What is Acceptance and Commitment Therapy (ACT)?
Acceptance and commitment therapy utilizes metaphors, analogies, acronyms, and scales as nondirective interventions to gain trust and “buy-in” from clients.The counselor supports and facilitates the collaborative journey up the proverbial mountain of which the counselor has acquired tools to climb and help others. Acceptance and commitment therapy is guided by the six core processes of the Hexaflex model which will be discussed later in this blog.
Acceptance and commitment therapy (which will also be referred to as ACT in this paper) integrates several different philosophies and psychological approaches to counseling to ultimately direct the client to take action toward their values. In turn, this will allow the client to relate to their experiences, but symptom reduction is not an explicitly targeted priority in this theory. According to Dr. Russell Harris, a major contributor to ACT, in his manual ACT Made Simple, the goal of ACT is to help clients develop rich, full, and meaningful lives through psychological flexibility.
The birth of ACT began when Steven Hayes developed a severe panic disorder early in his academic career. He engaged in a number of different cognitive and behavioral therapies with little desired effect. It was when he turned to Eastern, humanistic, and human potential theories and approaches that he began to gain traction in his recovery and move away from the focus of his anxiety. Acceptance and commitment therapy was part of a “third wave” of behavioral and cognitive therapies and was also influenced by Relational Frame Theory which emphasizes the harm that experiential avoidance and cognitive fusion cause.
Acceptance and commitment therapy is considered a contextual approach and focused on the present, not the past or future. Theorists that subscribe to ACT argue that responses to situations in life can be addressed through six core processes which, combined, are referred to as the hexaflex. These core processes are 1) staying in contact with the present moment, 2) values, 3) committed action, 4) using the self as context, 5) cognitive defusion, 6) and acceptance — these ultimately lead to psychological flexibility. Contact with the present moment, acceptance, cognitive defusion, and using the self as context each are developed from mindfulness practices and values and committed action help move the client forward while benefiting from these mindfulness practices. Metaphors and exercises such as likert scales are often used in ACT to further ingrain the hexaflex into a client’s treatment.
Characteristics of Healthy Personality
Healthy personality in ACT can be described in terms of psychological flexibility or inflexibility. Psychological inflexibility, or otherwise known as psychological rigidity, can affect a client if one (or more) of the six core processes are limited leading to “mindless” ineffective action and thought or experiential avoidance. In ACT, the counselor will not work with the client on determining if harmful thoughts are accurate, but rather if they are workable. When a client can allow an experience to exist or a thought to occur and notice it without behavior being negatively impacted, this is a positive indicator of psychological flexibility. Committing to action and remaining values-focused through undesirable circumstances and thoughts are other major measures for psychological flexibility. When these align and take place long-term, this is considered ultimate psychological flexibility in ACT.
Factors That Contribute to Problems
Problems in ACT are theorized to derive from a few different misalignments of values including FEAR which serves as both the noun “fear” and also an explanatory acronym: F = fusion, E = expectations, A = avoidance, and R = remoteness. Fusion can present as critical evaluations of oneself or excuses which impede values-driven action. Expectations are not inherently damaging, but when expectations are unrealistic, they can cause distress or psychological rigidity. Avoidance of undesirable emotions, thoughts, and experiences limits a client. Lastly, remoteness from personal values leaves a client in a place of searching for meaning and fulfillment.
In the ACT Made Simple manual by Dr. Harris, he outlines psychological rigidity as the opposite of psychological flexibility relating to the aforementioned six core processes organized as the hexaflex: 1) loss of contact with the present moment, 2) cognitive fusion, 3) experiential avoidance, 4) self-as-content (rigid attachment to a particular view of self), 5) remoteness from values, 6) lack of effective, committed action (impulsive, ineffective, and/or avoidant). Ruiz states that attempting to control undesired internal or external experiences puts more focus on the issue and gives it more power which is counterproductive in the long-run and causes a client to get stuck. Fusion to and avoidance of undesired experiences also leads to a vicious cycle . This vicious cycle occurs when an unpleasant internal experience arises and four main elements make up this cycle: context of cognitive fusion, threat, experiential avoidance, and paradoxical effects or significant costs and is compared to quicksand in a metaphor within treatment interventions.
Stages of Life
Acceptance and commitment therapy theorists put little focus on formal life stages because the main goal of ACT is to reach or maintain well being in context of the client’s present moment. Theorists suggest that ACT is an appropriate therapeutic application for clients of various ages, as long as they are cognitively capable of being self-reflective. Metaphors and language may differ depending on the age of the client, particularly if the client is a child or adolescent. For example, the application of ACT with children may focus on social conditioning as that is developmentally appropriate for that age.
Influences on Development
Acceptance and commitment therapy is built upon the underlying theory of relational frame theory or RFT. In RFT, language and cognition are considered behaviors that build and derive symbolic meaning and this meaning influences a client’s view of internal and external events and their responses to such. As a person develops language this further strengthens the associations they have to a term, event, or experience. This is does not necessarily carry with it negative consequences, but it can contribute to psychological rigidity if the association causes a vicious cycle or FEAR as mentioned earlier in this post. Parents, social circles, and culture may influence a person’s associations, but ACT prioritizes that person’s internal and external experiences and their responses to such over the other people potentially impacting someone’s life. With this being said, there is little explicit discussion about influences on development outside of language, cognitions, and behaviors that negatively impact a person’s psychological flexibility and this can take place across much of the lifespan.
Cognitions and behaviors go hand-in-hand in ACT and RFT theories. These are two important elements that theorists would say influence emotion, physiological symptoms, and interpersonal relationships. When a client’s cognitions are fused or rigid, these will manifest as their behavioral responses to internal and external experiences. These behavioral responses will then impact emotions which will lead to a vicious cycle and integration of further psychological rigidity. Physiological symptoms may worsen with the focus on emotions and attempts to control internal or external events such as exacerbation of panic disorders. Lastly, interpersonal relationships are likely to suffer due to the inner turmoil a psychologically rigid person is experiencing, trying to control, and combat rather than utilizing the hexaflex core processes to become psychologically flexible and move past distressing issues.
References
Blackledge, J. T., Ciarrochi, J., & Deane, F. P. (2009). Acceptance and commitment therapy: Contemporary theory research and practice. Bowen Hills, QLD, Australia: Australian Academic Press.
Ciarrochi, J. Bilich, L., & Godsell, C. (2010). Psychological flexibility as a mechanism of change in acceptance and commitment therapy. In Ruth Baer’s (Ed), Assessing Mindfulness and Acceptance: Illuminating the Processes of Change.(pp. 51-76). Oakland, CA: New Harbinger Publications, Inc.
Harris, R. (2009). ACT made simple: An easy-to-read primer on acceptance and commitment therapy. Oakland, CA: New Harbinger Publications, Inc.
Hayes, S. C. (2016). Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies. Behavior Therapy, 47(6), 869-885.
Hayes, S. C., Levin, M. E., Plumb-Vilardaga, J., Villatte, J. L., & Pistorello, J. (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
Hayes S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change. New York, NY: The Guilford Press.
Herbert, J. D., Forman, E. M., Kaye, J. L., Gershkovich, M., Goetter, E., Yuen, E. K., . . . Marando-Blanck, S. (2018). Randomized controlled trial of acceptance and commitment therapy versus traditional cognitive behavior therapy for social anxiety disorder: Symptomatic and behavioral outcomes. Journal of Contextual Behavioral Science, 9, 88-96.
McHugh, L. (2011). A new approach in psychotherapy: ACT (acceptance and commitment therapy). The World Journal of Biological Psychiatry, 12(S1), 81-84.
Plumb, J. C., Stewart, I., Dahl, J., & Lundgren, T. (2009). In search of meaning: Values in modern clinical behavior analysis. The Behavior Analyst, 32(1), 85-103. doi:10.1007/bf03392177
Ruiz, F. J. (2010). A review of acceptance and commitment therapy (ACT) empirical evidence: Correlational, experimental psychopathology, component and outcome studies. International Journal of Psychology and Psychological Therapy, 10(1), 125-162.
Sharf, R. S. (2016). Theories of psychotherapy and counseling: Concepts and cases. Boston, MA: Cengage Learning.
____________________________________________________________________________
About the Author:
Anastasia is a practicum student through Brightside Counseling. She has returned to school after having worked professionally in inpatient, outpatient, and intensive outpatient settings as a music therapist. Anastasia can be reached for consultation at: practicum@brightsidecounseling.net or via call/text at: (720)923-2322