You already know CBT. How hard can it be to transition to ACT?

You've finally gotten the hang of setting collaborative agendas. You've figured out how to ask effective Socratic questions, and you are learning to provide psychoeducation without confusing or boring your clients. You can set behavioral homework assignments and conduct effective exposures. In other words, you've learned how to conduct solid CBT. And then...you decide to learn ACT.
"This is just another behavioral therapy," you tell yourself. "I know how to do that." So you read a few books and rehearse some metaphors, ready to deploy your existing skills in this new therapy. But something isn't quite working.
On its surface, ACT feels like it shouldn't be so different from CBT. Emotions, behaviors, and thoughts are central to both. You still assign homework and attend to behavioral change. Cognitive restructuring can shift to cognitive defusion. And yet, there are fundamental differences that can make the transition from practicing CBT to ACT quite difficult.
ACT emphasizes a flattened therapeutic hierarchy, in which we as therapists aim to show up as fellow human beings, modeling the same processes we are helping our clients to explore. CBT traditionally encourages the therapist to present as more of an expert, someone who can provide psychoeducation and teach relevant skills while guiding the client through the process of change. (Although there are ways to intentionally flatten the power hierarchy in CBT, that's a topic for another post.) CBT encourages setting agendas, providing signposts through the session, and offering explanations in moments of client confusion, whereas ACT asks therapists to lead in a more subtle manner.
In CBT, I might start a session early in treatment by providing psychoeducation to the client about anxiety and avoidance before asking them about aspects of their experience that fit this template. The tone is one of fact-gathering, and my role can feel almost like an instructor in a class, teaching the client about how their experience aligns with the data on anxiety more generally. In ACT, I would be more likely to ask the client about their unique experience with anxiety and avoidance in an open-ended and emotionally present manner, reflecting the ways in which avoidance strategies may not have been particularly workable for them. The tone here is less about facts and more about feelings, with the aim of fostering the client's connection to the emotions that arise around their futile efforts to control anxiety. As an ACT therapist, I am not an expert here - I'm just another person who has also known pain, and my role is to show up to the pain my client is experiencing in the moment in a real way.
Collaboration between therapist and client are emphasized in both CBT and ACT, but the nature of that collaboration looks and feels distinct.
Oddly enough, you might read a transcript of a CBT session and an ACT session and find them very similar. But the experience in the room is quite different. So much of ACT is about tone and process, which can be incredibly challenging as you transition from CBT. In CBT, we often focus on the content of our sessions. What items will go on the agenda? What principles do I need to remember while conducting an interoceptive exposure? What will the homework assignment be? While these content-based questions are also an important part of preparing to conduct an ACT session, much of the work in ACT is less about what is being said and more about how you are saying it and how your interaction with the client is functioning. In other words, process is often more important than content. It is possible to get all of the content 'right' and still not have a particularly successful ACT session.
This is especially true in situations when the process can actually undermine the content. It is common for new ACT practitioners to inadvertently send messages to their clients that experiencing emotional pain is bad or intolerable - a message that is completely at odds with the premise of ACT but which is nonetheless quite easy to convey accidentally. Imagine that you have the following exchange in therapy after conducting a creative hopelessness exercise in which you asked the client to list what they have been struggling with along with the strategies they have used to try to manage those struggles:
Therapist: What are you noticing when you think about all of the ways you have tried to get rid of your anxiety?
Client (sighing): It's a lot. I've tried so hard but nothing has really changed.
Therapist (cheerful): Yes, and that's exactly why you are here - to try to find a way to get through all of this and live a better life!
Validation and reassurance, while common elements of CBT and other types of therapy, can work against your goals in ACT. Using an upbeat tone to reassure the client that therapy will help them is a way of allowing them to escape from emotional pain in this moment. While this can seem like an innocuous (and even desired) exchange from a CBT perspective, it undermines the process of creative hopelessness. Here's a more ACT-consistent way of engaging:
Therapist: What are you noticing when you think about all of the ways you have tried to get rid of your anxiety?
Client (sighing): It's a lot. I've tried so hard but nothing has really changed.
Therapist (slow, present, sounding almost as sad as the client): Nothing has changed. What feelings are coming up when you say that?
Client: It's depressing. It feels impossible.
Therapist (gentle): There's so much pain here.
When you are used to approaching therapy from a CBT standpoint, this type of exchange can feel like you aren't really doing anything - where is the intervention? But from an ACT perspective, this is ideal. You are not trying to solve anything for the client or rescue them from painful feelings. Instead, you are doubling down and encouraging the client to really sit with those feelings. In ACT, our engagement as therapists is often quieter, less obvious. Rather than announcing our intentions or explaining our position from the role of the expert ("now, we will work on gaining aware of your emotions in the present moment in order to foster greater acceptance of your internal experiences"), we lead clients more gently. Again, tone is critical. Asking about a client's feelings in a fact-finding manner will pull for a factual answer in which the client provides the content you have requested without really experiencing the emotions they are naming. Asking about feelings using an emotional tone models showing up to the emotion and encourages the client to join you in that place. Slowing down and allowing space for silence helps the client to notice what is present.
This process is very different than checking 'creative hopelessness' off of a session agenda. When I first learned ACT, I could lead a client through all of the steps of a creative hopelessness activity, while still missing the point of the exercise. In my CBT-soaked brain, I thought I was doing great therapy! But if the client does not leave the session in contact with feelings of hopelessness around the futility of the control agenda, then I actually haven't accomplished what I set out to do. This is why training, supervision, and consultation are so critical - even if you have a lot of experience in CBT, it can be quite difficult to transition to practicing ACT because so much of the learning takes place in the practice itself.
Both CBT and ACT offer so much to our clients, and having competence in both will allow you to broaden the range of people you can help. However, transitioning from one to the other is not an easy task. Though both CBT and ACT are evidence-based therapies rooted in behavioral traditions, they are far from interchangeable. It's okay to find the transition challenging.
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