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Describe the theory and research behind Acceptance and Commitment Therapy
CE and PRICE
CE hours: 1.0 | fee:$10.00
Course Presenter(s):
Author(s): David Lukoff, Ph.D. | Gary Buck, PhD | (click author name for biography)
Course Description: Acceptance and Commitment Therapy (ACT) is an empirically validated psychological intervention that uses acceptance and mindfulness strategies mixed in different ways with commitment and cognitive-behavioral psychotherapy. ACT was originally created by Dr. Steven C. Hayes. The research and theory behind ACT are reviewed in this online course.
Acceptance and Commitment Therapy (ACT) was first developed in the late 1980s by Steven Hayes, currently professor of Psychology, University of Nevada, Reno. Early in his professional career, Hayes was plagued by panic attacks, especially in professional situations requiring him to speak in front of his peers or students. He tried Cognitive Behavioral Therapy along with a number of other self-help strategies, including Eastern meditation and EST. Three years of CBT led Hayes to the realization that, for him, processing his thoughts and feelings cognitively actually made them worse. He realized that he turned his painful fears into suffering whenever he tried various strategies to get rid of them. Then, in Hayes words,
"Something in that mixture of Eastern thinking and the human potential movement clicked for me. It was goofy.....But what I saw in what they did, in there, was the possibility of really pursuing this acceptance side."
Cloud J (2006) The Third Wave of Therapy. Time Magazine, Feb 13.
What Hayes had learned was that by relating to his panic attacks with acceptance, he created a space between himself and the emotions and thoughts of the attack itself. In this space he could choose to act differently. He didn't have to let his panic determine his behavior. Thus what is called the "Third Wave" of Behavioral Therapy was born.
The Third Wave of Behavioral Therapy
The initial period of Behavioral Therapy emphasized changing behavior alone. The theory proposed that when behavior was modified, changes in beliefs and emotions would follow. The "Second Wave" of Behavioral Therapy saw the introduction of cognition to the process. "Second Wave" therapy emphasized analyzing beliefs, then consciously changing those that needed changing. CBT therapists look for the ways in which the client's thoughts are inaccurate in a dysfunctional way. The therapist challenges these old inaccurate and problematic thoughts and beliefs and helps the client replace them with new ones that accurately reflect the client's life.
The "Third Wave" takes paradoxical approach to change. In a strong contrast with CBT, which uses the strategy of attacking and ultimately changing negative thoughts directly, ACT (along with other "Third Wave" therapies such as Dialectical Behavioral Therapy (DBT) and Mindfulness-Based Cognitive Therapy (MBCT)) doesn't try to control private experiences (thoughts, feelings, sensations, memories, etc.) "Third Wave" therapies are characterized more by acceptance and disidentification. Mindfulness training is the common element in "Third Wave" therapies.
Overview of ACT
ACT has its theoretical grounding in Relational Frame Theory (RFT). RFT takes the view that much of what we consider to be psychopathology results from negatively evaluating private events and subsequent internal strategies for trying to avoid them, both of which are linguistic functions. ACT therapist Jason Luomo, PhD, a Portland, OR, psychologist, summarizes the RFT/ACT connection as follows:
"RFT holds that while language has been key in allowing us to dominate the planet and create amazing levels of wealth and security, it also has a dark side. Basic properties of language seem to lie behind much of the suffering that humans experience. ACT, the applied technology resulting from RFT, attempts to help people circumvent language in those areas of life where it is less helpful, and strengthen the most useful aspects of language in the domains where it tends to be most helpful." Luomo, J. "Acceptance and Copmmitment Therapy."
In ACT, the client is taught to just notice, rather than evaluate, thoughts and emotions, accepting them as they are through the application of mindfulness.
For more on the RFT theoretical background of ACT see Yovel, I (2009) Acceptance and Commitment Therapy and the New Generation of Cognitive Behavioral Treatments. Isr J Psychiatry Relat Sci 46(4): 304-9.
This mindful approach further involves the recognition that thoughts and emotions are experiences we have as opposed to being what we are. In this process the client gets in touch with and identifies with the ongoing witness or knower of experiences. ACT sees this internal witness as a transcendental sense of self that is always there. ACT describes this shift as one from "self as content," in which we identify strongly with the content of our private experiences, to self as the context in which private experiences happen. For example a depressed client would make the shift from "I'm depressed." to "I'm having the thought that I'm depressed." The client with the tendency to be self critical might shift from "I'm a terrible person" to "I'm having the thought that I'm terrible." A patient suffering from psychotic delusions might make the shift from "I am the Queen of Sheba" to "I'm having the thought that I'm the Queen of Sheba." Such a client might continue to hear voices but not feel so compelled to act on them or take them seriously. This disidentification from thoughts and emotions and identification with the witness then allows more freedom of choice in relation to internal experiences. From Hayes's perspective, taking a disidentified stance and accepting attitude towards negative thoughts and emotions also paradoxically weakens them.
From the ACT perspective challenging thoughts and emotions are inevitable parts of human experience. The ACT theory takes the view that suffering is intensified by trying to avoid difficult or unpleasant experiences. We get stuck in unhealthy patterns of avoidance leaving us inflexible in the face of life's challenging experiences. This inflexibility leads in turn to an inability to access and act on our own core values.
As such, ACT combines acceptance and mindfulness skills with activities to help the client rediscover of their core values and then commit to changes in behavior that reflect them. Actually just the cultivation of a willingness to face and feel difficult or unpleasant thoughts and emotions with acceptance rather than struggling against them ultimately leads to greater awareness of our deepest values and yearnings. ACT therapists further support this turning towards core values by employing existential questions such as: "What do you really want your life to be about?" Other techniques include such exercises as writing your own epitaph or verbalizing your definition of a good person. Once core values are identified, clients are helped to identify and commit to a course of action to actualize them.
The overall goal of ACT is to choose effective behaviors in accordance with one's own core values even in the presence of challenging private (internal thoughts and emotions) events. For example a client who stays home from work for fear of an impending confrontation with their boss, learns to be able to go to work even though fearing confrontation.
The ACT Therapeutic Approach and the Role of Mindfulness The ACT therapist helps the client develop in six core as follows areas:
Cognitive diffusion: disidentification from thoughts, feelings other private experiences. A thought is not what I am but something I have or that happens to me. Thoughts are just thoughts, not reality.
Acceptance: Allow private experiences to come and go without trying to influence them.
Contact with the present moment: a "here and now" focus of awareness accompanied with openness to and interest in whatever is happening
Observing the self: utilizing and identifying with a transcendent, unchanging, continuous consciousness that witnesses one's experiences.
Values: opening to what are one's own deepest values.
Committed action: making goals and plans in accord with those values then acting to actualize them.
Of these six, the first four are strong elements of mindfulness practice. Mindfulness has a present moment focus that is non-judgmental towards all experience including thoughts and emotions. In mindfulness the practitioner also distinguishes between impermanent thoughts and emotions and that which knows them. ACT therapists use both metaphors and guided meditative activities to teach these mindfulness skills to their clients. For a sampling of such approaches see the following:
Two audios by ACT therapist Jason Luomo, PhD. The first is a generic mindfulness meditation exercise guiding the practitioner to be aware or the full range of present moment experience without judgment. The second is a standard ACT guided meditation called "Leaves on the Stream."
Audio of "Thoughts on a Highway" exercise. Guided meditation on working with thoughts, emotions and introduction to the observing. witnessing self.A
Hayes is careful to point out that although mindfulness is most commonly associated with Buddhism, all religions have practices that cultivate a non-judgmental relationship to our inner experiences. He is concerned that mindfulness is put into a Buddhist box when it is found in all traditions.
The metaphor and imagery are also used extensively to teach the ACT approach to clients. The following illustrate this intriguing, sometimes playful side of ACT:
Video illustrating an ACT metaphor "Demons on a Boat" from Russ Harris' book The Happiness Trap.
Video role play presentation of the ACT metaphor "The chessboard" (a metaphor of the mind and its contents).
Visual imagery: ACT therapist Joseph Ciarrochi, PhD has developed playful visual images to illustrate ACT principles like the one below. Six sets of such images can be found on his website.
"Thoughts about life are not equivalent to life: Sometimes
our minds tells us a mouse is a monster."
Research on ACT
Compared with older therapies like CBT, there is less research completed to date on ACT. Nonetheless, ACT is already listed as an evidence-based practice for depression by the American Psychological Association and is under consideration for similar listing for treatment of substance abuse by the Substance Abuse and Mental Health Services Administration. Other mental health issues for which positive research results have published include obsessive compulsive disorder, generalized anxiety disorder, social anxiety disorder, post-traumatic stress disorder, borderline personality disorder, psychosis, chronic pain, and coping with chronic physical diseases like diabetes or epilepsy.
Most research compares one therapeutic modality to a placebo, a wait list, or other kinds of control groups. Effective modalities show greater effects than those demonstrated by the control group. This has been true for ACT as well. However when effective modalities are tested against one another not so much difference is usually found. In contrast, ACT has done especially well when directly compared with other effective therapies. In such head-to-head trials against other modalities, ACT nearly always does modestly better than the other modality, no matter what it is.
Here is a recently published summary of research on ACT. For a more abbreviated overview of ACT research we turn to the website for the Association for Contextual Behavioral Science, the major professional organization associated with ACT.
Peer-reviewed articles co-authored by Steven Hayes:
Hayes SC, Villatte M, Levin M, Hildebrandt M (2010). Open, Aware, and Active: Contextual Approaches as an Emerging Trend in the Behavioral and Cognitive Therapies. Annu Rev Clin Psychol 7: 141-168.
Gaudiano BA, Herbert JD, Hayes SC (2010). Is it the symptom or the relation to it? Investigating potential mediators of change in acceptance and commitment therapy for psychosis. Behav Ther 41(4): 543-54. Epub 2010 Jun 9.
Twohig MP, Hayes SC, Masuda A (2006). Increasing willingness to experience obsessions: acceptance and commitment therapy as a treatment for obsessive-compulsive disorder. Behav Ther 37(1): 3-13. Epub 2006 Feb 21.
Other Recent Research Articles
Jurascio, AS, Forman, EM, Herbert, JD (2010) Acceptance and Commitment Therapy Versus Cognitive Therapy for the Treatment of Comorbid Eating Pathololgy. Behav Modif 34(2): 175-90.
Lundgren, T, Dahl, J, Yardi, N, Melin, L (2008). Acceptance and Commitment Therapy and Yoga for Drug-Refractory Epilepsy: A Randomized Controlled Trial. Epilepsy Behav 13(1): 102-8. Epub 2008 Mar 14.
Forman, EM, Herbert, JD, Moitra, E, Yeomans, PD, Geller, PA (2007). A Randomized Controlled Effectiveness Trial of Acceptance and Commitment Therapy and Cognitive Therapy for Anxiety and Depression. Behav Modif 31(6): 772-99.
Online audio interview with Steven C. Hayes, PhD, founder of ACT. This online interview with ACT founder Steven C. Hayes, PhD covers an overview of ACT and its relationship to RFT. (Running Time: Approx. 30 minutes)
Harris R (2010). Embracing Your Demons: An Overview of Acceptance and Commitment Therapy. Psychotherapy in Australia 12(4): 2-8.
Hayes SC (2005). Get Out of Your Mind and Into Your Life. Oakland, CA: New Harbinger. Hayes' bestseller for the general public about ACT.
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True/False Comprehension Quiz
ACT does not posit a "transcendent self"? True
Current research suggests that ACT has a statistically higher success rate for treatment of depression than control groups. True
The use of mindfulness-based acceptance strategies is common to both all forms of CBT and ACT. True
RFT, the theoretical basis for ACT, suggests that while language is effective at evaluating and solving external problems, when the same language strategies are applied to challenging emotions or thoughts, suffering is more likely to ensue. True
ACT research shows it to be effective for depression and anxiety disorders but not for psychosis. True
Steven Hayes considers ACT to be a Buddhist form of therapy. True
Steven Hayes, the developer of ACT, suffered from OCD. ACT came from his successfully treating himself. True
ACT is currently considered an evidence-based practice only for depression. True
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