Acceptance and commitment therapy
Acceptance and commitment therapy or ACT (typically pronounced as the word "act") is a form of clinical behavior analysis (CBA) used in psychotherapy. It is an empirically-based psychological intervention that uses acceptance and mindfulness strategies mixed in different ways with commitment and behavior-change strategies, to increase psychological flexibility. The approach was originally called comprehensive distancing. It was developed in the late 1980s by Steven C. Hayes, Kelly G. Wilson, and Kirk Strosahl.
ACT is developed within a pragmatic philosophy called functional contextualism. ACT is based on relational frame theory (RFT), a comprehensive theory of language and cognition that is an offshoot of behavior analysis. ACT differs from traditional cognitive behavioral therapy (CBT) in that rather than trying to teach people to better control their thoughts, feelings, sensations, memories and other private events, ACT teaches them to "just notice," accept, and embrace their private events, especially previously unwanted ones.
ACT helps the individual get in contact with a transcendent sense of self known as "self-as-context"—the you that is always there observing and experiencing and yet distinct from one's thoughts, feelings, sensations, and memories. ACT aims to help the individual clarify their personal values and to take action on them, bringing more vitality and meaning to their life in the process, increasing their psychological flexibility.
While Western psychology has typically operated under the "healthy normality" assumption which states that by their nature, humans are psychologically healthy, ACT assumes, rather, that psychological processes of a normal human mind are often destructive. The core conception of ACT is that psychological suffering is usually caused by experiential avoidance, cognitive entanglement, and resulting psychological rigidity that leads to a failure to take needed behavioral steps in accord with core values. As a simple way to summarize the model, ACT views the core of many problems to be due to the concepts represented in the acronym, FEAR:
- Fusion with your thoughts
- Evaluation of experience
- Avoidance of your experience
- Reason-giving for your behavior
And the healthy alternative is to ACT:
- Accept your reactions and be present
- Choose a valued direction
- Take action
ACT commonly employs six core principles to help clients develop psychological flexibility:
- Cognitive defusion: Learning methods to reduce the tendency to reify thoughts, images, emotions, and memories.
- Acceptance: Allowing thoughts to come and go without struggling with them.
- Contact with the present moment: Awareness of the here and now, experienced with openness, interest, and receptiveness.
- Observing the self: Accessing a transcendent sense of self, a continuity of consciousness which is unchanging.
- Values: Discovering what is most important to one's true self.
- Committed action: Setting goals according to values and carrying them out responsibly.
ACT had, as of October 2006, been evaluated in about 30 controlled time series studies or randomized clinical trials for a variety of client problems. As of 2011 that number has about doubled and new controlled studies are now appearing very regularly. Overall, when compared to other treatments designed to be helpful, the effect size for ACT is a Cohen's d of around 0.6 which is considered a medium effect size. In some studies ACT has exceeded the performance of gold standard treatments, in others it has been equally effective, and in one or two studies with minor problems it has not done as well.
As compared to treatments that are already known to be effective, the effect size so far is about .3, which is small. Across the whole empirical clinical psychology literature the average effect size for such comparisons approaches zero, however. All of these comparison and their effect sizes need to be viewed with caution, because many of the trials are unfunded and are based on a relatively small number of patients; and in some cases might be contaminated by the allegiance effect.
A large and well done trial by a major CBT research team on mixed anxiety disorders that showed superiority of ACT to gold standard CBT on the primary outcome measure has recently appeared however and in that study allegiance effects should have worked in the opposite direction, suggesting that at least some of the effects in favor of ACT are replicable by teams that are skeptical of this approach
In recent years larger and better controlled trials have begun to appear and the number of areas to which it has been successfully applied is growing. ACT is considered an empirically validated treatment by the American Psychological Association, with the status of "Modest Research Support" in depression and "Strong Research Support" in chronic pain, with several others specific areas such as psychosis and work site stress currently under review. ACT is also listed as evidence-based by the Substance Abuse and Mental Health Services Administration of the United States federal government which has examined randomized trials for ACT in the areas of psychosis, work site stress, and obsessive compulsive disorder, including depression outcomes.
ACT is still relatively new in the development of its research base with the randomized trials beginning in earnest only after the 1999 publication of the original book on ACT. ACT has shown preliminary research evidence of effectiveness in randomized trials for a variety of problems including chronic pain, addictions, smoking cessation, depression, anxiety, psychosis, workplace stress, diabetes management, weight management, epilepsy control, self-harm, body dissatisfaction, eating disorders, burn out, and several other areas. ACT has more recently been applied to children, adolescents and trainees, with good results.
Mediational analyses have provided evidence for the possible causal role of key ACT processes, including acceptance, defusion, and values, in producing beneficial clinical outcomes. Correlational evidence has also found that absence of these processes predicts many forms of psychopathology. A recent meta-analysis showed that ACT processes, on average, account for 16–29% of the variance in psychopathology (general mental health, depression, anxiety) at baseline, depending on the measure, using correlational methods.:12–13 A recent meta-analysis of 68 laboratory-based studies on ACT components has also provided support for the link between psychological flexibility concepts and specific components.
In New Zealand, the Department of Psychology at the University of Waikato, in conjunction with the local DHB approved research, to evaluate the effectiveness of ACT therapy (through self-help books) for people with chronic pain. The sample size was twenty-four with eligibility being reading comprehensive ability, no psychiatric disorder, stable medication and no childhood history of trauma.
The method was randomised two group study conducted over a six-week period with some participants required to read the self-help book and complete exercises. Pre-intervention and post-intervention questionnaires for acceptance, values illness, quality of life, satisfaction with life, depression, anxiety, and pain were completed. Interestingly, data demonstrated that those who completed the intervention evidenced statistically significant improvements (with large effect sizes) for acceptance, satisfaction with life and quality of life. Medium effect sizes were also established for enhancement in pain ratings. The findings maintained the proposition that utilising the self-help book, with minimal therapist contact adds value to the well-being of people who encounter chronic pain.
ACT, Dialectical Behavior Therapy, Functional Analytic Psychotherapy, Mindfulness-based Cognitive Therapy and other acceptance and mindfulness based approaches are commonly grouped under the name The Third Wave of Behavior Therapy, with the first wave commencing in the 1920s that related to Pavlov’s classical (respondent) and operant conditioning that was correlated to reinforcing consequences. The second wave emerged in the 1970s and included cognition in the form of irrational beliefs, dysfunctional attitudes or depressogenic attributions. In the late 1980s empirical limitations and philosophical misgivings of the second wave gave rise to Steven Hayes ACT theory which modified the focus of abnormal behaviour away from the content or form towards the context in which it occurs. ACT research has suggested that many of the emotional defences individuals use with conviction, to solve disorders, actually entangle humans into suffering.
Grounded in an empirical, principle-focused approach, the third wave of behavioral and cognitive therapy is particularly sensitive to the context and functions of psychological phenomena, not just their form, and thus tends to emphasize contextual and experiential change strategies in addition to more direct and didactic ones. These treatments tend to seek the construction of broad, flexible and effective repertoires over an eliminative approach to narrowly defined problems, and to emphasize the relevance of the issues they examine for clinicians as well as clients. The third wave reformulates and synthesizes previous generations of behavioral and cognitive therapy and carries them forward into questions, issues, and domains previously addressed primarily by other traditions, in hopes of improving both understanding and outcomes.
ACT has also been adapted to create a non-therapy version of the same processes called Acceptance and Commitment Training. This training process, oriented towards the development of mindfulness, acceptance, and values skills in non-clinical settings such as businesses or schools, has also been investigated in a handful of research studies with good preliminary results. This is somewhat similar to the awareness–management movement in business training programs, where mindfulness and cognitive-shifting techniques are employed.
The emphasis of ACT on ongoing present moment awareness, valued directions and committed action is similar to other psycho-therapeutic approaches that, unlike ACT, are not as focused on outcome research or consciously linked to a basic science program, including more humanistic or constructivist approaches such as Gestalt Therapy, Morita Therapy and Voice Dialogue, IFS and others.
Wilson, Hayes & Byrd explore at length the compatibilities between ACT and the 12-step treatment of addictions and argue that, unlike most other psychotherapies, both approaches can be implicitly or explicitly integrated due to their broad commonalities. Both approaches endorse acceptance as an alternative to unproductive control. ACT emphasizes the hopelessness of relying on ineffectual strategies to control private experience, similarly the 12-step approach emphasizes the acceptance of powerlessness over addiction. Both approaches encourage a broad life-reorientation, rather than a narrow focus on the elimination of substance use, and both place great value on the long-term project of building of a meaningful life aligned with the clients' values. ACT and 12-step both encourage the pragmatic utility of cultivating a transcendent sense of self (higher power) within an unconventional, individualized spirituality. Finally they both openly accept the paradox that acceptance is a necessary condition for change and both encourage a playful awareness of the limitations of human thinking.
Some within the field of clinical psychology have questioned if ACT's proposed mechanisms of change and approach to psychological experiences are different from other forms of intervention. This has led leaders in the field to critically examine the evidence supporting ACT pro and con.
The Association for Contextual Behavioral Science is committed to research and development in the area of ACT, RFT, and contextual behavioral science more generally. As of mid-2012 it had nearly 5,700 members world wide, about half outside of the United States. It holds annual "world conference" meetings: The 12th will be held in Minneapolis in June, 2014; the 13th will be held in Berlin in July, 2015.
The Association for Behavior Analysis International (ABAI) has a special interest group for practitioner issues, behavioral counseling, and clinical behavior analysis ABA:I. ABAI has larger special interest groups for autism and behavioral medicine. ABAI serves as the core intellectual home for behavior analysts. ABAI sponsors two conferences/year—one in the U.S. and one international.
The Association for Behavioral and Cognitive Therapies (ABCT) also has an interest group in behavior analysis, which focuses on clinical behavior analysis. ACT work is commonly presented at ABCT and other mainstream CBT organizations.
The British Association for Behavioural and Cognitive Psychotherapies (BABCP) has a large special interest group in ACT, with over 1,200 members.
Doctoral-level behavior analysts who are psychologists belong to the American Psychological Association's division 25—Behavior analysis. APA offers a diplomate[clarification needed] in behavioral psychology.
The World Association for Behavior Analysis offers certification in behavior therapy which covers knowledge of ACT.
- Behavior therapy
- Behavioral psychotherapy
- Clinical behavior analysis
- Experiential avoidance
- Jennifer C Plumb, Ian Stewart, Galway JoAnne Dahl, Tobias Lundgren (Spring 2009). "In Search of Meaning: Values in Modern Clinical Behavior Analysis". Behav Anal. 32 (1): 85–103.
- Hayes, Steven. "Acceptance & Commitment Therapy (ACT)". ContextualPsychology.org.
- Zettle, Robert D. (2005). "The Evolution of a Contextual Approach to Therapy: From Comprehensive Distancing to ACT". International Journal of Behavioral Consultation and Therapy 1 (2): 77–89.
- Murdock, N. L. (2009). Theories of counseling and psychotherapy: A case approach. Upper Saddle River, N.J: Merrill/Pearson
- "Getting in on the Act - The Irish Times - Tue, Jun 07, 2011". The Irish Times. 2011-06-07. Retrieved 2012-03-16.
- Harris, Russ (August 2006). "Embracing your demons: an overview of Acceptance and Commitment Therapy". Psychotherapy in Australia 12 (4): 2–8.
- Robb, Hank (2007). "Values as Leading Principles in Acceptance and Commitment Therapy". International Journal of Behavioral Consultation and Therapy 3 (1): 118–23.
- Hayes, Steven C.; Luoma, Jason B.; Bond, Frank W.; Masuda, Akihiko; Lillis, Jason (2006). "Acceptance and Commitment Therapy: Model, processes and outcomes". Behaviour Research and Therapy 44 (1): 1–25. doi:10.1016/j.brat.2005.06.006. PMID 16300724.
- 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): 125–62.
- Lappalainen, R.; Lehtonen, T.; Skarp, E.; Taubert, E.; Ojanen, M.; Hayes, S. C. (2007). "The Impact of CBT and ACT Models Using Psychology Trainee Therapists: A Preliminary Controlled Effectiveness Trial". Behavior Modification 31 (4): 488–511. doi:10.1177/0145445506298436. PMID 17548542.
- Wicksell, Rikard K.; Melin, Lennart; Lekander, Mats; Olsson, Gunnar L. (2009). "Evaluating the effectiveness of exposure and acceptance strategies to improve functioning and quality of life in longstanding pediatric pain – A randomized controlled trial". PAIN 141 (3): 248–57. doi:10.1016/j.pain.2008.11.006. PMID 19108951.
- Zettle, R. D.; Rains, J. C.; Hayes, S. C. (2011). "Processes of Change in Acceptance and Commitment Therapy and Cognitive Therapy for Depression: A Mediation Reanalysis of Zettle and Rains". Behavior Modification 35 (3): 265–83. doi:10.1177/0145445511398344. PMID 21362745.
- Forman, E. M.; Herbert, J. D.; Moitra, E.; Yeomans, P. D.; Geller, P. A. (2007). "A Randomized Controlled Effectiveness Trial of Acceptance and Commitment Therapy and Cognitive Therapy for Anxiety and Depression". Behavior Modification 31 (6): 772–99. doi:10.1177/0145445507302202. PMID 17932235.
- Zettle, Robert D. (2003). "Acceptance and Commitment Therapy (ACT) vs. Systematic Desensitization in Treatment of Mathematics Anxiety". The Psychological Record 53 (2): 3.
- Levin, Michael; Hayes, Steven C. (2009). "Is Acceptance and Commitment Therapy Superior to Established Treatment Comparisons?". Psychotherapy and Psychosomatics 78 (6): 380; author reply 380–1. doi:10.1159/000235978. PMID 19738405.
- Arch, Joanna J.; Eifert, Georg H.; Davies, Carolyn; Vilardaga, Jennifer C. Plumb; Rose, Raphael D.; Craske, Michelle 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): 750–65. doi:10.1037/a0028310. PMID 22563639.
- Gifford, Elizabeth V.; Kohlenberg, Barbara S.; Hayes, Steven C.; Pierson, Heather M.; Piasecki, Melissa P.; Antonuccio, David O.; Palm, Kathleen M. (2011). "Does Acceptance and Relationship Focused Behavior Therapy Contribute to Bupropion Outcomes? A Randomized Controlled Trial of Functional Analytic Psychotherapy and Acceptance and Commitment Therapy for Smoking Cessation". Behavior Therapy 42 (4): 700–15. doi:10.1016/j.beth.2011.03.002. PMID 22035998.
- "APA website on empirical treatments". Retrieved 2009-09-01.
- "SAMHSA's National Registry of Evidence-Based Programs and Practices". Retrieved 2011-09-01.
- Hayes, Steven. "State of the ACT Evidence". ContextualPsychology.org.
- Murrell, Amy R.; Scherbarth, Andrew J. (2006). "State of the Research & Literature Address: ACT with Children, Adolescents and Parents". International Journal of Behavioral Consultation and Therapy 2 (4): 531–43.
- Gendron, Benedicte (2012). "Le développement du capital émotionnel au service du bien-être à partir de l'approche de la thérapie de l'acceptation et de l'engagement" [Development of emotional capital serving the emotional well being from the approach of acceptance and commitment therapy]. In Martin-Krumm, Charles; Tarquinio, Cyril. Traité de psychologie positive [Treatise on Positive Psychology] (in French). De Boeck Supérieur. ISBN 978-2-8041-6614-4.[page needed]
- Lundgren, Tobias; Dahl, Joanne; Hayes, Steven C. (2008). "Evaluation of mediators of change in the treatment of epilepsy with acceptance and commitment therapy". Journal of Behavioral Medicine 31 (3): 225–35. doi:10.1007/s10865-008-9151-x. PMID 18320301.
- Levin, Michael E.; Hildebrandt, Mikaela J.; Lillis, Jason; Hayes, Steven C. (2012). "The Impact of Treatment Components Suggested by the Psychological Flexibility Model: A Meta-Analysis of Laboratory-Based Component Studies". Behavior Therapy 43 (4): 741–56. doi:10.1016/j.beth.2012.05.003. PMID 23046777.
- Johnston, M., Foster, M., Shennan, J., Starkey, N. J., & Johnson, A. (2010). The effectiveness of an Acceptance and Commitment Therapy self-help intervention for chronic pain. 26(5), 393.
- Martell, Addis & Jacobson, 2001, p. 197
- Öst, L.G. (March 2008). "Efficacy of the third wave of behavioral therapies: a systematic review and meta-analysis". Behaviour research and therapy 46 (3): 296–321. doi:10.1016/j.brat.2007.12.005. PMID 18258216.
- Leahy, R. L. (2004). Contemporary cognitive therapy: Theory, research, and practice. New York, NY: Guilford Press.
- Hayes, S. C., & Smith, S., &. (2005). Get Out of Your Mind and into Your Life: The New Acceptance and Commitment Therapy Santa Rosa, CA.: New Harbinger Publications.
- Hayes, S.C.; Bond, F.W.; Barnes-Holmes, D. & Austin, J. (2007). Acceptance And Mindfulness at Work: Applying Acceptance and Commitment Therapy And Relational Frame Theory to Organizational Behavior Management. Binghamton, NY: Haworth Press.[page needed]
- Wilson, Kelly G.; Hayes, Steven C.; Byrd, Michelle R. (2000). Journal of Rational-Emotive and Cognitive-Behavior Therapy 18 (4): 209. doi:10.1023/A:1007835106007.
- Hofmann, Stefan G.; Asmundson, Gordon J.G. (2008). "Acceptance and mindfulness-based therapy: New wave or old hat?". Clinical Psychology Review 28 (1): 1–16. doi:10.1016/j.cpr.2007.09.003. PMID 17904260.
- Arch, Joanna J.; Craske, Michelle G. (2008). "Acceptance and Commitment Therapy and Cognitive Behavioral Therapy for Anxiety Disorders: Different Treatments, Similar Mechanisms?". Clinical Psychology: Science and Practice 15 (4): 263. doi:10.1111/j.1468-2850.2008.00137.x.
- Öst, Lars-Göran (2008). "Efficacy of the third wave of behavioral therapies: A systematic review and meta-analysis". Behaviour Research and Therapy 46 (3): 296–321. doi:10.1016/j.brat.2007.12.005. PMID 18258216.
- Gaudiano, Brandon A. (2009). "Öst's (2008) methodological comparison of clinical trials of acceptance and commitment therapy versus cognitive behavior therapy: Matching Apples with Oranges?". Behaviour Research and Therapy 47 (12): 1066–70. doi:10.1016/j.brat.2009.07.020. PMC 2786237. PMID 19679300.
- Twyman, J.S. (2007). "A new era of science and practice in behavior analysis". Association for Behavior Analysis International: Newsletter 30 (3): 1–4.
- Hassert, Derrick L.; Kelly, Amanda N.; Pritchard, Joshua K.; Cautilli, Joseph D. "The Licensing of Behavior Analysts: Protecting the Profession and the Public". Journal of Early and Intensive Behavior Intervention 5 (2): 8–19.
- Hayes, Steven C.; Spencer Smith (2005). Get Out of Your Mind and Into Your Life: The New Acceptance and Commitment Therapy. New Harbinger Publications. ISBN 1-57224-425-9.
- Hayes, Steven C.; Kirk D. Strosahl (2004). A Practical Guide to Acceptance and Commitment Therapy. Springer. ISBN 0-387-23367-9.
- Hayes, Steven C.; Kirk D. Strosahl; Kelly G. Wilson (2003). Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change. The Guilford Press. ISBN 1-57230-955-5.
- Eifert, Georg H.; John P. Forsyth (2005). Acceptance and Commitment Therapy for Anxiety Disorders: A Practitioner's Treatment Guide to Using Mindfulness, Acceptance, and Value-Guide Behavior Change Strategies. Oakland, CA: New Harbinger. ISBN 1-57224-427-5.
- Forsyth, John P.; Georg H. Eifert (2007). The Mindfulness and Acceptance Workbook for Anxiety: A Guide to Breaking Free From Anxiety, Phobias, and Worry Using Acceptance and Commitment Therapy. Oakland, CA: New Harbinger. ISBN 1-57224-499-2.
- Martell, Christopher R.; Michael E. Addis; Neil S. Jacobson (2001). Depression in Context: Strategies for Guided Action. New York: W. W. Norton. ISBN 0-393-70350-9.
- Contextualpsychology.org – Home for the Association for Contextual Behavioral Science, a professional organization dedicated to ACT, RFT, and functional contextualism. Also helpful for training opportunities for professionals interested in ACT and RFT. Most ACT workshops world wide are listed here.
- Steven C Hayes – One of ACT's main theorists, Dr. Hayes' is at the University of Nevada. Information can also be found at his website
- ACT Workshops in the UK
- An Introduction to Relational Frame Theory Online Tutorial
-  - GENDRON Benedicte, (2012), Le développement du capital émotionnel au service du bien-être à partir de l'approche de la thérapie de l'acceptation et de l'engagement -ACT-, Chapitre 21, in Ch. Martin-Krumm, C. Tarquinio (dir.), Traité de psychologie positive, De Boeck. :