a brief overview of acceptance and commitment therapy

7/24/2019 A Brief Overview of Acceptance and Commitment Therapy

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A brief overview of Acceptance and Commitment Therapy

Dr. Joseph Ciarrochi, School of Psychology, University of Wollongong

ACT targets six core processes that are designed to bild psychological flexibility.

Psychologocial flexibilityrefers to an individal!s ability to connect "ith the present #o#ent

flly, as a conscios h#an being, and to change or persist in behavior that is in line "ith

their identified vales $%ayes, et al., &'''(.

)ncreasing psychological flexibility involves helping clients to disentangle

the#selves fro# the cycle of experiential avoidance and cognitive fsion, not by challenging

or changing their thoghts and e#otions for exa#ple, bt by learning to react #ore #indflly

to sch experiences, so that they no longer see# to be barriers $Ciarrochi, et al., *++(.

Clients are encoraged to shift their energies a"ay fro# experiential control and to"ards

valed activity, and to consistently choose to act effectively, even in the presence of difficlt

private events. -or a detailed and co#prehensive accont of ACT readers are referred to

%ayes et al. $%ayes, et al., &'''(.

The ACT treat#ent #odel consists of six sbprocesses that are organi/ed into a

0hexaflex! $see -igre &(. The hexaflex can be divided into t"o #ain co#ponents. The first

incldes acceptance and #indflness processes $acceptance, defsion, the present #o#ent,

and a transcendent sense of self(, and the second reflects co##it#ent and behavioral

change processes $vales, co##itted action, the present #o#ent and a transcendent sense of

self(. The ACT practitioner targets these six processes in order to bild psychological

flexibility.


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-igre &1 The six core processes targeted by ACT are expected to bild psychological

flexibility

The hexaflex illstrates that these processes are all connected and spport each other.

There is no correct order for focsing on the processes and not all individals need to

concentrate extensively on each of the processes $Strosahl, et al., *++23 %ayes, et al., *++4(.

The lti#ate goal is to help people to persist in or change their behavior, depending on "hat

the sitation affords, in order to #ove to"ards "hat they vale.

ACT clinicians se a n#ber of exercises for each process to enhance adoption and

nderstanding of relevant s5ills $for #ore detail see %ayes, et al., &'''3 Strosahl, et al.,

*++2(. These inclde #etaphor, paradox and experiential exercises that ai# to nder#ine the


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po"er of experiential avoidance and cognitive fsion. A brief description of each process "ill

no" be provided.

Acceptance. The focs of this ACT process is to develop and enhance an individal!s

"illingness to have and accept their private experiences. Treat#ent involves exploring the

ftility of e#otional control and avoidance, "hich can often paradoxically increase an

individal!s level of distress and deter the# fro# engaging in prposefl and vital, vale

driven behavior. )nstead, individals are encoraged to accept their private experiences,

"hen doing so helps the# engage in valed behavior.

Defusionis a process that involves "ea5ening the langage processes that pro#ote

fsion $%ayes, et al., &'''3 Strosahl, et al., *++2(. People learn to see thoghts for "hat they

are and not "hat they say they are $%ayes, et al., &'''(, for exa#ple, sy#bols of one!s

experience and not actal descriptive 0realities!. Defsion exercises help people to notice

their langage processes as they nfold and to "atch the thoghts co#e and go, al#ost li5e a

netral observer. Defsion ths involves a radical shift in context, "here thoghts are

observed events, rather than literal trths that #st dictate behavior.

Getting in contact with the present moment. This ACT process is often e6ated to

#indflness. Clients are taght to bild their a"areness of their private experiences and be

flly open to "hat is happening in the present #o#ent. )n the #indfl state, thoghts are

expected to be experienced as "hat they are, events that co#e and go, rather than "hat they

often see# to be, trths that bind or actal barriers. -or exa#ple, a selfcritical thoght sch

as 7) a# seless8 can be vie"ed as a passing event rather than so#ething that #st control

behavior. 9indflness also connects to the vales and co##it#ent co#ponent of ACT, in

that it allo"s the reglation of action that is infor#ed by needs, feelings, vales, and their fit

"ith the crrent sitation $:ro"n, et al., *++;(. According to Strosahl et al. $*++2( and %ayes


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et al. $&'''(, the 6alities that reflect this process are vitality, spontaneity, connection, and

creativity.

Self-as-context. Clients are taght to bild their a"areness of their 0observing self!, or

selfascontext, and "or5 on letting go of their attach#ent to a conceptalised self $i.e. ) a#

boring3 ) a# seless(. The selfascontext is independent of content1 )t is the place "here

content is observed. ngaging in valedirected behavior can often prodce difficlt

experiences sch as distress, failre, and fsion. ACT helps people to see that choosing a

valed direction is not a per#anent thing. The choice #st be #ade again and again, for

exa#ple, after failre. ACT helps prepare people for the difficlt feelings and thoghts that


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"ill sho" p de to their valed striving and to be #ore "illing to 7carry8 those feelings and

thoghts in order to do "hat it ta5es to #ove in a valed direction.

The 7inflexahex8 is another "ay of loo5ing at the varios processes in ACT $:ach,

9oran, ? %ayes, $*++@(. >ach 7positive8 process in ACT has a negative conterpart, as

illstrated in -igre *.

-igre *1 The inflexahex #odel of sffering and proble#atic behavior


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Independent evaluations of empirical support for ACT

!he American Psychological Associationsggests ACT has research spport for chronic pain

$http1""".div&*.orgPsychologicalTreat#entstreat#entschronicpainBact.ht#l( and

depression$http1""".div&*.orgPsychologicalTreat#entstreat#entsdepressionBacceptance.ht#l(.

!he "nite States Substance Abuse an #ental $ealth Ser%ices Aministration $SA9%SA(

has no" listed ACT as an e#pirically spported #ethod as part of its videncebased Progra#s and Practices $PP(. )t is no" available on the PP Web

site at http://174.140.153.167/ViewIntervention.aspx?id=191 .

A sample of theoretical and review articles relevant to ACT

(coated "# $teve %a#es&

'on)ore* +. ,.* - orre* . (007&. o we need to chaene tho2hts in

conitive "ehaviora therap#? Clinical Psychology Review, 27* 173

17.

co)prehensive review o the evidence in three e#s areas that

82estion the idea that tr#in to chane the or) o tho2hts ishep2. It nds itte evidence that specic conitive interventions

sinicant# increase the eectiveness o ;


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%a#es* $. ;.* as2da* .*


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Concerning nonclinical and behavioral #edicine interventions $Table &(, there "as

sbstantial breadth in the target poplations, "hich inclded people "ho have a child "ith

atis#, "or5 in organi/ational settings, "or5 as consellors, have chronic pain and other

health proble#s, have cancer, and have a history of s#o5ing. Concerning otco#es, ACT

has been sho"n to i#prove #ental health and "ellbeing and pro#ote a broad range of

valeconsistent or 7positive8 behaviors, sch as increased innovativeness, redced ta5ing of

sic5 days and tili/ation of #edical resorces, redced cigarette s#o5ing, i#proved diabetes

selfcare, positive, nonprediced actions, better "eight #aintenance, behavioral activity

despite pain, and "illingness to se e#pirically spported treat#ents.

Trning to the isse of #ediation, of the stdies that sed the general Acceptance and

Action Festionnaire $ AAF( as a #easre of psychological flexibility, there "ere three

stdies in "hich ACT i#proved AAF $:on, et al., *+++3 -lax#an, *++3 =arra, et al.,

*++@(, and t"o stdies that did not reliably i#prove the AAF $:lac5ledge, et al., *++3

:ilich, et al., *++'( . :lac5ledge and %ayes $*++( fond no AAF i#prove#ents fro# pre to

post pK .4+3 one "ee5 after intervention( , and a #arginal effect fro# pre to follo"p $p L .

+2M, onetailed(. :ilich and Ciarrochi $*++'( fond no i#prove#ents fro# pre to post. :oth

of these stdies engaged in extensive adherence ratings "hich indicated considerable

presence of all ACTconsistent processes $-igre &( dring the intervention. T"o clinical

stdies also failed to find that ACT i#proved general AAF $to be discssed soon(

)n contrast to stdies that sed the general AAF, all eight stdies that focsed on

poplation specific #easres of acceptance fond effects. ACT i#proved acceptance and

flexibility related to s#o5ing $Hiffor, et al., *++2(, diabetes $Hregg, et al., *++;(, predice

$illis, et al., *++;(, "eight $illis, et al., *++'(, epilepsy $ndgren, et al., *++@(, and

chronic pain $9cCrac5en, et al., *++43 =o"les, et al., *++@3 Wic5sell, et al., *++@(. )n


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addition, there "as evidence that ACT inflenced poplationspecific believability #easres

$%ayes, et al., *++2a3 =arra, et al., *++@(.


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Table &1 ACT intervention stdies that assess #ediators of change1 dcation "or5shop $M@( for adlts

"ith Type * diabetes

AAF $diabetes focs( #ediated the beneficial inflence of ACT on diabetes selfcare $as

indicated in selfreports and biological #easres(

%ayes,

:issett, etal., $*++2a(

ACT $M+( vs. 9lticltral Training $9T, M2( vs. >dcational

control $*'( for sbstance abse consellors attitdes and

brnot

ACT and 9T redced stig#ati/ing attitdes, and ACT sho"ed greater redctions in brnot

than 9T. ACT, bt not 9T, effects "ere #ediated by redctions in the believability of

negative thoghts to"ards clients


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%esser, et al.

$*++'(

ACT $&'( for clients "ith tinnits distress Participants level of insession acceptance and cognitive defsion behaviors #ediated the

i#pact of positive treat#ent effects of ACT on tinnits distress. An acceptance and defsion

process #easre predicted ftre sy#pto# i#prove#ents

illis ?

%ayes.

$*++;(

ACT vs edcational lectre for predice, presented to

participants $M*( in conterbalanced order

Only the ACT intervention "as effective at increasing positive behavioral intentions at post

and &"ee5 follo" p, and these effects "ere partially #ediated by acceptance of predicial

thoghts and recognition that these thoghts do not act as barriers to nonpredicial action

illis et al.,

$*++'(

ACT $2+( vs. "eight list control $22( for adlts "ho had

co#pleted at least #onths of any strctred "eight loss

progra# in the past * years. The intervention targeted obesity

related stig#a and distress.

ACT participants sho"ed greater i#prove#ents in obesityrelated stig#a, 6ality of life,

psychological distress, and "eight. )#prove#ents in a "eight specific AAF #ediated

changes in otco#e

ndgren, et

al.$*++3*++@(

ACT $&2( or spportive treat#ent $ST, &M( for instittionali/ed

Soth Africans "ith epilepsy

ACT had significant beneficial effects on sei/res, 6ality of life, and "ellbeing co#pared

"ith ST. The beneficial effects of ACT "ere #ediated by epilepsyrelated acceptance, vales

attain#ent,, and persistence

9cCrac5en,

et al., $*++4(

ACT $&+@( for patients "ith chronic pain ACT i#proved e#otional, social, physical fnctioning, and redced healthcare visits for pain.

ACT significantly increased acceptance of pain and "illingness to engage in activities in thepresence of pain $CPAF(, and this increase "as associated "ith decreases in depression,

anxiety, physical and psychosocial disability, and sittostand perfor#ance.

=arra, et al.,$*++@(

ACT $M+( N e#pirically spported treat#ent $>ST( "or5shop

vs. edcation ? >ST $M+( for drg consellors attitdes to"ard

>ST

AAF and a redction in the believability of barriers #ediated the i#pact of the ACT

intervention on conselors "illingness to se >STs.

=o"les, ?9cCrac5en

$*++@(

ACT $&;;( for chronic pain patients "ho had co#pleted aninterdisciplinary treat#ent progra#

ACT redced pain, depression, painrelated anxiety, disability, #edical visits, and physicalperfor#ance. ACT increased acceptance of pain and "illingness to engage in activities in the

presence of pain $CPAF(, and increases in these processes "ere associated "ithi#prove#ents in otco#es.

Wic5sell, etal. $*++@(

ACTbased )ntervention $A:)3 &&( vs. treat#ent as sal $&&(for patients "ith chronic pain and "hiplash associated

disorders

A:) "as better than control in i#proving life satisfaction, and redcing pain disability, fear of#ove#ents, and depression. A:) also i#proved psychological inflexibility $pain specific

#easre(.


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We trn or revie" no" to a consideration of ACT interventions for #ental health and

sbstance abse $Table M(. ACT has sho"n so#e efficacy in treating a "ide variety of

disorders, inclding psychosis, social anxiety, anxiety and depression, borderline personality

disorder, obsessive co#plsive disorder, sbstance abse, and tinnits distress.

Concerning the i#pact of ACT on the general AAF, there "ere t"o failres of ACT

to inflence the AAF $:loc5, *++*3 %ayes, et al., *++2b3 %ayes, et al., *++(, and &+

sccesses $ettle, *++M3 Hrat, et al., *++3 Woods, et al., *++3 Dalry#ple, et al., *++;3

-or#an, *++;3 appalainen, et al., *++;3 o#a, et al., *++@3 oe#er, et al., *++@3 T"ohig,

*++'3 Qocovs5i, et al., )n press(. ACT has also been sho"n to redce believability of

hallcinations $:ach, et al., *++*3 Hadiano, et al., *++( and dysfnctional thoghts $ettle,

et al., &'@3 ettle, et al., *++'(.

Si#ilar to the stdies involving nor#al poplations and behavioral #edicine, the

clinical stdies generally sho"ed changes in the #ediator occrring at the sa#e ti#e as

changes in the otco#e $the t"o ti#e point #odel(. %o"ever, for stdies did provide

evidence for the three ti#epoint #odel. . %esser et al. $*++'( reliably coded the extent that

insession behaviors reflected either acceptance or cognitive defsion. They fond that the

pea5 level and fre6ency of cognitive defsion behaviors and pea5 level of acceptance rated

in session * predicted sy#pto# redction six #onths follo"ing treat#ent. They sho"ed that

these relationships cold not be acconted for by i#prove#ents that had occrred prior to the

#easre#ent of defsion and acceptance. Si#ilarly, Dalry#ple ? %erbert $*++;( and

Qocovs5i et al. $)n press( sho"ed that earlier changes in the AAF predicted later changes in

sy#pto# severity, even after controlling for earlier changes in sy#pto#s.


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)n another stdy, T"ohig et al. $*++'( collected session data on believability of

obsessions and "illingness to have obsessions "ithot reacting to the#. Ti#e lag

correlations sggested that the ACT processes "ere #ore li5ely to predict obsessive

sy#pto#s than vice versa. This stdy along "ith the other three sggest that acceptance and

defsion are li5ely to be precrsors of otco#es, rather than #erely conco#itants or

conse6ences


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Table *1 ACT intervention stdies that assess #ediators of change1 9ental health and sbstance abse

Stdy )ntervention design and sa#ple si/e $in parentheses( 9ediation findings

:ach ?

%ayes $*++*(

TAU $2+( vs. ACT N TAU $2+( for treat#ent of positive

psychotic sy#pto#s

Changes in believability of hallcinations #ediated the effect of the ACT intervention on

rehospitalisation of clients.

:loc5 $*++*( ACT $&M(, cognitivebehavioral grop therapy $C:HT3&M (, anda "ait list control $&M( in the treat#ent of social phobia

:oth ACT and CH:T participants sho"ed redctions in anxiety. ACT participants sho"ed lessbehavioral avoidance to a social sitation than C:HT participants. TAU $*&(

for hospitali/ed patients experiencing psychotic sy#pto#s

ACT had #ore beneficial effects at short ter# follo"p for social i#pair#ent and distress.

ACT alone decreased believability of hallcinations and redctions in believability "ereassociated "ith redctions in distress

Hrat/ ?

Hnderson$*++(

ACT and D:T inflenced intervention N TAU $&*( vs.

)ndividal otpatient therapy $TAU "aitlist( $&+( for fe#ales"ith :PD

The intervention had positive effects on selfhar#, e#otion dysreglation, :PDspecific

sy#pto#s, and distress, and i#proved scores on the AAF.


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$*++2b( opiates

Qocovs5i, et

al. $)n press(

ACTinfor#ed 9indflness and Acceptance grop therapy $2*(

for social anxiety disorder

AAF fro# baseline to #idtreat#ent significantly predicted change in social anxiety fro#

#idtreat#ent to posttreat#ent, controlling for change in anxiety fro# baseline to #id

treat#ent. There "as not evidence of the change in AAF occrring prior to the change in

social anxiety sy#pto#s.

appalainen,

. et al.

$*++;(

Otpatients $*@( rando#ly assigned to C:T or ACT condcted

by&2 trainee therapists.

Clients treated "ith ACT sho"ed better sy#pto# i#prove#ent than C:T. ACT i#proved

AAF bt not selfconfidence, "hereas C:T i#proved selfconfidence bt not AAF.

)#prove#ent in acceptance and selfconfidence "ere correlated "ith i#prove#ents insy#pto#s. When these variables "ere covaried, acceptance "as the ni6e predictor.

o#a, et al.,

$*++@(

ACT $@@( for treat#ent of selfstig#a in sbstance absing

poplation

ACT i#proved AAF, and changes in AAF "ere strongly correlated "ith changes in

internali/ed sha#e.


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More recent RCT evidence not cited in the table

IF) havin tro2"e eepin 2p with the rate o p2"ications* and

donFt have ti)e to interate the) into the a"ove ta"es. $o I wi eep a

ist o +;Fs (post Aowers )etaana#sis& here.

RCTs published since the 2009 Powers meta-analysis or

reanalyses and meditational analyses of RCTs!


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acceptance and conitive de2sion "ehaviors in acceptance"ased treat)ent o

tinnit2s distress. . (007&.rata)iento psicoPico para e

aronta)iento de cNncer de )a)a. Est2dio co)parativo entre estrateias de

aceptaciPn # de contro conitivo. AsicooncooQa* 4* 7595. BAs#chooicatreat)ent or copin with "reast cancer. co)parative st2d# o acceptance and

conitivecontro strateiesC.

Aearson* . M.* @oette* V. . - %a#es* $. ;. (in press&. piot st2d# o

cceptance and ;o))it)ent herap# (;& as a worshop intervention or "od#

dissatisaction and disordered eatin attit2des. ;onitive and rsio* $. .* - $atersAednea2t* D. (00&. EHcac# o an

acceptance"ased "ehavior therap# or eneraied anxiet# disorder: eva2ation

in a rando)ied controed tria. ,o2rna o ;ons2tin and ;inica As#choo#*

76(6&* 103109.

$)o2t* . @.* 'ono* .* %arrison* $.* inniti* +.* ices* .* - hite* ,. . (010&.

As#chosocia treat)ent or )etha)pheta)ine 2se disorders: prei)inar#rando)ied controed tria o conitive "ehavior therap# and acceptance and


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co))it)ent therap#. $2"stance "2se* 31(&* 9107.

reanor* .* Eris)an* $. .* $atersAednea2t* D.* +oe)er* '.* - >rsio* $. .

(011&. cceptance"ased "ehaviora therap# or : eects on o2tco)es ro)

three theoretica )odes. epression and nxiet#* (&* 17136.

wohi* . A.* %a#es* $. ;.* A2)"* ,. ;.* Ar2itt* '. .* ;oins* . sson* . '. (009&. Eva2atin the

eectiveness o expos2re and acceptance strateies to i)prove 2nctionin and

82ait# o ie in onstandin pediatric paina rando)ied controed tria. Aain*

141(3&* 457.

icse* +. D.* h8vist* ,.*


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"vidence that ACT wor#s by di$erent processes than

standard Co%nitive &ehavior Therapy C&T! and other common

interventions

Several of the available stdies allo" s to exa#ine "hether ACT "or5s by different

#echanis#s than other interventions. There are t"o general classes of stdies relevant to this

isse3 those stdies that co#pare ACT to a variety of edcational or spportive interventions,

and those stdies that co#pare ACT to a for# of cognitive therapy. -or stdies have sho"n

that ACT "or5s differently than edcational lectres for redcing predice $%ayes, et al.,

*++2a3 illis, et al., *++;(, increasing "illingness a#ong consellors to se e#pirically

spported treat#ents $=arra, et al., *++@(, and selfcare in diabetes $Hregg, et al., *++;(. T"o

other stdies sggest that ACT "or5s by different processes than spportive therapy

$ndgren, et al., *++@( and different processes than an intervention that teaches people to

#odify "or5place stressors $:on, et al., *+++(. These stdies generally sho" that "hile

ACT increases psychological flexibility, edcational lectres and spportive interventions do

not.

Seven stdies have co#pared ACT to a for# of cognitive therapy $CT(. ACT "as

better than CT at decreasing avoidant coping a#ongst cancer patients $:ranstetter, et al.,

*++2(. ACT has been sho"n to be better than CT at i#proving psychological flexibility

$AAF( a#ongst govern#ent e#ployees $-lax#an, *++(, niversity stdents "ith anxiety or

depression $-or#an, *++;(, people recrited fro# the general pblic "ith #ood and

interpersonal proble#s $appalainen, et al., *++;(, and people "ith clinical depression

$ettle, et al., &'@3 ettle, et al., *++'(.

One possible explanation for the general pattern of differences bet"een ACT and CT

is that ACT is si#ply better at inflencing any process #easre, regardless of "hether it is

ACT consistent or inconsistent. %o"ever, three stdies appear to be inconsistent "ith this


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hypothesis. Dalry#ple and %erbert $*++;( sho"ed that ACT i#proved psychological

flexibility bt did not i#prove s5ill at controlling private experience, an ACT incongrent

process. -or#an $*++;( sho"ed that C:T, bt not ACT, i#proved observing and describing

co#ponents of #indflness. appalainen et al. $*++;( sho"ed that ACT i#proved

psychological flexibility, "hereas C:T i#proved selfconfidence.

The reslts of -lax#an $*++( are so#e"hat #ore co#plicated bt generally spport

the notion that ACT and CT "or5 by distinct processes. :oth the ACT grop and the stress

inoclation grop $S)T, a for# of cognitive therapy( prodced i#prove#ents in ACT

consistent #easres $psychological flexibility( and CT consistent #easres $dysfnctional

attitdes(. -lax#an $*++( condcted #ediational analyses that loo5ed at the ni6e

inflence of psychological flexibility and dysfnctional attitdes and fond that

psychological flexibility "as the pri#ary #ediator in the ACT condition. )n contrast,

psychological flexibility did not #ediate the S)T otco#es, and there "as so#e evidence that

dysfnctional cognitions #ediated the effect of S)T bet"een ti#es & and M $bt not bet"een

ti#es & and *(.

)n a recent stdy, :ro"n, Hadiano, and 9iller $*+&&( srveyed second $e.g.C:T(

and third "ave $e.g., ACT( cognitive behavioral therapists concerning the techni6es they

sed in therapy. There "ere differences bet"een the t"o grops, "ith third"ave therapists

reporting greater se of exposre and second"ave therapists reporting greater se of

cognitive restrctring and relaxation techni6es.

How to learn more about ACT

The association for contextual behavioural science

This is the #ain organi/ation for ACT. )t has a "ebpage "ith lots of clinical resorces andannonce#ents of pco#ing events.


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http1""".contextalpsychology.org

ACT listserves

There are t"o internet grops, the international grop, and the Astralian and ne" ealand

grop. These provide a for# for people to discss ACT and to annonce pco#ing events.

International list server

[email protected]

Australian and New ealand !ist server

[email protected]
http://www.contextualpsychology.org/http://www.contextualpsychology.org/


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References


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a2diano*


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'2ndren* .* ah* ,. ;. and %a#es* $. ;. (00& SEva2ation o )ediators ochane in the treat)ent o epieps# with cceptance and ;o))it)ent

herap#S*o!rnal o" Behavior .edicine+*(3&: 535.'2ndren* .* ah* ,. ;.* ein* '. and Dies*


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Rette* +. . (003& Scceptance and co))it)ent therap# (;& vs. s#ste)aticdesensitiation in treat)ent o )athe)atics anxiet#S* Psychological Record)+(&: 19715.

Rette* +. . and %a#es* $. (196& S#s2nctiona contro "# cient ver"a"ehavior: he context o reason ivinS* The %nalysis o" eral Behavior,:303.

Rette* +. . and +aines* ,. ;. (199& Sro2p conitive and context2a therapies intreat)ent o depressionS*o!rnal o" Clinical Psychology,): 43445.

a brief overview of acceptance and commitment therapy

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