Acceptance and commitment therapy

Acceptance and Commitment Therapy (ACT) is a psychological intervention developed by Steven C. Hayes and colleagues in the 1980s. ACT assumes that psychological suffering is caused by experiential avoidance of symptoms and hurtful thoughts and feelings. 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.

ACT is used to help patients with various chronic conditions including multiple sclerosis, anorexia nervosa , epilepsy , anxiety disorder, and depression. Most research has focused on the treatment of chronic pain conditions. In myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) only a small feasibility study of ACT has been conducted.

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. 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 Aron Beck. It focused on correcting irrational thoughts and their behavioral consequences. 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.

Functional contextualism and Relational Frame Theory (RFT)
The philosophical underpinning of ACT is functional contextualism, which emphasizes the importance of context in determining the value and meaning of events. In the 1980s Steven C. Hayes and colleagues developed Relational Frame Theory (RFT), which would form the scientific basis of ACT. 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.” If persons 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. Instead of changing the content of mental events, to focus is to alter their interpretation and meaning.

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.



Acceptance
ACT differs from traditional cognitive behavioral therapy in its focus on acceptance. 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. Attempts to avoid, suppress, or eliminate unwanted private experiences are considered counterproductive. 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. 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.

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. 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.” Other de-literalization techniques include repeating words so often that their meaning becomes obscured. 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.

Being present
ACT promotes a non-judgmental relation with events and internal experiences as they occur. 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.

Self as context
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. 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. ACT assumes that persons with psychological problems often fail to distinguish themselves as separate from their experience.

The chessboard metaphor is used to make this distinction clear. Clients are told that they are not the players of the game who have a stake at reaching a particular outcome. Nor are they the chess pieces, because these represent thoughts, feelings, and experiences. The black pieces might represent bad experiences such as depression and anxiety while the white ones could represent happy thoughts that counter these experiences. Clients are encouraged to see themselves as the chessboard that is not playing the game but is merely observing.

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. 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.” 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.

Negates existence of psychological disease
ACT challenges the existence of distinct psychiatric disorders. Hayes and colleagues, for example, write that “psychiatric diseases are actually more myth than reality” and that “none of the most common mental health syndromes has yet met even the most basic criteria to be legitimately considered as a disease state—even such dramatic disorders as the schizophrenias or bipolar disorders.” According to Hayes and colleagues, “the DSM’s vision of human suffering has expanded across the world and has increasingly pathologized normal human difficulties, the ability of non-Western cultures to deal with suffering.”

The responsibility of the patient
ACT proponents claim that “psychological rigidity is a root cause of human suffering and maladaptive functioning.” Consequently, much responsibility is laid with patients who suffer from a psychiatric disorder. Someone with an anxiety disorder, for example, is suggested to have a choice in how to respond to feelings of fear and anxiety. Exercises such as the funeral thought experiment challenge patients if they want to be remembered as someone who lived their lives in fear.

Small effect sizes
The effect sizes for ACT have generally been small to moderate. Meta-analyses have shown that ACT is no more effective in the treatment of chronic pain and other health problems than traditional cognitive behavioral therapy. The quality of ACT trials is considered to be low because of the frequent use of inactive treatment comparisons. Proponents of ACT have been criticized for focusing on promotion and slogans instead of gathering reliable scientific evidence.

ACT-trials
A Swedish feasibility study of ACT in 40 patients with ME/CFS indicated that the treatment was accepted by participants, with a small drop-out rate and no reported harmful effects during or after treatment. The authors plan to do a larger randomized controlled trial with objective outcomes measures to test the efficacy of ACT in patients with ME/CFS.

A randomized trial compared ACT to enhanced care in patients with multiple functional somatic syndromes. Approximately 75% of the 180 patients in the trial met diagnostic criteria for chronic fatigue syndrome. Although the primary outcome, patient-rated overall health improvement, was significantly greater in the ACT-group, most of the 18 secondary outcomes showed no change over time compared to the control group. According to the authors, the results suggest "limited or no clinical effect of ACT as compared with enhanced care".

Studies on acceptance and psychological flexibility
Several studies investigated the role of acceptance in ME/CFS patients. Van Damme et al. found that acceptance was related to more emotional stability and less psychological distress, even after controlling for the effects of demographic variables, and fatigue severity. Acceptance however was not related to functional impairment, somatic autonomy, mobility control, psychic autonomy, social behavior or mobility range.

In a large study of 259 ME/CFS patients, Brooks et al. reported that lack of acceptance was associated with impaired physical functioning and work and social adjustment. Following CBT, acceptance increased, although there was no control group to account for placebo effects. Acceptance at baseline was not a predictor of outcomes of fatigue, physical functioning or social adjustment, post-treatment.

Poppe et al. found that  pre-treatment levels of acceptance were negatively correlated with changes in mental quality of life, suggesting that ME/CFS patients with low levels of acceptance benefit more from CBT. There was no correlation with physical quality of life however, and acceptance could only explain less than 10% of the variance in mental quality of life.

Densham et al. tested psychological flexibility (PF) in patients with ME/CFS, a concept that is central to ACT. Following treatment with graded exercise or CBT, PF did no improve, while quality of life and fatigue severity did. PF was not a mediator of outcomes.