Hope in the Face of Despair: An Acceptance and Commitment Therapy Approach to Working with Suicidal Ideation in Men

Abstract

Men, on average, are two to three times more likely to die by suicide than women. While there are multiple factors contributing to this gender difference, a growing area of interest is exploring whether men are more likely to die by suicide because hegemonic views of masculinity make it more difficult for them to seek help at times of crisis. With a view to contributing to this literature, we consider how Acceptance and Commitment Therapy (ACT) may be used to increase men’s psychological flexibility in the face of their emotional distress. As part of this exploration, we draw on the unique philosophy of science and theory of language and cognition underlying ACT to explain how the construction of male identity may contribute to this increased risk of suicide among men in the first place.

Meet Sean

Sean is a 42-year-oldmalewho recently lost hisjobfollowing unexpected redundancies in the supermarket that he had been working in. Living alone since separating from his ex-partner, Hannah, Sean only sees hischildren, Zoe (14) and James (8), for a few hours on a Saturday afternoon. As much as Sean appreciates seeing his daughter and son, he is growing increasingly frustrated that Zoe’s visits are becoming less frequent since she got a boyfriend and James isspendingan increasing amount of time playing videogames. Although Sean and Hannah do not have much contact with one another, he feels very upset that her new partner, Martin, will be moving in with her and thechildrensoon. Feeling down about his current circumstances, Sean tends to spend most of his time browsing day-time TV, smoking cannabis, surfing the internet, and watchingpornography. While Sean regularly fantasises about meeting someone, the opportunity has not arisen because he spends most of his time in his flat. Feeling increasingly hopeless about the future, Sean has been questioning the point in continuing to live, believing that hischildrenwould be better off without him, particularly now that Martin is moving in and taking over his role as afather. Despite wanting to reach out for help, Sean has been struggling to confide in his friend, Peter, about his problems because he fears judgement for being ‘weak’ and ‘failing’ to live up to his perceived responsibilities as a man.

Sean’s thoughts of ending his life mirror those of many other men. To suggest that all suicides are driven by a perceived lack of meaning and purpose in life would, however, be oversimplistic. For some historic indigenous people, suicide was seen as the ultimate act of life affirmation because it was believed to offer a pathway to the eternal (Lifton 1979). In stark contrast to this life-affirming view of suicide, throughout most of its history, the Judaeo-Christian tradition in the West has largely condemned suicide as an unforgivable ‘sin’ (Choron 1972). Given the extensive role that martyrdom played in the early beginnings of the Christian faith (Colt 1991), one could be forgiven for wondering why this ‘sinful’ view of suicide came to dominate so much of Western history (Marks 2003). Indeed, it was only in 1961—over 1500 years after St. Augustine of Hippo (353–430) first published his treatise on the ‘sinfulness’ of suicide—that the UK government decriminalised the act, so that those who did not succeed in their attempt were no longer at risk of being prosecuted for it.

While the meaning of suicide has varied across different cultures and historical periods, in his book The SuicidalMind Edwin Shneidman (1996) proposes that all suicidal acts, irrespective of their form, serve a common function: they offer a solution to a perceived problem. In the case of the aforementioned indigenous people, for example, suicide was seen to provide a solution to the problem of death by promising immortality to those who were willing to sacrifice themselves for the good of the tribe (Lifton 1979). Christ’s willingness to sacrifice himself on the cross and the martyrdom that based itself on his example could likewise be understood as attempts to ‘salvage’ humankind from its own ‘sinfulness.’ Reflecting on this problem-solving function of suicide, Shneidman (1996, p. 158) bleakly speculates on the function of most suicides in the modern world:

There are some suicides in which the idea of reunion with departed loved ones, in heaven or some other peaceful haven, is in the mind of the suicidal person. But most suicides… are disappointingly secular. The destination (or concern) is not to go anywhere except away. The goal is to stop the flow of intolerable consciousness; not to continue in an afterlife or an eternity.

It is this nihilistic form of suicide with which we are primarily concerned in this chapter.

Specifically, we aim to explore how Acceptance and Commitment Therapy (ACT; Hayes et al. 2012) might help suicidal men gripped by a sense of despair to find hope in the face of their suffering—a suffering which might seem so unbearable that self-extinction might appear like the only viable course of action. Our reason for focussing on suicidality in men is that men are two to three times more likely than women to die by suicide every year (Office for National Statistics; ONS 2017; World Health Organisation 2014). Although the reasons for this gender difference are complex, a growing area of interest is exploring whether men are more likely to die by suicide because dominant views of masculinity in society discourage them from accepting their emotional vulnerability and consequently seeking help for it at times of crisis (see Rasmussen et al. 2018; Seager and Wilkins 2014; and this volume). With the aim of contributing to this literature, we draw on the unique philosophy of science (Hayes et al. 1988) and theory of language and cognition (Hayes et al. 2001) underlying ACT to consider how the construction of male identity might account for this increased risk of suicide among men in the first place. Following the exposition of these ideas, we then examine the therapeutic potential of ACT for addressing suicidal ideation in men. To illustrate how we would work with a suicidal man using ACT, we provide a detailed example of how we would work with Sean to help him overcome his suicidal ideation by showing him that, no matter what challenges he was confronted by, it was always possible for him to find meaning in the face of his difficulties.

Functional Contextualism: The Philosophy of Science Behind ACT

Despite numerous mental health campaigns to encourage men to talk about their feelings (e.g., Campaign Against Living Miserably; CALM), the idea of the tough and stoic male has arguably remained the dominant view of masculinity in the UK (Haggett 2014). Although adverts on TV and the internet encourage men to open up about their feelings as a way of looking after their mental health, many men, like Sean, still find it difficult to confide in their friends and relatives, or indeed health professionals in general, about their personal struggles, given that they see such behaviour as being antithetical to ‘being a man’ (Williams et al. 2014). This constraining image of masculinity, however, was not always at the forefront of British society. While it was considered virtuous and wise for men to express their emotional vulnerability in Georgian times, this ‘cult of sensibility’ was subsequently replaced by a ‘cult of toughness,’ centred on power and control, as the demands of Victorian imperialism and capitalism came to define the idea of what it means to be a man (Haggett 2014).

The fact that ‘being a man’ has meant different things across different places and times suggests that essentialist views of gender—the idea that men and women differ from each other because of fixed and inherent differences in their nature—should be treated with caution. Many traditional models of male psychology have nevertheless been based on such essentialist views of masculinity (Addis et al. 2010). These essentialist views have in turn been founded on a philosophy of science known as elemental realism. Based on the root metaphor of the machine, elemental realist doctrines often liken the universe to a giant clock composed of discernable parts that mechanically interact with one another. According to this perspective, each part of the clock can be studied in isolation from its constituent parts. For instance, a cog can be distinguished from a spring, a spring can be distinguished from the pendulum, the pendulum can be distinguished from the clock hands, and so on. As can be seen in this example, a fundamental assumption of elemental realism is that there is a correspondence between the words that we use and the objects that they are meant to refer to. For example, an elemental realist would assume that the word ‘clock’ was referring to an actual object composed of real elements—‘cogs,’ ‘springs,’ etc.—that are essential to its nature. So far, so good.

Now imagine if one of these parts were suddenly to be removed from the clock, say for example, its hour-hand were to be taken off, so that one could no longer accurately read the time. Without this essential part, an elemental realist would consider the clock to be ‘faulty’ on the assumption that it could no longer carry out its essential function of telling the time. Seen from this perspective, one might also be tempted to conclude that the clock was inherently ‘dysfunctional,’ ‘bad,’ or ‘broken.’ The philosophy of science underpinning ACT, however, would offer an alternative point of view: from a functional contextualist perspective, it would not be possible to conclude that the clock was intrinsically ‘faulty’ as such a judgment would depend on the context in which it was found. For example, if someone wanted to play a practical joke on their work colleague, then a clock with no hour-dial might be considered ‘perfect’ for serving that function in that particular context. Similarly, if one were suddenly to run out of wood for a fire, then under desperate circumstances the ‘faulty clock’ might suddenly transform into an ‘excellent source of fuel’ for heating one’s home.

Given that the function of an object can vary across different contexts, functional contextualism does not assume that objects have an essential nature. Instead of assuming any direct correspondence between words and their referents, a functional contextualist would focus on the pragmatic value of a particular word or idea—that is to say, the degree to which it helped one to take effective action based on one’s goals at a particular place and time. If, for example, one were planning to direct a horror movie, then the previously ‘faulty clock’ might suddenly become an ‘excellent prop’ for setting a gothic ambience in a scene.

Extending this pragmatic perspective to narratives and ideas about male identity, a functional contextualist would refuse to attribute a priori ontological status to terms such as ‘man’ or ‘manly.’ Instead of being concerned with the ontological truth of a statement such as ‘men don’t cry,’ a functional contextualist would ask whether holding onto this idea was working for a man at a particular place and time. If his intent was to avoid the ridicule of an insensitive peer, then a man might certainly conclude that the idea that ‘men don’t cry’ was working for him. If, however, holding onto this idea was leading him to conceive of suicide as his only option for dealing with his distress, then the idea might not be considered to be working for him after all. Before considering the clinical application of this philosophy for addressing suicidality in men, we will consider the role that language plays in the formation of male identity and how this in turn might contribute to the increased risk of suicide among men.

Relational Frame Theory: The Role of Language in the Formation of Male Identity

Relational frame theory (RFT; Hayes et al. 2001) is a theory of language and cognition that is rooted in functional contextualism; it is also the theory upon which ACT is based (Hayes et al. 2012). While a complete account of RFT is beyond the scope of this chapter (see Hayes et al. 2001 for a comprehensive overview), a brief introduction to the key ideas of the theory will be provided to highlight the fundamental role that language plays in the construction of male identity (Addis et al. 2010; Sylvester and Hayes 2010).

RFT is founded on the simple but not obvious, observation that human beings are the only creature capable of deriving relations between objects without any direct training in those relations. For example, if we were to tell you that ‘John is Mark’s brother,’ then you would instantly be able to derive that ‘Mark is John’s brother’ without us having to explicitly inform you of this fact (see Fig. 1).

Fig. 1

If you learn that ‘John is Mark’s brother’, you can derive the relation that ‘Mark is John’s brother’ (shown by the dotted line) without any direct training

In addition to being able to derive such mutual relationships between objects, human beings are capable of deriving further relationships between objects by combining their mutual relationships. For instance, if we were to tell you that ‘John is Mark’s brother’ and ‘Adam is Mark’s brother,’ then you would immediately be able to derive that ‘John is Adam’s brother’ without necessarily having to be told this (see Fig. 2). What is especially interesting about this capacity for relating objects in mutual and combinatorial ways is that the resulting derived relations can influence the way we respond to the things specified in those relations. Returning to our example, if you did not like John due to some transgression that he might have committed against you in the past, then it is possible that you might also not like Mark and Adam after realising that they were related to John.

Fig. 2

If you learn that ‘John is Mark’s brother’ and ‘Adam is Mark’s brother,’ then you can derive that ‘John is Adam’s brother’ (shown by the dotted lines) without any direct training

While human beings with adequately developed language skills are capable of deriving such relations between objects, non-human animals and pre-verbal human infants do not demonstrate such a capacity. Indeed, research on human infant development suggests that the ability to derive mutual and combinatorial relationships between objects is acquired through an extensive learning history in early childhood during which a parent or caretaker repeatedly reinforces the bidirectional relationship between words and their referents—that is, if a word stands for its referent, then the referent stands for the word (Lipkens et al. 1993). For example, imagine that a parent first shows a rubber duck to a child, names it in their presence by saying ‘this is a duckie,’ and then reinforces any orientation that the infant makes towards the object. Following this initial exposure to the rubber duck, a parent might then ask the child ‘where’s the duckie’ while prompting them in the direction of the rubber duck and then reinforcing any orientation they make towards it. Through such repeated experiences of bidirectional learning, RFT proposes that children come to learn general operants for relating objects in particular ways. For instance, in the aforementioned example, the child would be said to have learnt to relate two objects in a relational frame of coordination because they had learnt to coordinate the word ‘duckie’ with the rubber duck, and vice versa. RFT metaphorically compares such general operants to relational frames because just as a picture frame can hold different pictures, so a relational frame can stipulate the relation between different objects. For example, using a frame of coordination, a child can learn not only that ‘duckie’ stands for rubber duck but also that ‘mama’ refers to mother, ‘bow wow’ to dog, ‘biscuit’ to treat, and so on.

A list of the main relational frames typically learnt in childhood is shown in Table 1 (Hayes et al. 2001). As can be seen from the list, a child typically learns to apply different relational frames depending on the relationship between objects they wish to specify. For example, if a young boy wanted to assert his difference or opposition to his younger sister, then he might employ a relational frame of distinction or opposition to state that ‘boys are different or opposite to girls.’ Similarly, if the boy wanted to declare his superiority to his sister, he could use a relational frame of comparison to state that ‘boys are better than girls.’ Drawing on the same relational frame of comparison, the boy might also wish to point out that he is ‘taller,’ ‘stronger,’ ‘older,’ ‘smarter,’ or simply ‘better’ than his younger sister in numerous other ways. If the boy was feeling less cantankerous towards his sister, then he could adopt a hierarchical relational frame to highlight that ‘boys and girls are both part of the same human race.’ If the boy continued to be in a hostile mood towards his sister, however, then he could draw on a temporal relational frame to brag that he was born ‘before’ her or a spatial relational frame to boast that he is “above” her in terms of his physical height. In a related vein, the boy might employ causal and deitic¹ relational frames to assert his authority over his sister by exclaiming: ‘you have to do as I say because mum said so.’ As can be seen from these examples, simple relational frames can be combined to create complex relational networks that gradually weave together the narrative and identity of the child.

Table 1 The main categories of relational frames typically learnt in childhood

Of all the frames listed in Table 1, the deictic frame is arguably the most central for identity formation because it involves specifying relations between objects from the perspective of the speaker (‘I-you,’ ‘here-there,’ ‘now-then’). This perspective is central to the formation of our identities because, while the contents and processes of our experiences are always changing, our sense of perspective remains unchanged. Consider, for instance, how you can still identify with your younger self in childhood even though the physical atoms and social narratives composing you have changed over time. Although your body and mind has been altered by a lifetime of experiences, there remains a continuity of consciousness between your ‘I-here-now’ and the ‘I-there-then’ of your childhood. It is upon this first person perspective that our identity is built, specifically through different relational frames combining with one another to form our self-narratives. Far from offering us an elemental realist perspective of our ‘true nature,’ however, the stories that we come to tell ourselves are heavily influenced by the verbal community we grow up in.

Nowhere is this perhaps more evident than in the case of gendered social learning where, depending on the historical time, geographical location, cultural milieu, and specific family situation, a child may be told different things about what it means to be ‘a boy’ or ‘a girl.’ As mounting evidence suggests, the cumulative effect of such learning on the sexes can be considerable (Fine 2017). For instance, the child may be told that ‘blue is for boys’ and ‘pink is for girls.’ Although such a specified relation between colour and gender are completely arbitrary, the relational frames that coordinate ‘blue’ with ‘boys’ and ‘pink’ with ‘girls’ can come to be seen as reflections of reality by being non-arbitrarily reinforced by the verbal community in which the child grows up. A boy, for example, may come to believe that ‘blue really is for boys’ and ‘pink really is for girls’ by being praised for wearing a blue item of clothing and ridiculed for choosing a pink one. Through such repeated experiences of differential reinforcement, children may also come to frame ideas ofmasculinityand feminity in opposition to one another, thereby leading them to see qualities associated with one gender to be contradictory to the other. For instance, if a young male is taught that ‘women are vulnerable, irrational, and emotional,’ then through a process of oppositional framing, he may come to believe that ‘men are strong, rational, and emotionless.’ In a similar vein, if a man is taught to equate feminity with help-seekingbehaviour, then he may conclude that such behaviour is antithetical ‘to being a man’ (Sylvester and Hayes 2010).

The implications of such processes can be far-reaching. While holding onto such beliefs may be functional in settings where help-seekingbehaviour by men would be met with rejection, such rigid and inflexible constructions of male identity can, in our experience, also lead to a narrowing of men’s behavioural choices in the context of emotional suffering. In extreme cases, we suggest that this can lead emotionally vulnerable men to conceive of suicide as their only option for dealing with their distress. Before considering ways of addressing this in the clinical setting, it is helpful to briefly explore how RFT can actually account for this problem-solving function of suicide in the first place.

Take a moment to imagine a young suicidal man who is experiencing such intense feelings of despair that it is difficult for him to conceive of an optimistic future. Given his situation, this man might think to himself ‘I will always feel hopeless; there is therefore no point in going on.’ While this imagined future might reflect a real possibility, note how it is through language, specifically through the combination of different relational frames, that the man is able to conceive of suicide as a logical solution to his perceived problems. Notice, for example, how the man’s belief—‘I will always feel hopeless’—consists of a deictic frame of ‘I-here-now’ being brought into a frame of coordination with a deictic frame of ‘I-there-then’ in the future. Both of these deictic frames, in turn, are brought into a frame of coordination with the grim experience of always feeling ‘hopeless;’ that is, the deictic frames of ‘I-here-now’ and ‘I-there-then’ are both brought into a frame of coordination with ‘hopeless.’ Based on this pessimistic construction of the future, the man next draws on a causal frame (highlighted by the word ‘therefore’) to conclude that if he ‘will always feel hopeless’ then ‘there is no point in [him] going on’ (see Table 2). As can be seen from this brief analysis, it is through the process of relational framing thatsuicidebecomes conceivable as a logical course of action.

Table 2 Relational frames involved in the construction of the following suicidal thought: ‘I will always feel hopeless; there is therefore no point in going on’

Reflecting on this process, Wilson et al. (2001) suggest that most suicidal ideation seems to consist of an over-extension of the following problem-solving formula: ‘now bad, do X, later better.’ While the ‘X’ in this equation could stand for a number of different avoidance strategies, including drinking alcohol, taking drugs, or watching pornography, at the most extreme end of the avoidance spectrum suicide can be conceived as the ultimate attempt to move from the ‘now bad’ to the ‘later better,’ especially when the emotional pain that one is attempting to overcome is perceived to be intolerable, interminable, and inescapable (Chiles and Strosahl 2005). Though perfectly logical in some respects, the trouble with this problem-solving mode of mind is that ‘it can readily address every human problem except the limits of verbal problem solving itself’ (Hayes et al. 2012, p. 57). Given these limitations of the problem-solving mind, we next explore how ACT might be used to address such suicidal ideation in men.

Promoting Psychological Flexibility in Men Through ACT

ACT is a third-wave mindfulness-based behavioural therapy that has been shown to be effective in addressing a wide range of presenting problems, including depression, anxiety, OCD, anorexia, psychosis, substance misuse, chronic pain, and terminal-illness-related stress (Hayes et al. 2012). Instead of focussing on symptom reduction, however, ACT aims to help us to live a meaningful and fulfilling life by encouraging us to drop the strugglewith our unwanted internal experiences. For many men, this is a completely new perspective, antithetical to their own cultural conditioning. Recognising that pain is a natural and unavoidable part of life, ACT notes that it is in fact the ongoing attempt to rid ourselves of unwanted experiences that leads to the development of psychological problems in the first place. Consider, for instance, how Sean had been browsing daytime TV, smoking cannabis, surfing the internet, and watching pornography on a daily basis. From an ACT perspective, these behaviours could be understood as attempts by Sean to escape his underlying sense of despair. Although these behaviours might have been giving him temporary relief from his troubles, they were unlikely to eliminate, or even ameliorate, his emotional pain in the long-term.

While ACT acknowledges that not all attempts to control our inner world are necessarily problematic, it is the extent to which these experientialavoidance strategies pull us away from the things that we value that is the criteria by which to judge whether a particular behaviour is working for us or not. For example, if Sean’s TV, cannabis, internet, and pornography use was not interfering with his ability to live a meaningful and fulfilling life, then these behaviours would not be deemed problematic. As Sean, however, had been contemplating taking his own life, we would ask him to consider whether these attempts at coping were actually working for him in terms of helping him live the life that he wanted. If Sean were to recognise that they were not, we would aim to help him to be more psychologically flexible in how he was dealing with his current circumstances.

According to ACT, psychological flexibility is the ability to be present and open to our moment-to-moment experience in such a way as to facilitate meaningful engagement with life. To explore how we might begin to help Sean to become more psychologically flexible, we will now go over the six core processes that ACT postulates to underlie such psychological flexibility: (1) values, (2) contacting the present moment, (3) defusion, (4) acceptance, (5) self-as-context, and (6) committed action (see Fig. 3).

Fig. 3

The ‘hexaflex’: this diagram is so called because the six core processes comprising the hexagon are postulated to work together to promote psychological flexibility (We would like to thank Professor Steven C. Hayes for kindly allowing us to reproduce this diagram)

The diagram depicted in Fig. 3 is commonly referred to as the ‘hexaflex’ because the six core processes comprising the hexagon all work together to promote psychological flexibility. While we have decided to start our illustration with a focus on values, it is important to point out that ACT does not adhere to a strict protocol in terms of where to begin on the hexaflex. To the contrary, ACT advocates that therapists be flexible when working towards increasing their clients’ psychological flexibility by encouraging them to ‘dance’ around the hexaflex as guided by the subtle ‘rhythm’ and ‘melody’ of the therapeutic encounter.

Values: Knowing What Matters

As you may recall, Sean had been feeling hopeless about the future because he had been feeling increasingly distant from his children, Zoe and James. Sean’s growing sense of isolation was compounded by concerns that he would eventually be displaced in his role as a father by Hannah’s new partner, Martin. Indeed, one reason why Sean had been contemplating ending his own life was because he was wondering whether Zoe and James would be better off without him. To add to his deepening sense of alienation, Sean had been spending most of his time in his flat, browsing daytime TV, smoking cannabis, surfing the internet, and watching pornography. As much as Sean wanted to be able to reach out to Peter for support, he feared doing so in case it exposed him as being inadequate as a man.

Given his growing sense of despair, Sean’s suicidal ideation could be understood as his verbal problem-solving mindtrying to help him by proposing suicide as a logical solution to his problems. After all, if Sean were dead, he would no longer have to feel the agonising loneliness and growing sense of hopelessness that was leading him to think of killing himself in the first place. As logical as this might seem, we would begin our work with Sean by getting him to reflect on whether ridding himself of his emotional distress was a prerequisite to him being able to move forward with his life, especially considering that the depth and intensity of his psychological pain was directly related to the amount he valued certain things in his life. For example, if Sean did not care about his relationship with his children or value his role as a father, then he would unlikely feel upset about Martin moving into the family home. Similarly, if intimate relationships were not important to Sean, then he would unlikely care about being single. By helping Sean to see such connections between his values and his pain, we would aim to help him understand that living a meaningful life did not necessarily entail him having to rid himself of his painful internal experiences. To the contrary, we would hope to help Sean honour his pain by supporting him to reconnect with what was most important to him in life and to take action on it in the face of his difficulties.

To this end, a crucial part of our work would focus on helping Sean to clarify what mattered to him in life. For example, what sort of father did he wish to be to Zoe and James? Similarly, what sort of friendship did he want to have with Peter? And what about his hopes and ambitions for his brief time on the planet: if he only had a short time left to live, would browsing daytime TV, smoking cannabis, surfing the internet, and watching pornography really be what he wanted to do? By helping Sean to clarify his values through questions such as this, we would hope to help him see that, no matter what the circumstances he found himself in, it was always possible for him to remain true to what was most important to him in life.

According to a common metaphor in ACT, values are like a compass because they can give us a sense of direction when we are feeling lost in life. If a value represents our chosen direction, goals are the destinations that lead us in that desired direction. Thus, after helping Sean to clarify what was most important to him, we would next ask him what goals he could set himself to start bringing his values to life. For example, if Sean told us that he wanted to be more connected to Zoe and James, then we would ask him what sort of things he might be able to do to transform this into a reality. Could he perhaps set aside some time every week to give Zoe a phone call if she preferred to spend her Saturdays with her boyfriend? Likewise, would he consider joining in when James was playing his computer games or, even better, could he think of alternative fun activities that they could do together? If he was concerned about opening up to Peter, what if anything might he be able to share with him as a first step to closing the gulf between them? After establishing what goals were most important for Sean to focus on, we would next explore what barriers were standing in the way of him taking action on them and then consider ways for him to overcome these. As a starting point, we would aim to help Sean to come more in contact with the present moment because this is, ultimately, where all of our actions take place.

Contacting the Present Moment: Being in the Here and Now

To be fully in contact with the present moment means attending to what is happening in the here and now with an attitude of openness and curiosity. As human beings, we find it extremely difficult to remain connected to our moment-to-moment experience because we can easily get caught up with what is going on in our minds. One reason why we struggle to stay in contact with the present moment is because the ‘verbal chatter’ in our heads tends to take us away from the here and now by leading us to ruminate about the past, worry about the future, or imagine hypothetical scenarios that may or not happen. Consider, for example, how Sean was capable of imagining being rejected by Peter without actually first reaching out to him for support. While Sean’s capacity to anticipate this scenario enabled him to prepare for imagined threats or dangers, it also came at the cost of him losing touch with his immediate surroundings.

To help Sean interact more effectively with the here and now, an important aspect our work would focus on developing his ability to notice his experience in the present moment. As bringing attention to his internal experiences could prove too threatening as a starting point, however, we would likely begin by teaching Sean how to ground himself in the here and now by asking him to observe what he could notice outside of himself using his senses. For instance, at the beginning of a session, we might invite Sean to take a moment to look around and notice five things that he could see, to close his eyes and to notice four things that he could hear, and to pause and notice three things that he could sense against his body; for example, the floor beneath his feet, the chair against his body, and the clothes against his skin. After Sean had an opportunity to familiarise himself with this grounding exercise, we might next invite him to take a few deep breaths and to notice the sensations involved in the act of breathing; for instance, the changes in the temperature of the air as it flowed in and out of his nostrils, the rise and fall of his chest and shoulders with each in-breath and out-breath, and the differences in effort between inhaling and exhaling. As Sean became more aware and open to these aspects of his internal experience, we would start to invite him to bring an attitude of openness and curiosity to anything else that he might be experiencing, including any difficult thoughts, feelings, images, memories, sensations, and urges that might be showing up for him during a session.

By helping Sean to become more aware of these aspects of his experience, our goal would be to help him begin to engage and interact more fully with his moment-to-moment experience, so that he could start taking more effective action on hisvalues. For example, if Sean noticed his mind telling him to pretend that everything was okay as he reached out to Peter for support, instead of allowing this thought to take him away from his valued course of action, we would hope that he would be able to start to notice and allow the thought to be there without necessarily having to let it influence his behaviour. As the verbal chatter in our heads can be very seductive, we would next aim to teach Sean how to step back from the contents of his mind when it was taking him away from what he valued.

Defusion: Stepping Back from Unhelpful Thoughts

Recall that one reason why Sean was struggling to reach out for support was because he thought that Peter might judge him as being ‘weak’ if he were to open up to him about his difficulties. Based on the aforementioned literature on RFT, we would hypothesise that one reason why Sean was struggling to seek help from Peter was because he had developed a relational network in which expressing emotional vulnerability was framed in opposition to being a man. Given this, we would expect thoughts like ‘men don’t cry,’ ‘I must be strong,’ or ‘I cannot show weakness’ as acting as a barrier to Sean confiding in Peter about his problems. Instead of getting into a debate with Sean about the ontological truth or otherwise of these ideas, consistent with functional contextual principles, we would ask him whether buying into these thoughts was taking him further or closer to what he valued. For example, if Sean believed that buying into the idea that ‘expressing vulnerability is a sign of weakness’ was helping him to have the sort of friendship that he wanted with Peter, then we would not challenge him on this point. As the idea, however, appeared to be taking him away from his friendship with Peter by leading him into social isolation, we would invite Sean to reflect on the effects of him holding onto it. If Sean were gradually able to recognise that holding onto this idea was leading him to withdraw from Peter and risking taking him away from everything that he valued by leading him to see suicide as the only logical solution to his problems, we would start to teach him to step back from his thoughts when they were being unhelpful in this way. Importantly, however, we would only start to move our work in this direction if Sean himself was able to recognise the value of doing so.

To help Sean begin to step back from his thoughts, we would introduce him to some basic defusion techniques, the purpose of which would be to help him distance himself from his ‘chatteringmind’ when it was being unhelpful. At its core, defusion involves looking at our thoughts with a sense of dispassionate curiosity and recognising them for what they are: a stream of words passing through our head that may or may not be helpful, depending on the situation we find ourselves in. Defusion is so called because it is the opposite of fusion—a state in which we are fused, entangled, or caught up with our thoughts because we respond to them as though they were literal truths. One way that we might help Sean to start holding his thoughts more lightly would be by getting him to label his thoughts as thoughts as they arose in session. For example, if Sean were to express the thought that reaching out to Peter would be a sign of weakness, we would encourage him to first notice that thought and then to label it as a thought by adding ‘my mind is having the thought that…’ as a prefix to it. To facilitate Sean’s capacity to recognise his thoughts as thoughts, we might also share certain observations with him in session, such as ‘I’m noticing that your mind is having the thought that…’ By continuously labelling Sean’s thoughts in this way, our aim would be to help Sean to learn to step back from his thoughts when they were being unhelpful and getting in the way of him taking effective action based on his values.

Another strategy that we might use to help Sean with this could include him learning to relate to his thoughts as though they were leaves on a stream that will move on if simply allowed to come and go at their own pace. Alternatively, we might invite Sean to relate to his mind as though it were a separate entity from himself; for example, an overly helpful friend who might mean well but whose suggestions might not always be helpful in every given situation. At such times, we might encourage Sean simply to acknowledge and thank his mind for the suggestion without engaging in any further dialogue with it. Whichever defusion techniques we were to introduce to Sean, the primary aim would be to help him to unhook or disentangle himself from his ‘chattering mind’ when it was preventing him from moving towards the things that he valued in life.

Acceptance: Noticing and Allowing Difficult Internal Experiences

While the mere thought of rejection was enough to prevent Sean from reaching out to Peter for support, we would be curious to explore other potential barriers standing in the way of him asking for help. For example, alongside his thoughts, it is likely that Sean would have also been experiencing strong feelings of anxiety about wanting to turn to Peter for support; memories of having his emotional vulnerability rejected by others in the past; and intrusive images of Peter judging him in the way that he feared. As a consequence of these painful internal experiences, it is likely that Sean would have also been experiencing an urge to stay away from Peter. To help Sean overcome these internal barriers, we would encourage him to notice these aspects of his experience without judgement and to see if he could allow them to be there in the service of what he valued.

To illustrate the rationale for this to Sean, we could invite him to engage in a literal tug of war with us in session, during which we would ask him to imagine that we were one of the difficult internal experiences—say his anxiety, for example—that he was wanting to get rid of. While engaged in this tug of war with us, we would encourage Sean to reflect on what he noticed as he got into a battle with us. Specifically, we would aim to help Sean notice how fighting hisanxietyonly added extratensionandstressto the emotional discomfort that was already there. Based on this insight, we would hope to help Sean see that by learning to accept his anxiety, the pain that he already felt did not have to be exacerbated by any further struggle with it. Indeed, for many men in clinical practice, who have been socialised to ‘give up’ or ‘give in’ under almost any circumstance, this moment of acceptance can bring great and welcome relief.

Given the above, we would aim to help Sean to practice being open and compassionate with his unwanted internal experiences, instead of struggling to alter them. For example, while inviting Sean to adopt a more accepting attitude towards his anxiety, we would be very clear with him that acceptance did not necessarily imply that he had to like what he was experiencing; instead it required him to be open and willing to experience whatever was there in the service of what he valued. To help Sean make space for his anxiety, we would encourage him to notice where it was located in his body—for instance, in the form of ‘butterflies’ in his stomach, tightness in his chest, or tension in his muscles—and then to gently breathe into and out from it, all the while seeing if he could just allow it to be there. By encouraging Sean to embrace his uncomfortable inner experiences in this way, our goal would be to help him to overcome any internal barriers that were standing in the way of him reaching out to Peter for support.

Self-as-Context: Connecting with the Unchanging Aspect of Our Experience

While we would hope that Sean would become better at noticing and allowing his uncomfortable inner experiences as our work progressed, we would remain conscious that he might not feel able to contain all of them based on his narrow conception of what it meant to be a man. For example, if Sean were to buy into the idea that ‘men don’t cry,’ then this would immediately limit his ability to be open to his emotional vulnerability. Drawing on the literature on RFT, we would see this self-limiting perspective as deriving from Sean’s overidentification with fixed and rigid ideas of masculinity.

In order to help Sean go beyond this narrow view of himself, we would aim to help him relate to his experience from the perspective of the self-as-context which, theoretically speaking, is constructed through the ‘I-here-now’ deictic frame upon which our identity is based (see Table 1). In contrast to the conceptualised self, which represents the narratives that shape and constrain our identity, the self-as-context refers to the ‘I-here-now’-ness of our experience—that locus or perspective within our conscious awareness that remains unchanged no matter what thoughts, feelings, images, memories, sensations, and urges we might be experiencing.

To gain an experiential sense of the self-as-context, sit in silence for a moment and notice what your mind is saying about our brief overview of the idea of the self-as-context so far. As you sit in silence, notice your thoughts and see if you can also notice the perspective from which you are noticing the thoughts that are currently running through your mind. Notice that although your thoughts are ever-changing (e.g., ‘what are they talking about… this isn’t making any sense… couldn’t they explain things more clearly…’), the ‘I-here-now’ perspective from which you observe your changing thoughts itself remains unchanged. This unchanging perspective from which we observe the changing contents of our consciousness is known as the self-as-context because it provides the context through which we experience our inner and outer world.

Therapeutically speaking, the self-as-context is an important aspect of our experience because it represents the part of ourselves that remains unchanged in the face of the ever-changing contents of our consciousness, including any uncomfortable thoughts, feelings, images, memories, sensations, and urges that we might be experiencing. Just as a chess board is unaffected by the battle that ensues between the black and white pieces on top of it, our self-as-context remains unchanged by any painful internal events that we may be experiencing. The therapeutic relevance of this unchanging perspective within ourselves is that it gives us a stable point from which we can engage more effectively with our experience. Seeing our consciousness as the sky and our ever-changing internal experiences as the weather offers another helpful way to understand this unchanging aspect of our experience: in the same way that the sky remains unharmed no matter if there is a snow storm, a hurricane, or drought, the perspective from which we perceive our internal experiences remains unchanged regardless of the depth and intensity of what we may be experiencing.

Through the use of experiential exercises and metaphors such as this, we would aim to help Sean to appreciate that, contrary to what his rigid and fixed self-narrative was suggesting, there was an aspect of himself that was limitless and boundless in terms of the uncomfortable inner experiences that he could contain. Through encouraging Sean to connect with this transcendent aspect of himself, our goal would be to help him weather any emotional storm, including the intense feelings of anxiety that he would likely experience while reaching out to Peter for support.

Committed Action: Doing What Matters

Our work with Sean would be incomplete if we did not support him to take this final step because, as already discussed, the ultimate aim of our work would be to help him to take action on what was most important to him in life. Thus, instead of just encouraging Sean to reflect on the deeper sense of connection that he wanted in his friendship with Peter, we would encourage him to do whatever it took to bring this value to life, even if doing so brought up pain and discomfort. To facilitate Sean to reach out to Peter for support, we would ask him to identify the necessary steps that he would have to take to turn his goal into a reality; for example, getting in touch with Peter, arranging where to meet up with him, and planning what to say to him. Having identified these steps, we would next ask Sean to consider any internal barriers that might get in the way of him carrying them out; for instance, anxiety about opening up to Peter and an accompanying urge to pretend that everything was okay. Lastly, we would ask Sean to think about which of the aforementioned processes—values, contacting the present moment, defusion, acceptance, and self-as-context—he could draw on to help him overcome these internal barriers. For example, to help Sean find the strength to reach out to Peter for support, we would encourage him to reflect on why it was important to him to do so. Similarly, we would encourage Sean to consider whether grounding himself in the here and now, stepping back from his chattering mind when it was being unhelpful, making room for his uncomfortable feelings in the service of his values, and relating to his internal experiences as if he were the sky and not the weather, could help him to deal with these internal barriers. By asking Sean to consider all of these things, our goal would be to enable him to do what he needed to do to strengthen and deepen his friendship with Peter. For those men, who have, like Sean, entrenched themselves in ever more deeply in isolation, such social reconnection can be profoundly important.

Building on this, we could apply the same formula to support Sean to take action on other things that were important to him in life, such as his wish to experience a greater sense of intimacy in his relationship with his children. By supporting Sean to bring his values to life, our ultimate aim would be to help him to find hope in the face of his despair by showing him that no matter what depth or intensity his emotional pain took on, it was always possible for him to honour his pain by remaining true to what was most important to him in life and taking action on it. Indeed, it is our clinical experience that for men, like Sean, who are questioning the meaning of their existence, learning to become more psychologically flexible by detaching from overvalued ideas about masculinity and reconnecting with what matters can be deeply transformative and, in many cases, life-saving. Based on this observation, we believe that ACT offers an extremely helpful approach for working with suicidal ideation in men. Given that the theory of language and cognition upon which ACT is based also offers intriguing insights into the construction of male identity and how this may lead to an increased risk of suicide among men, we hope that the ideas contained in this chapter will provide inspiration for clinical innovations and future research into this pressing area of concern.