CCPR: Welcome, Dr. Scarlet. We hear a lot about a variety of therapies for children and adolescents, including cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT). More recently, we are hearing a lot about acceptance and commitment therapy (ACT). Can you tell us what ACT is?
Dr. Scarlet: ACT seeks to teach us to mindfully observe our internal and external experiences and to increase our willingness to experience things, which may either be out of our control or otherwise necessary to honor our core values. Because ACT is almost entirely experiential, it often relies on metaphors to help people understand its guiding principles. The metaphors I like to use have to do with defining our painful experiences as our origin story.

CCPR: Origin story? This sounds like you’re talking about your comic book approach.
Dr. Scarlet: It can be. In fact, I call it “superhero therapy” as my goal as a therapist is to help my clients become their own version of a superhero. We do things through pop culture metaphors and connections.

CCPR: Can you tell us more about “superhero therapy?”
Dr. Scarlet: Superheroes can serve as metaphors to help kids and adults alike follow their core values, but this metaphor is not necessary for all kids. Kids could be taught mindfulness as a way to connect with “the Force,” for example, which is a Star Wars metaphor. They can be taught to use their own magical skills, such as acceptance and courage in taking committed action steps toward their core values. It is always important to consider the language ability of the client when implementing ACT, but so long as the skills are presented in an age-appropriate and language-appropriate skill level, the intervention can be used with most clients.

CCPR: So, this is where the core values come in?
Dr. Scarlet: Yes, exactly. Core values refer to our chosen life directions or domains, such as family, friends, education, and career, as well as compassion, playfulness, heroism, hobbies, creativity, and others. Core values are infinite, meaning that we always work on them, whereas goals are finite. For example, friendship is a core value, while seeing a movie with a friend is a value-oriented goal.

CCPR: How does this process lead to change?
Dr. Scarlet: We are built to avoid discomfort and look for pleasure. Hence, when something makes us uncomfortable, such as giving a speech in front of a class, we might purposely avoid it. I’ve seen many teens and young adults fail classes or drop out of school merely because they were too anxious to do presentations. However, if we can help people think about public speaking as a challenge—as an invitation to a heroic quest, something that Batman might have had to face—it might make it easier to face that challenge. Similarly, if we are able to help our clients connect with their core values and future goals, then present-moment discomfort may become more manageable.

CCPR: And that circles back to the idea of acceptance, of tolerating emotions?
Dr. Scarlet: Exactly. Most people understandably want to avoid situations that make them feel anxious, overwhelmed, or in other ways uncomfortable. However, the more willing we are to experience uncomfortable emotions, and the more we can remember what we are doing it for (eg, our core values), the more likely we are to tolerate these emotions. In fact, most people find that when they are willing to experience uncomfortable emotions, such as grief or anxiety, the emotions themselves become more tolerable over time.

CCPR: How does ACT help patients tolerate their emotions?
Dr. Scarlet: In some ways, ACT works as a gentle exposure to emotions. By allowing clients to notice the sensations that they are experiencing, they learn to not be afraid of these emotions over time. As my clients become more willing to experience these sensations, they often report feeling more “free” and no longer being held back by these emotions.

CCPR: Can you give a more specific example?
Dr. Scarlet: Sure. I had been working with a client who lost her mother in a tragic accident. As is common with tragic losses, my client avoided discussing her grief with others and developed panic disorder and agoraphobia. She could not understand why she would suddenly feel terrified and why she struggled in being far away from home or her partner. When we first started talking about the loss of her mother, she reported increased tension in her body, pain and tension in her chest and shoulders, and extreme anxiety. In practicing both mindfulness and acceptance ACT skills, I invited her to just observe these sensations without judging them as bad and without trying to make them go away.

CCPR: So, what was the result?
Dr. Scarlet: Within a few minutes her breathing slowed, and she settled in her body. She reported feeling more comfortable and more willing to talk about the details of her mother’s death than she previously had been. The more she practiced noticing and mindfully sitting with her emotions, the easier it became for her to experience them. She now reports that her body tension and pain have reduced significantly, and her emotions are far more tolerable. Her panic attacks have stopped completely, and she is able to experience her anxiety—if and when it shows up—without relying on her safety person.

CCPR: We haven’t talked much about the specific indication for ACT. For what diagnostic categories or situations might we consider it?
Dr. Scarlet: ACT is transdiagnostic, which means that it can be applied to any diagnosis. It has been used to treat depression, anxiety disorders, PTSD, schizophrenia, addiction, and others (Hayes SC et al, Behavior Research and Ther 2006;44(1):1–25).

CCPR: Many of our patients are on the autism spectrum or have related problems with social communication. Can ACT be used with patients who are verbal but who have trouble seeing the point of view of others, and are perhaps perseverative about things, such as Star Wars?
Dr. Scarlet: Yes, and I do see many adolescent clients on the autism spectrum. Some people can perseverate about their fandoms, be it Star Wars, Harry Potter, or Doctor Who. These very fandoms can be incorporated into ACT (or any other evidence-based therapy) to help people better understand social skills through examples found in these shows or movies. In addition, some people, especially those on the autism spectrum, are more likely to struggle in making connections with others but might feel connected to their fandom (this is called a parasocial relationship). ACT skills can then be taught through the lens of these parasocial relationships to help the clients see the importance of their actions and the effects that they have in the lives of others (Manning, L. Negotiating Doctor Who: Neurodiversity and Fandom. London: Macmillan; 2015).

CCPR: Your own work in ACT has had a more comic book hero cast to it. I really enjoyed reading your book Superhero Therapy: A Hero’s Journey Through Acceptance and Commitment Therapy. It was compact, clear, and had great illustrations. Are there other resources for learning about ACT?
Dr. Scarlet: I’m so glad you enjoyed it. The Happiness Trap by Russ Harris is a great resource for learning ACT, as are ACT boot camp trainings with ACT’s creator, Dr. Steve Hayes. I’ve also written 2 other ACT-based books, Harry Potter Therapy and Therapy Quest, which can be used by mental health professionals in treatment or prescribed to clients as a self-help resource.

CCPR: Thank you for your time, Dr. Scarlet.