who invents a determinism, is a person of bad
in the importance E. concedes to “initia- faith (Sartre, 1946/1999).
tive”. As we have seen, E. longs to “have” an
initiative so that he can act. This implies, in A second aspect would be related to the kinds
fact, a mechanistic (almost mechanical) con- of experiences E. refers to having in the pres-
ception of his own activity. “It’s as though I ence of other people. As mentioned earlier, E.
had a program,” he remarked to us in one of feels that others judge him, that they have the
the sessions. E.’s behaviour would thus be right to decide who he is, and this occasion-
a pure reflex determined by “intentions”, so ally generates strong resentment in him, as
that his responsibility for his acts becomes he ends up adopting the same value judge-
non-existent. Such behaviour was frequently ments about himself (in what he refers to as
found in the sessions. Thus, for example, in “fusion”). This type of experience that can be
carrying out a written task we set for him produced by the presence of other people has
on the assessment of values (Hayes, Strosahl been studied in detail by Sartre as “the look”
& Wilson, 1999), he avoided practically all in his work Being and Nothingness. As Sartre
responsibility with regard to the life-goals says:
considered. Instead of using verb forms such
as “I want”, “I would like”, “I aim”, etc., he I capture the look of the other in the very
used expressions with “I see” or “I see my- core of my act as the solidification and
alienation of my own possibilities (Sartre, These types of sensations varied widely, with
1943/1993, p. 291,). an example of them being the feeling of
discomfort one has when putting on a pair
Thus, E., on being contemplated by others, of trousers for the first time. As Sass (1992)
ceases to be pure possibility (transcendence) points out, this type of experience of the
and becomes something concrete (act, fac- strangeness of one’s own body represents a
ticity, behaviour): the nuisance who comes loss of tacit forms of knowing. Instead of E.
asking for a cigarette, the clumsy chap who finding himself living in his body and im-
bumps into him on the way out of the super- mersed in his sensory world, there is a strong
market, etc. His infinite possibilities are now separation between his consciousness (per-
reduced by the presence of another person ceived as a world of infinite possibilities) and
who confers upon him an objectivity and his body (as the empirical realization of his
concreteness as a being. It is not surprising body). This denial of bodily experiences can
that E. perceives that, while the rest judge, be seen, in fact, as a negation of one’s own
he finds himself incapable (“without the identity. One is one’s body –as Merleau-Pon-
right,” as he would say) of judging others. ty (1945/1999) would say–, at least to the ex-
“In the phenomenon of the look,” says Sartre tent that one has a capital of experience, and,
(1943/1993, p. 296), “one’s neighbour is, nec- reciprocally, my body is like a natural subject,
essarily, that which cannot be object”. like a provisional sketch of my total being. It
could be argued that this type of bodily sen-
Moreover, as regards the “fusion” E. experi- sation is involuntary, so that it has nothing to
ences with respect to his perceptions of oth- do with the matter of identity, seeing as the
ers’ opinions of him, nor is this surprising person’s freedom is not compromised. In any
from this existential position: case, we should not forget that freedom also
“it seems to us that the other fulfils for us involves assuming one’s responsibilities for
a function of which we are incapable and that which s/he has not created or desired,
which, nevertheless, is incumbent upon us: to but that one cannot escape one’s condition
see ourselves as we are [...] we are resigned to (Sartre, 1943/1993). On denying one’s own
seeing ourselves through the eyes of others.” nature as a corporeal being, E. rejects the
(Sartre, 1943/1993, p. 380). conditions from which the exercise of his
liberty is possible. Nor need it be said that in
However, it appears that E. does not resign the pure subjectivity of consciousness neither
himself to being seen through others’ eyes, these nor other limitations exist.
and struggles, in one way or another, against
this “fusion”. For E., the look of the other Thus, in our view, E.’s problem can be seen as
represents an illegitimate interference in the a question of identity or a disorder of the Self
determination of his identity. (Parnas, 2001) The problems in the formation
of his identity would be rooted in the experi-
A third difficulty in the formation of the ence of freedom of action, in the relationship
identity can be seen in the “struggle” that E. with others and in E.’s relationship with his
maintains against his “bodily sensations”. own body. Needless to say, all of these aspects
are profoundly existential and, at the same As we have described, E came to us in search
time, are matters that tend to emerge as a of help in order to palliate the unease pro-
result of the transition from adolescence to duced by his bodily sensations and his “fusion”
adulthood (Harrop & Trower, 2001). with other people. One of the first things
we asked of him was to tell us, in as much
4.The intervention in behaviourist terms. detail as possible, about each one of his at-
tempts to solve his problems to date. After his
They are multiple ways of presenting the highly detailed account, we asked him to tell
intervention carried out. For the sake of us whether any of these solutions had been
clarity, we feel it appropriate to use as a guid- fruitful. Obviously, E.’s response was “no”, as
ing criterion the objectives that ACT aims it was precisely for that reason he had asked
to achieve. The order in which these appear for our help. The following step, therefore,
should be understood more as a matter of was to suggest to him that we did not under-
logic than of chronology. We feel it might stand why none of this had worked: “There
even be said that a good application of the have been really good attempts at a solution,
therapy requires flexibility on the part of and quite varied, … and nevertheless…,” we
therapists as regards the objective (or objec- said to him. In our opinion it is especially
tives) towards which they are working at a important in this phase of the therapy to use
given time. It should also be underlined that indirect language. The final objective is that
what is presented here is simply a summary the client asks himself questions, more than
of the intervention carried out, and that the that he finds a solution. At some points it
selection criterion for presenting some issues seemed that E. was truly desperate, even with
and omitting others is that of being able to il- regard to our treatment: “I don’t think it’s go-
lustrate clearly the goals of the therapy. Hav- ing to work,” he said. Nevertheless, on other
ing clarified these matters, we shall continue occasions, it appeared he hadn’t thrown in
by presenting the work with E., which was the towel: “the more pain you have, the more
carried out over a period of five months with you want to fight”. Although it is frequent to
two sessions per week. use some type of metaphor to illustrate the
situation in which the client finds himself
4.1.Creative despair. (see Hayes, Batten, Gifford, Wilson, Afairi &
McCurry, 1999; Hayes, Strosahl & Wilson,
The ultimate objective of this phase is for the 1999), in this case this convention was not
patient to experience how all his attempts followed. We continued to work repeatedly, at
at a solution have failed, and that, therefore, different points of the therapy, on the useless-
the solution may be that there is no solution. ness of any solution tried.
We feel it important to recall that, as pointed
out by Hayes et al. (1999), it is an experience We also worked on despair in relation to
the client must have, more than something almost all the existential aspects from which
he should understand intellectually. In fact, E. aimed to escape. Thus, for example, with
confusion is a typical reaction, and is desirable regard to the question of freedom, we used
at this point. Sartre’s well-known phrase “condemnation
to freedom”. E. was made to see that he had us “when you don’t want it, it comes.” In the
the option of not choosing, but that the only third session he indicates something similar
way he could do so was by “choosing not to in relation to the search for a solution to his
choose”. The reactions of E. were of confu- problems: “the more I need a solution, the
sion, and sometimes of anger. We applauded further away I feel.” At that point we used the
his expressions of confusion, on the grounds “polygraph metaphor” (see Hayes, Strosahl
that he understood everything (“because & Wilson, 1999). In order to present it we
understanding this means not understand- asked E. to imagine that at that very moment
ing it”). We thus responded to the effect of a we pulled a gun on him and, pointing it at
paradox with another paradox. In the face of him, threatened to kill him if he didn’t paint
his expressions of anger towards the therapist the wall of the room with paint and a brush
(“I’d like to punch him in the face,” he was that we had brought for that purpose. “Would
heard to say), we asked him to take note of you do it?”, we asked him. E. told us that he
them, to feel them and to continue with the would, and we congratulated him for having
course of therapy. Here we feel it important saved his own life. We then proposed to him
to underline the importance the paradox a different situation: this time, E. would be
may have in dealing with matters of a vital or connected to a polygraph capable of detect-
existential nature. Such matters are not eas- ing the slightest feeling of unease in him, and
ily grasped using linear logical schemes. The once again, we made an outrageous threat: “If
paradox therefore serves as an appropriate this polygraph detects the slightest sensation
instrument for making contact with the con- of unease in your body, I’ll shoot you.” We
tradictory nature of existence (Van Deurzen- asked him if, on this occasion, he would save
Smith, 1997). his life. In this case, it seems E. did not feel
capable of surviving. We used these situations
4.2. Control as a problem. to consider the matter of control of pain,
bodily sensations, anger, etc. (polygraph situ-
From ACT it is considered that a large pro- ation), as opposed to control of publicly ob-
portion of psychological problems can be servable behaviour (wall-painting situation).
understood as vain attempts to suppress or E. then told us that, on occasions, he had
modify certain private experiences (emo- tried not to control his unease. We asked him
tions, thoughts, etc.) (Hayes, Wilson, Gif- why, to what end, and he told us he had done
ford, Follete & Strosahl, 1996; Luciano & it as another attempt to stop the sensations.
Hayes, 2001). The object of this phase of the Our aim was to try and make him see that,
therapy would be, therefore, that the cli- perhaps, “not controlling” so that something
ent realizes that his attempts to control his ceased was actually a form of control. “What
private experiences may meet with more or do I have to do, then?”, he asked. “Nothing?”
less success in the short term, but that in the We insisted that, quite possibly, not doing
long term things tend to get worse. In the anything is doing something. The reader will
case of E., he himself, in the second session, note that here we have returned to the sub-
introduces the idea of control as a problem. ject of despair, since all the objectives of the
Thus, with regard to the pain he feels, he tells therapy are necessarily intertwined.
4.3. Distance with respect to language his life in which he thinks he is incapable of
doing certain things (e.g., “feeling like this I
The aim here is that the client achieves a can’t go to the beach”), but nevertheless can
degree of perspective with regard to his do them. Realizing that one is wearing tinted
thoughts. ACT does not attempt to modify sunglasses would mean that, for example, one
the client’s thoughts, however uncomfort- could go to the beach thinking that one is
able, upsetting or painful they may be. All the incapable of doing so. After we had proposed
same, it is attempted to make sure the cli- the metaphor to E., he told us he thought
ent does not lose sight of the fact that such it very difficult to do such a thing. We then
thoughts are just that: thoughts, that is, some- asked him straight away if, when he said it
thing the person him/herself produces, and was “very difficult”, he realized that he was
not objective realities. wearing glasses, that this thought was also
influenced by the colour of the lenses.
In order to illustrate this aspect with E. we
used the “sunglasses metaphor”. It was sug- In a similar direction, and also with a view to
gested to E. that a person’s mind might be creating a distance with respect to language,
like a pair of sunglasses tinted in different we asked E. to say the word “chocolate” just
colours according to the moment. On some once. After he had done so, we asked him
occasions they are black, and things appear to what sensations he had felt. E. told us he re-
us as replete with difficulties and problems. ally felt as though he were eating chocolate. It
At other times the glass might be rose-tinted, is important to stress how the client insisted,
so that the world appears marvellous. E. was in this exercise, on the vividness with which
made to see that the problem is not that we he experienced the taste of chocolate on say-
wear some capricious glasses that change ing the word. We then asked him, instead of
colour according to the occasion. The problem just once, to say “chocolate” many times over
would be that, for the majority of people, it and as quickly as possible. Together with him
is quite difficult to realize that we are wear- we repeated the word for one minute, un-
ing sunglasses. In order to illustrate the type til we finally asked him if, when he said the
of problem that occurs when we are unaware word so many times, the taste came into his
that we are wearing sunglasses (that we have mouth. E. said no, that in this case he didn’t
a mind that evaluates, judges, etc.), we gave E. taste chocolate. We then told him it was
a blank sheet of paper and a blue pencil. We important for him to note that, although at
asked him to imagine he was wearing glasses the beginning he experienced quite vividly
tinted in exactly the same colour as the pencil. the sensation that accompanied the word
“If you were wearing the blue glasses, could “chocolate”, subsequently, on repeating it so
you write with this pencil on the paper?”, many times, the word lost all the power it had
we asked him. E.’s response was “no”, as the and appeared as it really is, simply a word, a
paper and pencil would appear to be the same sound. We took advantage of the occasion to
colour. Immediately afterwards, we tried to suggest something similar might be happen-
make him see that perhaps something similar ing when E. thinks “I can’t” or “I haven’t the
happened to him in many other situations in right”, or other thoughts. People experience
these thoughts quite intensely, even though, it permits the physical representation of the
at bottom, they are nothing but words. difference between the person and his/her
cognitive content.
Another exercise we have employed many
times in session, and whose orientation is 4.4. The distinction between the person and
similar, is that known as “taking the mind his/her behaviour.
for a walk” (Hayes, Strosahl & Wilson, 1999,
Bach & Hayes, in press). The first time we Here, the aim is for the person to put some
used it we began by asking E. how many distance between him/herself and his or her
people were in the room at that moment, to behaviour. This approach is based on the
which E. responded that there were two. We belief that patients, on realizing that they are
told him that in fact there were four people: not reducible to their behaviours, will be in a
E., the therapist, E.’s mind and the therapist’s better situation to accept and integrate certain
mind. In order to continue with the exercise aspects of their personality that have been
we proposed to E. that, for 10 minutes, the actively avoided.
therapist would act as E.’s mind and E. would
act as himself. Thus, both E. and his mind Thus, in the case of E. we used the “chess
would leave the consulting room and take metaphor” (Hayes, Strosahl & Wilson, 1999;
a walk around the corridors of the Faculty. Pérez, 1996). E. was asked to imagine a chess-
Then, and for another 10 minutes, E. would board on which there are black pieces (his
act as the therapist’s mind and the therapist uncomfortable bodily sensations, his thoughts
as himself. Finally, and for a similar length of of inferiority with respect to others, etc.) and
time, E. and the therapist would walk sepa- white pieces (sensations of well-being, of
rately, taking note of the fact that, indeed, being in control of situations, etc.). They are
each has a mind that evaluates, judges, criti- fighting each other. The black pieces form one
cizes, affirms, denies, orders, and so on. The team and the white pieces another. We asked
only rule of the exercise is that the person E. whom he could be in the situation we have
acting as the person is not allowed to ask his presented. E. quickly replied “the white piec-
mind to change the subject, avoid a mat- es”. We then asked him to go a little further
ter, etc. The person must go where he wants, and imagine whom he might be if his previ-
regardless of what the mind tells him. During ous answer were incorrect. First of all he told
the time the therapist acted as E.’s mind, he us he didn’t identify with anything but the
made sure to insist on the type of thoughts white pieces, but after we repeated the ques-
about which E. usually complained. Thus, tion he said: “... you’re going to tell me I’m
special emphasis was placed on how others the board”. And indeed, that was the point
would be judging us and on how ridiculous we wanted to reach. With E. as the board, he
and minuscule E. was in the eyes of other contains both white pieces (pleasant sensa-
people. The exercise was repeated on two tions, thoughts of control and power, etc.)
more occasions. We believe this exercise can and black pieces (unpleasant bodily sensa-
be especially useful in cases of people most tions, feelings of inferiority, impotence, etc.).
strongly fused with their thoughts, in that But the board is not the pieces, so that E. is
equivalent to neither the black pieces nor the self at the same time as putting a distance
white pieces, but transcends them both. between what one does (or has done) and
what one is. It is unnecessary to underline the
With a similar aim we carried out the exer- importance of this in cases where personal
cise “observer of oneself ” (Hayes, Strosahl & identity is compromised, such as that which
Wilson, 1999). We should begin by pointing concerns us here.
out that, as the second author of the present
work has indicated (Pérez, 2001), this exercise 4.5. Work on values.
is functionally coincident with the existen-
tial de-identification technique used for the As regards values, in our view they are the
purpose of “acquisition of strength” in the most important aspect of ACT. The creators
face of fear of death (Yalom 1980/1984). In of the therapy recognize that the acceptance
the case of the “observer of oneself ” exercise of negative thoughts, of unpleasant emotions,
we began by asking E., with his eyes closed, and so on, only makes sense and is legitimate
to be aware of his body at that moment – his to the extent that it permits the client to be
position on the chair, his breathing, his ten- directed towards those goals that are person-
sion or relaxation, the thoughts that came to ally important to him or her (Dougher, 1994;
him, etc. We insisted that it was not a case Hayes, Strosahl & Wilson, 1999). In the case
of changing anything, but simply of making of E., work on values certainly occupied a
contact with these experiences. Meanwhile, large proportion of the time spent with him.
we told him he should also notice that there Earlier we saw how E. played at not being,
is part of him we shall call “observer of him- that is, at not choosing, at not valuing. It is
self ”, which is the one who is noticing these not surprising, therefore, that a large part of
experiences. We then asked him to recall in as the work on values was devoted to showing
much detail as possible a painful event in his him the inexorable necessity of valuing, and,
life. At the same time we stressed once more above all, the need to invent values. We there-
that he should notice how once again it is the fore began by distinguishing decisions from
“observer of himself ” that is experiencing this choices. As Pérez (1996) points out, decisions
painful event. This procedure was repeated result from a logical analysis that weighs up
with a happy event. We also repeated it in different options. Decisions consist in the
relation to his body when it was extremely selection of an alternative for certain reasons.
thin and to how it was now, etc. Throughout On the other hand, a choice is an alterna-
the entire exercise we insisted on how impor- tive selected without a reason, even though
tant it was, not just that E. “believed” there reasons may exist. In order to emphasize this
existed an “observer of himself ”, but that he distinction, we used a variation of the exercise
really lived through the experience of it be- “choosing: Coke versus 7-Up”, cited in Hayes,
ing “him” (as observer of himself ) who had Batten, Gifford, Wilson, Afairi & McCurry
been sad and happy, who had had a thin body (1999). In our case, we took a pencil and an
and a fatter one, who had been nervous and eraser from the room we were working in and
calm, etc. As it can be seen, the exercise aims asked E. to choose one or the other. After
to construct a “transcendental” sense of the E. had made his choice we asked him to tell
us why he had chosen the object in question didn’t. We then asked him to imagine he was
and not the other one. E. gave us a series of the Dean of the Faculty and had the possibil-
reasons that we recognized as coherent and ity of using his influence to make everyone
sensible. We then asked him whether or not wear striped socks, even though he didn’t like
it was true that, for equally good reasons, he them at all. We asked E. what he could do to
could have chosen the other object. E. replied make everyone wear striped socks. E. began
that it was true – that he could indeed have to suggest an extensive series of actions that
chosen the other object. Thus, we repeated would lead to everyone in the faculty wear-
the exercise, asking him to choose again. We ing this type of socks, from giving them away
again asked him for his reasons, we again as presents at the door, to awarding “extra
recognized them as valid and we again asked points” to students who wore them continu-
him whether, with these reasons (or tastes ously throughout the academic year. We then
or preferences), he couldn’t have chosen the made him realize that, if he didn’t saying
other alternative. The exercise was repeated anything, everyone would think he were a fan
until, finally, E. responded that he had chosen of striped socks. In other words, we tried to
one of the objects instead of the other “just make him see that it is actions that lead to
because” (i.e., for no reason). This was pre- achieving certain goals, and that such actions
cisely the point we were trying to reach. We may be independent of the desires one has.
wanted to show in this way that, in the end, “Your tastes,” we told him, “don’t leave traces,
any choice we make in life is one’s own re- but your actions do.”
sponsibility, with no room for hiding behind
tastes, preferences, reasons or motives for The relationship between values and accep-
evading such responsibility. It is not necessary tance was also illustrated with the “rubbish
here to stress the importance that existential bin” metaphor. We asked E. to imagine that
philosophy has given to the “invention” of the wastepaper bin in the office was full of all
values and to the anguish that results from sorts of rubbish, the most disgusting things
recognizing that people’s freedom is the basis he could think of. We asked him if he would
of their values, without that freedom having put his hand in it – to which he obviously
its own foundations (Sartre, 1943/1993). The responded, “no”. “And what would happen,”
exercise presented aims precisely at the cli- we asked him, “if at the bottom of the bin
ent’s acceptance of this anguish of recogniz- there was a present someone had given you
ing him or herself as the ultimate basis of his and that was special for you, or something
or her choices. else that was very important for you. Would
you put your hand in?” We tried to make him
Another matter that we tried to clarify in see that in such a situation it wouldn’t make
relation to values concerned the fact that they sense to ask him “not to be disgusted”: reach-
are always translated into specific actions, ing into the bin would be an unpleasant expe-
and are independent of certain private states. rience. Putting his hand into the waste bin
Thus, we used the “striped socks” metaphor for the sake of it, without having anything
(Hayes, Strosahl & Wilson, 1999). We asked to fish out of it, would be foolish. But put-
E. whether he liked striped socks. He said he ting up with the disgust in order to take out
something of importance does make sense. Thus, in order to keep them calm and as quiet
Likewise, it would not be appropriate for E. as possible, E. had systematically succumbed
to feel unpleasant bodily sensations for the to their blackmail. We asked E., given this
sake of it, for no reason. However, there may situation, what he could do, as driver, to take
be something for which it is worth having the roads on which he wanted to drive. E.
these or other symptoms. The thing is that, in soon realized that the only way of achieving
E.’s case, he also has to invent the important this would be to put up with the passengers’
thing at the bottom of the bin, since values shouting and complaining, not giving in to
are chosen freely by people themselves. their blackmail. We made sure to stress that
Also in relation to values we used, with E., it was E. who, after all, was at the wheel of
the questionnaires and exercises for their the bus, and we asked him to recall if at any
clarification. Since these are highly structured time these passengers had actually removed
instruments, we refer the reader to the thera- him from his post as driver. It would seem
py manual that provides details of the proce- that these passengers that were feared so
dure (Hayes, Strosahl & Wilson, 1999). much were more loud-mouthed than power-
ful. We suggested to him that perhaps their
4.6. Commitment. only power was similar to that we saw words
to have in the exercise where he had to say
Commitment means that people are capable “chocolate”. In order for E. to experience
of directing their life in those directions they this, we proposed an exercise. This exercise
consider important despite uncomfortable involved going to the students’ room and
private states that may appear. To illustrate asking the person there about a party that
this idea of “commitment” we used the bus was due to take place that weekend. E. had to
metaphor (Hayes et. al., 1999). We asked E. do this and note how the passengers moved
to imagine he was a bus driver, and that, at close to where he was sitting and began to
a certain moment, some difficult passengers, shout and threaten him. On returning from
rough-looking and apparently threatening, the students’ room, E. remarked that he had
boarded his bus. Such passengers could be the had feelings of inferiority, that he didn’t know
uncomfortable bodily sensations, the feel- what to do, and that he had the sensation of
ings of inferiority on speaking to people, etc. non-existence. “That was all that mattered
When E. tried to drive the bus in a certain there,” he told us. We then told him that the
direction, these passengers stood beside him important thing was that he had taken the
and starting shouting and threatening him. bus where he wanted, and that his driving
What did E. do then? In the majority of was more meritworthy the more threatening
cases E. declined to follow the direction he passengers appeared. Driving without passen-
had begun to take, so that the passengers (the gers is very easy, so that there is little merit
bodily sensations, the unease, etc.) went back in driving the bus in that situation. What is
to the rear of the bus and quietened down. difficult, and therefore meritworthy, is driving
Every time E. tried to go in certain directions when the passengers get up from their seats
that were important for him, these passengers and cause trouble.
began to shout and move up close to him.
4.7. Diagnosis of the case. gard, E. became involved in more and more
activities, and made concrete achievements
Finally, but no less relevantly, we should point as the therapy advanced, and especially after
out that to conclude the clinical sessions we its conclusion. Nevertheless, it should also be
“diagnosed” E. has having a problem of an pointed out that E. made no reference what-
“excess of lucidity”. To this end we took ad- soever to changes in his “internal situation”,
vantage of an earlier conversation in which E. that is, in his felt experiences. Therefore, the
complained that, when he described many of changes we shall describe here concern solely
his problems to other people, they always told E.’s public behaviours.
him such things weren’t that important, and
happened to everyone. We told him frankly Thus, one month and 10 days after the begin-
that, in our opinion, dependence on others’ ning of the treatment, E. began once more
judgements, discomfort with certain bodily to play the guitar and read, and made visits
sensations or unease about personal respon- to one or two museums. It should be stressed
sibility were quite common in people. What that playing the guitar again involved a spe-
made E.’s case different was that he felt these cial effort for E., since this activity requires
things more acutely than others, so that, in good coordination of the fingers. E frequent-
short, his problem was an “excess of lucidity”. ly complained of his clumsiness and lack of
What was important was that such lucidity control over his fingers. Six weeks after the
should not paralyze E.’s life. His task was to beginning of the therapy, E. began helping
live in full awareness of the difficulties and his mother to look after his grandmother,
contradictions life holds – a task which, as we who has since died, but who at that time was
made clear to E., is not at all easy. Perhaps suffering from degenerative dementia. Two
you have to be mad. months after the beginning of the treatment
he began playing the electric guitar, which he
5.Monitoring and evolution of the case. considered as a big step forward. Ten weeks
after our first interview E. took responsibil-
On following the evolution of the case, we ity for the first time in session for not having
should stress the fact that we avoided the use done a certain task we set for him over the
of questionnaires or other pencil-and-paper weekend. Instead of using an expression such
tests. As pointed out elsewhere, it does not as “I couldn’t”, etc., he told us that he “didn’t
appear that this type of “test” is very sensi- want to do it”. After three and a half months
tive to the kinds of change that ACT aims he began visiting shopping centres, going to
to achieve. On the other hand, a good way the beach and doing press-ups. He admitted
of confirming the correct functioning of the in session that he was “a little more active”.
therapy would seem to be that of taking note During this time he also began to take an
of clients’ achievements in their life, which interest in computers and, especially, in “surf-
will be all the more valuable the more they ing the net”. Four and a half months after the
are made with the symptoms that previously beginning of the treatment he signed up for
paralyzed them (García, 2002). In this re- a short computing course. Also at this time,
he began to go out some nights with a group between them and himself. Two months later
of friends. The therapy ended after five and a he began a course of paid practical experi-
half months. ence in a printing firm, given his interest in
matters related to graphic design. Finally,
At the first follow-up, after six weeks, E. told a year and ten months after the end of the
us he was doing two short courses (word treatment, E. began working full-time at the
processing and horticulture), was download- printing firm where he had done the practical
ing music from the internet, was temporarily experience.
head of his building’s residents’ association
(substituting his mother) and was continuing 6.Discussion.
to look after his grandmother, whose health
had worsened considerably. He surprised us In our view, the conclusions that can be
during the session on asking us to open the drawn from the present case study are lim-
window because he was hot (he had never ited by the very nature of the work we have
previously asked us to change anything). described. With just one client, we cannot
After we had pointed this out to him, E. infer causal relationships between the inter-
told us that in the six weeks since the end of vention and the subsequent evolution of the
the treatment he had also taken an analgesic case. Even so, we feel it equally fair to stress
when he had a headache, something he had the fact that E.’s case had developed over a
never done before in his life. The next time long period, so that, since the age of 17, his
we contacted E., five months after the end life had lacked any kind of stable direction. It
of the treatment, he appeared to have left is also important to stress that the client was
off some of his activities. Thus, he remarked not being treated simultaneously with any
that he had dropped out of the Friday-night type of drug that might obscure or call into
meetings with friends because “he’s miserable question the effectiveness of the intervention
and he ruins it for everyone else”. Neverthe- carried out, as often occurs in other works
less, seven months later, he told us he had (García & Pérez, 2001). Another aspect
done two more short courses (page-making worth underlining is the excellent therapeu-
applied to graphic design and graphic design tic relationship maintained between E. and
and illustration). He also told us he had sev- the person attending him. It would not be
eral difficulties for adapting to the work team, unreasonable to think that the effects of the
especially at first. A year and four months intervention through ACT were enhanced by
after the final clinical session, E. obtained this factor. In any case, radical behaviourism,
his first paid work, carrying out a survey in of course, also recognizes the relevance of the
a working-class neighbourhood of his town. therapist-patient relationship (Kohlenberg &
With the money he earned he bought a Tsai, 1991).
computer to practise with various programs
for graphic design and page-making, which Bearing all of this in mind, we feel it appro-
had become a hobby for him. Likewise, he priate to make some remarks in relation to
remarked that he had made new friends, the problem and intervention presented here.
though he was still keeping some distance The first point concerns the present case
and, in general, the importance of the con- nique possible. It thus becomes essential for
struction of the identity in the development the psychologist (of whatever orientation) to
and course of schizophrenia. This idea is far be acquainted with the basic questions that
from novel, having been mentioned by nu- affect any person by the very fact of being hu-
merous authors (Chadwick, Birchwood, & man. Indeed, the high profile in recent years
Trower, 1996; Harrop & Trower, 2001; Laing, of acceptance as a psychological interven-
1960/1993; Niv, 1980; Sass, 1992). Here we tion technique demonstrates both the limits
simply wish to add that, before anything else, of psychotherapy in the solution of human
the construction of the identity is an existen- problems and the growing “psychologization”
tial question that, obviously, is not without of these problems, which affects more and
its difficulties in modern culture (Harrop & more sectors of the population. In the face of
Trower, 2001; Sass, 1992). Therefore, a com- this, there is a need for a psychology that does
prehensive approach to schizophrenia cannot not lose sight of the vital and social context
ignore either the patient’s social context or in which people act and develop. Thus, not
the vital problems s/he is facing at the time. uncommonly, the psychologist’s task is, para-
In the case of E. we saw the importance of, doxically, to “de-psychologize” the problems
for example, the concept of the “condemna- with which the client comes to the consult-
tion to freedom” and, in general, the work on ing room (Gutiérrez & García, 2001; Pérez,
values aimed at enabling the client to develop 2001). We feel that in the case presented here
activities that progressively opened up new it can be appreciated how important it was to
roads for him. play down the psychological variables (believ-
ing or not believing that one will achieve the
A second consideration concerns the rel- goal, wanting to or not, feeling comfortable
evance that should be attributed to existential or uncomfortable, etc.) as determinants of
questions in therapy supposedly based on ac- behaviour. On the other hand, we highlighted
ceptance. The founding authors of ACT have throughout the intervention the weight car-
studied the types of circumstances in which ried by action in the construction of a person’s
acceptance would be a good intervention life and identity.
strategy. Thus, for example, they cite those sit-
uations in which the very process of change is Finally, we believe it important for both
in contradiction to the desired result (Hayes, authors coming from the behavioural tradi-
1994) or certain complex contingencies in tion and those representing existential psy-
which a given achievement is necessarily ac- chotherapy to be acquainted with the type
companied by some losses (Dougher, 1994). of work carried out from either perspective,
In our view, existential facts (the bodily na- with the goal of achieving mutual enrich-
ture of the human being, our condemnation ment. There are clearly important affinities
to freedom, the social nature of man, the between the two traditions, and which have
finite nature of life, etc.) constitute the area long since been identified (Day, 1969; Fallon,
in which acceptance becomes not just a good 1992; Kvale & Grenness, 1967). The question
therapeutic instrument, but the only tech- now is for these actual affinities to become
elective, thus giving rise to new combina-

tions and, in turn, to improvements in health
(Pérez, 2001).
REFERENCES
Bach, P. & Hayes, S. C. (2002). The use of García, J. M. & Pérez, M. (2001). ACT como
Acceptance and Commitment Therapy tratamiento de síntomas psicóticos.
to prevent the rehospitalization of El caso de las alucinaciones auditivas.
Psychotic Patients: a randomized con- Análisis y Modificación de Conducta, 27,
trolled trial. Journal of Consulting and 455-472.
Clinical Psychology. 70(5): 1129-1139 Gutiérrez, O., & García, J. M. (2001). Po-
Chadwick, P., Birchwood, M., & Trower, P. sibilidades y límites de la terapia de
(1996). Cognitive Therapy for Illusions, aceptación y compromiso (ACT) en
Voices and Paranoia. Chichester: Wiley. el tratamiento de agresiones sexuales
Day, W. F. (1969). Radical behaviorism in [Possibilities and limits of acceptance
reconciliation with phenomenology. and commitment therapy (ACT) in
Journal of the Experimental Analysis of sexual assault treatment]. Anuario de
Behavior, 12, 2, 315-328. Psicología Jurídica, 11, 11-20.
Dougher, M. J. (1994). The act of acceptance. Harrop, C. & Trower, P. (2001). Why does
In S. C. Hayes, N. S. Jacobson, V. M. schizophrenia develop at late adoles-
Follete & M. J. Dougher (Ed.). Accep- cence? Clinical Psychology Review, 21, 2,
tance and Change: content and context in 241-266.
psychotherapy (pp. 37-45). Reno: Con- Hayes, S. C. (1994). Content, context and the
text Press. types of psychological acceptance. In S.
Dougher, M. J. & Hayes, S. C. (1999). Clini- C. Hayes, N. S. Jacobson, V. M. Follete
cal behavior analysis. In M. J. Dougher & M. J. Dougher (Ed.). Acceptance and
(Ed.), Clinical Behavior Analysis. (pp. Change: content and context in psycho-
11-25). Reno: Context Press. therapy (pp. 13-32). Reno: Context
Fallon, D. (1992). An existential look at B. F. Press.
Skinner. American Psychologist, 47, 11, Hayes, S. C., Batten, S., Gifford, E., Wilson,
1433-1440. K., Afairi, N., & McCurry, S. (1999).
García, J. M. (2002). El papel de la supresión de Acceptance and Commitment Therapy.
pensamientos auto-discrepantes sobre la An individual psychotherapy manual for
calidad perceptiva de las ilusiones auditi- the treatment of experiential avoidance.
vas. Oviedo: Publications service of the Reno: Context Press.
University of Oviedo.
Hayes, S. C., Strosahl, K. D., & Wilson, K. Niv, M. D. (1980). Schizophrenia: an existen-
G. (1999). Acceptance and Commitment tial approach. The American Journal of
Therapy. An Experiential Approach to Psychoanalysis, 40, 1, 43-52.
Behavior Change. New York: Guilford Ortega y Gasset, J. (1995). El Hombre y la
Press. Gente. Madrid: Revista de Occidente
Hayes, S. C., Wilson, K. G., Gifford, E. V., en Alianza Editorial. (Orig. 1957).
Follette, V. M., & Strosahl, K. (1996). Ortega y Gasset, J. (1996). Ideas y creencias.
Emotional avoidance and behavioral Madrid: Revista de Occidente en
disorders: a functional dimensional Alianza Editorial (Orig. 1979).
approach to diagnosis and treatment. Parnas, J. (2001). Self, solipsism and schizo-
Journal of Consulting and Clinical Psy- phrenic delusions. Philosophy, Psychia-
chology, 64, 1152-1168. try, & Psychology, 8, 2/3, 101-120.
Kohlenberg, R. J., Hayes, S. C. & Tsai, M. Pérez, M. (1996). La psicoterapia desde el punto
(1993). Radical behavioral psychother- de vista conductista. Madrid: Biblioteca
apy: two contemporary examples. Clin- Nueva.
ical Psychology Review, 13, 579-592. Pérez, M. (2001). Afinidades entre las nue-
Kohlenberg, R. J. & Tsai, M. (1991). Func- vas terapias de conducta y las terapias
tional Analytic Psychotherapy. Creating tradicionales con otras orientaciones.
intense and curative relationships. New Revista Internacional de Psicología Clíni-
York: Plenum Press. ca y de la Salud, 1, 1, 15-33.
Kvale, S. & Grenness, C. E. (1967). Skin- Sartre, J. P. (1943/1993). El ser y la nada. Bar-
ner and Sartre: towards a radical phe- celona. Altaya.
nomenology of behavior? Review of Sartre, J. P. (1946/1999). El existencialismo
Existential Psychology and Psychiatry, 7, es un humanismo. Barcelona: Edhasa
128-150. (Orig. 1946).
Laing, R. D. (1960). The Divided Self. Lon- Sass, L. A. (1992). Madness and Modernism.
don: Tavistock. Insanity in the light of modern art, litera-
Luciano, M. C. & Hayes, S. C. (2001). Tras- ture, and thought. Cambridge: Harvard
torno de evitación experiencial. Revista University Press.
Internacional de Psicología Clínica y de la Van Deurzen-Smith, E. (1997). Everyday
Salud, 1, 1, 109-157. Mysteries. Existential dimensions of psy-
Merleau-Ponty, M. (1945/1999). Fenom- chotherapy. London: Routledge.
enología de la percepción. Barcelona: Yalom, I. D. (1980/1984). Psicoterapia existen-
Altaya. cial. Barcelona: Herder. (Orig. 1980)

ACT Therapy for Negative Schizophrenia

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International Journal of Existential Volume 3, Number 1

Psychology & Psychotherapy January, 2010

elective, thus giving rise to new combina-

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