History of Presenting Problem

Sarah reports that her symptoms began about six months ago, shortly after the end of a long-term relationship and a significant dip in freelance work. Initially, she chalked it up to a “rough patch” and assumed she would bounce back. However, as the months went on, she found herself becoming increasingly isolated, sleeping more than 10 hours a day, and struggling to complete even small work tasks.

Psychiatric/Medication History

Sarah has no previous hospitalisations for mental health but does have a history of mild depressive episodes in her late 20s, which she managed through journaling and increased physical activity. However, this current episode feels “heavier” and more persistent.

About four months ago, her family doctor prescribed sertraline (50mg/day), which she took inconsistently due to concerns about side effects like nausea and emotional blunting. After about two months, she stopped altogether without consulting her doctor. She has not tried any other psychiatric medications but has considered going back to her GP to explore other options.

History of Suicidal Ideation

Sarah denies any current suicidal intent but admits to passive suicidal ideation. She describes occasional thoughts like, “Maybe it would be easier if I didn’t wake up,” but says she does not want to die—she just wants the pain to stop. She has never attempted suicide but once, around three months ago, looked up methods online late at night. The next morning, she felt ashamed and has not done it since, but the memory of that night scares her.

Sarah Mitchell is a 35-year-old woman working as a freelance graphic designer.

Family and Social Connections

Sarah is estranged from her father and has a somewhat strained but ongoing relationship with her mother, who lives in another city. Her younger brother checks in occasionally but is focused on his own family. Sarah is single and does not currently have a partner. Over the past six months, she has withdrawn from her once-vibrant social circle. Two close friends still reach out, though she often cancels plans or doesn’t respond, leading to feelings of guilt and shame.

Community Involvement

Previously active in a local printmaking collective and a queer women’s book club, Sarah has not participated in either for several months. Though she values creative and queer community spaces, she now feels disconnected and describes being “on the outside looking in.”

Identity and Worldview

Sarah identifies as queer and neurodivergent (self-diagnosed ADHD). She often masks these aspects of herself in professional settings, which adds to her exhaustion. She values creativity, authenticity, connection, and justice, but currently feels cut off from them.

Pets

Sarah’s six-year-old rescue cat, Miso, is a consistent source of comfort and routine. She says Miso is “probably the only reason I get out of bed most days” and sometimes the thought of caring for her prevents further emotional decline.

Evolutionary and Biological Background

Humans evolved with large brains that gave us dominance and adaptability, but this same brain now generates suffering by blending objective and subjective realities, creating rigid internal rules about how we should feel and live. These mental processes often run invisibly, making it hard to question or manage them.

FACT sees people as trapped by these mental rules, which create unnecessary suffering. Rather than eliminate painful thoughts or emotions, FACT teaches skills to help people relate to them differently—through awareness, openness, and values-based engagement. These psychological skills, often overlooked in traditional education and therapy, offer a way to break free from rigid thinking and live more meaningfully.

In FACT, suffering is not seen as abnormal. Instead, it’s viewed as a natural outcome of human language and thought. While language is useful for navigating the external world, it can cause problems when applied to our internal experiences. This often leads people to live “in their heads,” stuck in unhelpful thinking patterns and disconnected from the present moment. FACT introduces two key modes of mind: the problem-solving mind, which is analytical and cause-and-effect focused, and the wise mind, which is more present-focused and allows for greater perspective and emotional well-being. When the problem-solving mind dominates, people tend to become rigid and avoidant. Psychological flexibility is the alternative, supported by three core pillars: awareness, openness, and engagement. The goal is to help clients notice unworkable rules from their mind and create space to reconnect with what matters to them.

The Process of Radical Change

FACT’s approach to change centres on the idea that even limited interventions can lead to powerful, lasting outcomes. Rather than focusing on symptom elimination, FACT helps clients move beyond their struggle by targeting the rigidity that keeps them stuck. Symptoms are seen not as disorders, but as common reactions to life’s challenges. Change involves learning from experience—trying new behaviours, noticing what happens, and building on that. Therapists work to create momentum by connecting small shifts in behaviour to larger, personally meaningful goals. This helps strengthen motivation and builds a sense of purpose. One of the core strategies is asking powerful, open-ended questions rather than offering interpretations or advice. This helps clients stay engaged with their experience and supports long-term flexibility and growth.

One of the key techniques in FACT is focused interviewing, which uses a specific sequence of questions to help clients move toward rapid and meaningful change. These “Focusing Questions” are designed to gently expose the cost of avoidance and check whether the client’s current path aligns with what they truly value. It starts with, “What are you seeking?” — which often brings out the desire to eliminate pain. Then, “What have you tried?” invites clients to reflect on their coping strategies. Next, “How has it worked?” often reveals that the efforts to avoid pain are actually making things worse. The fourth question, “What has it cost you?” shifts attention to what’s been sacrificed along the way, relationships, opportunities, peace of mind. Finally, the question “What kind of life would you choose if you could choose?” redirects focus to personal values and hopes for the future. These five questions, used in sequence, often reframe the entire problem and can themselves be a powerful intervention.

Strategies and Tools for Increasing Motivation

FACT includes a variety of tools to quickly tap into motivation and identify areas where change is most possible. One of the therapist’s roles is to spot “leverage points” — moments in the conversation where clients show emotional reactions, become avoidant, or use “rule speak,” which often points to sensitive or meaningful areas. Tools like the Life Path and Turnaround Exercise or the True North Exercise help clients visualise where they’re headed versus where they want to go. This contrast often highlights the personal cost of avoidance and brings clarity to what really matters. For clients needing a more in-depth approach, therapists can use things like the Flexibility Profile Worksheet to assess psychological flexibility and the Four Square Tool to map out workable and unworkable behaviours. Progress is tracked using quick, in-session ratings, asking clients to rate the severity of their problem, their confidence, and how helpful the session was, keeping things grounded and responsive.

Promoting Radical Change

The heart of FACT lies in helping clients develop the skills they need to live a meaningful life, even when things are hard. Once a client recognises that their avoidance strategies aren’t working, therapy focuses on building the three pillars of psychological flexibility: awareness, openness, and engagement. FACT is ultimately a behaviour-focused model, aimed at giving people real tools for resilience. Change happens iteratively, clients try something new, learn from the result, and refine their approach. For awareness, techniques might include mindfulness, present-moment exercises, or creating distance from difficult thoughts. For openness, the work involves building willingness to feel discomfort instead of running from it. And for engagement, clients take action in the direction of what matters most, even when it’s hard. Metaphors like “true north” or “life path” help ground these ideas. The approach is flexible and adaptive, if one strategy isn’t working, the therapist shifts gears. The ultimate goal is to help clients invest their energy in a life guided by values rather than ruled by fear or avoidance.

Let’s take a look at a few of the principles:

Psychological Flexibility Related to Suffering

Sarah reports a persistent depressive episode that feels “heavier” than previous depressive episodes she’s experienced and has decided to stop taking medication due to its side effects of nausea and emotional blunting. A core principle of FACT is that efforts to change, suppress, eliminate, or control feelings can lead to ineffective problem-solving (Strosahl et al., 2012).

Her choice to stop taking her medication shows her resistance to eliminating her emotional pain, and gives us an opening to offer her the choice to observe and accept the presence of these experiences. FACT teaches clients to find a way to relate to difficult feelings without needing to suppress or eliminate them.

Connecting with and Pursuing Personal Values

Another key feature of FACT is its emphasis on helping clients connect with personal values, and engage in committed actions that are consistent with those values (Strosahl et al., 2012). Sarah has indicated that she wants to feel connected to her values again. FACT interventions are designed to help clients identify what they want to stand for in life and take committed actions toward those declarations.

Addressing Identity, Masking, and Exhaustion

FACT is a non-pathologizing approach that views suffering as arising from deficits in core processes of awareness, openness, and engagement and it works to address unworkable responses, as opposed to “symptoms” of an underlying illness (Strosahl et al., 2012). Sarah’s need to “mask” her neurodivergence and identity can be understood in the FACT framework as adhering to social rules about how she “should” behave or present herself to avoid negative outcomes. 

In Summary:

Sarah's experiences of exhaustion, feeling disconnected from values, and challenges related to her identity and neurodivergence fall within the broad scope of problems that FACT is designed to address.

Glover, N. G., Sylvers, P. D., Shearer, E. M., Kane, M.-C., Clasen, P. C., Epler, A. J., Plumb-Vilardaga, J. C., Bonow, J. T., & Jakupcak, M. (2016). The efficacy of Focused Acceptance and Commitment Therapy in VA primary care. Psychological Services, 13(2), 156–161. https://doi.org/10.1037/ser0000062

Kyllönen, H. M., Muotka, J., Puolakanaho, A., Astikainen, P., Keinonen, K., & Lappalainen, R. (2018). A 

brief Acceptance and Commitment Therapy intervention for depression: A randomized controlled trial with 3-year follow-up for the intervention group. Journal of Contextual Behavioral Science, 10, 55–63. https://doi.org/10.1016/j.jcbs.2018.08.009

Ruiz, F. J., Peña-Vargas, A., Ramírez, E. S., Suárez-Falcón, J. C., García-Martín, M. B., García-Beltrán, 

D. M., Henao, Á. M., Monroy-Cifuentes, A., & Sánchez, P. D. (2020). Efficacy of a two-session repetitive negative thinking-focused acceptance and commitment therapy (ACT) protocol for depression and generalized anxiety disorder: A randomized waitlist control trial. Psychotherapy, 57(3), 444-456. https://doi.org/10.1037/pst0000273

Strosahl, K., Robinson, P., & Gustavsson, T. (2012). Brief interventions for radical change: Principles 

and practice of focused acceptance and commitment therapy. New Harbinger Publications.

Truscott, D., & Crook, K. H. (2021). Ethics for the Practice of Psychology in Canada, Third Edition. University of Alberta Press.

Techniques:

• Focused Interviewing: We could begin by asking Sarah questions like, “What are you seeking?” to better understand what she hopes to achieve (Strosahl et al., 2012). This might include feeling less depressed, having more energy, or other personal goals, and it’s important that we tailor our approach to align with these. Next, we could explore, “What have you tried in the past?” to unpack her previous efforts. Let’s say she discusses her use of medication and her decision to stop taking it. A crucial follow-up would be to ask, “How has that worked?” and “What has that cost you?” For instance, Sarah might describe side effects such as emotional blunting and the continued presence of “heavier” depression which may be signs that her current strategies may not be serving her well. We could then help Sarah recognize the paradox: that attempts to control or eliminate emotional pain through medication or internal avoidance strategies may be preventing her from living in alignment with her values and preferred way of being.

• Promoting Openness & Awareness (Acceptance): Since directly changing her emotions has had unwanted side effects, we could work alongside Sarah to discuss the willingness to experience discomfort like sadness or depression as a choice she could make to move toward a more authentic life. 

  There’s also an opportunity to help Sarah notice her internal experiences and the external world in the present moment without getting lost in thinking or avoidance. This could be introducing present-moment breathing to anchor her attention to the present, or just simply noticing and encouraging simple observation of thoughts and feelings without judgment or analysis (Strosahl et al., 2012).

Techniques:

• Values Clarification: To get clear on how Sarah wants to live her life, we could ask “What kind of life would you choose if you could choose?” (Strosahl et al., 2012). Tools like Life Path and True North Exercise could help Sarah continue identifying and articulating her values (like creativity, authenticity, connection, and social justice) and see where her current behaviours are taking her away from living these values. 

• Promoting Engagement (Committed Action): Next, we could look at identifying workable behaviours using the Four Square Tool (page 5) to look at Sarah’s public and private behaviours and identify small actions to move her closer to her values of creativity, connection, engaging in social justice work, and practicing authenticity.

  With these small actions, we could frame them as not just tasks, but as embodying her values and symbolizing movement towards a better life (Strosahl et al., 2012). For example, doing a creative act is not just about doing art, but about living alongside Sarah’s value of creativity.

Techniques:

• Transdiagnostic Approach: FACT doesn’t treat Sarah’s queer or neurodivergent identity as challenges, but focuses on the processes (avoidance, fusion, rule-following) that create suffering related to these identities (Strosahl et al., 2012). Sarah has identified her struggle with masking, which can be framed as following rules related to dominant discourses. FACT helps expose those ways of thinking and can help reframe how strictly Sarah decides to follow those rules.

• Promoting Openness Related to Identity: Helping Sarah be willing to experience the vulnerability, anxiety, or fear of judgment that comes with not masking and identifying small steps aligned with connection and authenticity. This could be Sarah sharing a small, authentic detail with a trusted friend or connecting with queer or neurodivergent communities. To wrap up, it’s important to recognize and validate Sarah’s efforts, framing these authentic actions as courageous steps toward living more fully in alignment with her values.

In Focused Acceptance and Commitment Therapy (FACT), the therapist, as described by Strosahl et al. (2012), serves as both a model and a facilitator of acceptance, mindfulness, and committed action. These include:

• Therapist as a role model : Demonstrate acceptance, present-moment awareness, intentional choice, and committed action throughout the session. The therapist supports the client without judgement, and each session should be approached with openness, compassion, and genuine curiosity. The therapist also acts as a role model to clients to connect to emotions during intense or uncomfortable moments, encouraging the clients to do the same

• Work as equal partners “in the same stew together”:
  Create a collaborative, horizontal therapeutic relationship. Acknowledge that both therapist and client experience human suffering, with the therapist walks alongside the client.

• Use skillful questioning: Guide the conversation using open-ended questions like “What showed up for you just now?” or “How did that feel?” Avoid “why” questions, which can lead to rationalizations or defensiveness.

• Focus on the client’s lived experience: The therapist must prioritize the client’s inner world, thoughts, and feelings rather than offering interpretations. Questions such as "Would you" are important to help engage the client in the process of change.

To begin, we may show transparency and acceptance to normalize Sarah’s struggles by saying, “That sounds really tough, and it makes sense that you’d feel overwhelmed in that moment,” or, “I notice I’m feeling something as you share this…this is a heavy moment, and it’s okay to feel that together”. We can also begin modeling acceptance and openness toward difficult emotions by suggesting staying in the present moment together. For example: “Would it be okay if we just stayed with that feeling for a moment?” or, “Let’s just take a breath and notice what’s here right now, even if it’s uncomfortable”.

In these moments, we take on the role of a facilitator, helping Sarah feel more capable of navigating her emotional experiences. By maintaining a consistent presence during emotional difficulties, we model how to tolerate and stay with painful feelings. According to Glover et al. (2016), FACT promotes meaningful psychological improvements, including reductions in depressive symptoms, by helping individuals remain present with difficult emotions instead of avoiding them.

As Sarah learns to sit with distress, she may gain clearer insight into the changes she wants to make. This process supports her in finding greater meaning in life through actions aligned with her values and personal engagement. Moreover, these therapeutic shifts may contribute to a reduction in her suicidal ideation.

• Biological and psychological aspects

• Ethical and legal responsibilities

• Systemic influences

• Interpersonal and community connections

• Transference and countertransference

These factors could be affecting her energy and mood, contributing to oversleeping "more than 10 hours a day” and difficulty completing small work tasks. These symptoms may be consistent with the diagnostic criteria for depression in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2022). Furthermore, Sarah also suspects herself as having attention deficit hyperactivity disorder (ADHD). It is important for Sarah to consult with a doctor or psychiatrist to assess any underlying biological or medical contributors. If Sarah brings up these concerns, we can encourage her to openly discuss her symptoms and questions with her healthcare provider, including the possibility of medication or further evaluation. The goal is to support Sarah in being empowered to manage of her care in a way that feels respectful and meaningful to her. This may include regular consulting with her doctor about her medication.

Psychologically, Sarah presents with low mood, social withdrawal, and suicidal ideation. These experiences suggest difficulties with emotional regulation, self-worth, and a sense of hopelessness. In therapy, these areas can be explored to help decrease Sarah’s symptoms and support her in developing more effective ways to cope.

Additionally, therapeutic work can focus on finding ways to reduce Sarah’s psychological pain and build emotional resilience.

This process may involve exploring the nature of her suicidal thoughts, understanding what these thoughts are communicating to her, and assessing whether she has a specific plan or access to means. Sarah has also disclosed experiencing passive suicidal ideation and researching methods online at night.

It is also important for us to clearly communicate the limits of confidentiality, especially in situations where Sarah’s safety may be at risk. In addition, collaboratively developing a safety plan is essential. This plan may include identifying coping strategies, creating a list of support contacts, and encouraging the use of services such as a crisis line. We may also explore ways for Sarah to reconnect with family or friends so that she can draw on social support during difficult moments.

In situations of elevated risk, discussing the option of seeking hospital support may be necessary. Within sessions, we can support Sarah in developing strategies to manage suicidal thoughts and remain grounded in the present.

Sarah has identified as queer, and her experience of needing to "put on a mask" in certain environments suggests that she may not feel safe or accepted expressing her full identity. This suppression of authenticity can lead to chronic stress and emotional fatigue, particularly if she is navigating spaces that are heteronormative or lack cultural competence around gender and sexuality. The psychological toll of feeling unseen or invalidated in one’s identity may further contribute to her depression, sense of hopelessness, and withdrawal from community activities.

In therapy, it’s important to validate the impact of these systemic influences and create a space where Sarah feels safe to explore her identity without fear of judgment. Supporting Sarah in finding affirming relationships or community spaces could also serve as a protective factor in her healing process.

In addition to family factors, Sarah’s social world has also been affected. She once had a vibrant social circle, especially among her former art school peers and colleagues. However, over the past six months, Sarah has increasingly withdrawn, often cancelling plans or not replying to messages. Although two close friends continue to reach out, she finds it difficult to engage and has expressed guilt and shame about not being “a good friend". This ongoing withdrawal not only disrupts her connections but may also deepen her sense of isolation and reinforce self-critical beliefs. She has also stopped participating in community activities, which were once a meaningful part of her routine.

In therapy, exploring both family and social dynamics can help Sarah better understand how past and present relationships shape her emotional experiences. It may also offer opportunities to build or restore connections that support her healing and sense of belonging.

We may also experience countertransference, such as frustration if Sarah disengages or a desire to “fix” things quickly when she expresses emotional pain. If not recognized, these reactions could unintentionally reinforce Sarah’s fear of being a burden or misunderstood. To navigate these dynamics, the therapist can use a stance of openness and consistency. For example, acknowledging absences with curiosity rather than judgement. Reflections like “it looks like last week was a hard week for you, would it feel okay to talk about what came up?” could help build trust and model emotional safety.