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Acceptance and commitment therapy
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==Theory== ACT assumes that psychological suffering is caused by experiential avoidance of symptoms and hurtful thoughts and feelings.<ref name="Hayesbook">{{Cite book | url = https://books.google.be/books?id=RvIxDwAAQBAJ&pg=PA54&lpg=PA54 | title = Acceptance and Commitment Therapy: The Process and Practice of Mindful Change | last = Hayes | first = Steven C. | last2 = Strosahl | first2 = Kirk D. | last3 = Wilson | first3 = Kelly G. | date = 2016-08-29|location=Oakland, Calif| publisher = Guilford Publications|isbn=9781462528943|language=en | pages = 54|edition=2}}</ref> The objective of ACT is not to correct or eliminate these painful experiences but to prevent them from becoming a barrier towards value-driven behavior. ACT aims to help the individual clarify their personal values and to increase psychological flexibility towards distressing thoughts or feelings.<ref name="Gordon2017">{{Cite book | title = The ACT Approach a Comprehensive Guide for Acceptance and Commitment Therapy.|isbn=978-1-68373-083-5|language=en | url =http://search.ebscohost.com/login.aspx?direct=true&scope=site&db=nlebk&AN=1662062 | date = 2017| publisher = PESI Publishing & Media | last = Gordon | first = Timothy | last2 = Borushok | first2 = Jessica | last3 = Polk | first3 = Kevin L|oclc=1105452637|location=Ashland}}</ref> ACT is used to help patients with various chronic conditions including [[multiple sclerosis]],<ref name="Nordin">{{Cite journal | last = Nordin | first = Linda | last2 = Rorsman | first2 = Ia | date = Jan 2012 | title = Cognitive behavioural therapy in multiple sclerosis: a randomized controlled pilot study of acceptance and commitment therapy | url = https://www.ncbi.nlm.nih.gov/pubmed/22234322 | journal = Journal of Rehabilitation Medicine | volume = 44 | issue = 1 | pages = 87–90|doi=10.2340/16501977-0898|issn=1651-2081|pmid=22234322}}</ref> [[Anorexia and eating disorders|anorexia nervosa]],<ref name="Parling">{{Cite journal | last = Parling | first = Thomas | last2 = Cernvall | first2 = Martin | last3 = Ramklint | first3 = Mia | last4 = Holmgren | first4 = Sven | last5 = Ghaderi | first5 = Ata | date = 2016-07-29 | title = A randomised trial of Acceptance and Commitment Therapy for Anorexia Nervosa after daycare treatment, including five-year follow-up | url =https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4966749/ | journal = BMC Psychiatry | volume = 16|doi=10.1186/s12888-016-0975-6|issn=1471-244X|pmc=4966749|pmid=27473046}}</ref> [[epilepsy]],<ref name="Lundgren">{{Cite journal | last = Lundgren | first = Tobias | last2 = Dahl | first2 = JoAnne | last3 = Melin | first3 = Lennart | last4 = Kies | first4 = Bryan | date = 2006 | title = Evaluation of Acceptance and Commitment Therapy for Drug Refractory Epilepsy: A Randomized Controlled Trial in South Africa—A Pilot Study | url = https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1528-1167.2006.00892.x | journal = Epilepsia|language=en | volume = 47 | issue = 12 | pages = 2173–2179|doi=10.1111/j.1528-1167.2006.00892.x|issn=1528-1167}}</ref> [[anxiety]] disorder, and [[depression]].<ref name="Twohig2017">{{Cite journal | last = Twohig | first = Michael P. | last2 = Levin | first2 = Michael E. | date = Dec 2017 | title = Acceptance and Commitment Therapy as a Treatment for Anxiety and Depression: A Review | url =https://www.ncbi.nlm.nih.gov/pubmed/29080598 | journal = The Psychiatric Clinics of North America | volume = 40 | issue = 4 | pages = 751–770|doi=10.1016/j.psc.2017.08.009|issn=1558-3147|pmid=29080598}}</ref> Most research has focused on the treatment of [[chronic pain]] conditions.<ref name="Veehof2016">{{Cite journal | last = Veehof | first = M.M. | last2 = Trompetter | first2 = H.R. | last3 = Bohlmeijer | first3 = E.T. | last4 = Schreurs | first4 = K.M.G. | date = 2016 | title = Acceptance- and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review | url =https://www.ncbi.nlm.nih.gov/pubmed/26818413 | journal = Cognitive Behaviour Therapy | volume = 45 | issue = 1 | pages = 5–31|doi=10.1080/16506073.2015.1098724|issn=1651-2316|pmid=26818413}}</ref><ref name="Simister">{{Cite journal | last = Simister | first = Heather D. | last2 = Tkachuk | first2 = Gregg A. | last3 = Shay | first3 = Barbara L. | last4 = Vincent | first4 = Norah | last5 = Pear | first5 = Joseph J. | last6 = Skrabek | first6 = Ryan Q. | date = Jul 2018 | title = Randomized Controlled Trial of Online Acceptance and Commitment Therapy for Fibromyalgia | url = https://www.ncbi.nlm.nih.gov/pubmed/29481976 | journal = The Journal of Pain: Official Journal of the American Pain Society | volume = 19 | issue = 7 | pages = 741–753|doi=10.1016/j.jpain.2018.02.004|issn=1528-8447|pmid=29481976}}</ref><ref name="Hann2014">{{Cite journal | last = Hann | first = K.E.J. | last2 = McCracken | first2 = L.M. | date = 2014 | title = A systematic review of randomized controlled trials of Acceptance and Commitment Therapy for adults with chronic pain: Outcome domains, design quality, and efficacy. | url = https://www.sciencedirect.com/science/article/abs/pii/S1746068916300475 | journal = Journal of Contextual Behavioral Science | volume = 3 | pages = 217-227}}</ref> In [[ME/CFS|myalgic encephalomyelitis/chronic fatigue syndrome]] (ME/CFS) only a small feasibility study of ACT has been conducted.<ref name="Jonsjo2019">{{Cite journal | last = Jonsjö| first = Martin A. | author-link = Martin Jonsjö | last2 = Wicksell | first2 = Rikard K. | author-link2 = | last3 = Holmström | first3 = Linda | author-link3 = | last4 = Andreasson | first4 = Anna | author-link4 = | last5 = Olsson | first5 = Gunnar L. | author-link5 = Gunnar Olsson | date = 2019-04-01 | title = Acceptance & Commitment Therapy for ME/CFS (Chronic Fatigue Syndrome) – A feasibility study | url = https://www.sciencedirect.com/science/article/pii/S2212144718301959 | journal = Journal of Contextual Behavioral Science|language=en | volume = 12 | issue = | pages = 89–97|doi=10.1016/j.jcbs.2019.02.008|issn=2212-1447|pmc=|pmid=|access-date=|quote=|via=}}</ref> === The third wave of cognitive behavioral therapies === Together with dialectical behavior therapy and mindfulness-based stress reduction, ACT is considered part of the third wave of cognitive behavioral therapies.<ref name="Hayes2017">{{Cite journal | last = Hayes | first = Steven C. | last2 = Hofmann | first2 = Stefan G. | date = Oct 2017 | title = The third wave of cognitive behavioral therapy and the rise of process‐based care | url =https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5608815/ | journal = World Psychiatry | volume = 16 | issue = 3 | pages = 245–246|doi=10.1002/wps.20442|issn=1723-8617|pmc=5608815|pmid=28941087}}</ref> The first wave began in the 1920s and consisted of classical operant conditioning with simple reinforcement or extinction of behaviors, as developed by Ivan Pavlov, John B. Watson and later B. F. Skinner. The second wave emerged in the 1970s through the work of Aaron Beck. It focused on correcting irrational thoughts and their behavioral consequences.<ref name="CBT-tsunami">{{Cite book |isbn=9781782206644 | url = https://www.routledge.com/CBT-The-Cognitive-Behavioural-Tsunami-Managerialism-Politics-and-the/Dalal/p/book/9781782206644 | title = CBT: The Cognitive Behavioural Tsunami: Managerialism, Politics and the Corruptions of Science|edition=1st|location=Abingdon, Oxon| publisher=Routledge|language=en | date = 2019 | last = Dalal | first = Farhad | author-link = | last2 = | first2 = }}</ref> The third wave no longer tries to control or correct negative feelings but promotes acceptance and detachment. Whereas second wave therapies treat psychopathology by challenging thoughts and emotions, third wave approaches target the context and function of these private events.<ref name="Hayes2017" /> ===Context=== In ACT, context is seen as key in determining the value and meaning of events.<ref name="Hayes2006">{{Cite journal | last = Hayes | first = Steven C. | last2 = Luoma | first2 = Jason B. | last3 = Bond | first3 = Frank W. | last4 = Masuda | first4 = Akihiko | last5 = Lillis | first5 = Jason | date = Jan 2006 | title = Acceptance and commitment therapy: model, processes and outcomes |url =https://www.ncbi.nlm.nih.gov/pubmed/16300724 | journal = Behaviour Research and Therapy | volume = 44 | issue = 1 | pages = 1–25|doi=10.1016/j.brat.2005.06.006|issn=0005-7967|pmid=16300724}}</ref> In the 1980s Steven C. Hayes and colleagues developed Relational Frame Theory (RFT), forms the scientific and philosophical basis of ACT.<ref name="Hayes2006" /><ref name="McHugh2011">{{Cite journal | last = McHugh | first = Louise | date = Sep 2011 | title = A new approach in psychotherapy: ACT (acceptance and commitment therapy) | url = https://www.ncbi.nlm.nih.gov/pubmed/21906000 | journal = The World Journal of Biological Psychiatry: The Official Journal of the World Federation of Societies of Biological Psychiatry | volume = 12 | issue = Suppl 1 | pages = 76–79|doi=10.3109/15622975.2011.603225|issn=1814-1412|pmid=21906000}}</ref> According to RFT, the core of language and cognition is the ability to mentally relate events and change their function and meaning based on their relations to other events. One often used example is that of a young child who thinks a nickel is worth more than a dime because of its larger size. That changes, however, as soon as the child learns the arbitrarily defined money value attached to a nickel and a dime. This human ability to create mental realities is central to ACT. According to ACT, suffering occurs "when people so strongly believe the literal contents of their mind that they become fused with their cognitions."'<ref name="Hayesbook" /> If people take their unpleasant thoughts and feeling as a reality, this might lead to experiential avoidance and psychological problems. To goal of ACT is to bring verbal cognitive processes under better contextual control.<ref name="Hayes2006" /> Instead of changing the content of mental events, to focus is to alter their interpretation and meaning.<ref name="Prevedini">{{Cite journal | last = Prevedini | first = Anna Bianca | last2 = Presti | first2 = Giovambattista | last3 = Rabitti | first3 = Elisa | last4 = Miselli | first4 = Giovanni | last5 = Moderato | first5 = Paolo | date = Jan 2011 | title = Acceptance and commitment therapy (ACT): the foundation of the therapeutic model and an overview of its contribution to the treatment of patients with chronic physical diseases |url =https://www.ncbi.nlm.nih.gov/pubmed/21488484 | journal = Giornale Italiano Di Medicina Del Lavoro Ed Ergonomia | volume = 33 | issue = 1 Suppl A| pages=A53–63|issn=1592-7830|pmid=21488484}}</ref> ===The hexaflex=== ACT consists of 6 main processes: acceptance, defusion, being present, self as context, values and committed action. These are often presented graphically in the form of a hexagon. Because the ultimate goal of ACT is to increase the client’s psychological flexibility, this hexagon is commonly referred to as the hexaflex.<ref name="Gordon2017" /> ====Acceptance ==== ACT differs from traditional cognitive behavioral therapy in its focus on acceptance.<ref name="Hayes2006" /> Rather than trying to teach people to better control their unpleasant sensations, clients learn to accept them in the appropriate context. According to ACT, it is psychologically healthy to have unpleasant thoughts and feelings.<ref name="Hayesbook" /> Attempts to avoid, suppress, or eliminate unwanted private experiences are considered counterproductive.<ref name="Cioffi1993">{{Cite journal | last = Cioffi | first = D. | last2 = Holloway | first2 = J. | date = Feb 1993 | title = Delayed costs of suppressed pain | url =https://www.ncbi.nlm.nih.gov/pubmed/8433273 | journal = Journal of Personality and Social Psychology | volume = 64 | issue = 2 | pages = 274–282|issn=0022-3514|pmid=8433273}}</ref> Asking a person not to think of chocolate biscuits, for example, will most likely result in that person thinking about chocolate biscuits. Negating unpleasant experiences often results in experiential avoidance, which might bring short-term relief but often exacerbates problems in the long term. Persons who drink to numb hurtful experiences for example, will most likely increase rather than solve their problems.<ref name="Hayesbook" /> As an alternative, ACT proposes a willingness to come into contact with a person's whole experience, including the painful aspects. Acceptance doesn’t mean liking or wanting these experiences or giving up on doing anything about it, but simply accepting that they are there.<ref name="Hayes2013">{{Cite journal | last = Hayes | first = Steven C. | last2 = Levin | first2 = Michael E. | last3 = Plumb-Vilardaga | first3 = Jennifer | last4 = Villatte | first4 = Jennifer L. | last5 = Pistorello | first5 = Jacqueline | date = Jun 2013 | title = Acceptance and commitment therapy and contextual behavioral science: examining the progress of a distinctive model of behavioral and cognitive therapy | url = https://www.ncbi.nlm.nih.gov/pubmed/23611068 | journal = Behavior Therapy | volume = 44 | issue = 2 | pages = 180–198|doi=10.1016/j.beth.2009.08.002|issn=1878-1888|pmc=3635495|pmid=23611068}}</ref> ==== Cognitive defusion ==== Humans tend to experience language in a very literal way. According to ACT, many psychological problems occur when persons so strongly believe the contents of their mind that they become fused with their cognitions.<ref name="Hayesbook" /> Cognitive defusion techniques are used to undermine the negative effects of language by teaching clients to get some distance from their thoughts. Clients are for example encouraged to label and provide context to their internal experiences. The feeling "I’m no good" could be rephrased as "I am having the thought that I am no good."<ref name="McHugh2011" /> Other de-literalization techniques include repeating words so often that their meaning becomes obscured.<ref name="Hayesbook" /> The resulting detachment from inner thoughts and feelings is designed to increase psychological flexibility and the range of behavioral responses toward mental experiences. ACT teaches how one can be aware of one's flow of experiences without attachment to them.<ref name="Sixprocesses">{{Cite web | last = Hayes | first = S | date = 2006 | url = https://contextualscience.org/the_six_core_processes_of_act | title = The Six Core Processes of ACT | website = Association for Contextual Behavioral Science | access-date = 2019-03-17}}</ref> ==== Being present ==== ACT promotes a non-judgmental relation with events and internal experiences as they occur.<ref name="Sixprocesses" /> This means observing them in the present and not trying to relate them to possible causes or consequences. Focusing on the present increases psychological flexibility, as it does not restrict interpretations and actions based on what happened in the past or what might happen in the future. According to ACT, searching for possible explanations of why something happened and ruminating about ''what if'' realities, are often unhelpful in working out psychological problems.<ref name="Hayesbook" /> ==== The chessboard metaphor ==== According to ACT, people interpret their experiences as relating to a coherent self, an identity that determines interpretations of thoughts and feelings and their behavioral consequences. A person who labels herself as incompetent or shy for example might behave in a manner that maintains that self-description.<ref name="Twohig2012">{{Cite journal | last = Twohig | first = Michael P. | author-link = | date = Nov 2012 | title = Acceptance and Commitment Therapy | url = https://linkinghub.elsevier.com/retrieve/pii/S1077722912000508 | journal = Cognitive and Behavioral Practice|language=en | volume = 19 | issue = 4 | pages = 499–507|doi=10.1016/j.cbpra.2012.04.003|pmc=|pmid=|access-date=|quote=|via=}}</ref> ACT promotes detachment from such verbally constructed identities as they may cause psychological rigidity. As an alternative ACT proposes the self as context, where one steps back from all definitions and descriptions about one's self. The self as context is the idea that our selves are the observer of our experiences and not the content we observe.<ref name="Gordon2017" /> ACT assumes that persons with psychological problems often fail to distinguish themselves as separate from their experience. The chessboard metaphor is used to description the use of detachment.<ref>{{Cite book | title = Acceptance & Commitment Therapy for the Treatment of Post-traumatic Stress Disorder & Trauma-related Problems: A Practitioner's Guide to Using Mindfulness & Acceptance Strategies | pages = 116|isbn=978-1-57224-472-6|edition= | volume = |language=en| title-link = | url = https://books.google.co.uk/books?id=Qlm6BX-K40QC&lpg=PA116&=PA116#v=onepage&q=chess-board=true|access-date= | date = 2007| publisher = New Harbinger Publications | last = Walser | first = Robyn D. | author-link = | last2 = Westrup | first2 = Darrah | author-link2 = |veditors=|others=|doi=|oclc=|quote=|archive-url=|archive-date=|location=|editor-last = |editor-first = | editor1-link = |editor-last2 = |editor-first2 = }}</ref> Clients are told that their inner experiences are similar to playing chess, and different chess pieces can be used to their represent thoughts, feelings, and experiences. The chess pieces might represent either comfortable ("good") or uncomfortable ("bad") experiences, and are placed on the chessboard in a group according to whether they represent "good" or "bad" experiences. Larger pieces are used to represent the more distressing experiences such as traumatic events. Clients are encouraged to see these thoughts, feelings and experiences as in conflict, with the client only winning when the "good" beats the "bad". The fear of the bad itself is also a part of the game, so it is added to the board as a new piece. There is no winning this game because new experiences continue to happen, and the bad experiences (the client's history) can't be erased. Clients are then encouraged to see themselves as the ''chessboard'' instead: the chessboard never wins or loses, it simply observes the good and bad thoughts, feelings and experiences. This chessboard metaphor of detachment is a central part of ACT.<ref name="Hayesbook" /> ==== Values ==== ACT encourages clients to get in touch with their personal values. Actions are often determined by social conformity and attempts to please others with the result that one loses touch with core values. When we say someone made a bad choice, we usually refer to the negative outcome of an action rather than the values that guided it. ACT therapists frequently use the funeral thought experiment to help clients think about their values.<ref name="Hayesbook" /> Clients are asked to think about what they want their loved ones to say at their own funeral. Usually, people want to be remembered as loving and generous, not as someone who made a lot of money. Consequently, clients learn to differentiate means from goals, the important from the unimportant. ==== Committed action ==== Finally, ACT encourages effective action based on those chosen values. The eventual goal of ACT is to encourage behavioral change. As noted by one ACT textbook: ''"If a client does not change his or her behavior, then all of our efforts working on defusion–acceptance, present moment–self-as perspective, and values are for naught."''<ref name="Hayesbook" /> Clients are encouraged to lessen experiential avoidance. A person with agoraphobia, for example, might be afraid to go out to the supermarket to buy groceries. By avoiding such experiences patients could get stuck in a self-perpetuating cycle. ACT tries to break that cycle. Exercises on acceptance or cognitive defusion are meant to diminish the behavioral consequences of unpleasant experiences.<ref name="Twohig2012" />
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