ACCEPTANCE & COMMITMENT THERAPY

(ACT)
BY INDRANI KARMAKAR
M.Sc Clinical Psychology, 2 nd Year
 ACT – AN OVERVIEW
Acceptance and commitment therapy (ACT) is a descendant of
cognitive-Behavioral therapy (CBT). This therapy model draws
techniques from a wide variety of sources and unites them within a
philosophical and scientific framework to create a principle- driven
therapy. Psychopathology is understood as a narrowing behavioral
repertoire that develops over time through maladaptive strategies to
cope with unwanted private events. The approach combines processes
of acceptance and mindfulness with those of commitment and
behavioral change to produce increased psychological flexibility and an
expand behavioral repertoire. Since its introduction in 1999, an
increasing number of trials show promising results for a wide range of
conditions. ACT was developed by Steven C. Hayes as a treatment
around 1982 to create an approach integrating key features of cognitive
therapy & behavior analysis.
 THE ORIGIN OF
ACT
Acceptance and commitment therapy (ACT) has been described as part of the third wave
of cognitive-behavioral therapy (CBT) (Hayes 2004). The first wave was traditional
behavioral therapy, which focuses on observable behavior and direct interaction with the
environment. Pavlov, Watson, Thorndike and Skinner are among the well-known figures
from that era. Exposure work and skills training are the main interventions within a
clearly defined empirical framework. Such interventions worked but were unable to
account for the problems of thinking and the influence of private events on behavior. In
response to this weakness, cognitive theories began to emerge and over the past 30
years cognitive methods have taken center stage. In this second wave, Beck and Ellis
have been the key figures, and illogical thinking or thinking error is seen as the primary
cause of any problem. The evidence base for standard CBT is extensive, with an
emphasis on outcome research in randomized control trials across a wide range of
disorders. The second wave was a tremendous advance but the scientific link between
the processes of
cognitive change and outcomes has not been established. This set the scene for the
emergence of new treatment models that focus on the function of problematic cognitions
rather than the content. The third wave differs from the first wave in that it has a
considerable focus on private events, and it differs from the second in that it does not try
to change the form or frequency of these private events. Over the past 15 years, these
new treatments have developed an expanding evidence base. Based on acceptance and
mindfulness procedures, this third wave of CBT includes dialectical behavior therapy
(DBT) and mindfulness-based cognitive therapy (MBCT) as well as ACT. Historically, third-
wave treatments were seen as particularly appropriate for people who were not
benefiting from pre-existing treatments like classical CBT. However, it is now believed
that for some individuals, a third-wave therapy option may make sense as a first-line
treatment.
 THEORY THAT
UNDERPINS ACT
Relational frame theory (RFT) has been developed over the past 25 years as a post-
Skinnerian model providing an empirically based account of language and cognition
(Hayes 2001) that underpins ACT. This theory emerges from earlier work on rule
governance and derived stimulus relations in the behavior analytic tradition. Relational
frame theory extends these ideas to regard thinking itself as a special form of learned
behavior in its own particular class. From the RFT perspective, language is seen as the
main difference between humans and non- humans and relational framing as the core
process in developing language. In a developmental continuum, more complex language
abilities develop over time, and relational frames continue to expand throughout the
lifespan.
This language ability is called 'transformation of functions' and it appears to have played
a significant role in allowing the human race to become successful problem solvers and
attain a position of dominance on the planet. However, there is a darker side to the
process that can underpin many mental health disorders. From a clinical perspective, RFT
shows how humans are able to interact with events purely on the basis of verbally
ascribed functions while being completely unaware of the underlying process of
language. In the world of thought, the event and the person thinking about the event are
usually experienced as one, so it appears real. Words alone can elicit pain. Consequently,
in ACT clinical work, undermining the functions contained in language plays a central
role, as opposed to changing the content of thoughts themselves.
COGNITIVE FUSION :This is the tendency to act in the world on the basis of verbally
ascribed functions is referred to as cognitive fusion. The thought and the person thinking
the thought become as one, or fused, hiding the nature of the language process. Fusion
can lead to a loss of contact with actual events, or real experience, so that thoughts start
to become self-confirming .

EXPERIENTIAL AVOIDANCE : From an ACT point of view, the increasing dominance of

cognitive fusion is one aspect of the way in which psychopathology develops and
produces a restricted repertoire. The other is more behavioral and emanates from the
process by which verbally ascribed functions easily lead to negative emotions. For
instance, worry can develop when thinking about the imagined future. and sadness or
guilt can result from remembering the past. Mainly these are normal experiences and
most people develop strategies to cope. The situation becomes problematic when
individuals try to suppress or avoid the pain that is evoked through thinking. This
tendency is known as experiential avoidance, and has been defined as “the attempt to
escape or avoid the form, frequency or situational sensitivity of private events, even
when the attempt to do so causes psychological harm” (Hayes 1996).
 AN EXAMPLE OF COGNITIVE FUSION :
If someone with depression is fused with the thought 'I don't have enough confidence', it
is likely that they will do less. Doing less sets up a cycle in which there is a reduced
contact with actual events and a further (natural) loss of confidence. Fusion with the
thought is strengthened and a pattern is established that could develop into a mental
disorder over time.
PSYCHOLOGICAL INFLEXIBILITY

Experiential Cognitive Fusion. Over-identification/ Inaction,

Preoccupation Lack of
Avoidance. Attachment to Impulsivity.
with past/future. Values.
conceptualized self.
 Acceptance & Commitment Therapy
Therapeutic Aim Therapy Model

Cognitive fusion and experiential In their first presentation of ACT, Hayes et

avoidance tend to create behavioral al defined six core components:
repertoires that are insensitive to the acceptance; defusion; contact with the
events of the moment and inflexible in present moment; self-as-context; values
changing circumstances. The fundamental (valued directions or actions); and
objectives of ACT are to undermine these committed action (Hayes 1999). These are
processes and to help clients move forward not sequential, but are interlinked to create
in valued directions by developing a fluid model in which therapist flexibility is
behavior that is sensitive to the current also important.
context. Collectively, this is known as
psychological flexibility, and an increased
ability to adapt is the main aim of ACT.
 SIX CORE COMPONENTS OF ACT :

◦ ACCEPTANCE (Open Up)

This means taking a position of nonjudgemental awareness towards thoughts, feelings and bodily
sensations as they arise. The process begins with the client learning to notice behaviors that are
not moving towards values, known in ACT as se unworkable. After that, the client moves on to
noticing how attempts to control unwanted private experience leads to a struggle. Acceptance
involves letting go of this struggle, while still working on external issues that can be changed.
◦ DEFUSION (Watch your thinking)
Cognitive defusion addresses the problem of cognitive fusion described above. It is about trying
to dilute the impact of harmful functions contained in language. It involves trying to shift focus
from the content of thoughts to the process of thinking itself, thus weakening the verbally
ascribed functions. Delusion creates distance from the thoughts, as if the individual were
standing back from their mind, like an observer.
◦ CONTACT WITH PRESENT MOMENT (Focusing on “right now”)
Clients are taught to notice their external and internal experience in the present moment. The
practice of mindfulness provides the foundation. Later, this can be extended into operant
exposure routines in which clients learn to develop new behavior, based on values that they
choose (see below), in the presence of previously avoided experience.
◦ SELF AS CONTEXT (Pure Awareness)
Cognitive fusion with thoughts such as 'I'm worthless' is referred to as self-as-content: the
person's identity is caught up in the content of the particular thought. Acceptance and
commitment therapy assumes that, in order to fully experience painful feelings or really
stand back from difficult thoughts without trying to change them, a wider e perspective is
necessary. This transcendent sense of self is referred to as self-as-context, and can be
developed through defusion and mindfulness. a From this perspective, the 'observer' self is
not threatened by the content of experience, but is instead the context in which all
experience unfolds.
◦ VALUES (Know what Matters)
Clients are encouraged to clarify their valued directions or actions. These 'values' are neither
feelings nor goals, but connect to a deeper sense of purpose and meaning as an ongoing
process of behavior. This component closely resembles modern existential ideas (Frank
2006), where choice and freedom of action are the main focus Consequently, in ACT the
individual focuses on the future, as opposed to exploring the past, and their chosen values
underpin all aspects of therapy.
◦ COMMITTED ACTION (Do what it takes)
Committed action is about learning to move in valued directions while in the presence of
unwanted or painful thoughts and feelings. The choice between an easy life and a rich, full
life is presented, and clients are encouraged to find the willingness to have painful thoughts
and feelings in the service of moving in a valued direction. Vitality develops as the client's
behavior becomes more oriented to their underlying values.
 CLINICAL STYLE & TECHNIQUES OF ACT
With ACT, metaphors, paradoxes, and experiential exercises are frequently used, Many interventions are
playful, creative, and clever. ACT protocols can vary from short interventions done in minutes to those that
extend over many sessions. There are myriad techniques categorized under the following five protocols that
are extrapolated from the clinical materials assembled by Gifford, Hayes, and Stroshal (2005). These
represent only a fraction of material available as resources for clinicians .
 Facing the current situation ("creative hopelessness")
Encourages clients to draw out what they have tried to make better, examine whether they have truly
worked, and create space for something new to happen. Confronting the unworkable reality of their multiple
experiences often leaves the client not knowing what to do next, in a state of "creative hopelessness." The
state is creative because entirely new strategies can be developed without using the previous rules
governing their behavior.
 Acceptance techniques are geared toward reducing the motivation to avoid certain situations.
An emphasis is given to "unhooking"-realizing that thoughts and feelings don't always lead to actions.
Often these techniques are done "in vivo," structuring experiences in session. Discriminating between
thoughts, feelings, and experiences is a salient focus.
Cognitive defusion (deliteralization)
Redefines thinking and experiencing as an ongoing behavioral process, not an outcome. Techniques are
designed to demonstrate that thoughts are just thoughts and not necessarily realities (Blackledge, 2007). It
can involve sitting next to the client and putting each thought and experience out in front as an object in an
effort to "defuse and deliteralize”.
Valuing
Valuing as a choice clarifies what the client values for his or her own sake: What gives life
meaning? The goal is to help clients understand the distinction between a value and a goal,
choose and declare their values, and set behavioral tasks linked to these values.
Self as context
Here the therapist teaches the client to view his or her identity as separate from the content
of his or her experience.

INTERVENTIONS
Acceptance : The therapist identifies examples of unworkable behavior (behavior that is
not moving towards the individual's values) and develops suitable metaphors for them.
Once a suitable metaphor is found, the therapist refers to it each time the client mentions
an unworkable behavior . In this phase, the therapist sets homework and conducts exercises
that amplify the cost of unworkable solutions from the perspective of valued living . Once
the client has started to notice the futility of the struggle to control unwanted feelings or
thoughts, the therapist will introduce the idea that all of these are forms of 'control' that
operate paradoxically - 'The harder you try, the worse it gets'. The idea of letting go is
allowed to surface, and experiential exercises are used to undermine avoidance further and
dichotomize the choice between control and willingness.
 Defusion : The mind is introduced as a functional organ that just does a job. In response to an
example of the client's cognitive fusion, the therapist may well ask 'Is that what your mind is telling
you?' or say 'Thank your mind for that thought’ . 'Leaves on the stream' is one of several
mindfulness exercises that can be used to help the client develop an experiential sense of distance
from their mind/thoughts . Examples of more structured defusion exercises include inviting the
client to write thoughts on cards and to sing them out loud, or say them very slowly or in a silly
voice. Imaginal work can be done to find voices or characters that render the thought less
believable, or more comical. Such exercises are used to increase interaction with the fused thought
in a new context.
 Contact with present moment : The therapist is alert for experiential avoidance during sessions
and gently brings the client back into contact using questions that reorient attention. It is common
to hear interventions such as 'What are you noticing right now?' or 'What are you aware of in this
moment?' throughout all phases of therapy . Formal mindfulness practices can be used to f help
the client develop this ability. These exercises combine with operant exposure as the therapist tries
to amplify experiencing and develop new behaviors in the presence of previously avoided
experience.
 Self-as-context : In the chessboard metaphor, the client is encouraged to recognize the
distinction between the chess pieces and the chess board. Thoughts and feelings are the chess
pieces, which are constantly moving, opposing each other in a never-ending struggle. The client is
encouraged to adopt the metaphorical role of the board, which just holds the pieces. Therapists ask
clients to notice experience on a regular basis in sessions. The self-as-context question is then to
ask 'Who is noticing that?', In this component, longer exercises are used to help the client find
experiential contact with the 'observing self'.
 Value Clarification : The client's values (valued directions or actions) are thought of metaphorically
as directions on a compass. The individual is taught to distinguish values from feelings and
directions from goals. Ogden Lindsley's 'dead man's test' can be used effectively to counteract the
normal tendency to think in terms of symptom removal: if a dead person can achieve something,
then it is not usually considered a good direction for a living person. For instance, dead people aren't
depressed, don't have anxiety or OCD and don't take drugs. This is an effective device to focus back
on the behavioral nature of values as living action . Homework and assignments are used in this
phase to clarify values and identify any discrepancy between how important a compass point is and
the amount of actual movement towards it. Imaginal work is used to establish even greater contact
with values and to strengthen motivation.
 Committed Action : Helping clients break tasks down into small steps is very similar to standard
practice in behavioral therapy. If the client is struggling with feelings or is fused, the passengers-on-
the-bus metaphor can be used as a way of examining the relationship with unwanted content or of
creating a sense of distance. The therapist may even turn the metaphor into an experiential exercise
using props or index cards. Various experiential exercises will be used to build new patterns of action
using small steps. Throughout, the emphasis is on generating new behavior towards values while in
the presence of previously avoided feelings. The 'pick up your keys' exercise illustrates this approach
and shows how willingness is worked on. Such new behavior is the overall goal of ACT.
In Session 1 ,the therapist explores the unworkable strategies the client has been using & suggests
that these solutions may actually be part of the problem.
In Session 2, which is held 3 days after the first session, the client is asked to describe their
symptoms in detail
Including content, frequency & mode of severity of distress. A detailed discussion is held
to see how the client responds to thought content & especially to establish whether their
main strategy is to get rid of the unwanted symptoms.
In Session 3, ,which is held 3 to 5 days later ,focus is laid on developing acceptance.
Here, valued directions are explored again & the client is asked to compare the
consequences of trying to control symptoms verses acceptance in relation to these
values.
Session 4 is held 3 days later (or in severe cases within 3 days of the client’s discharge
from hospital ). This mainly includes a review of the previous sessions.

BENEFIT OF ACT
One core benefit of ACT is the impact it has on psychological flexibility. Psychological
flexibility is the ability to embrace your thoughts and feelings when they are useful and
to set them aside when they are not. This allows you to thoughtfully respond to your
inner experience and avoid short-term, impulsive actions, focusing instead on living a
meaningful life . Psychological flexibility can improve one’s ability to accept and function
with symptoms of conditions like anxiety or depression. Often, those symptoms may
lessen significantly as a result of this increase in psychological flexibility.
When can we use ACT ?
Research shows ACT to be effective at treating a wide range of conditions,
including some that span several diagnoses. ACT also appears to improve
quality of life, and it may help people deal with physical conditions and chronic
pain.
Anxiety Disorders
Depression
Post traumatic stress disorder (PTSD)
Obsessive Compulsive disorder (OCD)
Chronic pain
Eating disorders
Substance abuse disorders
Reducing Psychotic symptoms
 RESEARCH FINDINGS ON ACT
Since the publication of the first ACT reference book (Hayes 1999), evidence on the efficacy of the
intervention has been accumulating at an increasing rate and for a widening range of conditions.
There are currently over 50 published randomized controlled trials (RCTs). During recent years
there have been three independent reviews of these data (Öst 2008; Pull 2008; Powers 2009)
comparing ACT with standard CBT.
The reviews of the RCT outcome data contain areas of agreement and of difference. The reviewers
all point to methodological flaws in the ACT studies, and the ACT community is in agreement with
this. There is also general agreement that the ACT data show promising outcomes that are in line
with CBT outcomes but no better. A reply from the ACT perspective (Gaudiano 2010) points out
differences in the life cycle of the two therapies: standard CBT has been generating RCTs for over
35 years, so trials are now more focused on controlling the methodology, whereas research into
ACT is only around 10 years old and is still focusing more on outcomes and conditions. Gaudiano
also notes ACT studies have focused more on complex conditions and less on the standard mood
disorders such as depression and anxiety that are the focus of much of the CBT literature. The two
therapies do not differ much in effectiveness in mood disorders, but show different processes of
change. Acceptance and commitment therapy shows promise in treating conditions thathave not
responded well to CBT, The debate will continue. In possibly the most balanced review of the ACT
outcome data, Pull (2008) offers this summary:
 “The available evidence suggests that ACT works through different processes than active
treatment comparisons, including traditional CBT. Although currently available data are promising
there is, however, a need for more well controlled studies to verify whether ACT is generally as or
more effective than other active treatments across the range of problems examined”.
Beyond outcome data, the ACT community is working to identify mediational effects of the six
components of the model. The 7-item Acceptance and Action Questionnaire II (AAQ-II)
(Bond 2011) uses the construct of 'psychological flexibility’ to summarize the effects of the six
components, with experiential avoidance at the lower end of the scale . In the future it is hoped
that mediational effects will be established for each of the six components. The start of this
seems to be happening with the acceptance component in the area of chronic pain (Mason 2008),
with acceptance correlated to the World Health Organization quality of life measure.

CONCLUSION
Acceptance and commitment therapy (ACT) is a type of psychotherapy that
emphasizes acceptance as a way to deal with negative thoughts, feelings. symptoms,
or circumstances. It also encourages increased commitment to healthy. constructive
activities that uphold your values or goals . ACT therapists operate under a theory that
suggests that increasing acceptance can lead to increased psychological flexibility. This
approach carries a host of benefits, and it may help people stop habitually avoiding
certain thoughts or emotional experiences, which can lead to further problems.