Acceptance and Commitment Therapy (ACT) – part I

Acceptance and commitment therapy has its roots in behavior therapy, mindfulness and relational frame theory. It associates psychiatric problems with excessive or improper control of verbal processes, known as cognitive fusion; and the avoidance of private experiences, known as experiential avoidance (Hayes et al., 2006). ACT has been endorsed by the Substance Abuse and Mental Health Services Administration (SAMHSA) as an evidence-based practice. Dozens of studies have been conducted both in the US and abroad that support its effectiveness with a multitude of client concerns. What makes ACT unique is in the way it addresses clients’ thoughts and feelings. It helps clients become fully aware of their thoughts and feelings, rather than avoiding or changing them, so they can make value-based decisions (Hayes et al., 2006).

For instance, from ACT’s point of view, a client struggling with shame would be fused (cognitive fusion) with denigrating thoughts about themselves while also attempting to avoid experiencing the thoughts and feelings related to shame (experiential avoidance). So a client struggling with a shame-based substance use could get triggered by phone calls from friends, an old song, or a TV commercial. This client then would want to avoid the shameful feelings by acting compulsively on the triggers, avoiding contact with friends or relapsing to numb feelings. At the same time, the individual is stuck in his own head trying to rationalize or analyze the shame in an effort to try to achieve some relief from the painful feelings and thoughts. This, in turn, is preventing him from experiencing supportive personal relationships, working on his goals or enjoying distress-free moments. This self-perpetuating cycle only reinforces the anxiety or addictive behaviors without allowing the client to work though the emotional pain.

ACT in Action

ACT helps clients become more mindful and accept their experiences instead of blocking or fighting them. Clients learn to see themselves as separate from their current behaviors and increase their psychological flexibility. According to Hayes (2006), psychological flexibility is the ability to experience a negative state (e.g. a depressive feeling) while moving in a valued direction (e.g. showing up at work on time). In order to achieve psychological flexibility, ACT suggests 6 skill sets – acceptance, cognitive defusion, contact with the present moment, self as context, values, and committed action. The first four skills are also categorized as mindfulness and acceptance processes, while the last four skills are known as commitment and behavioral change processes (Hayes et al., 2006). The ACT model is flexible enough to be customized to the client’s needs, so there is no single ACT model or approach. ACT is more of a set of guiding principles or theoretical underpinnings that can be tailored as necessary.

Acceptance

Acceptance includes techniques to counteract avoidance by helping clients to stay active and aware of their private experiences, thoughts and feelings without feeling the need to change or get rid of them (Hayes et al., 2006). Generally speaking, a client experiencing shame may believe that they should not be feeling shame or that they cannot deal with such feelings without avoiding them. Such a focus on controlling these feelings gets the client “fused” with such thoughts and feelings and this can lead to further rumination and negative evaluation of the self. ACT therapists would encourage this client not only to accept their private experiences of shameful thoughts and feelings, but also to notice that their level of distress is constantly changing. Understanding that some days will have less distress and shame than others can help clients work through these emotions instead of avoiding them. Becoming willing to experience distress is a decision clients make in order to be able to move in a valued direction.

Cognitive Defusion

Cognitive defusion techniques teach clients that their thoughts are just thoughts. Clients find new ways of relating to their thoughts by recognizing their context and diminishing their unhelpful functions (Hayes et al., 2006). For instance, a client struggling with a shame-based substance abuse might be evaluating himself as worthless or pathetic. Cognitive defusion would help this client recognize that these are only thoughts and not literal evaluations of his self or worth. Looking at thoughts as only thoughts helps clients not let thoughts dictate their feelings or behaviors. The goal is to reduce the client’s level of attachment and “buy-in” to thoughts and feelings, not to eliminate or change negative thoughts or feelings altogether. Some useful cognitive defusion techniques are thanking one’s mind, observing a thought dispassionately, externalizing the thought by labeling it a story (there goes the “pathetic me” story again) and repeating the problematic word until it loses its meaning.

Contact with the Present Moment

Contact with the present moment helps clients focus their attention away from their undesirable internal thoughts, feelings and experiences and focus on the world around them. To do this clients develop nonjudgmental awareness of their psychological and physical environment. The goal is for clients to take a flexible approach to what is happening around them and commit to what matters most to them. Clients are also encouraged to examine “workability”, i.e. whether what they are doing in the present moment is in line with their values. Contact with the present moment is best achieved through mindfulness exercises and an accepting, nonjudgmental view of self (Hayes et al., 2006). For example, a client can learn to stay in the moment and focus on her children even when experiencing negative thoughts in her mind because it is in line with her value of wanting to be a good mother.

To be continued…

Acceptance and Commitment Therapy References

Gutierrez, D., & Hagedorn, W.B. (2013). The toxicity of shame applications for acceptance and commitment therapy. Journal of Mental Health Counseling, 35, 43-59.

Hayes, S. C, Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and Commitment Therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44, 1-25.