Acceptance and Commitment Therapy (ACT)
Overview
Acceptance and Commitment Therapy (ACT) is a contemporary variant of Cognitive Behavioral Therapy (CBT). ACT utilizes acceptance and mindfulness strategies, together with commitment and behavior change strategies, to increase one’s psychological flexibility (i.e. more fully connect with the present moment). The six core principles of ACT which build psychological flexibility include: cognitive defusion; acceptance; contact with the present moment; the observing self/self as context; values and committed action.[1]
Based on Relational Frame Theory, ACT highlights the ways that language can harm someone within an internal mind-based struggle. As much of life is disorderly and unstable/ever-changing, Walser et al. (2007) note that, “ACT asks whether it is possible to let go of conscious, deliberate, purposeful control when that no longer works. Instead it walks through the process needed to come into the present, even when we have abandoned the security blanket of feel-goodism and the illusion of omnipotence.”[2]
Through metaphor, paradox, and experiential exercises, one can learn how to build healthier contact with thoughts, feelings, memories, and physical sensations that have been feared and avoided. ACT helps a person gain the skills to recontextualize and accept private events, develop greater clarity about personal values, and commit to needed positive behavior change. By building psychological flexibility, Acceptance and Commitment Therapy can aid in overcoming problematic cognitive fusion and experiential avoidance.[3]
Surprisingly, reduction of symptoms is not the focus in ACT sessions; however, symptom reduction does occur (if only as a by-product of this therapy). The goal of ACT is to create a rich and meaningful life, while accepting the pain that inevitably goes with it, using mindful action to create a meaningful life. This modality teaches mindfulness skills as an effective way to handle barriers such as unpleasant and unwanted "private experiences" (thoughts, images, feelings, sensations, urges, and memories). In Western culture, psychological suffering is often seen as abnormal; a disease or syndrome driven by unusual pathological processes, the ongoing attempt to get rid of one’s symptoms is said to be the basis of a clinical disorder in the first place. As private experiences become labeled as effectual “symptoms”, a struggle with said symptom is therefore created and viewed as something that should be ceased. However, ACT aims to transform the relationship with difficult thoughts and feelings, so that they are no longer perceived as negative symptoms, but as harmless (though uncomfortable) transient psychological events. It is through this process in which ACT achieves symptom reduction.[4]
A key component of ACT, mindfulness seeks to consciously bring awareness to the here-and-now experience with openness, interest and receptiveness. When practicing mindfulness, one lives in the present moment, fully engaging in their experience rather than “getting lost” in one’s thoughts - allowing feelings to be as they are, and letting them come and go rather than trying to control them. When private experiences are observed with openness and receptiveness, even the most painful thoughts, feelings, sensations and memories can seem less threatening or unbearable. In this regard, mindfulness can help transform a relationship with painful thoughts and feelings in a way that reduces their impact and influence over one’s life.
With a major emphasis on values, forgiveness, acceptance, compassion, living in the present moment (i.e. practicing mindfulness), and accessing a transcendent sense of self, ACT has been described as an “existential humanistic cognitive behavioral therapy.”[5]
History/Development
In the 1950s-60s, the “first wave” of behavioral therapies focused on overt behavioral change, utilizing techniques which linked to operant and classical conditioning principles. In the seventies, the “second wave” utilized cognitive interventions as a key strategy, with Aaron Beck’s Cognitive Therapy (CT) as the dominant modality.[6]
As cognitive concepts were centralized in behavior therapy during the 1970s, there was confidence that carefully defined and empirically-tested interventions would allow people to “get better.” The cognitive and behavioral tradition had adopted cultural beliefs about the importance of getting actions and attitudes “in order” to get healthy. In essence, negative feelings were sought to be removed and replaced with positive ones.[7]
Created in 1986 by Steve Hayes, Acceptance and Commitment Therapy is one modality in the “third wave” of behavioral therapies which place a major emphasis on the development of one’s mindfulness- along with Dialectical Behavior Therapy (DBT), Mindfulness-Based Cognitive Therapy (MBCT) and Mindfulness-Based Stress Reduction (MBSR).[8]
The third generation of behavioral and cognitive therapy moves away from the notion of removing negative feelings; instead, it focuses on moving towards concepts such as acceptance and mindfulness towards one’s relationship, and to the content of their thoughts and feelings. As Walser et al. explain, “This is not a superficial change. It means we are fundamentally changing our view of whether order as we formerly understood it is important.”[9]
ACT differs from the other third-wave therapies (DBT, MBCT, and MBSR) in many ways. Both MBSR and MBCT present as manualized treatment protocols which are designed for use with groups for treatment of stress and depression. DBT is typically a combination of group skills training and individual therapy, designed primarily for group treatment of Borderline Personality Disorder. ACT is differentiated in that it can be used with individuals, couples and groups, in either short or long-term therapy, in a wide range of clinical populations. Additionally, ACT allows the therapist (with or without their client) to create and individualize mindfulness techniques, rather than following a manualized protocol.[10]
Although early research and theorizing on ACT began in the 1980’s, this modality only began to be widely researched and disseminated after the publication of an official treatment manual in 1999. Hayes et al. noted that since that time, there has been an increasing number of studies of ACT interventions and processes,[11] as well as considerable interest in the approach’s potential clinical and nonclinical applications.[12]
Components
Acceptance and Commitment Therapy utilizes six core principles to develop greater psychological flexibility:
Cognitive Defusion
Acceptance
Contact with the Present Moment
The Observing Self/Self as Context
Values
Committed Action
1. Cognitive Defusion: The process of learning how to perceive thoughts, images, memories and other cognitions as nothing more than bits of language, words and pictures- not as threatening events, objective truths and facts. One’s thoughts can have an enormous influence over one’s behavior; they can seem to be the literal truth, important events that require full attention or threatening events that must be avoided. Cognitive defusion equates with being able to “step back” and observe language, without being caught up in it. By recognizing that thoughts are nothing more or less than transient private events, they have much less impact and influence.
Research finds over a hundred varied cognitive defusion techniques (e.g. observing an unpleasant thought with detachment or repeating it until it becomes a meaningless sound). Unlike traditional cognitive approaches, cognitive defusion does not involve evaluating or disputing unwanted thoughts.[13,14]
2. Acceptance: Making room for unpleasant feelings, sensations, urges, and other private experiences to come and go without struggling with them, avoiding, or giving them undue attention.[15]
By actively embracing thoughts, feelings and sensations as they occur, acceptance counteracts experiential avoidance.[16] The more time and energy we spend trying to avoid or get rid of unwanted private experiences, the more we are likely to suffer psychologically in the long term.[17] Hayes et al. note that acceptance (i.e. willingness to experience private events) is promoted because the attempt to control private events will paradoxically tend to produce more of them/more suffering over the long-term.[18,19]
Stories built around negative events and trauma can lead to negative functioning as lives get centralized around such stories. Spending extended time ruminating about something that occurred a short while or years ago or evaluating how things “could have been/should have been different” leads to the building of a narrative to explain “what happened, what should have happened” to subsequently avoid having the same happen again. Walser et al. note that loneliness is born in these places and lives remain cut off and out of balance. Further, people often begin to evaluate traumas and react to them in ways that are problematic and increase suffering as one becomes beset by judgments, arguments, evaluations, struggle, proclamations, wishes, shame, and desires to control or have some other experience.[20]
Worrying about the future also keeps one out of the present moment, reducing mindfulness. A perpetual focus on the future is often driven by wanting to control internal experiences arising out of fear of what could happen. Trauma survivors often tend to worry how much of their future will be burdened with their current problems (feeling anxious, afraid, etc.).[21] By accepting current feelings, thoughts and sensations and letting them come and go without remaining centralized and primary, one can become more mindful in their current situation without dwelling on an unknown future.
3. Contact with the Present Moment: Mindfulness brings one into the present moment with full awareness of their here-and-now experience, with openness, interest, and receptiveness. Further, one focuses on and engages fully in what they are doing and where they are.[22]
Anxiety and fears ebb and flow. Similarly, thoughts come and fade in a similar manner. Worrying about the future and trying to control it, rather than experiencing what is happening in the now, leads to undue suffering. As the future is unknown and uncontrollable, anxiety regarding the future can perpetuate further anxiety. Practicing being present in the moment, mindful that thoughts and feelings are ongoing/changeable experiences can lessen suffering.[23]
4. The Observing Self/Self as Context: Accessing a transcendent sense of self; a continuity of consciousness that is unchanging, ever-present, and impervious to harm. From this perspective, one can experience directly that they are not their thoughts, feelings, memories, urges, sensations, images, roles, or physical body. These factors change constantly and comprise various aspects of a person, but they are not the essence of who a person truly is.[24]
The conceptualized self is described by Hayes et al. (2004) as “a collection of self-referential relations that generally are both descriptive (e.g. gender) and evaluative (e.g. ‘I am unwell and have insomnia.’).”[25] These self-narratives often promote inhibitory cause-effect relationships serving as obstacles to one’s behavioral change (e.g., “I am stupid so I don’t deserve a raise”). ACT proposes that a person can become more stable when they are not defined by their thought processes; in other words, a person is not defined by their private experiences – they are a conscious vessel that contains private events.[26]
5. Values: Clarifying what is most important, significant and meaningful to you; the type of person you want to be; and what one wants to represent and stand for in their life.[27] ACT encourages individuals to personally define their values across: family, intimate relationships, friendships, career, health, education, and spiritual realm. Values differ from goals, in the sense that values pose direction, whereas goals represent specific plans of action. Goals, however, should be consistent with one’s values. Flexibility in the values concept counteracts one’s maladaptive cognitive fusion tendencies. Defining one’s values also serves to motivate in a way that allows individuals to persist in behavior change efforts even though they may be associated with unwanted private events.[28]
6. Committed Action: Utilizing your defined values to set goals and taking effective action to achieve them.[29] Most consistent with classic behavioral approaches, committed action also emphasizes the importance of values-action consistency. According to Hayes et al. (2004): “Commitments in ACT involve defining goals in specific ways along one’s valued path, then acting on these goals while anticipating and making room for psychological barriers.”[30] The other five components of ACT are central to both promote and maintain consistency of action.[31]
Treatment Techniques
In an effort to promote psychological flexibility, ACT utilizes a variety of techniques and strategies. Exposure and behavioral activation are examples of traditionally behavioral methods used. Other techniques used, which are more unique to ACT, include the use of metaphors and stories, logical paradoxes and experiential exercises.[32]
Many psychotherapeutic approaches, such as traditional CBT, prescribe explicit rules to adhere to. However, as this may potentially promote cognitive fusion, there is the chance of hampering adaptive responses to changing environmental contingencies. In ACT, the use of metaphorical language is believed to have several advantages: it is flexible and thus open to multiple interpretations; it is less linear and analytical; it is more easily remembered; and it is easier to apply in various contexts and settings. Logical paradoxes are also utilized in ACT to counteract cognitive fusion. Paradoxes demonstrate how language processes can trap people into unworkable strategies. Experiential exercises are designed to aid someone to reach contact with previously avoided private events, foster nonjudgmental awareness and acceptance, as well as undermine cognitive fusion through direct experience.[33] Strosahl, et al. (2004) note, “Mindfulness meditation practice can be conceptualized from an ACT perspective as an experiential exercise that combines aspects of acceptance, defusion, self as context, and contact with the present moment.”[34] Further, these activities expose someone to unwanted or undesirable internal stimuli that are typically avoided. Therefore, ACT employs strategies that expose someone to feared external stimuli (as with traditional behavior therapy) as well as feared internal stimuli much more broadly with the ultimate goal of acceptance (not elimination) of these experiences, in order to achieve desired therapeutic goals.[35]
Efficacy
ACT has been shown to be effective amongst a diverse range of clinical conditions: depression, OCD, workplace stress, chronic pain, stress of terminal cancer, anxiety, PTSD, anorexia, heroin abuse, marijuana abuse, and even schizophrenia.[36-40] Further, a study by Bach & Hayes[41] noted that hospital readmission rates for schizophrenic patients dropped by 50% over the next six months, after treatment of only four hours of ACT.
Specifically, regarding mindfulness, research indicates it has a positive impact in many settings. Cohen-Katz et al. (2005) and Beddoe & Murphy (2004) have found it is an effective treatment for psychological burnout in health care practitioners of differing disciplines.[42,43] Mindfulness practice has been found to improve chronic pain and stress in the elderly.[44] Ma and Teasdale (2004) found that a mindfulness-based form of cognitive therapy was effective in preventing recurrence of depression in recovered patients who had previously experienced at least three previous episodes.[45] Further research suggests that mindfulness meditation is effective in preventing relapse among substance abusers.[46] Comparing traditional CBT and ACT, Arch et al. (2012) found the modalities improved similarly across all outcomes from pre- to post-treatment, indicating that ACT is a highly viable treatment for anxiety disorders.[47]
In a 2018 meta-analysis of dropout rates in ACT, Ong, Lee and Twohig examined 68 studies, representing 4,729 participants. The weighted mean dropout rates in ACT exclusive conditions and ACT inclusive conditions (i.e. those including an ACT intervention) were 15.8% and 16.0%, respectively. Therefore, ACT dropout rates were not significantly different from those of other established psychological treatments. In addition, they found that dropout rates did not vary by client characteristics nor study methodological quality.[48]
A further benefit to patients, Strosahl, Hayes, Bergan and Romano[49,50] found that the utilization of Acceptance and Commitment Therapy increases therapist effectiveness. Further, Hayes et al (2004) noted this modality reduces therapist burnout.[51]
If you would like to explore if ACT might benefit you, please reach out to a licensed therapist for an appointment to explore your options.
Contributed by: Jennifer (Ghahari) Smith, Ph.D.
References
1 “Acceptance & Commitment Therapy (ACT),” Association for Contextual Behavioral Science (ACBS) (accessed 8-10-20) contextualscience.org/act
2 Walser, Robyn, et al. Acceptance and Commitment Therapy for the Treatment of Post-Traumatic Stress Disorder and Trauma-Related Problems : A Practitioner's Guide to Using Mindfulness and Acceptance Strategies, New Harbinger Publications, 2007.
3 “Acceptance & Commitment Therapy (ACT),” Association for Contextual Behavioral Science (ACBS)
4 “Embracing Your Demons: An Overview of Acceptance and Commitment Therapy,” Psychotherapy.net (accessed 8-10-20) www.psychotherapy.net/article/Acceptance-and-Commitment-Therapy-ACT
5 Ibid.
6 Ibid.
7 Walser, Robyn, et al. (2007)
8 “Embracing Your Demons: An Overview of Acceptance and Commitment Therapy,” Psychotherapy.net
9 Walser, Robyn, et al. (2007)
10 “Embracing Your Demons: An Overview of Acceptance and Commitment Therapy,” Psychotherapy.net
11 Hayes, S.C., Luoma, J.B., Bond, F.W., Masuda, A., & Lillis, J. (2006). Acceptance and Commitment Therapy: Model, Processes and Outcomes. Behaviour Research and Therapy, 44, 1–25.
12 Hayes, S.C., & Strosahl, K.D. (Eds.). (2004). A Practical Guide to Acceptance and Commitment Therapy. New York: Springer.
13 “Embracing Your Demons: An Overview of Acceptance and Commitment Therapy,” Psychotherapy.net
14 Gaudiano, B.A. (2011). A Review of Acceptance and Commitment Therapy (ACT) and Recommendations for Continued Scientific Advancement. The Scientific Review of Mental Health Practice, 8:2.
15 “Embracing Your Demons: An Overview of Acceptance and Commitment Therapy,” Psychotherapy.net
16 Hayes, S.C., Strosahl, K.D., Bunting, K., Twohig, M., & Wilson, K.G. (2004). What is Acceptance and Commitment Therapy? In S.C. Hayes & K.D. Strosahl (Eds.), A Practical Guide to Acceptance and Commitment Therapy (pp.7). New York: Springer.
17 “Embracing Your Demons: An Overview of Acceptance and Commitment Therapy,” Psychotherapy.net
18 Hayes, S.C. (2004). Acceptance and Commitment Therapy, Relational Frame Theory, and the Third Wave of Behavioral and Cognitive Therapies. Behavior Therapy, 35, 639–665.
19 Wenzlaff, E.M., & Wegner, D.M. (2000). Thought Suppression. Annual Review of Psychology, 51, 59–91.
20 Walser, Robyn, et al. (2007)
21 Ibid.
22 “Embracing Your Demons: An Overview of Acceptance and Commitment Therapy,” Psychotherapy.net
23 Walser, Robyn, et al. (2007)
24 “Embracing Your Demons: An Overview of Acceptance and Commitment Therapy,” Psychotherapy.net
25 Hayes et al. (2004) pp 8-9.
26 Hayes, S.C., Strosahl, K.D., & Wilson, K.G. (1999). Acceptance and Commitment Therapy: An Experiential
Approach to Behavior Change. New York: Guilford. pp 188.
27 “Embracing Your Demons: An Overview of Acceptance and Commitment Therapy,” Psychotherapy.net
28 Gaudiano, B.A. (2011).
29 “Embracing Your Demons: An Overview of Acceptance and Commitment Therapy,” Psychotherapy.net
30 Hayes et al. (2004) pp 11.
31 Gaudiano, B.A. (2011).
32 Ibid.
33 Hayes, S.C., Strosahl, K.D., & Wilson, K.G. (1999).
34 Strosahl, K.D., Hayes, S.C., Wilson, K.G., & Gifford, E.V. (2004). An ACT Primer: Core Therapy Processes, Intervention Strategies, and Therapist Competencies. In S.C. Hayes & K.D. Strosahl (Eds.), A Practical Guide to Acceptance and Commitment Therapy (pp. 21–58). New York: Springer.
35 Gaudiano, B.A. (2011).
36 Bond, F. W. & Bunce, D. (2000). Mediators of change in emotion-focused and problem-focused worksite stress management interventions. Journal of Occupational Health Psychology, 5, 156-163
37 Branstetter. A. D., Wilson, K. G., Hildebrandt, M., & Mutch, D. (2004). Improving psychological adjustment among cancer patients: ACT and CBT. Paper presented at the Association for Advancement of Behavior Therapy, New Orleans
38 Dahl, J., Wilson, K. G., & Nilsson, A. (2004). Acceptance and commitment therapy and the treatment of persons at risk for long-term disability resulting from stress and pain symptoms: A preliminary randomized trial. Behavior Therapy, 35, 785-802
39 Twohig, M. P., Hayes, S. C., Masuda, A. (2006). Increasing willingness to experience obsessions: Acceptance and Commitment Therapy as a treatment for obsessive compulsive disorder. Behavior Therapy, 37:1. 3-13
40 Zettle, R. D., & Raines, J. C. (1989). Group cognitive and contextual therapies in treatment of depression. Journal of Clinical Psychology, 45, 438-445.
41 Bach, P. & Hayes, Steven C. (2002). The use of Acceptance and Commitment Therapy to prevent the rehospitalisation of psychotic patients: a randomized controlled trial. Journal of Consulting and Clinical Psychology, 70, 1129-1139.
42 Cohen-Katz, J., Wiley, S., Capuano, T., Baker, D., Deitrick, L., & Shapiro, S. (2005). The effects of mindfulness-based stress reduction on nurse stress and burnout: A qualitative and quantitative study. Holistic Nursing Practice , 19(2), 78-86.
43 Beddoe, A. E., & Murphy, S. O. (2004). Does mindfulness decrease stress and foster empathy among nursing students? Journal of Nursing Education , 43(7), 305-312.
44 McBee, L. (2003). Mindfulness practice with the frail elderly and their caregivers: Changing the practitioner-patient relationship. Topics in Geriatric Rehabilitation , 19(4), 257-264.
45 Ma, S. H., & Teasdale, J. D. (2004). Mindfulness-based cognitive therapy for depression: Replication and exploration of differential relapse prevention effects. Journal of Consulting and Clinical Psychology , 72(1), 31-40.
46 Breslin, F. C., Zack, M., & McMain, S. (2002). An information-processing analysis of mindfulness: Implications for relapse prevention in the treatment of substance abuse. Clinical Psychology: Science and Practice , 9(3), 275-299.
47 Arch, J. J., Eifert, G. H., Davies, C., Vilardaga, J. C. P., Rose, R. D., & Craske, M. G. (2012). Randomized clinical trial of cognitive behavioral therapy (CBT) versus acceptance and commitment therapy (ACT) for mixed anxiety disorders. Journal of Consulting and Clinical Psychology, 80(5), 750-765.
48 Ong, C.W.,Lee, E.B., & Twohig M.P. (2018). A Meta-Analysis of Dropout Rates in Acceptance and Commitment Therapy. Behaviour Research and Therapy, 104, 14-33.
49 Strosahl, K. D., Hayes, S. C., Bergan, J., & Romano, P. (1998). Does field based training in behavior therapy improve clinical effectiveness? Evidence from the Acceptance and Commitment Therapy training project. Behavior Therapy, 29, 35-64
50 Hayes, S. C., Bissett, R., Roget, N., Padilla, M., Kohlenberg, B. S., Fisher, G., et al. (2004). The impact of acceptance and commitment training on stigmatizing attitudes and professional burnout of substance abuse counselors. Behavior Therapy, 35, 821-836.
51 Hayes et al. (2004).