In Acceptance and Commitment Therapy, Dr. Steven C. Hayes illustrates this empirically supported intervention. The goal of acceptance and commitment therapy (ACT) is to increase psychological flexibility, or the ability to enter the present moment more fully and either change or persist in behavior when doing so serves valued ends. Therapists and clients work to establish psychological flexibility through six core ACT processes, including acceptance, the opposite of experiential avoidance; cognitive defusion, in which negative thoughts are observed mindfully instead of avoided or reasoned away; chosen values; and committed action.
In this session, Dr. Hayes works with an African American woman who is dealing with multiple health issues and is struggling with anger and guilt from not living up to her mother's expectations. Dr. Hayes teaches the client skills to accept her emotions, to mindfully observe her thoughts, and to recognize that her actions can be determined by personal values instead of guilt.
ACT is an approach to psychological intervention defined in terms of certain theoretical processes, not a specific technology. We can define ACT in theoretical and process terms as a psychological intervention based on modern behavioral psychology, including Relational Frame Theory (RFT), that applies mindfulness and acceptance processes and commitment and behavior change processes to the creation of psychological flexibility.
The core conception of ACT is that psychological suffering is usually caused by the interface between human language and cognition, and the control of human behavior by direct experience. Psychological inflexibility is argued to emerge from experiential avoidance, cognitive entanglement, attachment of a conceptualized self, loss of contact with the present, and the resulting failure to take needed behavioral steps in accord with core values.
Buttressed by RFT, an extensive basic research program on an associated theory of language and cognition, ACT takes the view that trying to change difficult thoughts and feelings as a means of coping can be counterproductive, but new, powerful alternatives are available, including acceptance, mindfulness, cognitive defusion, values, and committed action.
Research seems to be showing that these methods are beneficial for a broad range of clients. ACT teaches clients and therapists alike how to mentally alter the way difficult private experiences function rather than having to eliminate them from occurring at all. This empowering message has been shown to help clients cope with a wide variety of clinical problems, including depression, anxiety, stress, substance abuse, and even psychotic symptoms. The benefits are as important for the clinician as they are for clients: ACT has been shown empirically to quickly alleviate therapist burn-out. In addition, we are learning that these same processes help us understand and change a variety of other behavioral problems, including such areas as human prejudice, work performance, or the inability to learn new things.
Model of Pathology
From an ACT and RFT point-of-view, whereas psychological problems can emerge from the general absence of relational abilities (e.g., in the case of mental retardation), a primary source of psychopathology (as well as a process exacerbating the impact of other sources of psychopathology) is the way that language and cognition interact with direct contingencies to produce an inability to persist or change behavior in the service of long-term valued ends. This kind of psychological inflexibility is argued in ACT and RFT to emerge from weak or unhelpful contextual control over language processes themselves, and the model of psychopathology is thus linked point-to-point to the basic analysis provided by RFT. This yields an accessible and clinically useful middle-level theory bound tightly to more abstract basic principles.
A core process that can lead to pathology is cognitive fusion, which refers to the domination of behavior regulatory functions by relational networks, based in particular on the failure to distinguish the process and products of relational responding. In contexts that foster such fusion, human behavior is guided more by relatively inflexible verbal networks than by contacted environmental contingencies. This is fine in some circumstances, but in others it increases psychological inflexibility in an unhealthy way. As a result, people may act in a way that is inconsistent with what the environment affords relevant to chosen values and goals. From an ACT and RFT point-of-view, the form or content of cognition is not directly troublesome, unless contextual features lead this cognitive content to regulate human action in unhelpful ways.
The functional contexts that tend to have such deleterious effects are largely sustained by the social and verbal community. There are several. A context of literality treats symbols (e.g., the thought, "life is hopeless") as one would referents (i.e., a truly hopeless life). A context of reason giving bases action or inaction excessively on the constructed "causes" of one's own behavior, especially when these processes point to nonmanipulable "causes" such as conditioned private events. A context of experiential control focuses on the manipulation of emotional and cognitive states as a primary goal and metric of successful living.
Cognitive fusion supports experiential avoidance—the attempt to alter the form, frequency, or situational sensitivity of private events even when doing so causes behavioral harm. Due to the temporal and comparative relations present in human language, so-called "negative" emotions are verbally predicted, evaluated, and avoided. Experiential avoidance is based on this natural language process—a pattern that is then amplified by the culture into a general focus on "feeling good" and avoiding pain. Unfortunately, attempts to avoid uncomfortable private events tend to increase their functional importance—both because they become more salient and because these control efforts are themselves verbal linked to conceptualized negative outcomes—and thus tend to narrow the range of behaviors that are possible because many behaviors might evoke these feared private events.
The social demand for reason-giving and the practical utility of human symbolic behavior draws the person into attempts to understand and explain psychological events even when unnecessary. Contact with the present moment decreases as people begin to live "in their heads." The conceptualized past and future, and the conceptualized self, gain more regulatory power over behavior, further contributing to inflexibility. For example, it can become more important to be right about who is responsible for personal pain than it is to live more effectively with the history one has; it can be more important to defend a verbal view of oneself (e.g., being a victim, never being angry, being broken, etc.) than to engage in more workable forms of behavior that do not fit that verbalization. Furthermore, since emotions and thoughts are commonly used as reasons for other actions, reason-giving tends to draw the person to focus more on the world within as the proper source of behavioral regulation, further exacerbating experiential avoidance patterns. Again psychological inflexibility is the result.
In the world of overt behavior, this means that long-term desired qualities of life—values—take a backseat to more immediate goals of being right, looking good, feeling good, defending a conceptualized self, and so on. People lose contact with what they want in life beyond relief from psychological pain. Patterns of action emerge and gradually dominate in the person's repertoire that are detached from long-term desired qualities of living. Behavioral repertoires narrow and become less sensitive to the current context as it affords valued actions. Persistence and change in the service of effectiveness is less likely.
The Six Core Processes in ACT
The general goal of ACT is to increase psychological flexibility—the ability to contact the present moment more fully as a conscious human being and to change or persist in behavior when doing so serves valued ends. Psychological flexibility is established through six core ACT processes. Each of these areas is conceptualized as a positive psychological skill, not merely a method of avoiding psychopathology.
Acceptance is taught as an alternative to experiential avoidance. Acceptance involves the active and aware embrace of those private events occasioned by one's history without unnecessary attempts to change their frequency or form, especially when doing so would cause psychological harm. For example, anxiety patients are taught to feel anxiety, as a feeling, fully and without defense; pain patients are given methods that encourage them to let go of a struggle with pain, and so on. Acceptance (and defusion) in ACT is not an end in itself. Rather, acceptance is fostered as a method of increasing values-based action.
Cognitive defusion techniques attempt to alter the undesirable functions of thoughts and other private events, rather than trying to alter their form, frequency, or situational sensitivity. Said another way, ACT attempts to change the way one interacts with or relates to thoughts by creating contexts in which their unhelpful functions are diminished.
There are scores of such techniques that have been developed for a wide variety of clinical presentations. For example, a negative thought could be watched dispassionately, repeated out loud until only its sound remains, or treated as an externally observed event by giving it a shape, size, color, speed, or form. A person could thank their mind for such an interesting thought, label the process of thinking ("I am having the thought that I am no good"), or examine the historical thoughts, feelings, and memories that occur while they experience that thought. Such procedures attempt to reduce the literal quality of the thought, weakening the tendency to treat the thought as what it refers to ("I am no good") rather than what it is directly experienced to be (e.g., the thought "I am no good"). The result of defusion is usually a decrease in believability of, or attachment to, private events rather than an immediate change in their frequency.
ACT promotes ongoing nonjudgmental contact with psychological and environmental events as they occur. The goal is to have clients experience the world more directly so that their behavior is more flexible and thus their actions more consistent with the values that they hold. This is accomplished by allowing workability to exert more control over behavior and by using language more as a tool to note and describe events, not simply to predict and judge them. A sense of self called "self as process" is actively encouraged: the defused, nonjudgmental ongoing description of thoughts, feelings, and other private events.
Self as Context
As a result of relational frames such as I versus you, now versus then, and here versus there, human language leads to a sense of self as a locus or perspective and provides a transcendent, spiritual side to normal verbal humans. This idea was one of the seeds from which both ACT and RFT grew and there is now growing evidence of its importance to language functions such as empathy, theory of mind, sense of self, and the like.
In brief the idea is that "I" emerges over large sets of exemplars of perspective-taking relations (what are termed in RFT "deictic relations"), but since this sense of self is a context for verbal knowing, not the content of that knowing, its limits cannot be consciously known. Self as context is important in part because from this standpoint, one can be aware of one's own flow of experiences without attachment to them or an investment in which particular experiences occur: Thus defusion and acceptance is fostered. Self as context is fostered in ACT by mindfulness exercises, metaphors, and experiential processes.
Values are chosen qualities of purposive action that can never be obtained as an object but can be instantiated moment by moment. ACT uses a variety of exercises to help a client choose life directions in various domains (e.g., family, career, spirituality) while undermining verbal processes that might lead to choices based on avoidance, social compliance, or fusion (e.g., "I should value X" or "A good person would value Y" or "My mother wants me to value Z"). In ACT, acceptance, defusion, being present, and so on are not ends in themselves; rather, they clear the path for a more vital, values-consistent life.
Finally, ACT encourages the development of larger and larger patterns of effective action linked to chosen values. In this regard, ACT looks very much like traditional behavior therapy, and almost any behaviorally coherent behavior change method can be fitted into an ACT protocol, including exposure, skills acquisition, shaping methods, goal setting, and the like. Unlike values, which are constantly instantiated but never achieved as an object, concrete goals that are values consistent can be achieved and ACT protocols almost always involve therapy work and homework linked to short-, medium-, and long-term behavior change goals. Behavior change efforts in turn lead to contact with psychological barriers that are addressed through other ACT processes (acceptance, defusion, and so on).
Taken as a whole, each of these processes supports the other and all target psychological flexibility, the process of contacting the present moment fully as a conscious human being and persisting or changing behavior in the service of chosen values. The six processes can be chunked into two groupings. Mindfulness and acceptance processes involve acceptance, defusion, contact with the present moment, and self as context.
Indeed, these four processes provide a workable behavioral definition of mindfulness (see Fletcher & Hayes, in press, in the Suggested Reading list). Commitment and behavior change processes involve contact with the present moment, self as context, values, and committed action. Contact with the present moment and self as context occur in both groupings because all psychological activity of conscious human beings involves the now as known.
About the Therapist:
Steven C. Hayes, PhD, is Nevada Foundation Professor in the Department of Psychology at the University of Nevada. An author of 32 books and nearly 400 scientific articles, he has shown in his research how language and thought leads to human suffering, and has developed a popular therapy method, acceptance and commitment therapy, that is surprisingly helpful in a wide variety of areas. His popular book Get Out of Your Mind and Into Your Life was featured in a lengthy story in Time Magazine and for a time was the number 1 best-selling self-help book in the United States, briefly outselling even "Harry Potter."
Dr. Hayes has been president of several scientific societies and has received several national awards, such as the Lifetime Achievement Award from the Association for Behavioral and Cognitive Therapy and the Impact of Science on Application award from the Society for the Advancement of Behavior Analysis.
"Must Have" Books
Hayes, S. C., Strosahl, K., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press. [This is still the ACT bible, but it should no longer stand alone. A revision will be coming along in 2008 or 2009.]
Luoma, J., Hayes, S. C., & Walser, R. (2007). Learning ACT. Oakland, CA: New Harbinger. [A step-by-step learning companion for the 1999 book]
Hayes, S. C., & Strosahl, K. D. (2005). A practical guide to acceptance and commitment therapy. New York: Springer-Verlag. [Shows how to do ACT with a variety of populations]
Eifert, G., & Forsyth, J. (2005). Acceptance and commitment therapy for anxiety disorders. Oakland, CA: New Harbinger. [Great book with a super protocol that shows how to mix ACT processes into a brief therapy for anxiety disorders]
Hayes, S. C., & Smith, S. (2005). Get out of your mind and into your life. Oakland, CA: New Harbinger. [A general purpose ACT workbook; works as an aid to ACT or on its own, but it will also keep new ACT therapists well oriented
Hayes, S. C., Follette, V. M., & Linehan, M. (2004). Mindfulness and acceptance: Expanding the cognitive behavioral tradition. New York: Guilford Press. [Shows how ACT is part of a change in the behavioral and cognitive therapies more generally]
There are now several specialized ACT books for professional and consumers targeting specific problems and disorders. These include especially the series of self-help ACT books by New Harbinger Publications and books by Context Press, among others.
Hayes, S. C., Barnes-Holmes, D., & Roche, B. (Eds.). (2001). Relational frame theory: A post-Skinnerian account of human language and cognition. New York: Plenum Press. [Not for the faint of heart, but if you want a treatment that is grounded on a solid foundation of basic work, you've got it. This book is the foundation.]
Hayes, S. C., Hayes, L. J., Reese, H. W., & Sarbin, T. R. (Eds.). (1993). Varieties of scientific contextualism. Reno, NV: Context Press. [If you get interested in the philosophical foundation of ACT, this will help.]
Many important resources are available on the Association for Contextual Behavioral Science website