What is Acceptance and Commitment Therapy?

Introduction

Acceptance and commitment therapy (ACT, typically pronounced as the word “act”) is a form of psychotherapy and a branch of clinical behaviour analysis.

It is an empirically-based psychological intervention that uses acceptance and mindfulness strategies mixed in different ways with commitment and behaviour-change strategies, to increase psychological flexibility. The approach was originally called comprehensive distancing. Steven C. Hayes developed acceptance and commitment therapy in 1982 in order to create a mixed approach which integrates both covert conditioning and behaviour therapy. There are a variety of protocols for ACT, depending on the target behaviour or setting. For example, in behavioural health areas a brief version of ACT is called focused acceptance and commitment therapy (FACT).

The objective of ACT is not elimination of difficult feelings; rather, it is to be present with what life brings us and to “move toward valued behaviour”. Acceptance and commitment therapy invites people to open up to unpleasant feelings, and learn not to overreact to them, and not avoid situations where they are invoked. Its therapeutic effect is a positive spiral where feeling better leads to a better understanding of the truth. In ACT, ‘truth’ is measured through the concept of ‘workability’, or what works to take another step toward what matters (e.g. values, meaning).

Technique

Basics

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 behaviour analysis. Both ACT and RFT are based on B.F. Skinner’s philosophy of Radical Behaviourism.

ACT differs from some other kinds of cognitive behavioural 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 who 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 behavioural steps in accord with core values. As a simple way to summarise 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 behaviour.

And the healthy alternative is to ACT:

  • Accept your reactions and be present.
  • Choose a valued direction.
  • Take action.

Core Principles

ACT commonly employs six core principles to help clients develop psychological flexibility:[9]

  • Cognitive defusion: Learning methods to reduce the tendency to reify thoughts, images, emotions, and memories.
  • Acceptance: Allowing unwanted private experiences (thoughts, feelings and urges) 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. (e.g., mindfulness)
  • The observing self: Accessing a transcendent sense of self, a continuity of consciousness which is unchanging.
  • Values: Discovering what is most important to oneself.
  • Committed action: Setting goals according to values and carrying them out responsibly, in the service of a meaningful life.

Correlational evidence has found that absence of psychological flexibility predicts many forms of psychopathology. A 2005 meta-analysis showed that the six ACT principles, 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. A 2012 meta-analysis of 68 laboratory-based studies on ACT components has also provided support for the link between psychological flexibility concepts and specific components.

Research

A 2008 meta-analysis concluded that the evidence was still too limited for ACT to be considered a supported treatment, and raised methodological concerns about the research base. A 2009 meta-analysis found that ACT was more effective than placebo and “treatment as usual” for most problems (with the exception of anxiety and depression), but not more effective than CBT and other traditional therapies. A 2012 meta-analysis was more positive and reported that ACT outperformed CBT, except for treating depression and anxiety.

A 2015 review found that ACT was better than placebo and typical treatment for anxiety disorders, depression, and addiction. Its effectiveness was similar to traditional treatments like cognitive behavioural therapy (CBT). The authors suggested that the CBT comparison of the previous 2012 meta-analysis may have been compromised by the inclusion of nonrandomised trials with small sample sizes. They also noted that research methodologies had improved since the studies described in the 2008 meta-analysis.

The number of randomised clinical trials (RCT) and controlled time series evaluating ACT for a variety of problems is growing. In 2006, only about 30 such studies were known, but in 2011 the number had approximately doubled. The website of the Association for Contextual Behavioural Science states that there were 171 RCTs of ACT published as of December 2016, and over 20 meta-analyses and 45 mediational studies of the ACT literature as of Spring 2016. Most studies of ACT so far have been conducted on adults and therefore the knowledge of its effectiveness when applied to children and adolescents is limited.

Professional Organisations

The Association for Contextual Behavioural Science is committed to research and development in the area of ACT, RFT, and contextual behavioural science more generally. As of 2017 it had over 7,600 members worldwide, about half outside of the United States. It holds annual “world conference” meetings: The 16th will be held in Montreal, in July 2018.

The Association for Behaviour Analysis International (ABAI) has a special interest group for practitioner issues, behavioural counselling, and clinical behaviour analysis ABA:I. ABAI has larger special interest groups for autism and behavioural medicine. ABAI serves as the core intellectual home for behaviour analysts. ABAI sponsors three conferences/year – one multi-track in the US, one specific to Autism and one international.

The Association for Behavioural and Cognitive Therapies (ABCT) also has an interest group in behaviour analysis, which focuses on clinical behaviour analysis. ACT work is commonly presented at ABCT and other mainstream CBT organisations.

The British Association for Behavioural and Cognitive Psychotherapies (BABCP) has a large special interest group in ACT, with over 1,200 members.

Doctoral-level behaviour analysts who are psychologists belong to the American Psychological Association’s (APA) Division 25 – Behaviour analysis. ACT has been called a “commonly used treatment with empirical support” within the APA-recognized specialty of behavioural and cognitive psychology.

Similarities

ACT, dialectical behaviour therapy (DBT), functional analytic psychotherapy (FAP), mindfulness-based cognitive therapy (MBCT) and other acceptance- and mindfulness-based approaches are commonly grouped under the name “the third wave of cognitive behaviour therapy”. The first wave, behaviour therapy, commenced in the 1920s based on Pavlov’s classical (respondent) conditioning 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 try to solve their problems actually entangle humans into greater suffering. Rigid ideas about themselves, lack of focus on what is important in their life and struggling to change sensations, feelings or thoughts that are troublesome only serve to create greater distress.

Steven C. Hayes described this group in his ABCT President Address as follows:

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 valued 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 programmes, 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 behavioural science programme, including 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, individualised 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.

Criticisms

Some published empirical studies in clinical psychology have argued that ACT is not different from other interventions. Stefan Hofmann argued that ACT is similar to the much older Morita therapy.

A meta-analysis by Öst in 2008 concluded that ACT did not yet qualify as an “empirically supported treatment”, that the research methodology for ACT was less stringent than cognitive behavioural therapy, and that the mean effect size was moderate. Supporters of ACT have challenged those conclusions by showing that the quality difference in Öst’s review was accounted for by the larger number of funded trials in the CBT comparison group.

Several concerns, both theoretical and empirical, have arisen in response to the ascendancy of ACT. One major theoretical concern was that the primary authors of ACT and of the corresponding theories of human behaviour, relational frame theory (RFT) and functional contextualism (FC), recommended their approach as the proverbial holy grail of psychological therapies. Later, in the preface to the second edition of Acceptance and Commitment Therapy, the authors clarified that “ACT has not been created to undercut the traditions from which it came, nor does it claim to be a panacea.” Psychologist James C. Coyne, in a discussion of “disappointments and embarrassments in the branding of psychotherapies as evidence supported”, said: “Whether or not ACT is more efficacious than other therapies, as its proponents sometimes claim, or whether it is efficacious for psychosis, is debatable”. The textbook Systems of Psychotherapy: A Transtheoretical Analysis provides criticisms of third-wave behaviour therapies including ACT from the perspectives of other systems of psychotherapy.

Psychologist Jonathan W. Kanter said that Hayes and colleagues “argue that empirical clinical psychology is hampered in its efforts to alleviate human suffering and present contextual behavioural science (CBS) to address the basic philosophical, theoretical and methodological shortcomings of the field. CBS represents a host of good ideas but at times the promise of CBS is obscured by excessive promotion of ACT and Relational Frame Theory (RFT) and demotion of earlier cognitive and behaviour change techniques in the absence of clear logic and empirical support.” Nevertheless, Kanter concluded that “the ideas of CBS, RFT, and ACT deserve serious consideration by the mainstream community and have great potential to shape a truly progressive clinical science to guide clinical practice.”

ACT currently appears to be about as effective as standard CBT, with some meta-analyses showing small differences in favour of ACT and others not. For example, a meta-analysis published by Francisco Ruiz in 2012 looked at 16 studies comparing ACT to standard CBT. ACT failed to separate from CBT on effect sizes for anxiety, however modest benefits were found with ACT compare to CBT for anxiety and quality of life. The author did find separation between ACT and CBT on the “primary outcome” – a heterogeneous class of 14 separate outcome measures that were aggregated into the effect size analysis. This analysis however is limited by the highly heterogeneous nature of the outcome variables used in the analysis, which has the tendency to increase the number needed to treat (NNT) to replicate the effect size reported. More limited measures, such as depression, anxiety and quality of life decrease the NNT, making the analysis more clinically relevant, and on these measures ACT did not outperform CBT.

A 2013 paper comparing ACT to cognitive therapy (CT) concluded that “like CT, ACT cannot yet make strong claims that its unique and theory-driven intervention components are active ingredients in its effects.” The authors of the paper suggested that many of the assumptions of ACT and CT “are pre-analytical, and cannot be directly pitted against one another in experimental tests.”

Book: The Resilience Workbook

Book Title:

The Resilience Workbook – Essential Skills to Recover from Stress, Trauma, and Adversity.

Author(s): Glenn R. Schiraldi (PhD).

Year: 2017.

Edition: First (1st), Illustrated Edition.

Publisher: New Harbinger.

Type(s): Paperback and Kindle.

Synopsis:

What is resilience, and how can you build it? In The Resilience Workbook, Glenn Schiraldi-author of The Self-Esteem Workbook-offers invaluable insight and outlines essential skills to help you bounce back from setbacks and cultivate a growth mindset.

Why do some people sail through life’s storms, while others are knocked down? Resilience is the key. Resilience is the ability to recover from difficult experiences, such as death of loved one, job loss, serious illness, terrorist attacks, or even just daily stressors and challenges. Resilience is the strength of body, mind, and character that enables people to respond well to adversity. In short, resilience is the cornerstone of mental health.

Combining evidence-based approaches including positive psychology, cognitive behavioural therapy (CBT), acceptance and commitment therapy (ACT), mindfulness, and relaxation, The Resilience Workbook will show you how to bounce back and thrive in any difficult situation. You will learn how to harness the power of your brain’s natural neuroplasticity; manage strong, distressing emotions; and improve mood and overall well-being. You will also discover powerful skills to help you prevent and recover from stress-related conditions like post-traumatic stress disorder (PTSD), anxiety, depression, anger, and substance abuse disorders.

When the going gets tough, you need real, proven-effective skills to manage your stress and heal from setbacks. The comprehensive and practical exercises in this workbook will help you cultivate resilience, stay calm under pressure, and face all of life’s challenges.

Book: Emotion Efficacy Therapy

Book Title:

Emotion Efficacy Therapy: A Brief, Exposure-Based Treatment for Emotion Regulation Integrating ACT and DBT.

Author(s): Matthew McKay (PhD) and Aprilia West (PSyD, MT).

Year: 2016.

Edition: First (1st).

Publisher: New Harbinger.

Type(s): Paperback and Kindle.

Synopsis:

If you treat clients with emotion regulation disorders – including depression, anxiety, post-traumatic stress disorder (PTSD), bipolar disorder, and borderline personality disorder (BPD) – you know how important it is for these clients to take control of their emotions and choose their actions in accordance with their values. To help, emotion efficacy therapy (EET) provides a new, theoretically-driven, contextually-based treatment that integrates components from acceptance and commitment therapy (ACT) and dialectical behaviour therapy (DBT) into an exposure-based protocol. In doing so, EET targets the transdiagnostic drivers of experiential avoidance and distress intolerance to increase emotional efficacy.

This step-by-step manual will show you how to help your clients confront and accept their pain, and learn to apply new adaptive responses to emotional triggers. Using a brief treatment that lasts as little as eight weeks, you will be able to help your clients understand and develop a new relationship with their emotions, learn how to have mastery over their emotional experience, practice values-based action in the midst of being emotionally triggered, and stop intense emotions from getting in the way of creating the life they want.

Using the transdiagnostic, exposure-based approach in this book, you can help your clients manage difficult emotions, curb negative reactions, and start living a better life. This book is a game changer for emotion exposure treatment!

Book: The Mindfulness and Acceptance Workbook for Self-Esteem

Book Title:

The Mindfulness and Acceptance Workbook for Self-Esteem.

Author(s): Joe Oliver.

Year: 2020.

Edition: First (1st).

Publisher: New Harbinger, Workbook Edition.

Type(s): Paperback and Kindle.

Synopsis:

We all have stories we have created about ourselves-some of them positive and some of them negative. If you suffer from low self-esteem, your story may include these types of narratives: “I’m a failure,” “I’ll never be able to do that,” or “If only I were smarter or more attractive, I could be happy.” Ironically, at the end of the day, these narratives are your biggest roadblocks to achieving happiness and living the life you deserve. So, how can you break free from these stories-once and for all?

Grounded in evidence-based acceptance and commitment therapy (ACT), this workbook offers a step-by-step programme to help you break free from self-doubt, learn to accept yourself and your faults, identify and cultivate your strengths, and reach your full potential. You will also discover ways to take action and move toward the life you truly want, even when these actions trigger self-doubt. Finally, you’ll learn to see yourself in all your complexity, with kindness and compassion.

Book: Acceptance and Commitment Therapy (A.C.T.)

Book Title:

Acceptance and Commitment Therapy (A.C.T.): Workbook to Get Out From Anxiety, Relieve Depression, and Break Free From Stress and Worry, for a Newfound Mental Health.

Author(s): Gerald Paul Clifford.

Year: 2020.

Edition: First (1st).

Publisher: Independently Published.

Type(s): Paperback and Kindle.

Synopsis:

Life can present many challenges, some of which can be incredibly difficult to overcome. When these more troubling challenges arise, it can feel impossible to know how to navigate them and the many experiences they bring.

You may feel worried about your thoughts, emotions, behaviours, or all three. Especially when these parts of your experience seem hijacked by anxiety, anger, fear, frustration, depression, or other difficult emotions, it can be overwhelming to navigate them and the many behavioural experiences they bring.

Acceptance and Commitment Therapy (A.C.T) is a type of psychotherapy that relies on talk therapy techniques to assist you with achieving a more functional state in your life. By adjusting your perspective, increasing your awareness, and taking intentional action, you deepen your ability to recognise and navigate your emotions.

Book: Acceptance And Commitment Therapy For Dummies

Book Title:

Acceptance And Commitment Therapy For Dummies.

Author(s): Freddy Jackson Brown and Duncan Gillard.

Year: 2016.

Edition: First (1st).

Publisher: Wiley.

Type(s): Paperback.

Synopsis:

Do you want to change your relationship with painful thoughts and feelings that are holding you back from making changes to improve your life?

In this book, you will discover how to identify negative and unhealthy modes of thinking and apply Acceptance and Commitment Therapy (ACT) principles throughout your day-to-day life, creating a healthier, richer and more meaningful existence with yourself and others.

Book: 30 Days 30 Ways to Overcome Anxiety

Book Title:

30 Days 30 Ways to Overcome Anxiety.

Author(s): Bev Aisbett.

Year: 2019.

Edition: First (1st).

Publisher: HarperCollins Publishers.

Type(s): Paperback and Audio CD.

Synopsis:

Outlines a thirty day programme to overcoming anxiety, with daily exercises and mantras to help readers manage the emotion.

Book: The 10 Best-Ever Anxiety Management Techniques

Book Title:

The 10 Best-Ever Anxiety Management Techniques.

Author(s): Margaret Wehrenberg.

Year: 2018.

Edition: Second (2nd).

Publisher: W.W. Norton & Company.

Type(s): Paperback and Kindle.

Synopsis:

The newly updated workbook companion for putting the top anxiety management techniques into practice, first edition released in 2008.

Brimming with exercises, worksheets, tips, and tools, this complete how-to workbook companion expands on the top 10 anxiety-busting techniques Margaret Wehrenberg presents in the earlier edition of this book, showing readers exactly how to put them into action.

From panic disorders, generalised anxiety, and social anxiety, to overall worry and stress, manifestations of anxiety are among the most common – and often debilitating – mental health complaints. But thanks to a flood of supporting brain research, effective, practical strategies have emerged that allow us to manage day-to-day anxiety on our own.

Here Dr. Wehrenberg offers us a trove of them, showing just how physical, emotional, and behavioral symptoms can be alleviated with targeted methods. Step-by-step exercises for practicing counter-cognition, mindfulness meditation, thought-stopping, and thought-replacement, “breathing minutes,” demand delays, cued relaxation, affirmations, and much, much more are presented – all guaranteed to overcome your anxious thoughts.

The accompanying audio downloads feature an array of calming, author-guided exercises including targeted breath work, muscle relaxation, mindfulness, and much more.

Book: The 7 Principles of Stress

Book Title:

7 Principles of Stress: Extend Life, Stay Fit, and Ward off Fat. What You Didn’t Know About How Stress Can Reboot Your Mind, Energy, and Sex Life.

Author(s): Ori Hofmekler.

Year: 2017.

Edition: First (1st).

Publisher: North Atlantic Books, US.

Type(s): Paperback and Kindle.

Synopsis:

Ori Hofmekler, acclaimed author of The Warrior Diet and one of the first proponents of intermittent fasting, challenges conventional wisdom about diet, fitness, and anti-aging with a new approach to health that uses stress to live longer, stay fit, and ward off fat.

Supported by cutting-edge research, this book redefines the term “nutrition” as it reveals the stress-mimicking nutrients that yield the same benefits as fasting and exercising.

At the core of the book is the biology of stress and the way it affects key aspects of life from feeding and sexual behavior to mental and physical performance. Hofmekler demonstrates that that there is a thin line between beneficial stress and harmful stress, and shows how to put knowledge of the difference into powerful practice.

His book is a call to action – a manifesto of living life to its utmost evolutionary potential, under stress, as nature intended.

Book: Your Anxiety Beast and You

Book Title:

Your Anxiety Beast and You – A Compassionate Guide to Living in an Increasingly Anxious World.

Author(s): Eric Goodman, PhD.

Year: 2020.

Edition: First (1st), Illustrated Edition.

Publisher: Exisle Publishing.

Type(s): Paperback and Kindle.

Synopsis:

Just like The Beast in the fairy tale Beauty and the Beast, anxiety is an emotion that society initially misjudges as the villain. Your Anxiety Beast and You is a kinder, more compassionate approach for people suffering from anxiety. Rather than living with an enemy inside your mind, you are encouraged to see anxiety for what it really is – an inner hero. It is always trying to protect you from threats, however, it is completely confused about what are true threats in the modern world.

Learn how to cope with your anxiety and train it to be a better inner-companion through integrating therapeutic methods from compassion-focused therapy, Cognitive Behavioural Therapy (CBT) and Acceptance and Commitment Therapy (ACT). Gain an understanding of why society stigmatises anxiety and gain a better understanding of your own anxiety beast with humour and compassion. Your Anxiety Beast and You takes you through step-by-step strategies to cope with the howling of the beast in your mind, the physical effects of anxiety on your body, and then focuses on ways to come up with ‘teachable moments’ for your anxiety to learn that what you fear is not actually a threat.

With over 25 years of experience helping people with anxiety disorders and OCD, Dr Goodman aims to help you make peace with the reality of your anxiety. And then to help you re-focus on making your anxiety a better companion.