According to Bach and Hayes (2002): “Acceptance and Commitment Therapy (ACT) is based on the view that many maladaptive behaviors are produced by unhealthy attempts to avoid or suppress thoughts, feelings, or bodily sensations (Hayes, Wilson, Gifford, Follette & Strosahl, 1996). Among other components, patients are taught (a) to identify and abandon internally oriented control strategies, (b) to accept the presence of difficult thoughts or feelings, (c) to learn to “just notice” the occurrence of these private experiences, without struggling with them, arguing with them, or taking them to be literally true, and (d) to focus on overt behaviors that produce valued outcomes.”
ACT has a wide variety of clinical applications. Research has demonstrated that it is especially useful in helping to reduce negative behaviors and their impact by teaching practitioners to accept troubling and stressful thoughts and emotions instead of fighting them. Acceptance of these thoughts and emotions then keeps them from interfering with desired positive behaviors (Bond & Bunce, 2000). ACT has also been used to increase acceptance (tolerance) of chronic pain, even if the pain itself is not reduced (Hayes, Bissett, et al., 1999).
ACT: A Contextual Approach
Steven C. Hayes, of the University of Nevada, Reno, is the founder of ACT. It is a contextual approach, meaning that it is based on the four factors of Contextual Therapy. These factors are: 1. facts pertinent to the client (medical history, genetic factors, physical health, employment, etc.); 2.individual psychology (the patient’s psychodynamic constitution); 3. Systemic interactions (how the patient interacts with the family system, and other factors pertaining to the biopsychosocial context in which the patient lives), and 4. Relational ethics (the unwritten and often unspoken rules about how the patient interacts with her family, and how the family interacts with her). The “context” of contextual approaches refers to all of the factors that make up a person’s personal narrative; her life story. Contextual therapies believe that all behavior, even maladaptive behavior, is purposeful when examined in the patient’s context. From this viewpoint, a therapist asks, “What is the function of the dysfunction?” In other words, what contextual processes are serving to maintain the problematic interactions?
The basic premise behind ACT is that a certain amount of suffering in the form of anxiety, stress, depression and other troublesome thoughts and behaviors, is inevitable. ACT seeks to minimize the negative impact of negative thoughts and feelings by teaching practitioners how to accept them. This is often expressed with the acronym ACT: Accept the effects of life’s hardships, Choose directional values, and Take action.
Relational Frame Theory (RFT)
Another key element of ACT is relational frame theory (RFT). One of the aspects of this approach is the theory that many psychopathologies are the result of attempts to avoid negative internal thoughts, feelings and behaviors. RFT examines how we use our language and vocabulary to remain trapped in these cycles of approach/avoidance. By examining the language we use to contextualize such situations, we are able to restructure these internal dialogues so that they have more positive outcomes. We do so by accepting that negative thoughts and feelings are a normal part of existence.
Core Processes of ACT
Hayes (2005) describes six core processes of ACT: 1. acceptance, 2. cognitive defusion, 3.being present, 4. self as context, 5. valuing, and 6. committed action. Wilson et al (1996) provides a method for using these six core processes in therapeutic interventions. An overview of this process would be:
1. Acceptance: This is the “A” portion of ACT. The first step in acceptance in ACT is to assess the patient’s patterns of avoidant behavior. These behaviors are then re-contextualized to patterns of acceptance.
2. Cognitive Defusion: If the therapeutic goal is to reduce anxiety, and effort is a cause of anxiety, then “trying hard” to minimize anxiety only generates even more anxiety. By examining this paradox in context, ACT defuses it by allowing the patient to recognize that thoughts and feelings are just processes of the mind. Thoughts and feelings are not facts; they are merely thoughts and feelings.
3. Being Present: attempting to avoid internal negative processes is akin to trying to run away from your own shadow. By turning to face these processes instead, patients learn to accept them without having to engage in the downward spiral they tend to create. This is done by avoiding the tendency to assume that thoughts and feelings are facts, but instead asking yourself, “Is acting on this thought helpful or effective?”
4. Self as Context: Here the patient learns to step back from “self in content,” and to engage “self in context.” This idea is similar to the process of externalization in Narrative Therapy. The patient is taught to engage the objective internal observer (True Self) to recognize that thoughts and feelings are content separate from the context of the True Self.
5. Valuing: ACT defines this as, “Choosing a direction and establishing willingness (acceptance)” to focus on process instead of content. This means learning to avoid the temptation to confuse values with goals. ACT enhances a client’s motivation to work towards values by engaging in the process of living, rather than becoming stuck in focusing on the content of negative thoughts and emotions.
6. Committed Action: This is the “C” portion of ACT. In the final stages of therapy, the patient makes a commitment to stop trying to avoid the past and to move forward by continuing to seek opportunities for further empowerment.
ACT Techniques and Protocols
Techniques in ACT include the use of metaphors, paradoxes, and experiential activities. Gifford, Hayes, and Stroshal (2010) define several protocols for designing these techniques. Some of these include:
1. Creative hopelessness: In this protocol, patients are asked to examine things that they have tried to make better, and to see which of these techniques have actually worked. For those that have not worked, they are asked to “make space” for something else to happen. This protocol encourages a 180-degree turn from behaviors that have not worked in the past. In short, “If what you’re doing isn’t working, try something else.”
2. Acceptance techniques: Patients are asked to reduce their motivation to engage in avoidance behaviors by unhooking their thoughts and feelings from their actions. This acceptance strategy allows them to realize that they don’t necessarily have to act on thoughts and feelings just because they are experiencing them.
3. Deliteralization (cognitive defusion): In this protocol, patients learn to observe the process without getting caught up in the outcome. By learning that thoughts are simply processes, not outcomes, the content of maladaptive thoughts can be deliteralized or defused so that they don’t have to become outcomes.
4. Valuing: In this protocol, patients are asked to focus on the things that give their lives meaning. By making choices on values, the client develops a clearer sense of self. This helps to draw the distinction between values and goals.
5. Self as context: This is a shift from content to context. This protocol allows the client to use her values to define an identity that is separate from the content of her experience. It is designed to help the client realize her identity is not the sum of the contents of her experience.
ACT Resources
There are several sites that contain resources on Acceptance and Commitment Therapy. You may wish to bookmark these for future reference:
