Dificultades y barreras del terapeuta en el aprendizaje de la Terapia de Aceptación y Compromiso (ACT)

Purpose and Context

The article by Luciano and colleagues presents a comprehensive description of the obstacles and difficulties that therapists encounter during the process of learning and implementing Acceptance and Commitment Therapy (ACT). Despite ACT's exponential growth in recent years—with numerous workshops, specialized training courses, international conferences, and a solid empirical evidence base—the authors note that significant difficulties arise when theory and clinical practice are not properly aligned. This analysis is particularly relevant given that ACT involves a complex integration of principles from functional contextualism, Relational Frame Theory (RFT), and functional analysis of behavior.

Theoretical and Conceptual Foundation

The authors contextualize their discussion within the evolution of third-generation contextual therapies, emphasizing that the most important paradigm shift in contemporary therapy comes from traditional cognitive-behavioral perspective toward a functional vision of private events. Rather than viewing private events (thoughts, emotions, memories) as problems requiring direct modification—as in cognitive therapy—ACT proposes a fundamental restructuring of the relationship with these events. Building on Skinner's lineage that considered private events as fundamental behaviors, ACT advances toward a functional understanding of psychological suffering and proposes interventions centered on generating psychological flexibility.

Psychological inflexibility, a central concept in ACT, is defined as a rigid and avoidant reaction to private events that produces a state of profound dissatisfaction. Conversely, psychological flexibility—the therapeutic objective—involves developing the capacity to experience private events while acting in service of the individual's personal values. This conceptual framework fundamentally differs from traditional cognitive-behavioral approaches and creates the first layer of difficulties in ACT learning: therapists must unlearn previous patterns and adopt novel functional and relational logic.

Central Difficulties in ACT Learning

1. Misalignment Between Theory and Practice

The article identifies as a fundamental problem the disconnection between theoretical knowledge and systematic clinical implementation. Many therapists learn ACT in a fragmented manner, without a solid foundation in the fundamental principles of functional contextualism, relational frame theory, or functional analysis of behavior. This lack of deep understanding generates difficulties when the therapist must respond flexibly to unforeseen clinical situations. The authors emphasize that understanding the logic and laws of human behavior—particularly how language and cognition function—is essential to adapt ACT interventions effectively and contextually.

2. Generic Therapist Barriers

The authors describe a set of common barriers that obstruct the development of effective therapeutic skills:

• Therapist's experiential avoidance: The therapist experiences discomfort with certain private events arising during the session and consequently avoids important aspects of therapeutic work
• Blocking and non-responsiveness: The therapist finds themselves without words or clear direction when the patient presents unexpected responses
• Lack of directional clarity: The therapist fails to provide clear guidance about what to do or where to go in the session
• Reactivity to derived rules: The therapist automatically follows previous rules or beliefs without contextual flexibility
• Lack of systematic supervision: The absence of structured feedback and ongoing supervision prevents development of clinical competencies

3. The Problem of Patient "Problematic" Behaviors

The authors illustrate how therapists frequently become trapped in an inflexible pattern of attempting problem resolution. When the patient presents behavior the therapist identifies as problematic, the natural reaction is to attempt direct behavior change. However, ACT proposes different logic: the therapist must help the patient develop a functional relationship with private events while acting in service of personal values. This requires the therapist to learn to discriminate between:

• What the patient feels, thinks, and experiences in session
• What these experiences mean in terms of the patient's avoidant-inflexible pattern
• How to direct the patient's behavior toward constructing a flexible repertoire

The authors present detailed clinical examples of patients with profound depression, chronic anxiety, and other complex clinical problems, demonstrating how rigid adherence to attempts at direct symptom change can obstruct therapeutic progress. In these cases, the patient requires experiencing the continuity of private events while learning to act in ways that increase meaning and satisfaction in life.

4. Barriers in Therapeutic Interaction

A critical aspect analyzed is how interactions between therapist and patient can reveal problematic dynamics. In ACT, as in any psychological therapy, special functions are activated during therapeutic interaction in which both behaviors—those of patient and therapist—affect the outcome of change. The authors emphasize that:

• Interactions are not effective or ineffective in themselves, but depend on context and the direction the therapist establishes
• The therapist must endeavor to ensure interactions with the patient move toward improving the patient's life according to personal values
• This requires the therapist to generate conditions for the patient to learn to discriminate their own behavior in a flexible manner

The therapeutic relationship in ACT must allow the patient to observe how the therapist acts with flexibility and purpose, modeling openness to private events (such as discomfort, uncertainty, or pain) while maintaining clear direction toward meaningful objectives.

5. The Two-Sided Coin: Theory and Practice

The authors argue that producing a complete flexible repertoire requires therapists to be capable of manufacturing "both sides of the coin": they must understand theory deeply (functional contextualism, RFT, functional analysis) and must also master concrete techniques and processes of clinical implementation. However, difficulties arise when there is discrepancy between these two aspects. A common practical problem is that trainees observe patterns from only one side of the coin, without seeing how theory translates into effective action. This motivated the authors to develop a systematic training model integrating both aspects.

Systematic ACT Training Framework

The authors present a training model addressing three interconnected strategies for developing therapists' ability to generate psychological flexibility in patients:

First Strategy: Discrimination of Inflexible Behavior

This strategy seeks to help the therapist learn to discriminate when a patient is in a pattern of avoidance or rigidity. The therapist learns to identify the invariant pattern—how the patient responds consistently inflexibly to certain private events. In session, the therapist directly invites the patient to become aware of their own behavior, discriminating between what they feel/think (private events) and what they do (observable behavior). This discrimination is fundamental because it establishes the foundation for the patient to understand their problematic pattern.

Second Strategy: Hierarchical Detection and Framing of Behavior

Once the inflexible pattern is discriminated, the therapist must help the patient detect how this behavior relates hierarchically to the broader deficit or problem. That is, the therapist seeks to clarify the patient's meaningful direction, connecting their problematic behavior to the values and life directions that matter. This implies that therapist and patient work together to understand how current avoidance or inflexibility is obstructing the life the patient desires to live.

Third Strategy: Detection of Augmenting Functions and Direction

The third strategy aims to help the patient detect the augmenting functions (how certain private events coordinate with problematic behavior) and the direction in which the patient might act differently. Thus, at other moments, the therapist's action will be more directed toward clarifying the patient's meaningful direction, while remaining open to any thoughts and emotions that arise in the process.

These three strategies are present in one another, so that working in one means working in the others, because all are channeled to a single objective: generating a flexible repertoire in the patient technically defined by framing one's own behavior in hierarchy with the deictic I (Törneke et al., 2015).

Integration: How Learning Context Structures Difficulties

A crucial aspect presented is that difficulties in ACT are not simply a consequence of insufficient training or deficient technique, but emerge as a direct result of lacking systematic and precise training on tools and processes. A general problem relates to the imprecise practical misalignment between theory and practice that does not gather the multiple examples necessary to learn the functioning and versatility of tools in which they are situated. A specific problem involves the patient's behaviors that produce functions in the therapist; as a result, if the therapist has not generated behavior with both sides, they cannot continue to use it with the patient.

The authors indicate that the technology for producing a complete coin appears to be available, and although a more detailed and extensive publication on this is underway, the article aims to share information accumulated through long periods of research, teaching, and clinical practice. They have made it available beyond laboratory boundaries and to those who through collaboration or participation in training have had access to it from the beginning.

Illustrative Clinical Case

The manuscript includes an extensive and detailed dialogue between a supervisor (S) and a trainee therapist (T), demonstrating how the described difficulties emerge in real practice. The example shows a case of a patient with profound depression reporting continuous sadness, inability to imagine a future, and self-sabotaging behaviors (such as abandonment of meaningful activities). Through supervised dialogue, it illustrates how:

• The therapist initially attempts to provide explanations and quick solutions
• The patient experiences blocking and avoidance regarding certain emotional topics
• The supervisor helps the therapist detect their own avoidance and reactivity
• Gradually, the therapist learns to generate conditions for the patient to develop their own flexible repertoire

The dialogue demonstrates how the supervisor facilitates the therapist discriminating what they feel in session, what they do, and the effect of this on their patient. Equally, it facilitates the trainee therapist having the opportunity to see themselves reacting in a way more aligned to facilitate the flexible repertoire in their patient. To conduct practice, through multiple examples, the supervisor will invite the therapist to practice outside session with similar sensations and thoughts.

Production of Flexible Repertoire in Presence of Therapist Barriers

The authors present two main routes to producing flexible repertoire in presence of barriers:

Generic Route: Consists of organizing a system or protocol of multiple examples designed so that trainee therapists learn to be present with their thoughts/emotions and to act in service of objectives that interest them in different areas of their life. This flexibility training would be applied later in a new context (in this case, clinical work with patients), to feel their own conduct in session and apply meaningful action to promote flexible movement in their patient.

Specific Route: Consists of working directly with the trainee therapist regarding the specific problem they present, taking them from there to expand their repertoire through multiple examples outside and inside the session.

Conclusion

The authors conclude that learning ACT involves addressing multiple levels of complexity. First, it requires deep understanding of theoretical foundations: functional contextualism, laws of behavior, and particularly how language and cognition function. Second, it requires application of this knowledge in specific therapist actions, transforming that knowledge into effective therapeutic behaviors that exemplify contextual principles. The authors emphasize that difficulties arising during ACT learning are not simply insufficient training or superficial understanding, but are a direct consequence of not having the necessary skill to deal in session with one's own emotions and thoughts arising from the context of behaviors the client presents.

These problems have been catalogued as "therapist barriers" and represent an ineffective way of reacting to one's own conduct in session, which unfortunately leads to unattained therapeutic objectives. Around this problem, the authors have described part of the history developed in the training approach and have presented some examples illustrating psychological flexibility in session. In sum, the therapist will be able to acquire a flexible repertoire, inside and outside session, that allows them to translate along this line, and from that perspective there would be ample space to exercise chosen action linked to personal values at each moment.

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