Acceptance and commitment therapy

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Acceptance and commitment therapy, or ACT, is a cognitive-behavioral model of psychotherapy.[1] It is an empirically based psychological intervention that uses acceptance and mindfulness strategies mixed in different ways[2] with commitment and behavior-change strategies, to increase psychological flexibility. Originally this approach was referred to as comprehensive distancing.[3] 'ACT' is spoken as a single word, not as separate initials.

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 framed as 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.[3]

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.[4] 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 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[4]:

  1. Cognitive defusion: Learning to perceive thoughts, images, emotions, and memories as what they are, not what they appear to be.
  2. Acceptance: Allowing them to come and go without struggling with them.
  3. Contact with the present moment: Awareness of the here and now, experienced with openness, interest, and receptiveness.
  4. Observing the self: Accessing a transcendent sense of self, a continuity of consciousness which is unchanging.
  5. Values: Discovering what is most important to one's true self.[5]
  6. Committed action: Setting goals according to values and carrying them out responsibly.

Evidence

ACT has, as of October 2006, been evaluated in over 30 randomized clinical trials for a variety of client problems [6]. Overall, when compared to other active treatments designed or known to be helpful, the effect size for ACT is a Cohen's d of around 0.6[7][8], which is considered a medium effect size. Effect sizes that large are not surprising when comparing well-designed treatments to wait list controls, but they are not common when the comparison conditions are themselves evidence-based approaches (across the whole empirical clinical psychology literature the average effect size for such comparisons approaches zero). However, these comparisons and their effect sizes (Cohen's d around 0.6) should be viewed with caution, because most of the trials are not clinically representative (e.g., they are based on small number of patients) and might be contaminated by the allegiance effect. Despite this, ACT is considered an empirically validated treatment for depression by some organisations, such as the American Psychological Association, by whom it is listed as an empirically supported treatment, with "Modest Research Support" status [9].

As of|2006, ACT is still relatively new in the development of its research base. Nevertheless, ACT has shown preliminary research evidence of effectiveness for a variety of problems including chronic pain, addictions, smoking cessation, depression, anxiety, psychosis, workplace stress, diabetes management.[10]

Recently ACT has been applied to children. The initial results are encouraging.[11]

Mediational analyses have provided evidence for the possible causal role of key ACT processes, including acceptance, defusion, and values, in producing beneficial clinical outcomes[12]. 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 [see Hayes et al., 2006, pp. 12–13, and Table 1].

Similarities

ACT is sometimes grouped together with Dialectical behavior therapy, Functional Analytic Psychotherapy, and Mindfulness-based Cognitive Therapy as The Third Wave of Behavior Therapy[13][14] which Steven C. Hayes defined 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.

Similarities are also found with the awareness-management movement in business training programs, where mindfulness and cognitive-shifting techniques are being employed to generate rapid positive shifts in mood and performance[15].

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.

The emphasis of ACT on present-mindedness, direction and action is similar to other approaches within psychology 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 narrative psychology, Gestalt Therapy, Morita Therapy[16], or Re-evaluation Counselling among many others.

Wilson, Hayes & Byrd [17] explore at length the compatibilities between ACT and the 12-step treatment of addictions and argue, 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 emphasises the hopelessness of relying on ineffectual strategies to control private experience, similarly the 12-step approach emphasises 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

ACT has been contrasted with Dialectical Behavior Therapy, since both are behavior therapies that focus on balancing acceptance and change [18]. The major difference is ACT's focus on direct research from relational frame theory[19]. ACT has similarities to the mystical aspects of some of the major spiritual and religious traditions such as Buddhism[20]. The approach has at times generated controversy within the field of clinical psychology[21][22] as to its proposed mechanisms of change and as to whether or not ACT takes a radically different approach to psychological experiences than other forms of intervention. This has led leaders in the field to examine the evidence supporting ACT with a critical eye [23][24].

Professional Organizations

The Association for Contextual Behavioral Science is committed to research and development in the area of ACT. In addition, it has a large practitioner contingent.

The Association for Behavior Analysis International has a special interest group for practitioner issues, behavioral counseling, and clinical behavior analysis ABA:I. Association for behavior analysis international has larger special interest groups for autism and behavioral medicine. Association for behavior analysis international serves as the core intellectual home for behavior analysts.[25][26] The Association for Behavior Analysis International sponsors 2 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. In addition, the Association for Behavioral and Cognitive Therapies has a special interest group on addictions.

Doctoral level behavior analysts who are psychologists belong to American Psychological Association's division 25- Behavior analysis. APA offers a diplomateTemplate:Clarify in behavioral psychology.

The World Association for Behavior Analysis offers ceritification in behavior therapy which covers knowledge of ACT [3]


References

  1. ↑ http://www.thehartcenter.com/mentalHealthDetails.php?id_mentalHealth=7
  2. ↑ Hayes, Steven. "Acceptance & Commitment Therapy (ACT)". ContextualPsychology.org. http://www.contextualpsychology.org/act. 
  3. ↑ 3.0 3.1 Zettle, R.D. (2005). The Evolution of a Contextual Approach to Therapy: From Comprehensive Distancing to ACT. IJBCT, 1(2), Page 77-89 [1]
  4. ↑ 4.0 4.1 Harris, R. (August 2006). Embracing your demons: an overview of acceptance and commitment therapy. Psychotherapy in Australia, 12, 4, 2-8.
  5. ↑ Hank Robb (2007): Values as Leading Principles in Acceptance and Commitment Therapy. IJBCT, 3(1), 118-123 BAO
  6. ↑ Hayes, S. C., Luoma, J., Bond, F., Masuda, A., & Lillis, J. (2006). Acceptance and Commitment Therapy: Model, processes, and outcomes. Behaviour Research and Therapy, 44(1), 1-25.
  7. ↑ 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, 488-511.
  8. ↑ Zettle, R. D., & Rains, J. C. (1989). Group cognitive and contextual therapies in treatment of depression. Journal of Clinical Psychology, 45, 438-445.
  9. ↑ "APA website on empirical treatments for depression". http://www.psychology.sunysb.edu/eklonsky-/division12/treatments/depression_acceptance.html. Retrieved 2009-05-05. 
  10. ↑ Hayes, Steven. "State of the ACT Evidence". ContextualPsychology.org. http://www.contextualpsychology.org/state_of_the_act_evidence/. 
  11. ↑ Amy R. Murrell and Andrew J. Scherbarth (2006): State of the Research & Literature Address: ACT with Children, Adolescents and Parents. IJBCT, 2(4), 531-543 BAO
  12. ↑ Lundgren, T., Dahl, J., & Hayes, S. C. (2008). Evaluation of mediators of change in the treatment of epilepsy with Acceptance and Commitment Therapy. Journal of Behavior Medicine, 31(3), 225-235.
  13. ↑ Martell, Addis & Jacobson, 2001, p. 197
  14. ↑ 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. 
  15. ↑ 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.
  16. ↑ Hofmann, S. G. (2008). Acceptance and Commitment Therapy: New Wave or Morita Therapy? Clinical Psychology: Science & Practice, 15, 280-285.
  17. ↑ Kelly G. Wilson, Steven C. Hayes & Michelle R. Byrd (2000) Exploring Compatibilities Between Acceptance And Commitment Therapy and 12-Step Treatment For Substance Abuse Journal of Rational-Emotive & Cognitive-Behavior Therapy Volume 18, Number 4, Winter http://www.springerlink.com/content/q8l117087428434k/
  18. ↑ Chapman, A.L. (2006). Acceptance and Mindfulness in Behavior Therapy: A Comparison of Dialectical Behavior Therapy and Acceptance and Commitment Therapy. IJBCT, 2(3), Pg. 308 [2]
  19. ↑ Blackledge, J.T. (2003). An Introduction to Relational Frame Theory: Basics and Applications. The Behavior Analyst Today, 3 (4), 421-434 BAO
  20. ↑ Hayes, S. C. (2002). Buddhism and Acceptance and Commitment Therapy. Cognitive and Behavioral Practice, 9, 58-66.
  21. ↑ Hofmann, S. G., & Asmundson, G. J. (2008). Acceptance and mindfulness-based therapy: New wave or old hat? Clinical Psychology Review, 28(1), 1-16.
  22. ↑ Arch, J. J., & Craske, M. G. (2008). Acceptance and commitment therapy and cognitive behavioral therapy for anxiety disorders: Different treatments, similar mechanisms? Clinical Psychology: Science & Practice, 5, 263-279.
  23. ↑ Öst, L. (2008). Efficacy of the third wave of behavioral therapies: A systematic review and meta-analysis. Behaviour Research and Therapy, 46(3), 296-321.
  24. ↑ Gaudiano, B (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. doi:10.1016/j.brat.2009.07.020. PMC Template:=pmcentrez&artidTemplate:=2786237 2786237. PMID 19679300. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2786237. 
  25. ↑ Twyman, J.S. (2007). A new era of science and practice in behavior analysis. Association for Behavior Analysis International: Newsletter, 30(3), 1-4.
  26. ↑ Hassert,D.L, Kelly, A.N., Pritchard, J.K. & Cautilli, J.D. (2008). The Licensing of Behavior Analysts:Protecting the profession and the public . Journal of Early and Intensive Behavior Intervention,5(2), 8-19 BAO

External links

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