Catholic Medical Quarterly

The Journal of the Catholic Medical Association (UK)

Building knowledge. Building faith. Protecting the vulnerable.

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Catholic Medical Quarterly Volume 74(3) Aug 2024

Paper

ACT: A Framework for Healthcare Chaplains Responding to Patients who Experience Intrusive Worry and Anxiety

By Rev Mr Paul Green BA (Hons); BSc (Hons) MSc, PG Dip CBT, FHEA,
Parish Deacon at Holy Rood, Barnsley and Chaplain at Kendray Hospital.

Which of you can add a single hour to his life by worrying about it?’ (Mt 6:27). The rhetorical question posed by Jesus sums up the sheer pointlessness of worry. It forms one pithy remark among a series of injunctions against worry that appear in St Matthew’s Gospel. The colourful comparisons to birds and flowers, flourishing as part of God’s creation without this trait, conclude with some sage advice: ‘Do not worry about tomorrow for tomorrow will worry about itself. Each day has enough trouble of its own’ (Mt 6:34). Nevertheless, following such wise words is easier said than done, particularly for those who experience anxiety disorders of one kind or another. How should chaplains respond when meeting patients in healthcare settings who are affected by this issue? There is a framework to guide our under- standing of anxiety and how it affects the self which provides an answer to that question.

Acceptance and Commitment Therapy (ACT) is an approach to psychological problems which facilitates acceptance rather than avoidance of suffering. Individuals are encouraged to tolerate symptoms of mental distress while focusing on the values that enable them to live lives of meaning and purpose.[1] However, traditional self-help models based, like ACT, on the principles of cognitive behavioural therapy (CBT) have tended to focus on the eradication of difficult thoughts and feelings. As the architect of ACT, Steven Hayes has pointed out, ‘a central tenet of traditional CBT that is problematic came to dominate the popular understanding of the approach – we need to change negative or distorted thoughts and convert them to positive and rational ones.’[2] In my own prior experience of working as a therapist, this is particularly true of CBT treatment models for depression and anxiety disorders. Hayes himself recalls how fruitless such an approach proved in the long-term when he applied it to his own experience of panic disorder: ‘ The more determined I became that I needed to get over panic, or through it, or around it, the more I had panic attacks. [3]

Hayes developed a form of therapy based on learning to step back from negative thoughts, sensations and emotions rather than engaging with them.[4] Roemer and her colleagues found that this is particularly helpful for those diagnosed with generalised anxiety disorder, a condition characterised by intrusive worry.[5] Commenting on their findings, Hayes points out that the technique of defusing from negative thoughts, letting go of them as if they are leaves floating away on a stream, allows sufferers to live in the present moment and abandon rumination.[6] This in turn facilitates the pursuit of a life that is found to be meaningful as it is in accordance with one’s own values. He contrasts this with a contemporary focus on socially compliant goals based on dominant cultural norms or the expectations of others.[7] Moreover, defusing from negative thoughts and accepting symptoms of anxiety rather than trying to escape from them results in an outward rather than an inward-looking focus of attention. This may then encourage compassion toward others and greater spiritual well-being.[8]

The perception that suffering is an unavoidable aspect of the human condition is one that ACT shares with the Judaeo-Christian tradition.[9] Joshua J. Knabb and Keith G. Meador have tried to integrate the psychological insights provided by ACT with a theology of suffering.[10] They point to the example of Jesus who endured suffering while remaining faithful to his values of servanthood and sacrifice.[11] The authors focus on the importance of ‘distress endurance’ in which suffer- ing is accepted for the sake of things that truly matter, just as ACT advocates for values-based living in the face of challenges posed by the human condition.[12] There are parallels here with Bonho- effer’s emphasis on action in the Christian life: ‘There arises everyday anew, the question how here, today and in my present situation am I to remain and be preserved in this new life with God.[13] Knabb and Meador also point to our modern emphasis on autonomy as ‘a sort of deification of human cognition’ in which we strive to be like God rather than made in his image.[14] This feeds into unrealistic expectations that life should be free of pain and suffering, reinforced by the biomedical model underpinning psychiatry.[15]

The CBT model for generalised anxiety disorder underpins the self-help techniques recommended by Leahy.[16] His book outlines a philosophy in which, by deliberately acting against our core anxieties and challenging unhelpful beliefs, we can simply re-write the script of our lives by choosing a different set of thoughts and behaviours. O’Gor- man links this to individualism and the ideology of the free market. In his view, the rhetoric of choice that pervades the psychology of self-help books leads to the conclusion that it is our fault if we are unhappy or unsuccessful.[17] This troubling realisation is one which occurred to me while working as a cognitive behavioural psychotherapist. I once remarked to my supervisor that philosophers, writers, and artists have grappled over the centuries with the fundamental questions of our existence. It seemed inherently unlikely to me that this latest form of therapy somehow had all the answers. Moreover, while helpful in managing problems such as anxiety and depression, CBT cannot simply erase or replace complex beliefs, thoughts and behaviours accumulated over many years through the experience of the self.

One of the best descriptions of anxiety is to be found, not in the writings of any therapist or psychologist but in a book by the Danish philosopher, Soren Kierkegaard. He wrote that ‘no Grand Inquisitor has such frightful torments in readiness as has anxiety and no secret agent knows as cunningly how to attack the suspect in his weakest moment, or to make so seductive the trap in which he will be snared.’ In the same passage, anxiety is also compared to a discerning judge who never lets the accused go.[18] However, in his view, anxiety can also become ‘a ministering spirit’ that leads to faith if it is accepted rather than warded off.[19]This is reflected in the notions of acceptance and commitment to one’s values that underpin ACT.

I regularly visit patients on acute mental health wards in my role as a chaplain. A recent conversation with one of them highlighted the issues explored in this article. He described a long history of trying to control symptoms of anxiety and depression using medication, psychological treatments, avoidance strategies and various illegal substances. After stumbling across a self-help book on ACT following his admission, he discovered the notion of acceptance. The idea that he could learn to tolerate rather than seek to remove his symptoms has proved transformative for him. Our discussion ranged over topics including stoic philosophy, Buddhism, the Book of Job and what can be learned from the example of Christ’s suffering.
Roman Catholic hospital chaplains are often expected to work ecumenically, offering spiritual accompaniment to all who need it. For those struggling with the burden of mental or physical ill health, ACT offers a useful framework to explore questions of meaning, purpose, and value amid suffering. Chaplains are not therapists and should not dilute the distinctiveness of their role by acting as such. However, an approach which helps people to focus on treating themselves and others with kindness and to act in accordance with moral values is one which can only support them in their work.