Acceptance and Commitment Therapy - Encyclopedia of Social Work

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date: 30 September 2016

Acceptance and Commitment Therapy

Abstract and Keywords

Clinical social work is a derivative profession, drawing its knowledge and practice base from several theoretical schools. The four primary theoretical schools contributing to social-work philosophy are psychodynamic, humanist, cognitive–behavioral, and postmodern. Acceptance and commitment therapy (ACT), although considered one of the third-wave behavioral approaches, draws from all four theoretical schools of clinical intervention. This entry gives an overview of ACT development, its essential features, empirical base, tenets and techniques, and relevance to the social-work profession.

Keywords: acceptance and commitment therapy, ACT and social work, behavior therapy, mindfulness therapy, third-wave behaviorism

Introduction

Carl Jung is quoted as saying, “We cannot change anything unless we accept it. Condemnation does not liberate, it oppresses” (Jung, 1955, p. 234). Although Jung was a psychoanalyst, his words actually lay the groundwork for acceptance and commitment therapy (ACT), a decidedly behavioral approach.

Acceptance and commitment therapy, a practical approach designed to move a person toward a valued life, is considered one of the exposure-based behavioral therapies. Far from the early interpretations of behaviorism based on classical or operant conditioning, the aptly called ACT rightfully is housed in the third wave of behavioral therapies.

The first behavioral approaches were introduced by psychologists John Watson, B. F. Skinner, and Ivan Pavlov. These early behavioral theories were rooted in stimulus-response reactions and classical and operant conditioning. Clinical interventions were applied accordingly, such as exposure techniques based on classical conditioning and applied behavior analysis based on operant conditioning principles. This view of behavior is based on the belief that all behavior is controlled by its consequences (rewards and punishments) (Angell, 2008).

The second wave of behaviorism recognized the importance of cognition as a mediating influence on behavior triggered by external stimuli. More attention was paid to the internal event of thinking about an event. It was hypothesized and demonstrated that removing and replacing irrational thoughts would result in behavioral change. Thus, the cognitive–behavioral approach emerged.

The third wave of behaviorism includes the postmodern and existential thought promulgated by social constructionism. The focus is on changing “the context, rather than the content, of thoughts and feelings” (O’Brien, Larson, & Murrell, 2008, p. 16). Techniques involving mindfulness, acceptance, cognitive defusion, dialectics, and values are considered crucial to the process. Third-wave behavioral therapies, of which ACT is one, utilize basic behavioral techniques (functional analysis, skill building, baseline measurement, direct shaping) but emphasize the context rather than the content of thoughts and feelings (O’Brien et al., 2008).

As an exposure-based therapy, ACT goes beyond decreasing reactions to stimuli (desensitization based on classical conditioning) to increasing psychological flexibility to stimuli. As an example, the internal experience of fear is not necessarily removed, but the response to it can be varied. The reactions become “as they are” instead of what one says, or perceives, they will be.

Acceptance and commitment therapy is a unique, empirically based psychological intervention that uses acceptance and mindfulness processes and commitment and behavior change processes to produce psychological flexibility. At its simplest level ACT helps a person accept and make sense of a psychological wound, take control of one’s pain, and move toward the life one values.

Theoretical Frameworks

Acceptance and commitment therapy is built on two foundations: functional contextualism and relational frame theory (RFT). Functional contextualism provides the philosophical framework, whereas RFT, a theory of language and cognition, provides a theoretical foundation. Both are reminiscent of social constructivism in that every behavior is explained in terms of context. Thoughts and feelings do not occur in a vacuum and thus do not directly cause behavior. Neither is behavior totally governed by consequences (first-wave behaviorism) or cognition (second-wave behaviorism).

At its core, ACT is contextual learning in an effort to deal with experiential avoidance. Functional contextualism calls for examining behaviors in terms of the function or purpose they serve in a particular context. In this perspective, behavior is not necessarily seen as abnormal, but perhaps a functional response to an abnormal context. Acceptance and commitment therapy particularly emphasizes the role of language and cognition as processes used to create psychological inflexibility.

This use of language as it pertains to context suggests postmodern social constructionist interpretations of context, where the assumption is “words make worlds.” This lens suggests that “the realities we live in are outcomes of the conversations in which we are engaged” (Gergen, 2009, p. 4). Likewise, ACT uses those language processes to create more flexible psychological responses that direct behavior toward a value-driven goal (O’Brien et al., 2008).

Relational frame theory provides a framework for the analysis of behavior mediated by language. As explained by O’Brien et al. (2008), ACT specifically targets the behavior of experiential avoidance, a “by-product of language and cognition” (p. 25). O’Brien et al. posit, “Without language and cognition, we would not be able to say to ourselves, ‘I am anxious all the time,’ or ‘My parents were horrible,’ or ‘I will never be happy’. Neither would we be able to remember our past nor worry about the future” (p. 25). Relational frame theory assumes that human beings relate stimuli under changing contexts. Contextual cues are the relational frame. Change in ACT focuses on the functions of private events (thoughts and emotion, which are influenced more by language and cognition) rather than change focused on the content of private events.

Relational frame theory provides a definition of private and public events (cognitive and behavioral) in terms of the reciprocal responses derived from interpersonal relationships and context. Variables (such as gender or character traits) relate to other variables, thus influencing the frame in which a person reacts. Again, context provides the frame in which people relate or avoid experience. Roche, Barnes-Holmes, Barnes-Holmes, Stewart, and O’Hora (2002) explain “that derived relational responding is generalized operant behavior . . . the act of relating is a contextually controlled overarching response class than can occur with an infinite variety of stimulus topographies” (p. 76).

As a post-Skinnerian behavioral approach, ACT acknowledges that not every behavior is observable or quantifiable. Yet the essence of mindfulness is observation. We cannot observe thoughts, yet we attach words to our experience, even our thoughts. We can observe the thought in terms of the words. Observing words, such as “depressed” or “understand,” brings mindfulness and curiosity into the world of words and attaches a different context.

Both functional contextualism and RFT emphasize the power of words to influence context. For example, every time a story is told, it is in a different context, which in turn influences the context in which it is being told. It is a reciprocal relationship.

Consider the following example:

“I am noticing that I am having the thought that depression is insurmountable.” (relational frame)

“Where were you when you noticed you were having that thought?” (functional contextualism)

Putting the thought in context can diminish the power of the thought because the thought becomes something that happens along with many other events. It distances and externalizes the experience that is being avoided.

Acceptance and commitment therapy is akin to postmodern schools of therapy, such as narrative and solution-focused approaches, which also emphasize externalizing the problem. Solution-focused approaches postulate that the problem is not the problem; rather, the solution is the problem. The focus is on the solution, not the problem. Narrative therapists would say, “the problem is the problem; the person is not the problem.” Acceptance and commitment therapy goes beyond externalizing problems to acceptance, observation, and movement to achieve a peaceful coexistence with the problem.

The theoretical foundations of ACT, RFT, and functional contextualism can be reduced to the following:

Relational frame theory: Learning, and thus, behavior, is contextual. (If thinking of sucking on a lemon can provoke a perceived sour taste reaction, likewise thinking of a trauma can evoke associated physical reactions).

Functional contextualism: Is the behavior working (functional) in this context? (The context is seen as the bigger picture.)

This foundation allows for a multitude of interventions focusing on both private (psychological) and public (behavioral) experiences of clients, which will be discussed in a subsequent section.

Major Concepts

Steven C. Hayes, widely accepted as the father of ACT, and coauthor Jason Lillis (Hayes & Lillis, 2012) provide an overview of ACT’s main influences and its basic principles. The authors demonstrate how ACT illuminates the ways in which language encourages avoidance in clients’ psychic lives. Acceptance and commitment therapy is used to help clients accept private experiences (thoughts and emotions), become more mindful, develop greater clarity about personal values, and commit to needed behavior change. The acronym ACT stands for accept, choose, take action.

Acceptance and commitment therapy does not strive to take away pain, but acknowledges that pain is a natural part of living. Hayes, Strosahl, and Wilson (2012) refer to “the dilemma of human suffering” (p. 3). The authors posit that “psychiatric diseases are actually more myth than reality” (Hayes et al., 2012, p. 7).

Succinctly described by Thyer and Wodarski (1998), ACT concentrates on the verbal and rule-governed behavior of people. The rules and language that govern behavior are categorized into three major sets: (a) literality, (b) reason giving, and (c) control. Literality means using literal definitions (anxiety literally means an uncomfortable state to most people). Reason giving goes beyond literality to explain behavior, as if internal experiences (anxiety) explain why a person cannot perform an action (experiential avoidance). The context of control implies that certain events must happen for other events to occur (anxiety must be eliminated for a person to function).

Eschewing these rules, ACT strives to change these “contingencies of reinforcement by exploring the paradoxes of such contexts” (Thyer & Wodarski, 1998, p. 336). An elemental step in this process is to separate clients’ words and actions from the clients themselves, distinguishing people from their behavior. Demonstrating that people can exist and function with uncomfortable internal states (anxiety) eliminates the “control exerted by the contexts of literality, reason giving, and control [and] is a major goal of therapy” (Thyer & Wodarski, 1998, p. 336).

Acceptance and commitment therapy is related to cognitive behavioral therapy (CBT); however, it is also distinctly different. Acceptance and commitment therapy does not depend on a client changing his or her thinking, but rather changing the behavioral functions of that thinking. Thus, a person may indeed continue to have the same thought, but develop a different or additional response to the thought. In CBT, it is preferable that a thought be challenged and modified, with changed behavior a result of the correction in thinking.

The goal of incorporating mindfulness, acceptance, and change also distinguishes ACT from traditional CBT. Acceptance and commitment therapy combines the process-oriented aspects of mindfulness and the action-oriented processes of behavior and change with the desired goal of increasing psychological flexibility (Boulanger, Hayes, & Lillis, 2009). The goal is not to change distorted thinking, but to accept irrational thoughts for what they are, internal experiences, “not literal truth” (O’Brien et al., 2008, p. 16), and for clients to change their relationship to their thoughts. The authors go on to explain, “When clients are able to balance acceptance and change, accepting their thoughts as thoughts and thereby changing their relationship to their thoughts, they gain the flexibility to move in valued directions” (p. 16).

Although elements of ACT cross over with elements of CBT, ACT addresses the existential aspect of finding meaning in experience and emphasizing values-consistent action. Even if no meaning can be found, ACT teaches one how to accept a void in purpose and still commit to change. The mindfulness aspect of ACT involves nonjudgmental acceptance of the present moment, especially body or emotional sensations coupled with nonconcern for the future.

Mindfulness

The mindfulness, relatively spiritual, component of ACT constitutes a major distinction from other CBT approaches. As one of the third-wave approaches, it is in a class that includes dialectical behavior therapy and mindfulness cognitive behavioral therapy. This third-wave class of therapies broadens attention to the psychological, contextual, and experiential world of its constituents (Dewane, 2012).

Although some approaches might view emotional and behavioral symptoms as psychopathological, in ACT an individual’s “symptomatology” is interpreted only as experiential avoidance. An elemental presupposition of ACT is that many adjustment problems in both children and adults are the result of “experiential avoidance,” which is defined as the inclination of people to avoid contact with a particular experience, somatic, cognitive, behavioral, and emotional. Acceptance and commitment therapy “emphasizes the need to undermine the avoidance of unwanted private experiences” (O’Brien et al., 2008, p. 18). To achieve acceptance, the opposite of avoidance, mindfulness is necessary.

Mindfulness calls for transcending a trauma, an event, or an injury and deciding how not only to survive but also to thrive. The client is not responsible for a harmful event, but is always responsible for the healing of the injury. Mindfulness often involves making peace with the past and with the self. Mindfulness techniques produce a detachment from ongoing preoccupations (de-centering) and should activate the rational system in the prefrontal lobe and attenuate the reflexive system (Beck, 2012).

An existential bent of ACT lies in its belief that suffering is a basic characteristic of human life, a premise reminiscent of that espoused by Viktor Frankl’s concept of logotherapy (Frankl, 1992), and represents a dramatic change from traditional behaviorism and CBT. Being present with both external and internal stimuli is similar to Eastern philosophies of contemplative healing. In addition, mindfulness extends into the present encounter between therapist and client. It sees the therapeutic relationship as a microcosm of the client’s world, not unlike the relational dynamics concepts utilized in contemporary psychodynamic approaches.

Mindfulness implies observing and noticing, especially one’s own experience, “a way of being with oneself” (Hill, 1986, p. 29). Using an experiential approach means that a new way of being with oneself and thus a way of being with the distress in one’s life defines the mindfulness component of ACT. Hill (1986) describes feminist work with posttraumatic stress disorder (PTSD) in which an ultimate goal would be to stand outside of the pain and regard it in some way. Self-acceptance, which then goes beyond to establish a relationship with the distress in a new way, is what ACT would interpret as increasing psychological flexibility.

Acceptance

Acceptance involves letting go of a psychological struggle without denying the reality of it. Accepting thoughts and private experiences, somatic or emotional, as what they are means accepting the verdict of an event, but rejecting its sentence. Instead of fighting or avoiding the experience, a person develops a different relationship to the experience, perhaps noticing it and peacefully coexisting with it.

Acceptance in ACT does not imply resignation. Accepting and experiencing the problem in a different way is definitive. Hill (1986) colorfully describes one client’s different relationships with emotional pain: first trying to wipe it out with substance abuse, then denying that it was even real with subsequent rage toward it for not disappearing, and seeking help through prescribed medication to numb and silence it. An experiential ACT therapist would attest to the failure of these relationships as testament to the psyche’s insistence to heal. The pain is seeking to be heard, not denied, suppressed, or silenced.

There are six core processes in ACT:

  1. 1. Acceptance

  2. 2. Cognitive defusion

  3. 3. Self as context

  4. 4. Being present

  5. 5. Values

  6. 6. Committed action

Each of the processes contributes to behavior change. Techniques designed to implement these processes are described in the subsequent section.

In summation, “reducing the hold of language” (Batten, 2011, p. 28) and learning by doing and experiencing (behavior), rather than learning and acting by words (cognition), comprise the major concepts of ACT. The outcome of ACT actually becomes a process.

Interventions and Techniques

The goal of ACT to achieve valued living with less struggling is defined by doing, not talking about it. It goes beyond reducing symptoms (strict behaviorism) to helping people construct lives they value. The therapeutic process of ACT can be summed up in achieving acceptance and mindfulness through the use of specific client-driven exercises, metaphors, and behavioral homework.

Acceptance and commitment therapy is a cognitive and experiential therapy in that it involves “doing” and attaching contexts to cognition. It shares some techniques of other approaches, but, in a way that is focused on a contextual behavioral model, focusing on processes that may underlie all behavior (avoidance of painful experience) and cognitive fusion (being stuck by language). Problems are viewed as “stuck stories.” Assessment in ACT is a determination of the levels of stuckness and discovering where one’s life is not stuck. The therapist also avoids getting hooked into the stuckness by making nonevaluative statements such as “You are noticing that your mind labeled this experience as stuck.” Multiple ACT-specific instruments have been developed to measure ACT processes (Hayes, 2009).

The overarching therapeutic goal is less struggling with suffering and more moving toward valued living. Clients are guided to ask themselves, “Am I moving toward the desired value or struggling with the suffering? Given what is important to me, what am I willing to do and experience to move me in that direction, in this moment?”

Problem stories told by the client are usually stories of being “stuck.” Instead of focusing on negatives, the therapist uses “creative hopelessness” to put the stuckness in a bigger context by asking, “Where were you when you thought that? What wasn’t working? Are you willing to consider another way that we don’t know yet?” Creative hopelessness (facing the situation) techniques are often used as a precursor to acceptance work.

Techniques

Techniques used in ACT are often clever and playful and reinforce the doing and experiential aspect of the model. ACT uses language processes, such as metaphors and paradox, and experiential exercises to create more flexible psychological responses that direct behavior toward a values-driven goal (O’Brien et al., 2008). A comprehensive list of techniques has been developed by Stroshal, Hayes, Wilson, and Gifford (2004), some of which are described in the remainder of this section.

Values Techniques.

Techniques are designed to clarify what the client values and what gives life meaning, which underlies most behavior. These techniques determine whether behavior is moving toward these valued outcomes and what a person is willing to do to move toward the values. Clients are guided between values-driven behavior and goal-oriented behavior. The Valued-Living Questionnaire (Wilson, Sandoz, Kitchens, & Roberts, 2010) is used in ACT as a part of values clarification techniques.

Other simple techniques, such as listing values in all major life areas or having a client write his or her eulogy or tombstone, are used in addition to more sophisticated techniques, such as “traumatic deflection,” establishing what pain a client would have to endure to do what is valued.

Creating confusion may also be part of the values identification process. According to Hayes and Smith (2005), “Outcome is the process through which process becomes the outcome” (p. 161).

Other values techniques include the following:

Technique/Metaphor

Intention

Redefining inaction as choosing not to choose

Accepting that choice cannot be avoided. We are always making choices; even no choice is a choice.

What if no one could know?

Imagining no one could know of one’s achievements, what would a person still do? The answer defines values-driven behavior.

Traumatic deflection

Identifying what lengths or pain one would endure to do what you value?

Note. Extrapolated from An ACT primer, in S. C. Hayes & K. D. Strosahl, (Eds.), A practical guide to acceptance and commitment therapy (pp. 31–51), by K. Stroshal, S. Hayes, K. Wilson, and E. Gifford, 2004, New York, NY: Springer-Verlag. Copyright 2004 Springer-Verlag. Adapted with permission.

Acceptance Techniques.

Acceptance techniques are designed to give permission to the client to endure whatever inner experiences occur, if doing so produces action. The Acceptance and Action Questionnaire, versions I and II (Bond et al., 2011), is an instrument designed to measure acceptance and behavioral effectiveness in ACT.

Sample acceptance techniques are as follows:

Technique/Metaphor

Intention

Unhooking

Separating a thought from an action: thoughts/feelings do not always result in action.

Exploring effects of avoidance

How has avoiding worked? How has it not?

Amplifying responses

Bring the experience (the monster or pink elephant) into the room.

 

In vivo exposure

In-session flooding and desensitization.

The Serenity Prayer

Change what is possible; accept what is not.

Note. Extrapolated from An ACT primer, in S. C. Hayes & K. D. Strosahl, (Eds.), A practical guide to acceptance and commitment therapy (pp. 31–51), by K. Stroshal, S. Hayes, K. Wilson, and E. Gifford, 2004, New York, NY: Springer-Verlag. Copyright 2004 Springer-Verlag. Adapted with permission.

Mindfulness Techniques.

Often homework given in ACT entails “noticing”: noticing when the mind gets hooked or stuck, noticing where it is associated in the body, then noticing what one does as a consequence. This type of detachment is empowering and is the main component of mindfulness techniques. Mindfulness experiential awareness essentially is noticing and paying attention to internal experiences and how they are somaticized. Brown and Ryan (2003) offer a tool to assess a client’s capacity for mindfulness. The Mindful Attention Awareness Scale is a 15-item measure assessing mindfulness of moment-to-moment experience.

Simple education techniques (unhooking a thought from an action) clarify that thoughts or emotions do not always result in action; the thought is an inner behavior that does not have to manifest in an outward behavior.

Mindfulness techniques also include exploring and observing the consequence of avoidance. “Leaning in” to fear instead of away from it is the opposite of experiential avoidance.

Some techniques offered by Stroshal et al. (2004) include the following:

Technique/Metaphor

Intention

Noticing the struggle/tug of war

The metaphor envisions a tug of war with a monster; the goal is to drop the rope, not win the war.

Rehearsing the opposite/practice the unfamiliar

Paying attention to what happens when not doing the automatic response.

Distinguish willing from wallowing (moving through a swamp)

The only reason to jump into a swamp is because it is in the way of getting to the other side of where one wants to go.

Chinese handcuffs

No matter how hard one pulls to get out of them, it is pushing that does the trick.

Driving with the rearview mirror

Control strategies (avoiding experience) do not work.

Note. Extrapolated from An ACT primer, in S. C. Hayes & K. D. Strosahl, (Eds.), A practical guide to acceptance and commitment therapy (pp. 31–51), by K. Stroshal, S. Hayes, K. Wilson, and E. Gifford, 2004, New York, NY: Springer-Verlag. Copyright 2004 Springer-Verlag. Adapted with permission.

The three therapeutic components of ACT, which are primarily client driven, are as follows:

  1. 1. Behavioral activation—do something different;

  2. 2. Noticing—self-awareness through mindfulness; and

  3. 3. Reverse cognition—defusing thoughts and separating from behavior.

In ACT, a therapist and client have a variety of experiential exercises and metaphorical and paradoxical techniques at their disposal to achieve the goal of valued living.

Empirical Evidence

Third-wave behavioral approaches have broad applicability. Studies have shown ACT’s usefulness across a span of adult clinical syndromes. Boulanger et al. (2009) state that an array of psychological and behavioral problems including depression, self-harm, chronic pain, anxiety, psychosis, prejudice, worksite stress, employee burnout, diabetic self-management, adjustment to cancer, obsessive–compulsive disorder, trichotillomania, adjustment to epilepsy, and self-stigma can be ameliorated with ACT.

Researchers have explored the effectiveness of ACT with life skills such as parenting. O’Brien (2011) found compelling evidence to support the use of ACT as an intervention for parenting. The use of ACT as a new approach to improve athletic performance has been proposed (Gardner & Moore, 2004). The authors demonstrated that a mindfulness, acceptance, commitment approach to sports psychology appears to be more effective than traditional cognitive–behavioral approaches.

Acceptance and commitment therapy may be suitable for multiple comorbid disorders. Batten and Hayes (2005) provide a convincing case study in which an individual with comorbid PTSD and substance abuse is treated with ACT. Twohig (2009) describes a case of treatment-resistant PTSD and major depressive disorder successfully ameliorated with a course of ACT. Considering that many major diagnoses carry others with them (PTSD/substance abuse), the approach strives to target not symptoms of a particular disorder but the experiential avoidance that gives rise to the symptoms of all disorders (Batten, 2011). In this view, one model does fit all.

Acceptance and commitment therapy continues to be studied across targeted populations. Its relevance for work with substance-abusing populations has been studied (Hayes, Wilson, et al., 2004). ACT seems to be well suited to the spiritual “letting go” aspects of traditional Twelve-Step substance-abuse treatment. One randomized clinical trial (RCT) with 138 opiate abusers compared methadone maintenance alone with methadone maintenance combined with ACT or Intensive Twelve-Step Facilitation. Results were that methadone maintenance alone resulted in a higher relapse rate, but methadone maintenance combined with either ACT or Intensive Twelve-Step Facilitation saw reduced drug use posttreatment and at the 6-month follow-up.

Behavioral approaches have traditionally been used in smoking cessation. In an initial investigation (Gifford et al., 2004) ACT has been applied in a comparison with nicotine-replacement therapy (NRT), in which ACT concentrated on the process of smoking and NRT focused on the outcome. Negative reinforcement available through avoidance is an important component of nicotine dependence (Shiffman, 1993, as cited in Gifford et al., 2004) and is a potent predictor of failed smoking cessation. Smoking serves to reduce negative internal states. Most smokers want to avoid the uncomfortable physical sensations that accompany quitting and to maintain the positive calming and numbing effect smoking supplies for negative internal states. Because smoking is often used to medicate negative internal experiences (uncomfortable somatic sensations), the acceptance-related dominance of ACT seems well suited. The researchers suggest that treatment focused exclusively on eliminating the uncomfortable residuals of smoking cessation is not the only option.

Gifford (2002) developed a four-layer process model for smoking cessation. Generated from this model was an ACT approach toward smoking cessation. The ACT approach was compared with NRT in a pilot study involving 76 participants with long-standing nicotine dependence and multiple histories of failed quit attempts. Participants were randomly assigned to NRT or ACT for a seven week treatment. Measurements were taken posttreatment and at six month and one year follow-ups. Quit rates were virtually the same posttreatment. At the six month follow-up, ACT participants maintained higher quit rates; in the one year follow-up the quit rate among ACT participants equaled that of posttreatment rates, whereas the quit rate among NRT participants remained significantly lower. The quit rate for participants in the ACT treatment was 2.3 times higher compared with the control group. Because ACT seems to produce longer-term results, it is presumably safe to say that the treatment provided an additional way for participants to calm internal states while simultaneously accepting and dealing with negative physical states in a new way, other than NRT delivered in another form. The authors suggest confirmatory studies be undertaken to determine whether ACT was the significant factor or whether the additive effect of any treatment coupled with NRT contributes to a higher quit rate.

In an interesting study on providers rather than patients, the influence of ACT was compared with multicultural training with regard to mitigating stigma, prejudice, and professional burnout of substance-abuse counselors (Hayes, Bissett, et al., 2004). The ACT protocol used in the training was drawn from the psychotherapy ACT protocols but was considered training rather than treatment, provided in a day-long workshop. The multicultural training had an immediate effect on reducing stigmatizing processes. The ACT intervention had a longer-term effect on mitigating burnout.

Proponents claim ACT to be user-friendly by both client and therapist. Beyond traditional uses for behavioral approaches, such as smoking cessation, ACT studies indicate that its applicability ranges from treating psychotic behaviors (Bach & Hayes, 2002; Gaudiano & Herbert, 2006) to working with pediatric chronic illness (Montgomery, Kim, & Franklin, 2011.) Twohig and Woods (2004) found three of six patients successfully decreased trichotillomania behaviors.

The use of ACT with various experiences of trauma demonstrates its potential usefulness. Trauma exposure is viewed as an important risk factor for emotionally avoidant behavior (experiential avoidance). Acceptance and commitment therapy has been suggested for the treatment of survivors of childhood sexual abuse (Walser & Westrup, 2007; Orsillo & Batten, 2005; Wilson, Follette, Hayes, & Batten, 1996) as well as a cautious primary or adjunct therapy for veterans suffering from PTSD. Vujanovic, Niles, Pietrefesa, Potter, and Schmertz (2011) elucidate ways in which the mindfulness approaches, including ACT, can mitigate trauma reactions. Vujanovic, Niles, Pietrefesa, Potter, & Schmertz (2011), reports an ongoing study of mindfulness approaches and ACT with PTSD. Two trials are currently underway for ACT, one for combat-related distress and another for PTSD.

Studies suggest ACT as a useful intervention for those suffering from panic symptoms or panic disorder (Levitt, Brown, Orsillo, & Barlow, 2004; Karekla, Forsyth, & Kelly, 2004). Researchers have found ACT applicability in coping with pain (Luciano et al., 2010; Dahl, Wilson, & Nilsson, 2004; Gutierrez, Luciano, Rodriguez, & Fink, 2004).

A meta-analysis (Hayes, Luoma, Bond, Masuda, & Lillis, 2006) provides a comprehensive review of the efficacy literature. Ruiz (2010) provides a thorough review of ACT empirical evidence, concluding the studies strongly support ACT with a wide range of psychological disorders.

Acceptance and commitment therapy is now considered an empirically supported treatment on the American Psychological Association list of empirically based treatments with moderate support in depression and strong research support in pain control (Society of Clinical Psychology, n.d.), and it is listed as an evidence-based practice on the Substance Abuse and Mental Health Administration’s National Registry of Evidence-Based Programs and Practices (Substance Abuse and Mental Health Administration, 2012).

Founders recommend ACT for problem areas where it has an evidence base, such as affective disorders and chronic pain. Sufficient evidence also exists to suggest its use with smoking cessation, substance abuse, some psychoses, and occupational stress. It is recommended on an experimental basis, as an adjunct therapy or primary approach when other empirically based treatments have failed, where the presenting problem appears to involve a lack of value clarification, cognitive fusion, experiential avoidance, and resulting psychological rigidity.

The Association for Contextual Behavioral Sciences reports that as of March 2012 there are just under 60 RCTs of ACT published or in press. The studies average over 75 participants each—which totals over 4,000 participants. Over half of this literature has appeared since 2009 and 40% of it originated outside of the United States, attesting to the international reach of ACT (Hayes, 2010).

The Association offers a compilation of published and current ongoing major studies, divided into randomized controlled trials and other types of studies (for example, pre–post designs or single-case designs). The following table of ACT data is current as of early 2011 (Hayes, 2012).

ACT DATA/OUTCOME STUDIES

Depression

5 RCTs; 3 other. Some indication that ACT is superior to CBT in some settings. Evidence of a distinct process.

Anxiety/stress/obsessive–compulsive disorder

9 RCTs; 11 other. Data supporting the application of ACT with a number of different problems related to anxiety and stress. Some indication that it is superior to CBT in some settings, but data also indicate that it can be beaten by traditional behavioral therapy in minor anxiety problems. Evidence of changes in ACT processes mediating outcomes.

Psychosis

3 RCTs; 5 other. Not yet compared with other psychosocial methods beyond support but effects are good for amazingly small interventions. Used in addition to antipsychotic medication. Mediated by ACT processes.

Substance abuse

3 RCTs; 3 other. Some indication that ACT does better than existing pharmacotherapy methods or supplements their effects.

Smoking

3 RCTs; 2 other. Indication that ACT does better than existing pharmacotherapy methods or supplements their effects.

Chronic pain

3 RCTs; 7 other, including 3 decent-size effectiveness trials. Good outcomes. No good head-to-head comparisons with empirically supported alternative methods yet. Works through ACT-relevant processes.

Prejudice and burnout

3 RCTs; 1 crossover. Beats multicultural counseling and education alone. Works through ACT-relevant processes. Helps in both stigma and burnout. Other good studies completed and forthcoming.

Marital problems

1 other. Very limited data.

Eating disorder or body dissatisfaction

2 RCTs; 1 other.

Sexual deviation

2 other. Very limited data.

Dually diagnosed

1 RCT (subanalysis); 1 other. Promising but limited data.

Self-harm/borderline personality disorder

2 RCTs, 1 that mixed ACT with dialectical behavior therapy. Good outcomes. Limited follow-up. Did move ACT-relevant processes.

Epilepsy

3 RCTs. Good outcomes on both seizures and quality of life. 1-year follow-up. Mediated by ACT processes.

Diabetes management

1 RCT. Good outcomes at follow-up on self-management and glucose control. Mediated by ACT processes.

Weight maintenance

2 RCTs. Good outcomes that were mediated through ACT processes.

Augmenting training in other therapies

2 RCTs. Found ACT can increase the adoption of evidence-based psychotherapy methods by clinicians and is mediated through ACT processes.

Coping with cancer

3 RCT; 1 other. Preliminary data suggest ACT can improve coping with cancer. One RCT shows ACT is more helpful than traditional CBT elements in dealing with end-stage cancer and works through a different process.

Sports performance

3 other. Very limited data suggesting ACT can improve performance in various sports.

Note. Extrapolated from State of the ACT evidence. Association for Contextual Behavioral Science. 2012, by S. Hayes, 2012. Adapted with permission.

In perhaps the most relevant research for social workers, Montgomery et al. (2011) completed a comprehensive review of ACT literature specifically geared toward social workers working with vulnerable populations. The authors point out that “social workers are frequently called on to help manage and treat [challenging psychological and physiological illness] in mental health and health settings” (p. 177). The authors found that evidence strongly suggests ACT may be an effective therapy for clients struggling with mood disorders. The evidence for dealing with psychosis is less compelling, yet there was a statistically significant effect in the reduction of distress associated with psychotic symptoms. For physiological illness, the authors found that ACT is proven effective in the management of chronic pain, epilepsy, trichotillomania, and skin picking and has promise for use with illnesses such as diabetes and obesity. The authors recommend that social workers consider ACT an important intervention in social-work education, practice, and research.

There is increasing evidence for using ACT with children and adolescents (Greco & Hayes, 2008). O’Brien et al. (2008) include ACT as a promising third-wave behavioral approach for children and adolescents. Using developmentally appropriate exercises, ACT can be adapted for individuals ages 8 and older. Empirical evidence exists for ACT’s effectiveness with youth populations, such as girls with anorexia, pediatric pain, adolescent girls engaging in risky sexual behavior, and adolescents at risk for dropping out of school (O’Brien et al., 2008).

The mainstay of most behavioral approaches with children, functional analysis, is considered best practice for children’s behavioral dysregulation. This analysis must include the family’s role in providing positive reinforcement for negative behavior. In an ACT view, the family is seen as the context in which symptoms (behaviors) may be functional (functional contextualism).

Theoretically, ACT would be suitable for children in that the exercises and metaphors can be playful. Children may be more appreciative than adults, being in the moment and noticing, thus making them easily receptive to mindfulness exercises. The symbolic use of objects and metaphorical language can be easily adapted to work with children. Along with other mindfulness-based approaches, such as mindfulness cognitive behavioral therapy or dialectical behavior therapy, ACT has recently been used for at-risk children and adolescents. It has been studied as effective for pediatric chronic pain, primary care, borderline personality disorder, externalizing disorders, and body-image problems. The use of ACT with children literally is in its infancy. The challenge and apparent contradiction is to help children use language in a different way, yet children only know the world through rules imposed by language. However, used skillfully, “acceptance and mindfulness training should broaden children’s repertoires without creating conflicts between different styles of interacting verbally with their world” (Hayes & Greco, 2008, p. 7).

The literature about ACT across a variety of populations and challenges in living is considerable and ongoing. Proponents of all behavioral approaches point to the ease in which quantifiable outcomes can be demonstrated with the behavior therapies, and ACT is no exception.

Relevance to Social Work

Where is the intersection of social-work ideology and ACT? Is ACT applicable across cultures? Does ACT recognize or address issues of social injustice that may be contributing to the client’s distress?

Perhaps one of the main criticisms of ACT from a social-work perspective is its emphasis on the individual to the neglect of the individual’s environment. Because ACT is a contextual psychology, is it assumed that an individual’s context (environment) is taken into account? More likely, the immediate context in which psychological inflexibility occurs is the emphasis. Proponents of ACT do recognize that in ACT work with children, it is essential to include their social contexts, such as families, schools, neighborhoods, and communities (Hayes & Greco, 2008).

The relevance of behavioral and cognitive therapies to social issues is evolving. Hayes, Bissett, et al. (2004) report on the usefulness of ACT in a multicultural training developed to reduce stigmatizing attitudes and professional burnout. They suggest that ACT has potential in reducing stigma toward marginalized populations. The core principles of ACT are consonant with several core concepts of social work, however.

In ACT psychopathological symptoms are seen not as a deficit, but as a clue to a need for experiential avoidance, consistent with social work’s core principle of the inherent worth and dignity of each individual. Acceptance and commitment therapy is a distinctly client-driven and collaborative approach. Because client self-determination is a foundational principle of the field of social work, ACT represents movement toward client-centered behavioral treatment.

Whereas the second-wave behavioral approaches, including CBT, tend to emphasize content more than relational process, the third-wave approaches are bringing the therapeutic relationship back to the forefront as essential to treatment. Acceptance and commitment therapy and other mindfulness-based approaches have placed increasing emphasis in the relational “moment to moment dynamic which results in therapeutic change” (Turner, 2009, p. 101). The relationship as the cornerstone of cure is paramount in social-work ideology. In ACT, the reliance on mindfulness, by both the client and the therapist, represents a unique expression of “use of self,” another salient concept in social-work practice.

The Social Work Special Interest Group of the Association for Contextual Behavioral Sciences (Boone, 2011) is “committed to supporting the intersection of social-work theory and practice and contextual behavioral science” (Mission/Objectives). The group purports that ACT is well suited to the practice of social work in that both ACT and social work share a focus on context, strengths, and understanding human suffering in ways that avoid pathologizing individuals and communities.

In an interview as the first social worker to be designated as a peer-reviewed ACT trainer, Joanne Steinwachs stated,

I cannot think of a theory that is more in line with social work values than functional contextualism. We provide the bulk of mental health care in this country and it breaks my heart that more social workers don’t know about contextual behavioral science. I feel really good coming home to social work after all these years of hanging out with psychologists. There’s a deep sense of “these are my people” that I feel when I talk functional contextualism with social workers. (Long, 2012, para. 11)

Conclusion

Although the third wave of behavioral therapies is relatively new (emerging in the mid-1990s), ACT has demonstrated empirically driven, cost-effective, efficacious, culturally sensitive intervention across multiple populations. It is consistent with social-work empowerment philosophy as clients are guided to recognize their own capacities. It reflects person-in-environment in the sense that context is environment defined by the client. Labeling and pathology orientation are discouraged, consistent with a social-work strengths perspective.

At the very least, techniques from ACT can be integrated into other approaches. At the very best, ACT used exclusively represents the best of the four dominant schools of intervention in social work:

  • The use of relational dynamics in ACT borrows from contemporary psychodynamic practice.

  • The growth-oriented emphasis of ACT represents humanistic philosophy.

  • The influence of the cognitive–behavioral school is evident by ACT identifying and using private experiences (thoughts); realizing the importance of cognitive control, but teaching new forms of thinking that are not exclusively replacing distorted thoughts.

  • Finally, the postmodern influence is seen in ACT’s perspective of the social construction of language and context, combined with the existential philosophy of accepting that suffering is a necessary part of the human condition but does not define the quality of human existence. “Mind over matter” becomes “mind over mind.”

Despite persistent criticism that the approach has not been sufficiently empirically proven, there is a substantial body of literature demonstrating its effective use with varied areas of distress. There is no body of literature disproving its effectiveness. Certainly the absence of such study does not guarantee that ACT is effective, but the literature supporting its efficacy is considerable.

As with most specialized approaches, with proper training and supervision, ACT may be very appropriate for social workers to use, particularly with clients who have experienced trauma. Although ACT may not address the core social-justice issues of social-work practice, its potentially significant contribution to social-work intervention with individuals cannot be ignored.

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Further Reading

Austin, J. (2006). Acceptance and mindfulness at work: Applying acceptance and commitment therapy and relational frame theory to organizational behavior management. Journal of Organizational Behavior Management, 26(1/2).Find this resource:

Bach, P. A., & Moran, D. J. (2008). ACT in practice: Case conceptualization in acceptance & commitment therapy. Oakland, CA: New Harbinger.Find this resource:

Baer, R. A. (2010). Assessing mindfulness & acceptance processes in clients: Illuminating the theory & practice of change. Oakland, CA: New Harbinger.Find this resource:

Blackledge, J. T., Ciarrochi, J., & Deane, F. P. (Eds.). (2009). Acceptance and commitment therapy: Contemporary theory, research and practice. Brisbane, Australia: Australian Academic Press.Find this resource:

Bond, F. (2009). Acceptance and commitment therapy: Distinctive features. York, NY: Routledge.Find this resource:

Ciarrochi, J., Bailey, A., & Hayes, S. C. (2008). A CBT practitioner’s guide to ACT: How to bridge the gap between cognitive behavioral therapy & acceptance & commitment therapy. Oakland, CA: New Harbinger.Find this resource:

Dewane, C. (2008). The ABCs of ACT: Acceptance and commitment therapy. Social Work Today, 8(5), 34.Find this resource:

Eifert, G., & Forsyth, J. (2009). Acceptance and commitment therapy for anxiety disorders: A practitioner’s guide to using mindfulness, acceptance, and values-based behavior change strategies. Oakland, CA: New Harbinger.Find this resource:

Fletcher, L., & Hayes, S. C. (2005). Relational frame theory, acceptance and commitment therapy, and a functional analytic definition of mindfulness. Journal of Rational–Emotive & Cognitive–Behavior Therapy, 23(4), 315–336.Find this resource:

Follette, V., Heffner, M., & Pearson, A. (2010). Acceptance and commitment therapy for body image dissatisfaction: A practitioner’s guide to using mindfulness, acceptance, and values-based behavior change strategies. Oakland, CA: New Harbinger.Find this resource:

Forman, E. M., Herbert, J. D., Moitra, E., Yeomans, P. D., & Geller, P. A. (2007). A randomized controlled effectiveness trial of acceptance and commitment therapy and cognitive therapy for anxiety and depression. Behavior Modification, 31(6), 772–799.Find this resource:

Hall, M. L., & Palm, K. M. (2004). Acceptance-based treatment for smoking cessation. Behavior Therapy, 35(4), 689–705.Find this resource:

Harris, R. (2009). ACT made simple: An easy-to-read primer on acceptance and commitment therapy. Oakland, CA: New Harbinger.Find this resource:

Hayes, S. C., Barnes-Holmes, D., & Roche, B. (2001). Relational frame theory: A post-Skinnerian account of human language and cognition. New York, NY: Kluwer Academic/Plenum.Find this resource:

Hayes, S. C., Berry, K., Niccolls, R., Bissett, R., Roget, N., & Padilla, M. (2004). The impact of acceptance and commitment training and multicultural training on the stigmatizing attitudes and professional burnout of substance abuse counselors. Behavior Therapy, 35(4), 821–835. doi:10.1016/S0005-7894(04)80022-4Find this resource:

Hayes, S. C., Follette, V. M., & Linehan, M. M. (Eds.). (2004). Mindfulness and acceptance: Expanding the cognitive–behavioral tradition. New York, NY: Guilford Press.Find this resource:

Hayes, S. C., & Levin, M. (Eds.). (2012). Mindfulness and acceptance for addictive behaviors: Applying contextual CBT to substance abuse and behavioral addictions. Oakland, CA: Context Press.Find this resource:

Hayes, S. C., Levin, M. E., Plumb-Vilardaga, J., Villatte, J. L., & Pistorello, J. (2011). Acceptance and commitment therapy and contextual behavioral science: Examining the progress of a distinctive model of behavioral and cognitive therapy. Behavior Therapy. doi:10.1016/j.beth.2009.08.002Find this resource:

Hayes, S., & Pierson, H. (2005). Acceptance and commitment therapy. In Encyclopedia of Cognitive Behavior Therapy (pp. 1–4). New York, NY: Springer.Find this resource:

Herbert, J. D., & Forman, E. M. (2010). Acceptance and mindfulness in cognitive behavior therapy: Understanding and applying the new therapies. Hoboken, NJ: Wiley.Find this resource:

Hick, S. F. (2009). Mindfulness and social work. Chicago, IL: Lyceum Books.Find this resource:

McCracken, L. (2011). Mindfulness and acceptance in behavioral medicine: Current theory and practice. Oakland, CA: Context Press.Find this resource:

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Roemer, L., & Orsillo, S. M. (2009). Mindfulness-and acceptance-based behavioral therapies in practice. New York, NY: Guilford Press.Find this resource:

Sandoz, E., Sandoz, E. K., Wilson, K. G., & DuFrene, T. (2011). Acceptance and commitment therapy for eating disorders: A process-focused guide to treating anorexia and bulimia. Oakland, CA: New Harbinger.Find this resource:

Törneke, N. (2010). Learning RFT: An introduction to relational frame theory and its clinical applications. Oakland, CA: New Harbinger.Find this resource:

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Twohig, M., Pierson, H., & Hayes, S. (2007) Acceptance and commitment therapy. In N. Kazantzis, & L. L’Abate (Eds.), Handbook of homework assignments in psychotherapy: Research, practice, and prevention (pp. 113–132). New York, NY: Springer.Find this resource:

Walser, R. D., & Westrup, D. (2007). Acceptance & commitment therapy for the treatment of post-traumatic stress disorder: A practitioner’s guide to using mindfulness & acceptance strategies. Oakland, CA: New Harbinger.Find this resource:

Wilson, K., & DuFrene, T. (2009). Mindfulness for two: An acceptance and commitment therapy approach to mindfulness in psychotherapy. Oakland, CA: New Harbinger.Find this resource:

Wilson, K. G., & Sandoz, E. K. (2008). Mindfulness, values, and therapeutic relationship in acceptance and commitment therapy. In S. F. Hick & T. Bien (Eds.), Mindfulness and the therapeutic relationship (pp. 89–106). New York, NY: Guilford Press.Find this resource:

Wilson, K. G., Sandoz, E. K., Kitchens, J., & Roberts, M. E. (2010). The Valued Living Questionnaire: Defining and measuring valued action within a behavioral framework. The Psychological Record, 60, 249–272.Find this resource:

Wilson, K., Sandoz, E., & Slater, R. (2009). Acceptance and commitment therapy. In A. R. Roberts (Ed.), Social workers’ desk reference (2nd ed., pp. 283–293). New York, NY: Oxford University Press.Find this resource:

Woods, D. W., & Twohig, M. P. (2008). Trichotillomania: An ACT-enhanced behavior therapy approach therapist guide (Vol. 1). New York, NY: Oxford University Press.Find this resource:

Acknowledgment:

The author thanks Rebecca S. Traub, MLS, for her invaluable research and editorial expertise.