Acceptance and commitment therapy

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Acceptance and commitment therapy or ACT is a psychological therapy developed by Steven C. Hayes and colleagues in the 1980s.[1]

Theory[edit | edit source]

ACT assumes that psychological suffering is caused by experiential avoidance of symptoms and hurtful thoughts and feelings.[2] 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.[3]

ACT is used to help patients with various chronic conditions including multiple sclerosis,[4] anorexia nervosa,[5] epilepsy,[6] anxiety disorder, and depression.[7] Most research has focused on the treatment of chronic pain conditions.[8][9][10] In myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) only a small feasibility study of ACT has been conducted.[11]

The third wave of cognitive behavioral therapies[edit | edit source]

Together with dialectical behavior therapy and mindfulness-based stress reduction, ACT is considered part of the third wave of cognitive behavioral therapies.[12] 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.[13] 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.[12]

Context[edit | edit source]

In ACT, context is seen as key in determining the value and meaning of events.[14] In the 1980s Steven C. Hayes and colleagues developed Relational Frame Theory (RFT), forms the scientific and philosophical basis of ACT.[14][15]  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."'[2] 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.[14] Instead of changing the content of mental events, to focus is to alter their interpretation and meaning.[16]

The hexaflex[edit | edit source]

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.[3]

Acceptance[edit | edit source]

ACT differs from traditional cognitive behavioral therapy in its focus on acceptance.[14] 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.[2] Attempts to avoid, suppress, or eliminate unwanted private experiences are considered counterproductive.[17] 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.[2] 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.[18]

Cognitive defusion[edit | edit source]

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.[2] 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."[15] Other de-literalization techniques include repeating words so often that their meaning becomes obscured.[2] 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.[19]

Being present[edit | edit source]

ACT promotes a non-judgmental relation with events and internal experiences as they occur.[19] 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.[2]

The chessboard metaphor[edit | edit source]

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.[20] 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.[3] 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.[21] 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.[2]

Values[edit | edit source]

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.[2] 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[edit | edit source]

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."[2] 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.[20]

Evidence[edit | edit source]

Criticism[edit | edit source]

Negates existence of psychological illness[edit | edit source]

ACT challenges the existence of distinct psychiatric disorders. Hayes and colleagues, for example, write that "psychiatric diseases are actually more myth than reality"[2] 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."[2] 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."[2]

The responsibility of the patient[edit | edit source]

ACT proponents claim that "psychological rigidity is a root cause of human suffering and maladaptive functioning."[2] 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.[2]

Evidence[edit | edit source]

Small effect sizes[edit | edit source]

The effect sizes for ACT have generally been small to moderate.[8] 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.[8][9] The quality of ACT trials is considered to be low because of the frequent use of inactive treatment comparisons.[10] Proponents of ACT have been criticized for focusing on promotion and slogans instead of gathering reliable scientific evidence.[22]=== Studies on acceptance and psychological flexibility === Several studies investigated the role of acceptance in ME/CFS patients. Van Damme et al.[23] 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.[24] 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.[25] 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.[26] tested psychological flexibility (PF) in patients with ME/CFS, a concept that is central to ACT. Following treatment with graded exercise or CBT, one aspect of PF improved (activity engagement), along with quality of life and fatigue severity.

ME/CFS[edit | edit source]

A Swedish feasibility study of ACT in 40 patients with ME/CFS indicated that the treatment was accepted by participants, with a drop-out rate of 20% and no reported harmful effects during or after treatment.[11] The primary outcome measured was psychological flexibility, which is a concept within ACT. 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.[27]

A larger randomized trial by Pedersen et al. compared ACT (2018) to enhanced care in patients with multiple functional somatic syndromes included many patients with chronic fatigue syndrome.[28] 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."[28]

Clinicians[edit | edit source]

See also[edit | edit source]

Learn more[edit | edit source]

References[edit | edit source]

  1. Zettle, Robert D. (2005). "The Evolution of a Contextual Approach to Therapy: From Comprehensive Distancing to ACT". International Journal of Behavioral Consultation and Therapy. 1 (2): 77–89. ISSN 1555-7855.
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 Hayes, Steven C.; Strosahl, Kirk D.; Wilson, Kelly G. (August 29, 2016). Acceptance and Commitment Therapy: The Process and Practice of Mindful Change (2 ed.). Oakland, Calif: Guilford Publications. p. 54. ISBN 9781462528943.
  3. 3.0 3.1 3.2 Gordon, Timothy; Borushok, Jessica; Polk, Kevin L (2017). The ACT Approach a Comprehensive Guide for Acceptance and Commitment Therapy. Ashland: PESI Publishing & Media. ISBN 978-1-68373-083-5. OCLC 1105452637.
  4. Nordin, Linda; Rorsman, Ia (January 2012). "Cognitive behavioural therapy in multiple sclerosis: a randomized controlled pilot study of acceptance and commitment therapy". Journal of Rehabilitation Medicine. 44 (1): 87–90. doi:10.2340/16501977-0898. ISSN 1651-2081. PMID 22234322.
  5. Parling, Thomas; Cernvall, Martin; Ramklint, Mia; Holmgren, Sven; Ghaderi, Ata (July 29, 2016). "A randomised trial of Acceptance and Commitment Therapy for Anorexia Nervosa after daycare treatment, including five-year follow-up". BMC Psychiatry. 16. doi:10.1186/s12888-016-0975-6. ISSN 1471-244X. PMC 4966749. PMID 27473046.
  6. Lundgren, Tobias; Dahl, JoAnne; Melin, Lennart; Kies, Bryan (2006). "Evaluation of Acceptance and Commitment Therapy for Drug Refractory Epilepsy: A Randomized Controlled Trial in South Africa—A Pilot Study". Epilepsia. 47 (12): 2173–2179. doi:10.1111/j.1528-1167.2006.00892.x. ISSN 1528-1167.
  7. Twohig, Michael P.; Levin, Michael E. (December 2017). "Acceptance and Commitment Therapy as a Treatment for Anxiety and Depression: A Review". The Psychiatric Clinics of North America. 40 (4): 751–770. doi:10.1016/j.psc.2017.08.009. ISSN 1558-3147. PMID 29080598.
  8. 8.0 8.1 8.2 Veehof, M.M.; Trompetter, H.R.; Bohlmeijer, E.T.; Schreurs, K.M.G. (2016). "Acceptance- and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review". Cognitive Behaviour Therapy. 45 (1): 5–31. doi:10.1080/16506073.2015.1098724. ISSN 1651-2316. PMID 26818413.
  9. 9.0 9.1 Simister, Heather D.; Tkachuk, Gregg A.; Shay, Barbara L.; Vincent, Norah; Pear, Joseph J.; Skrabek, Ryan Q. (July 2018). "Randomized Controlled Trial of Online Acceptance and Commitment Therapy for Fibromyalgia". The Journal of Pain: Official Journal of the American Pain Society. 19 (7): 741–753. doi:10.1016/j.jpain.2018.02.004. ISSN 1528-8447. PMID 29481976.
  10. 10.0 10.1 Hann, K.E.J.; McCracken, L.M. (2014). "A systematic review of randomized controlled trials of Acceptance and Commitment Therapy for adults with chronic pain: Outcome domains, design quality, and efficacy". Journal of Contextual Behavioral Science. 3: 217–227.
  11. 11.0 11.1 Jonsjö, Martin A.; Wicksell, Rikard K.; Holmström, Linda; Andreasson, Anna; Olsson, Gunnar L. (April 1, 2019). "Acceptance & Commitment Therapy for ME/CFS (Chronic Fatigue Syndrome) – A feasibility study". Journal of Contextual Behavioral Science. 12: 89–97. doi:10.1016/j.jcbs.2019.02.008. ISSN 2212-1447.
  12. 12.0 12.1 Hayes, Steven C.; Hofmann, Stefan G. (October 2017). "The third wave of cognitive behavioral therapy and the rise of process‐based care". World Psychiatry. 16 (3): 245–246. doi:10.1002/wps.20442. ISSN 1723-8617. PMC 5608815. PMID 28941087.
  13. Dalal, Farhad (2019). CBT: The Cognitive Behavioural Tsunami: Managerialism, Politics and the Corruptions of Science (1st ed.). Abingdon, Oxon: Routledge. ISBN 9781782206644.
  14. 14.0 14.1 14.2 14.3 Hayes, Steven C.; Luoma, Jason B.; Bond, Frank W.; Masuda, Akihiko; Lillis, Jason (January 2006). "Acceptance and commitment therapy: model, processes and outcomes". Behaviour Research and Therapy. 44 (1): 1–25. doi:10.1016/j.brat.2005.06.006. ISSN 0005-7967. PMID 16300724.
  15. 15.0 15.1 McHugh, Louise (September 2011). "A new approach in psychotherapy: ACT (acceptance and commitment therapy)". The World Journal of Biological Psychiatry: The Official Journal of the World Federation of Societies of Biological Psychiatry. 12 (Suppl 1): 76–79. doi:10.3109/15622975.2011.603225. ISSN 1814-1412. PMID 21906000.
  16. Prevedini, Anna Bianca; Presti, Giovambattista; Rabitti, Elisa; Miselli, Giovanni; Moderato, Paolo (January 2011). "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". Giornale Italiano Di Medicina Del Lavoro Ed Ergonomia. 33 (1 Suppl A): A53–63. ISSN 1592-7830. PMID 21488484.
  17. Cioffi, D.; Holloway, J. (February 1993). "Delayed costs of suppressed pain". Journal of Personality and Social Psychology. 64 (2): 274–282. ISSN 0022-3514. PMID 8433273.
  18. Hayes, Steven C.; Levin, Michael E.; Plumb-Vilardaga, Jennifer; Villatte, Jennifer L.; Pistorello, Jacqueline (June 2013). "Acceptance and commitment therapy and contextual behavioral science: examining the progress of a distinctive model of behavioral and cognitive therapy". Behavior Therapy. 44 (2): 180–198. doi:10.1016/j.beth.2009.08.002. ISSN 1878-1888. PMC 3635495. PMID 23611068.
  19. 19.0 19.1 Hayes, S (2006). "The Six Core Processes of ACT". Association for Contextual Behavioral Science. Retrieved March 17, 2019.
  20. 20.0 20.1 Twohig, Michael P. (November 2012). "Acceptance and Commitment Therapy". Cognitive and Behavioral Practice. 19 (4): 499–507. doi:10.1016/j.cbpra.2012.04.003.
  21. Walser, Robyn D.; Westrup, Darrah (2007). Acceptance & Commitment Therapy for the Treatment of Post-traumatic Stress Disorder & Trauma-related Problems: A Practitioner's Guide to Using Mindfulness & Acceptance Strategies. New Harbinger Publications. p. 116. ISBN 978-1-57224-472-6.
  22. Coyne, James C. (August 20, 2017). "Is acceptance and commitment therapy (ACT) in a post-evidence phase?". Quick Thoughts. Retrieved March 17, 2019.
  23. Van Damme, Stefaan; Crombez, Geert; Van Houdenhove, Boudewijn; Mariman, An; Michielsen, Walter (November 2006). "Well-being in patients with chronic fatigue syndrome: the role of acceptance". Journal of Psychosomatic Research. 61 (5): 595–599. doi:10.1016/j.jpsychores.2006.04.015. ISSN 0022-3999. PMID 17084136.
  24. Brooks, Samantha K.; Rimes, Katharine A.; Chalder, Trudie (December 2011). "The role of acceptance in chronic fatigue syndrome". Journal of Psychosomatic Research. 71 (6): 411–415. doi:10.1016/j.jpsychores.2011.08.001. ISSN 1879-1360. PMID 22118384.
  25. Poppe, Carine; Petrovic, Mirko; Vogelaers, Dirk; Crombez, Geert (May 2013). "Cognitive behavior therapy in patients with chronic fatigue syndrome: the role of illness acceptance and neuroticism". Journal of Psychosomatic Research. 74 (5): 367–372. doi:10.1016/j.jpsychores.2013.02.011. ISSN 1879-1360. PMID 23597322.
  26. Densham, Sarah; Williams, Deborah; Johnson, Anne; Turner-Cobb, Julie M. (September 2016). "Enhanced psychological flexibility and improved quality of life in chronic fatigue syndrome/myalgic encephalomyelitis". Journal of Psychosomatic Research. 88: 42–47. doi:10.1016/j.jpsychores.2016.07.009. ISSN 1879-1360. PMID 27521652.
  27. "The prevalence and impact of psychoneuroimmunological factors in ME/CFS: Effects and mechanisms of ACT (2019) Olsson et al". Science for ME. Retrieved March 17, 2019.
  28. 28.0 28.1 Pedersen, Heidi Frølund; Agger, Johanne L.; Frosthom, Lisbeth; Jensen, Jens S.; Ørnbøl, Eva; Fink, Per; Schröder, Andreas (June 26, 2018). "Acceptance and Commitment group Therapy for patients with multiple functional somatic syndromes: a three-armed trial comparing ACT in a brief and extended version with enhanced care". Psychological Medicine: 1–10. doi:10.1017/S0033291718001666. ISSN 1469-8978. PMID 29941062.