Acceptance and Commitment Therapy
Acceptance and Commitment Therapy (ACT) is a psychological intervention method that applies acceptance and mindfulness processes, and commitment and behavior change processes, to the creation of psychological flexibility. ACT is based on a broad research program in human language and cognition, Relational Frame Theory (RFT). In controlled research, ACT has been shown to be helpful with a wide variety of problems including depression, self-harm, chronic pain, anxiety, psychosis, prejudice, worksite stress, employee burnout, diabetic self-management, adjustment to cancer, obsessive-compulsive disorder, trichotil-lomania, adjustment to epilepsy, and self-stigma, among others.
In the substance abuse area, ACT is known to be helpful for both clients and therapists. For clients, there are successful controlled studies in the areas of opioid addiction, marijuana abuse, smoking, and group treatment during inpatient drug and alcohol treatment. For therapists, ACT has been shown to reduce burnout among drug and alcohol counselors, to decrease judgmental attitudes toward recipients of care, and to increase openness to learning and adoption of new methods.
The ACT Model of Psychopathology
ACT is an approach that is defined in terms of certain theoretical processes, not a technology per se. From an RFT perspective, the most dominant characteristic of human language and cognition is that it is based on learned, relational, and arbitrarily applicable events. Children can readily be taught to relate events mutually and in combination in distinct ways. For example, children learn to treat events as equivalent, different, opposite, or better than one another. When these "relational frames" are learned, they can be applied to any event and the functions of these events can change as a result.
These abilities are spectacularly useful to humans in domains such as reasoning and problem solving, but they raise challenges. For example, humans can remember events by talking about them because symbols and events are mutually related, but this Page 5 | Top of Articlealso means that past painful events can be part of any situation at any time, based only on the minimal cues needed for human thought. Being able to compare events allows relative outcomes to be weighed successfully, but it also allows a person to compare rumor herself to an unrealistic ideal and to be found wanting. Being able to construct temporal sequences allows outcomes to be predicted, but it also allows people to fear the unlikely future or to live in the unresolved past to the extent that the present moment disappears. And because these habits of mind are learned, historical, and useful—even essential—they cannot be stopped, eliminated, or suppressed.
From an ACT point of view, verbal and cognitive processes of this kind are almost too useful in day-to-day problem solving and reasoning; as a result, they often become greatly overextended. Human behavior is often guided by relatively inflexible verbal and cognitive processes rather than by actual experience. This is termed cognitive fusion, meaning the domination of verbal regulation over other behavioral processes.
As a result of cognitive fusion, thoughts (e.g., "I'm bad") are treated as one would treat actual referents (i.e., a dangerous object). Emotions become labeled and evaluated, and negative emotions begin to be needlessly tracked and avoided. This centrally important process—experiential avoidance—also becomes overextended, and it persists even when avoidance causes behavioral harm. The goal of life becomes "feeling good" rather than living a valued life. Unfortunately, attempts to avoid uncomfortable private events tend to increase the importance of these very events and sometimes even their magnitude and frequency. Psychological inflexibility is the result of this process, as the long-term desired qualities of life (i.e., values) and committed actions that might lead in that direction take a backseat to more immediate goals of cognitive fusion (e.g., being right), or experiential avoidance (e.g., feeling good at all costs).
Substance abuse often seems to be exacerbated or perhaps even caused by these processes. It is known that substance use often has emotion regulatory functions. Use may be occasioned by difficult feelings, thoughts, or memories. Higher levels of experiential avoidance are correlated with higher levels of substance use. Thus, all of these key processes are targeted in ACT.
Six Core ACT Processes in ACT interventions
ACT aims to increase psychological flexibility by changing the context in which uncomfortable private events usually occasion experiential avoidance. Psychological flexibility is the ability to contact the present moment more fully as a conscious human being and to change or persist in behavior when doing so serves valued ends. The goal of ACT to get the individual to live a more vital life based on chosen values and direct experiences. Psychological flexibility is established through the following six core ACT processes.
Acceptance is taught as an alternative to experiential avoidance or control strategies. In essence, acceptance occurs when emotions are embraced with awareness and experienced as they are, without attempts to change them in frequency or form. Individuals rarely operate from the perspective that they are a person who is having an experience (feeling), which becomes verbally labeled (e.g., sad). Rather, emotions are viewed as end states that need to be regulated. For example, when someone feels sad, lonely, or worthless, the focus will generally be less on what that feeling is like than on how to get rid of it. Substance use often provides temporary relief from such feeling states, but the impact is only temporary. When an emotion is avoided, its importance in behavioral regulation is strengthened, not diminished. Acceptance methods teach the client to embrace the feeling as a feeling, without the need to take action to change or get rid of it. The client may learn to note where in his or her body urges appear or to note the rise and fall of sensations. Acceptance flows naturally from a state of cognitive defusion.
Cognitive defusion techniques attempt to alter the functions of uncomfortable private events by changing the verbal context in which they occur. Said another way, ACT attempts to change the way one interacts with or relates to thoughts, feelings, and bodily sensations. The main goal is to undermine the excessive literal quality of private events and to relate to them as aspects of Page 6 | Top of Articleongoing experience. Consider the thought "I can never stop using." ACT would provide a wide variety of contextual altering experiences. For example, the thought could be watched dispassionately, repeated several times out loud until only sounds remains, or treated as an external observation by giving it a shape, size, color, speed, or form. A person could thank his or her mind for such an interesting thought, label the process of thinking ("I am having the thought that I am no good"), or examine the historical thoughts, feelings, and memories that occur while experiencing that thought. All of these procedures attempt to reduce the literal quality of the thought, weakening the likelihood to treat the thought as what it refers to ("I am no good"). The result is usually a decrease in believability of, or attachment to, private events rather than a change in frequency. Disrupting the context of literal language reduces attempts to control or get rid of uncomfortable private events and creates flexibility to behave as one chooses.
Self as Context
Self as context is a transcendent sense of being beyond thoughts, feelings, and bodily sensations. Through experiential exercises, ACT attempts to create a sense of self where one experiences him- or herself to be the arena in which private events occur. From this standpoint, one can be aware of one's own flow of experiences without attachment to them or an investment in what experiences occur. Self as context stands in direct opposition to the traditional sense of self, self as content, where the content of thoughts and feelings are experienced as the essence of one's being. ACT believes that attachment to specific content (e.g., feeling happy, thinking "I am a good, sober, or beautiful person") is unnecessary and often unhelpful. A core ACT exercise has clients experience themselves as a chessboard, on which thoughts and feelings are the pieces fighting a war in which they have no investment. Both the client and the chessboard are in intimate contact with all the pieces and are unthreatened by them. Creating a self as context is used to aid both acceptance and defusion and is an example of both acceptance and defusion processes. The core ACT processes are both overlapping and interrelated.
ACT promotes observation and nonjudgmental description of experiences in the present moment. This is similar to meditation and can also be called mindfulness. The goal is to have clients experience the world more directly, rather than experiencing the world constructed by language, or what ACT calls "the world inside the head." Being present, or mindful awareness, is seen as an overarching meta-skill that can be used to aid in all of the ACT core processes.
In ACT, values are chosen qualities of purposive action. Acceptance, defusion, and being present are not ends themselves; rather, they clear the path for a more vital, successful life. ACT attempts to increase an ability to experience uncomfortable private events if doing so is in the service of value-based life choices. ACT does not suggest one should experience psychological pain for pain's sake. However, if, for example, letting go of substance use contacts historical psychological pain (e.g., negative evaluations of oneself, memories of past failed attempts to keep sober, urges), then ACT provides a space in which one can experience that pain without attachment in the service of a valued choice, such as continued sobriety. ACT views values as directions, not outcomes. Life is seen as a process by which valued directions are never attained but rather serve to guide the client through a process of vital living. ACT uses a variety of exercises to help clients choose valued directions in various domains (e.g., family, career, spirituality) while attempting to undermine verbal dominance (e.g., "I should value X" or "A good person would value Y").
Finally, ACT encourages direct changes in behavior that are consistent with chosen value directions. This involves setting short- medium- and long-term behavior change goals while identifying and working through psychological barriers that show up along the way.
Each of the other five ACT core processes plays a role in facilitating behavior change. The six processes can be chunked into two groupings. Mindfulness and acceptance processes involve acceptance, defusion, contact with the present moment, and self as context. Indeed, these four processes provide a workable behavioral definition of mindfulness. Commitment and behavior change processes involve contact with Page 7 | Top of Articlethe present moment, self as context, values, and committed action. Contact with the present moment and self as context occur in both groupings because the psychological activity of humans always involves actions in the present by a conscious person.
ACT is part of a larger set of procedures, many of which have been shown to be relevant to substance abuse, including dialectical behavior therapy, functional analytic psychotherapy, mindfulness-based cognitive therapy, and mindfulness-based relapse prevention. No one factor unites these new methods, but all have ventured into areas traditionally reserved for the less empirical wings of clinical intervention and analysis, emphasizing such issues as acceptance, mind-fulness, cognitive defusion, dialectics, values, spirituality, and relationship. Their methods are often more experiential than didactic; their underlying philosophies are more contextualistic than mechanistic. Together, they are sometimes labeled "third-generation" behavioral and cognitive therapy.
As the work with ACT shows, these new methods seem to have wide applicability, not just to substance abuse but to a variety of behavioral health problems. In addition, the issues they address are not relevant to a single theoretical wing or camp. Issues of acceptance are as relevant to Twelve-Step programs as to ACT. As such, they seem to have the promise of reducing the barriers that exist between the research and practice base and between the various theoretical and philosophical wings of the field.
Jennifer L. Boulanger, Steven C. Hayes, and Jason Lillis
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Gale Document Number: GALE|CX3074600014