Acceptance and Commitment Therapy (ACT): A guide to this type of therapy

Acceptance and Commitment Therapy (ACT) is a contextual therapy that uses acceptance and mindfulness strategies, to increase psychological flexibility and behavioral changes. Steven C. Hayes is the founder of the ACT model that is based on the behavioral school of therapy. ACT is part of the emerging third wave therapies that also include Dialectical Behavior Therapy (DBT) and Mindfulness-Based Cognitive Therapy (MBCT). While in ACT, individuals learn to accept what they cannot control and recognize the positive actions they can take to improve life.

Acceptance and Commitment Therapy

Acceptance and Commitment Therapy: A Mindful Life

Acceptance and Commitment Therapy (ACT) is a type of psychotherapy in counseling that uses mindful strategies and behaviors to improve self-awareness and psychological perspective. ACT is an action-based therapy that is most effective when a person accepts his or her hardships and improves behavior. The goal is to put all thoughts and feelings into a positive, conscious, and rational perspective. An individual’s perspective is based on personal values and principles they have developed through life. It is important to understand that these values are a reflection of how we see ourselves and others, and they should be thought about when we are going through struggles and hardships. This belief system is called: mindfulness.

As humans, we want to have a control over painful thoughts and harmful experiences. When thinking about it, the need for control over situations is sometimes what makes us feel overwhelmed and stressed-out. This is especially so when they are out of our control and emotional reach. Acceptance and Commitment Therapy helps with a range of psychological and cognitive disorders in both children and adults. Steven C. Hayes is the founder of the ACT model that is based upon the behavioral school of therapy. The belief behind ACT is that a fulfilled life can be attained even when negative thoughts and feelings are present. The mindfulness approach falls under the third wave cognitive behavioral therapy.

Third wave therapies are a group of emerging approaches to psychotherapy that represent both an extension of and deviation from traditional cognitive behavioral treatment approaches. The treatment is separate from older styles because it focuses on a person becoming more aware of his or her surroundings both inside and outside of therapy. The ‘third wave’ of behavioral therapies started with Acceptance & Commitment Therapy and now includes therapies such as Dialectical Behavior Therapy (DBT) and Mindfulness-Based Cognitive Therapy (MBCT), and of course, Cognitive Behavioral Therapy (CBT).

Mindfulness means that a person is engaged in their feelings at all times and acceptant to the different ways the world affects their being. It’s a hot topic in the Western world, especially when it has been empirically proven to reduce stress, increase emotional intelligence, decrease traumatic thoughts, and help cultivate a fulfilling mindset about life. Mindfulness has been a significant element of Eastern Buddhist traditions for thousands of years. Many techniques of Buddhism have been incorporated in formal acceptance and commitment therapy, such as human suffering, enlightenment, and personal core values. Even though ACT practitioners have adopted Zen Buddhist aspects of wisdom, the actual religious teachings and philosophies are strictly left out. ACT is based on Relational Frame Theory (RFT) and Functional Contextualism and aims to promote psychological therapeutic outcomes and a meaningful life, while Buddhism has its own philosophy and doctrines to promote spiritual awakening and enlightenment. Thus, the suffering referred to in Buddhism includes Samsara and the cycle of rebirth, while ACT focuses mainly on patients’ target concerns and other difficulties in life from a psychological perspective (Fung, 2014).

The Association for Contextual Behavioral Science (ACBS) views ACT as a therapy based on the idea that suffering is a natural and inevitable condition for humans. The therapy provides a platform for understanding how our cognition and language are tainted from painful experiences. Mindfulness training has emerged as a powerful, evidence-based tool for enhancing psychological health. It is empirically supported as an effective intervention in a wide range of clinical disorders, including chronic pain, anxiety disorders, depression, PTSD, OCD, substance abuse, and borderline personality disorder.

Acceptance and Commitment Therapy: Relational Frame Theory (RFT)

ACT is the only Western psychotherapy developed in relation to human language and cognition—Relational Frame Theory (RFT). Steven C. Hayes was also one of the first to develop the concepts behind RFT. The principles of RFT form the framework of acceptance and commitment therapy. ACT is a behavioral theory that was first based on the analysis of human cognition. According to RFT, the core of human language and cognition is the ability to learn to relate events under arbitrary contextual control (Hayes, 2004). Individuals seek relationships between objects and experiences so they can later relate what they have learned to new things. For example, a very young child will know that a nickel is bigger than a dime, but a slightly older child will learn that a nickel is “smaller than” a dime by attribution, even though in a formal sense it is not (Hayes, 2004). Relational Frame Theory focuses on how environmental interactions influence a wide range of human thoughts and behaviors (Hayes, Barnes-Holmes, & Roche, 2001).

Three requisites for considering the existence of a relational frame are: mutual entailment, combinatorial entailment, and transformation of functions (Ruiz, 2010).

1. Mutual entailment involves the given context: if A is related in a characteristic way to B, as a result, B is now related in another characteristic way to A (Hayes, Barnes-Holmes, Roche, 2001, p. 29).
2. Combinatorial entailment involves instances in which two or more relations that have acquired the property of mutual entailment mutually combine. A given context A is related in a characteristic way to B, and A is related to C, and as a result, a relation between B and C is now mutually entailed (Ruiz, 2010).
3. Transformation of functions involves that the functions of one of the members of a relational network can change the functions of the other members of the network, including psychological conditions.

The experiences that people face sometimes follow them through life, especially when they are negative. Clinically, RFT is related to therapy because it’s an extension of the three relations I just described. An example of a scenario would be to fear to go to the grocery store because you once had a panic attack in a grocery store. RFT highlights the avoidance, fear, sadness, and language associated with particular events that are hard to deal with. Certain relational frames inhibit individuals from avoiding pain from stimuli from the past. Instead of physically avoiding the situation, third-wave RFT in ACT suggests the entire context around why the memory is there should be accepted and cognitively defused. From an RFT perspective, the literal functions of language and cognition are not automatic or mechanical: they are contextual (Hayes, 2004). Maladaptive thought processes are a result of avoiding painful events. ACT targets these events so that the person can value new ways of behaving when stressful events follow them throughout life.

Acceptance and Commitment Therapy

Six Principles of Acceptance and Commitment Therapy

There is one goal in common when using the Six Core Processes of ACT – increasing psychological flexibility. Psychological flexibility, or an individual’s ability to connect with the present moment fully, as a conscious human being, is to change or persist in behavior that is in line with identified values (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). The processes are designed as a ‘hexaflex’ that targets each of the six cores of ACT treatment. The ACT therapeutic processes include (Hayes et al., 1999):

1. Acceptance
2. Defusion
3. Present Moment
4. Self-as-Context
5. Values
6. Committed Action

The two main components are the acceptance and mindfulness processes (acceptance, defusion, present moment, and sense of self) and the commitment and behavioral change processes (committed action, values, and sense of self).

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Acceptance and Commitment Therapy: Acceptance

Clients will focus on their acceptance towards what has happened in the past. The past is important to talk about since it has a lot to do with the feelings a person has in the present. Emotional control and avoidance are two treatments that help individuals gain control over their past and current situations. An individual should accept that he or she has anxiety and that is ok to embrace emotions. Getting rid of anxiety is not the answer. ACT analyzes the whole picture as to why clients portray psychological symptoms such as: denial, confusion, mood swings, shame, self-blame, and feeling disconnected.

Acceptance and Commitment Therapy: Defusion

Defusion is a process that helps people limit their overthinking and maladaptive behavior and to let go of weakening thoughts. Individuals will identify with their thoughts and avoid disruptive truths, meaning their ‘truth’ is often the culprit. It’s a realization that our thoughts are simply, ‘just thoughts,’ and they are not literal truths that should dictate our behavior. Thoughts can be very powerful and can cause anxiety. This is especially so when certain thoughts are creating fear. Thoughts such as “I think that my boyfriend/girlfriend doesn’t love me anymore” and “I feel like I am a failure” can be defused using a variety of techniques, including mindfulness and metaphors. A common metaphor used can be “your mind is hooked on your thoughts.” Guided therapeutic imagery is another useful tool in ACT.

Acceptance and Commitment Therapy: Present Moment

This ACT process is extremely important because clients can build their sense of awareness and openness to what is happening in the present moment. The treatment helps people connect their emotions with the present moment instead of focusing on the past and future. Mindfulness plays a role in this concept and allows the individual’s values and sense of self to be unified with the current situation.

Acceptance and Commitment Therapy: Self-as-Context

Individuals are taught to accept who they are, the values they have, and the experiences that shaped them into who they stand for today. The ‘observing’ self is different from the ‘conceptualized self’ that most people possess.

Acceptance and Commitment Therapy: Values

ACT clients are encouraged to let go of any truths holding them back from their own thoughts and interests. They are encouraged to live a passionate life according to the values they stand for. Values give us purpose and they give meaning to experiences we have throughout life. What matters most to you? Is it your career, family, relationships? Clients can evaluate what is standing in the way of their family time. Perhaps it’s a demanding career or health issues. When values are identified in ACT, clients will be able to understand who they are and what they desire.

Acceptance and Commitment Therapy: Committed Action

ACT approaches are very similar to other behavioral therapies when it comes to committed action. The ACT model predicts that individuals will be able to accept their thoughts and urges, attend the present moment, self-reflect on their values, and reduce their discomfort in life using their own values and goals.

Acceptance and Commitment Therapy Techniques

Acceptance and Commitment Therapy

Acceptance and Commitment Therapy has been widely accepted by clinicians and has the ability to help treat multiple mental disorders and trauma, such as personality disorders, schizophrenia, anxiety disorders, and addictions. It can be offered as self-help, individually or in a group, such as marriage counseling.

ACT typically starts with a discussion of the clients’ needs and goals and how they have tried to succeed in achieving them. ACT protocols can vary from short interventions and to those that extend over many sessions. The Six Core Processes that include eliminating fear and discomfort, self-realization, and committed action, all model traditional behavior therapy consisting of a strategy, directed goal, and behavior change. The client must recognize their control as the main issue. Memories and events have a strong hold and control over present emotions. The therapist will try to delineate control strategies so that the client can separate reality from what is invading their mind. The purpose of ACT is to get to the root of the issue, verbally and mentally. What a client is thinking, feeling, or remembering is never the core of the problem. The therapist knows that these experiences are part of the client’s growth. They are over with and must be defused with rationality and acceptance. The process of ACT is a cycle of detecting cognitive fusion and avoidance, defusing and letting go (thus establishing new, more flexible functions for these events) and moving in a valued direction in a way that builds larger and larger patterns of effective behavior (Hayes, 2004). Instead of trying to directly change negative thoughts, acceptance and mindfulness-based skills can be used to foster positive behavioral change.

ACT incorporates linguistic techniques that both address and attempt to solve inner issues. The therapist will first set out to ask what challenges are in the way of succeeding, what feelings are associated with them, and how do you want to solve them. ACT relies heavily on paradox, metaphors, stories, exercises, behavioral tasks, and experiential processes, while logical analysis has a relatively limited role (Hayes, 2004). When mindfulness is addressed in therapy, many therapists have exercises to help the client let go of their present emotions, painful memories, sensations, and feelings. The idea is to consciously bring awareness to the present moment to engage in therapy rather than getting lost in thought. The first phases of ACT are creative hopelessness, values clarification, and the promotion of the willingness to experience the feared private events.

“The aim of creative hopelessness is to facilitate the patients’ discrimination of the short and long term effects of the actions that they are doing in order to control or avoid their feared private events, and experience the futility of trying to control them. The aim of values clarification is to facilitate patients to realize what is important in their life and, if necessary, to establish a hierarchy of values. Finally, willingness to experience the feared private events is promoted as a way to behave in accordance with the chosen personal values” (Ruiz, 2010).

Acceptance and mindfulness-based interventions can also be used to help overcome psychological problems following acquired brain injuries (ABI) and traumatic brain injuries (TBI). Bédard et al.’s (2003) mindfulness-based intervention trial investigated the effectiveness of a mindfulness-based group-support intervention for individuals with a TBI. The therapy used insight meditation, breathing exercises, guided visualization to reduce depressive symptoms and increase acceptance. Results indicated that the TBI patients who completed the intervention had a substantial improvement in overall quality of life and a reduction of depressive symptoms.

Acceptance and Commitment Therapy: Eastern Philosophy in Western Psychology

Acceptance and Commitment Therapy

Third wave therapies integrate traditional Eastern perspectives and philosophy in Western forms of therapy. Western psychology is founded on the assumption that all of us are healthy and happy human beings. Suffering and anxiety are seen as abnormal, like a disease. Many Eastern Asian practices are becoming more popular every day in our culture, such as yoga, Tai Chi, and holistic medicine. In our Western world, we are constantly focusing on ourselves and how the world contributes to our anxiety. Emotional issues and mood swings are an inevitable part of life. ACT helps individuals learn to accept who they are and value everyday experiences. This article relates the similarities between the Eastern practice of Taoism and ACT. In Taoism, intellect is not the source of knowledge but simply a way to interpret experiences. Like Taoism, ACT focuses upon a healthy resolution of the dichotomies of life, acceptance of a situation, and the acknowledgment that language is not the ultimate truth (Hurley & Callahan, 2008). Acceptance and Commitment Therapy helps people build upon their awareness of who they are in the world and empower change.

References: 

Bédard, M., Felteau, M., Mazmanian, D., Fedyk, K., Klein, R., Richardson, J., . . . Minthorn-Biggs, M. B. (2003). Pilot evaluation of a mindfulness-based intervention to improve quality of life among individuals who sustained traumatic brain injuries. Disability and Rehabilitation, 25(13). doi:10.1080/0963828031000090489

Ciarrochi, J. Bilich, L., & Godsel, C. (2010). Psychological flexibility as a mechanism of change in Acceptance and Commitment Therapy. In Ruth Baer’s (Ed), Assessing Mindfulness and Acceptance: Illuminating the Processes of Change. (pp. 51-76). New Harbinger Publications, Inc.: Oakland, CA.

Fung, K. (2014). Acceptance and Commitment Therapy: Western adoption of Buddhist tenets? Transcultural Psychiatry, 52(4), 561-576. doi:10.1177/1363461514537544

Hayes, S. C., Strosahl, K., & Wilson, K. G. (1999). Acceptance and Commitment Therapy: An experiential approach to behavior change. New York: The Guilford Press.

Hayes, S. C., Barnes-Holmes, D., & Roche, B. (Eds.). (2001). Relational Frame Theory: A Post-Skinnerian account of human language and cognition. New York: Plenum Press. Pages 29-30

Hayes, S. C. (2004). Acceptance and Commitment Therapy, Relational Frame Theory, and the Third Wave of Behavioral and Cognitive Therapies. Behavior Therapy, 35(4), 639-665. Retrieved from https://doi.org/10.1016/S0005-7894(04)80013-3.

Hayes, S. C.; Luoma, J. B.; Bond, F. W.; Masuda, Akihiko; and Lillis, J., “Acceptance and Commitment Therapy: Model, processes and outcomes” (2006). Psychology Faculty Publications. Paper 101.

Hayes, S. (n.d.). Acceptance & Commitment Therapy (ACT). Retrieved from https://contextualscience.org/act

Hurley, E., & Callahan, J. L. (2008). Integrating eastern philosophy into western psychology: A primer for students of applied psychology. Modern Psychological Studies, 13(2), 5th ser., 50-59.

Kangas, M., & McDonald, S. (2011). Is it time to act? The potential of acceptance and commitment therapy for psychological problems following acquired brain injury. Neuropsychological Rehabilitation, 21(2), 250-276. doi:10.1080/09602011.2010.540920

Kashdan, T. B., & Rottenberg, J. (2010). Psychological Flexibility as a Fundamental Aspect of Health. Clinical Psychology Review, 30(7), 865-878. doi:10.1016/j.cpr.2010.03.001

Larmar, S., Wiatrowski, S., & Lewis-Driver, S. (2014). Acceptance & Commitment Therapy: An Overview of Techniques and Applications. Journal of Service Science and Management,7, 216-221. doi:10.4236/jssm.2014.73019

Ruiz, F. J. (2010). A Review of Acceptance and Commitment Therapy (ACT) Empirical Evidence: Correlational, Experimental Psychopathology, Component and Outcome Studies. International Journal of Psychology and Psychological Therapy, 10(1), 125-162.

What is Third Wave Cognitive Behavioral Therapy? (n.d.). Retrieved from https://www.3rdwavetherapy.com/what-is-third-wave-cognitive-behavioral-therapy

Jenna Buono

Jenna is a recent graduate who earned her B.A. in Psychology with a minor in Cognitive Science. She is passionate about how the mind functions and will continue her education studying Behavioral Neuroscience. She hopes to work with children and do research in the field of Developmental Psychology.