September/October 2008 Issue

The ABCs of ACT — Acceptance and Commitment Therapy
By Claudia Dewane, LCSW, DEd
Social Work Today
Vol. 8 No. 5 P. 34

From the “third generation” of behavior therapies, ACT is a contextual approach challenging clients to accept their thoughts and feelings and still commit to change.

Client: “I want to change, BUT I am too anxious.”

Social worker: “You want to change, AND you are anxious about it.”

This subtle verbal and cognitive shift is the essence of acceptance and commitment therapy (ACT). It suggests that a person can take action without first changing or eliminating feelings. Rather than fighting the feeling attached to a behavior, a person can observe oneself as having the feeling but still act (Mattaini, 1997). Acceptance-based approaches (Hayes & Wilson, 1994) postulate that instead of opting for change alone, the most effective approach may be to accept and change. The importance of acceptance has long been recognized in the Serenity Prayer.

As one of the postmodern behavioral approaches, ACT is being evaluated as another short-term intervention in a variety of populations seen by social workers.

Evolution of ACT
Psychodynamic approaches that emphasize insight imply that a change in attitude will most likely result in a change in behavior. In contrast, pure behavioral approaches suggest that altering behavior does not demand a change in attitude. However, changing a behavior may eventually result in a change in attitude or emotion. Focusing on changing behavior regardless of accompanying emotion is the emphasis.

Taking behaviorism a step further, ACT suggests that both behavior and emotion can exist simultaneously and independently. Acceptance has been described as the “missing link in traditional behavior therapy” (Jacobson & Christensen, 1996). ACT is part of a larger movement in the behavioral and cognitive realm, which includes the mindfulness approaches (Hayes, 2005).

Hayes (2006, 2005, 1994) has been credited as the founder of ACT as a contextual approach to treatment. He explores the paradoxes of context, such as separating words and actions, and distinguishing clients’ sense of self from their thoughts and behavior. For example, when a person doesn’t go to work because he or she is anxious about a confrontation with his or her boss, it is conceivable (and encouraged) that the individual can go to work while feeling anxious. Showing clients that they can live with anxiety and eliminate the control that contexts exert is a major goal of therapy (Thyer & Wodarski, 1998). Those familiar with rational emotive behavioral therapy will recognize this approach as consistent with verbal rule governance (“injunctions”).

ACT is born from the behavioral school of therapy. However, behavior therapy is divided into three generations: traditional behaviorism, cognitive-behavioral therapy (CBT), and the current “third generation” or contextual approaches to behavior (Hayes, 2005). This third wave of behaviorism has an existential bent in its premise that suffering is a basic characteristic of human life and represents a dramatic change from traditional behaviorism and CBT due to the inclusion of acceptance and mindfulness-based interventions. The third-wave, which also includes dialectical behavior therapy and mindfulness-based cognitive therapy, broadens attention to the psychological, contextual, and experiential world of its constituents.

The belief behind ACT is that a more fulfilled life can be attained by overcoming negative thoughts and feelings. The goal of ACT is to help clients consistently choose to act effectively (concrete behaviors as defined by their values) in the presence of difficult or disruptive “private” (cognitive or psychological) events. The acronym ACT has also been used to describe what takes place in therapy: accept the effects of life’s hardships, choose directional values, and take action.

Theoretical Base
Social work literature about ACT is limited. As is typical of much of social work’s derivative knowledge base, the literature from the fields of psychology and social psychology contribute to understanding ACT and its application to social work practice. The literature on ACT dates back to the early 1980s but, more recently, has been evidencing empirical promise (Hayes, 2005).

ACT is a unique psychotherapeutic approach based on relational frame theory (RFT). RFT questions the context in which rational change strategies exist based on principles of behavior analysis. By examining the interactions that people have with their natural and social environments (contexts), RFT provides an understanding of the power of verbal behavior and language. The theory holds that much of what we call psychopathology is the result of the human tendency to avoid negatively evaluated private events (what we think and feel). ACT highlights the ways that language traps clients into attempts to wage war against their internal lives. Clients learn to recontextualize and accept these private events, develop greater clarity about personal values, and commit to needed behavior change. For social workers, this philosophy is best understood as “person in environment,” with the added variable of how language is used to interpret and direct those environments.

Process
The core of ACT is a change in both internal (self-talk) and external (action) verbal behavior. Simply observing oneself having feelings and recognizing and accepting that feelings are a natural outgrowth of circumstances is freeing. Clients have feelings about feelings (e.g., they might be ashamed of being anxious, angry, or sad). ACT says that fighting emotions makes them worse. “If you can’t accept the feeling for now, you will be stuck with it, but if you can, you can change your world so you will not have that feeling later.” (Hayes & Wilson, 1994)

Mattaini (1997) explains that ACT does not mean we ask clients to accept every situation (e.g., abusive relationships), but that some circumstances should ultimately be accepted (i.e., physical reality or historical events), should be accepted for now, should be accepted with expectation of eventual change, or should be changed now.

For example, if a client is disturbed by memories of past events, he or she must accept that the event occurred; accompanying feelings can eventually be diminished. This concept is reminiscent of social work’s strengths perspective in which Saleebey (1996) advises that one can accept the verdict yet defy the sentence.

Reminiscent of the Serenity Prayer, Mattaini (1997) cautions that the initial work is to identify areas that can and cannot be changed. Physical handicaps and past trauma are examples of things that cannot be changed and are best accepted.

ACT focuses on a shift from the content of experience to the context of experience. Hayes (2005) describes six core processes of ACT: acceptance, cognitive defusion, being present, self as context, valuing, and committed action. Similarly, Wilson et al (1996) provides a sample model for intervention:

1. Clients often present with a goal of erasing the past or the pain associated with it. They have struggled for a long time with “the problem” in many different ways. Thus, avoidant behaviors are initially assessed. What has been the client’s “experiential avoidance”?—that which occurs when a person is unwilling to remain in contact with particular private experiences and takes steps to alter the form or frequency of these events and the contexts that trigger them, even when doing so causes psychological harm (Hayes, Luoma, Bond, Masuda, & Lillis, 2006).

2. Examine strategies that have not worked. The paradox is that working hard to solve the problem makes the problem seem worse. ACT sees the logic of the problem-solving system as flawed because it is based on culturally sanctioned, language-based rules for solving problems. These rules are taken for granted, such as the presence of unpleasant inner experiences (feelings, thoughts, sensations) is equivalent to a psychological problem. By default then, being healthy means the absence of these negative experiences. The ACT therapist works to challenge these rules by showing that efforts based on these rules can actually be the source of problems. A more valid and reliable source of problem solving is the client’s own direct experience and their feedback from life. “It is not the client’s life that is hopeless, but the strategies of experiential control (avoidance) that are hopeless” (Wilson, 1996).

3. Establish control with different strategies. A lifetime of distracting oneself from aversive private experiences is akin to constantly running away from one’s shadow. The result is that in the attempt to control the negative thoughts and feelings, one is at a loss for control in other life situations.

4. Identify that self as context, distinguished from self in content, is similar to the process of externalizing the problem in narrative approaches. Clients are taught to get in touch with an observant self—the one that watches and experiences yet is distinct from one’s inner experiences.

5. A lack of values or a confusion of goals with values can underlie the inability to be psychologically flexible. Thus, the next step in the ACT process is “choosing a direction and establishing willingness” and to identify motivating values and establish a willingness to help regain control of life, not necessarily just to control thoughts and feelings. Willingness is not resignation, nor is it the same as wanting. It is a willingness to experience, accept, and face “negatively evaluated emotional states” (Wilson, 1996). Again, the difference is noted between the feeling of willingness and being willing. The example given is that you may not feel willing to go to the dentist, but you may be willing to go anyway.

6. In the last stages of therapy, commitment is the focus. The commitment is to give up the war of denying or fighting one’s history and emotional states and find opportunities for empowering behaviors.

Techniques
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 (see Resource).

1. 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.

2. 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.

3. 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.”

4. 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.

5. Self as context teaches the client to view his or her identity as separate from the content of his or her experience.

Potential Populations
ACT has been empirically tested, and there is reason to believe that it could be beneficial for a variety of populations. Preliminary research suggested that ACT is useful for sexual abuse survivors, at-risk adolescents, and those with substance abuse or mood disorders (Wilson, 1996). Hayes (2005) suggests that the ACT model seems to be working across an unusually broad range of problems.

ACT would be appropriate for individuals with substance abuse issues, heightening motivational interviewing and enhancement approaches. ACT has been utilized with those experiencing psychotic ideation. In one study, psychiatric inpatients given ACT demonstrated improvement in affective symptoms, social impairment, and distress associated with hallucinations (Gaudiano & Herbert, 2006).

ACT has been proposed for trauma work, as well as for those with phobias and obsessive behavior (Twohig, Hayes, & Masuda, 2006). Using ACT approaches with victims of trauma seems particularly pertinent. Those who suffer from posttraumatic stress may benefit from being able to accept the experience without resigning oneself to its residuals. The unwillingness to experience pain associated with trauma creates an internal struggle (verbal battle) that keeps the trauma alive.

For social workers dealing with survivors of childhood abuse, ACT may be a potent tool. From an ACT perspective, the cognitions and emotions that result from a history of abuse are amenable to alteration. CBT might seek to change the form of self-talk. In contrast, ACT seeks to alter the function of the thoughts and feelings. Cognitive therapy views negative thoughts and feelings in terms of their logical reasonableness; ACT focuses on their psychological reasonableness (Wilson, 1996). To tell an incest survivor that her disturbing thoughts in situations of sexual intimacy are irrational is not particularly helpful. It is more useful to point out the psychological function of these thoughts (Wilson et al, 1996).

ACT has been proposed for work with couples and families. One study demonstrated that acceptance strategies increased the effectiveness of traditional behavioral marital therapy (Jacobson & Christensen, 1996). The goal is not to necessarily accept all partner behaviors but rather to effectively “generate a context where both accepting and changing will occur” (Jacobson & Christensen, 1996). Three ways in which ACT interventions assist couples are generating greater intimacy with the conflict area used as a vehicle, generating tolerance, and generating change (Jacobson & Christensen, 1996). Acceptance is not accepting another’s behavior, but letting go of the struggle to try to change another’s behavior.

Certainly, to be proficient as an ACT therapist, training is indicated. For social workers dealing with the broad range of behavioral problems that demand short and empirically-based intervention, ACT has a place. “Get off your buts” is one of the techniques used in ACT, where all “buts” are replaced with “and.” So instead of saying, “I’d like to learn about ACT but don’t have the time,” consider saying, “I’d like to learn about ACT, and it is worth the time!”

— Claudia Dewane, LCSW, DEd, is a senior lecturer at Temple University’s Graduate School of Social Administration. She is the founder of Clinical Support Associates, providing supervision, consultation, and training to professional social workers.

Resource
A comprehensive list of protocols, techniques, and training related to acceptance and commitment therapy can be found at www.contextualpsychology.org, the official site for the Association for Contextual Behavioral Science.

References
Blackledge, J. T. (2007). Disrupting verbal processes: Cognitive defusion in acceptance and commitment therapy and other mindfulness-based psychotherapies. The
Psychological Record, 57, 555-576.

Gaudiano, B. A. & Herbert, J. D. (2006). Acute treatment of inpatients with psychotic symptoms using acceptance and commitment therapy: pilot results. Behaviour Research and Therapy, 44, 415-437.

Gifford, E. Steve Hayes and Kirk Stroshal. (2005). Retrieved 9/20/2005. [www.acceptanceandcommitmenttherapy.com]

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), 1-25.

Hayes, Steven. (2009). Acceptance and commitment therapy (ACT). [www.contextualpsychology.org/act]

Hayes, S. C. & Wilson, K. G. (1994). Acceptance and commitment therapy: Altering the verbal support for experiential avoidance. The Behavior Analyst, 17, 289-303.

Jacobson, N. S. & Christensen, A. (1996). Acceptance and change in couple therapy: A therapist’s guide to transforming relationship. New York: W. W. Norton & Company.

Mattaini, M. A. (1997). Clinical practice with individuals. Washington, DC: NASW Press.

Saleeby, D. 1996. The strengths perspective in social work practice: Extensions and cautions. Social Work, 41(3), 296-305.

Thyer, B. A. & Wodarski, J. S. (1998). Handbook of empirical social work practice, volume 1, mental disorders. Hoboken, NJ: Wiley.

Twohig, M. P., Hayes, S. C., & Masuda, A. 2006. Increasing willingness to experience obsessions: Acceptance and commitment therapy as a treatment for obsessive-compulsive disorder. Behavior Therapy, 37(1), 3-13.

Wilson, K. G., Follette, V. M., Hayes, S. C., & Batten, S. V. (1996). Acceptance theory and the treatment of survivors of childhood sexual abuse. National Center for PTSD Clinical Quarterly, 6(2), 34-37.