Wednesday, August 24, 2016

Acceptance and Commitment Therapy (ACT)

Steven Hayes starts his book “Get Out of Your Mind& Into Your Life” with the questions: “Why is it so hard to be happy? Why is life so difficult? Why do humans suffer so much? And what can we realistically do about it?”
He states that Acceptance and Commitment Therapy (ACT) has some profound and life-changing answers to these questions.
In April, my colleague Kathleen and I participated in an introductory  workshop on ACT, which is officially pronounced as the word “act” and not as the initials, to emphasize that as a behavioral therapy at its core, it is about taking action, taking effective action guided by our deepest values, in which we are fully present and engaged.
What is ACT?
ACT is a fairly new, empirically supported behavioral therapy that is based on Relational Frame Theory (RFT). It was developed by Steven Hayes in 1986 and is closely related to other third-wave behavioral therapies such as Mindfulness Based Cognitive Therapy (MBCT) or Dialectical Behavior Therapy (DBT).
Unlike most Western psychotherapy, ACT does not focus on reducing symptoms, but does this as a by-product. Clients come to therapy to get rid of their depression, anxiety, urges to drink, traumatic memories, low self-esteem, fear of rejection, anger, grief and so on. In ACT, there is no attempt to try to reduce, change, avoid, suppress or control these private experiences and feelings. Instead, clients learn to reduce the impact and influence of unwanted thoughts and feelings through the effective use of mindfulness. This is based on the view that ongoing attempts to get rid of symptoms actually create a clinical disorder in the first place.
The goal of ACT is to transform our relationship with our difficult thoughts and feelings, so that we no longer perceive them as symptoms. Instead, we learn to  perceive them as harmless, even if uncomfortable, transient psychological events.  
Clients learn to stop fighting with their private experiences—to open up to them, make room for them, and allow them to come and go without a struggle. And the energy we previously invested in trying to control these unwanted feelings we now invest in taking effective action guided by our personal values to change our life for the better.
Therapeutic Interventions
ACT offers clients an alternative to Experiential Avoidance (EA) through a variety of therapeutic interventions. It focuses on two main processes:

1.      Developing acceptance of unwanted private experiences that are out of personal control. 
  1. Commitment and action toward living a valued life. 
At the foundation of these processes are the six core principles of ACT, which are organized in a so called “Hexaflex”.

  • Defusion (Watch your thinking)
  • Acceptance (Open up)
  • Contact with the present moment (Be here now)
  • The Observing Self (Self-as-context – Pure awareness)
  • Values (Know what matters)
  • Committed action (Do what it takes)

The model shows that these processes are all connected and support each other.

There is no correct order for focusing on these processes, but their application is the ultimate goal of ACT: psychological flexibility. Increasing psychological flexibility involves helping clients to disentangle themselves from the cycle of EA and cognitive fusion.

Clients are taught to focus on the things that they have influence over, like their behavior, depending on what the situation affords, in order to move towards what they value, instead of trying to control experiences over which they have no influence, such as their emotions and thoughs.

Each principle has its own specific methodology. These include metaphor, paradox and experiential exercises that aim to undermine the power of EA and cognitive fusion.

Experiential Exercises
One exercise we did in our workshop was on Defusion.* We had to bring back to mind an upsetting and recurring negative self-judgment to form a sentence in our head  like: “I am stupid“ or “I am incompetent” and were asked to hold that thought for several seconds and try to believe it as much as we could and observe how it affected us. Then we were asked to now change the sentence to: “I am having the thought that ….I am stupid or incompetent” and were asked to hold that thought again for several seconds and to notice how that would feel.
Most of us noticed a distance from the thought, with much less impact on our emotions. This exercise demonstrated also that there was no attempt to get rid of or change the thought – only the relationship with the thought had changed, seeing the thought as just words.
This was just one of the exercises we did in the workshop but there are many more. For example, to deal with an unpleasant thought, we might simply observe it with detachment; or repeat it over and over, or say it out aloud, until it just becomes a meaningless sound; or imagine it in the voice of a cartoon character; or sing it to the tune of “Happy Birthday”; or silently say “Thanks, mind” in gratitude for such an interesting thought.
In contrast to CBT, not one of these cognitive defusion techniques involves evaluating or disputing unwanted thoughts.
What to treat with ACT?
ACT has proven effective with a diverse range of clinical conditions, like depression, OCD, chronic pain and other health conditions, anxiety, PTSD, and substance abuse.
Critics say that ACT is not really based on new theory and is also borrowing interventions from other therapies, but I must say that I really enjoyed working with this complete model. It is easy to understand and work with, it is very flexible as you can start at any point of the hexaflex, the interventions are very illustrative and it is also really fun to use. A  key ingredient of ACT is definitely humor, demonstrated also by the facilitator Aline Kruit from the U-Center in Maastricht, a clinic that provides “Compassionate Care and Clinical Excellence” in the assessment and treatment of co-occurring disorders (see This workshop was given to counsellors, but reading through the books and materials and doing some of the exercises, I can see people also using ACT as a self-help guide.

Book recommendations
Steven Hayes, Get Out of Your Mind & Into Your Life, 2005
Russ Harris, The Happiness Trap, 2007
                                                                                                   Nicole Drinkwater