What is Acceptance and Commitment Therapy (ACT)

Modern psychology is grounded in the medical model, and the medical model rests on the assumption of healthy normality; that humans are inherently happy, connnected with others, altruistic and at peace with themselves. From this perspective, psychological suffering is seen as abnormal; a disease or syndrome driven by unusual pathological or physiological processes.

In this ‘disease’ model distressing thoughts, feelings, memories or sensations come to be viewed as ‘symptoms’ and specific clusters of these ‘ symptoms’ indicate pathology. Each year the DSM (The psychiatric ‘bible’ where these ‘pathologies’ are listed) grows in volume as new ‘diseases’ are added. Now imagine a therapy that neither recognizes many of our distressing or unwanted internal experiences as ‘symptoms’, nor makes any attempt to reduce these ‘symptoms’’. It rather sees experiences like depression, relational pain, loneliness, anxiety, boredom and other types of emotional distress. as a normal and acceptable, albeit painful, part, of our human experience. One has only to turn to any of our major religious tradition (whether eastern or western) to find confirmation of the idea that human suffering is a normal part of everyday life

Naturally, if these so called ‘symptoms’, are a normal part of our everyday human experience then having their illimination or reduction as a therapeutic goal is pointless (like trying to prevent and feeling of discomfort on a hot summer day). In fact our ongoing attempts to get rid of ‘symptoms’ actually creates a clinical disorder in the first place. As soon as a private experience is labeled a ‘symptom’, it immediately sets up a struggle with it because a ‘symptom’ is by definition something ‘pathological’; something we should illiminate.

In ACT, the aim is to readjust our attitudes and perceptions as to what is psychologically ‘normal’. This means transforming our relationship with our difficult thoughts and feelings, so that we no longer perceive them as ‘symptoms’. Instead, we learn to perceive them as harmless, even if uncomfortable, transient psychological events. Ironically, it is through this process that ACT actually achieves symptom reduction—but as a by-product and not the goal.

Destructive Normality

So if these uncomfortable, distressing or painful aspects of our human experience are not always symptoms of a pathology (of course some abnormal processes do exist), how do they arise and why are they so universal? We still need an explanation that will empower us to reduce their dysfunctional influence and allow us to live meaningful lives (Simply stating our intention to be positive and goal directed is not a solution). ACT offers such a explanation; it postulates that the core processes underlying these patterns of human psychological suffering arise in the functioning of the normal human mind and that the root of the problem is language itself. Language gives rise to both human achievement and human suffering; When ACT uses the term ‘language’ it is referring to all symbolic activity in whatever form it occurs including cognition, words, images, sounds, facial expressions and physical gestures.

All Neurosis is a substitute for legitimate suffering. Carl Jung

Probably the single biggest evolutionary advantage of human language was the ability to anticipate and solve problems. The essence of problem-solving is this:
Problem = something we don’t want.
Solution = figure out how to get rid of it, or avoid it.
This problem solving approach is adaptive and obviously works well in the material world. It has resulted in humans dominating the planet and mastering their enviroment. Given that this problem solving approach works well in the outside world, it’s only natural that we would tend to apply it to our interior world; the psychological world of thoughts, feelings, memories, sensations, and urges. Unfortunately, all too often when we try to avoid or get rid of unwanted private experiences, we simply create extra suffering for ourselves. Think of addiction, virtually every addiction known to mankind begins as an attempt to avoid or get rid of unwanted thoughts and feelings, such as boredom, loneliness, anxiety, depression and so on.

Language then has given us the tools to problem solve, evaluate, compare, judge, criticise and categorize our world, but as we have increasingly used these abilities to look inward, we have turned our internal experiences into a problem to be solved rather than a process to be fully experienced.

A Self Defeating Cycle

The more intent we become on avoiding or controlling unwanted private experiences, the more we are likely to suffer psychologically. Anxiety disorders provide a good example. It is not the presence of anxiety that comprises the essence of an anxiety disorder. After all, anxiety is a normal human emotion that we all experience. At the core of any anxiety disorder lies a major preoccupation with trying to avoid or get rid of anxiety. OCD with the elaborate rituals that OCD sufferers devise, in futile attempts to get rid of anxiety-provoking thoughts and images, is a good example of this. Sadly, the more importance we place on avoiding anxiety, the more we develop anxiety about our anxiety—thereby exacerbating it. It’s a vicious cycle, found at the centre of any anxiety disorder. (What is a panic attack, if not anxiety about anxiety?)
A large body of research shows that higher experiential avoidance is associated with anxiety disorders, depression, poorer work performance, higher levels of substance abuse, lower quality of life, high risk sexual behaviour, borderline personality disorder, greater severity of PTSD, long term disability and alexithymia.

Emotional Control Strategies

Of course, not all forms of experiential avoidance are unhealthy. For example, watching some TV to unwind at night is experiential avoidance, but it’s not likely to be harmful. However, watching for three hours, while your children’s attempts at getting your attention are ignored, is extremely harmful, in the long term. ACT targets experiential avoidance strategies only when you use them to such a degree that they become costly, life-distorting, or harmful. ACT calls these ‘emotional control strategies’, because they are attempts to directly control how we feel. Many of the emotional control strategies we use to try to feel good (or to feel ‘less bad’) may work in the short term, but self-destructive in the long term. For example, when we are depressed we often withdraw from socialising in order to avoid uncomfortable thoughts—‘I’m a boring’, ‘I have nothing to say’, ‘I won’t have fun ’—and unpleasant feelings such as anxiety, fatigue, fear of rejection. anceling a social engagement may afford short-term relief, but in the long term, the increasing social isolation makes us more depressed. ACT offers you an alternative to experiential avoidance.

The ACT alternative

You most likely will come to therapy with the intent of emotional control. You want to get rid of your depression, anxiety, compulsions, and so on. In ACT, there is no attempt to try to illiminate, suppress, or control these private experiences. Instead, you learn to reduce the impact and influence of unwanted thoughts and feelings, through the effective use of mindfulness. You learn to stop fighting with your private experiences—to turn toward them and make room for them, and allow them to come and go without a struggle.
The time and energy that you may have wasted previously on trying to control how you feel is then invested in taking effective action (guided by your values) to change life for the better.
Thus ACT interventions focus around two main processes:

1. developing acceptance of unwanted private experiences which are out of personal control,
2. commitment and action towards living a valued life.

Six Core Principles

ACT uses six core principles to help clients develop psychological flexibility:
• defusion
• acceptance;
• contact with the present moment
• the Observing Self;
• values, and
• committed action.

Each principle has its own specific methodology, exercises, homework and metaphors. Take defusion, for example. In a state of cognitive fusion we are caught up in language. Our thoughts seem to be the literal truth, or rules that must be obeyed, or important events that require our full attention, or threatening events that we must get rid of. In other words, when we fuse with our thoughts, they have enormous influence over our behaviour.
Cognitive defusion means we are able to ‘step back’ and observe language, without being caught up in it. We can recognise that our thoughts are nothing more or less than transient private events—an ever-changing stream of words, sounds and pictures. As we defuse our thoughts, they have much less impact and influence.For example, to deal with an unpleasant thought, we might simply observe it with detachment; or repeat it over and over, out aloud, until it just becomes a meaningless sound; or imagine it in the voice of a cartoon character; or sing it to the tune of ‘Happy Birthday’; or silently say ‘Thanks, Mr mind’ in gratitude for such an interesting thought. In contrast to CBT, not one of these cognitive defusion techniques involves evaluating or disputing unwanted thoughts.

A brief description of the six core principles of psychological flexibility.

1. Cognitive Defusion: learning to perceive thoughts, images, memories and other cognitions as what they are—nothing more than bits of language, words and pictures—as opposed to what they can appear to be—threatening events, rules that must be obeyed, objective truths and facts.
2. Acceptance: making room for unpleasant feelings, sensations,
urges, and other private experiences; allowing them to come and go without struggling with them, running from them, or giving them undue attention.
3. Contact with the present moment (mindfulness): bringing full awareness to your here- and-now experience, with openness, interest, and receptiveness; focusing on, and engaging fully in whatever you are doing, rather than ‘getting lost’ in your thoughts; and allowing your feelings to be as they are, letting them come and go rather than trying to control them. When we observe our private experiences with openness and receptiveness, even the most painful thoughts, feelings, sensations and memories can seem less threatening or unbearable. In this way mindfulness can help us to transform our relationship with painful thoughts and feelings, in a way that reduces their impact and influence over our life.

4. The Observing Self/Self as Context: accessing a transcendent sense of self; a continuity of consciousness that is unchanging, ever-present, and impervious to harm. From this perspective, it is possible to experience directly that you are not your thoughts, feelings, memories, urges, sensations, images, roles, or physical body. These phenomena change constantly and are peripheral aspects of you, but they are not the essence of who you are.
5. Values: clarifying what is most important, deep in your heart; what sort of person you want to be; what is significant and meaningful to you; and what you want to stand for in this life.
6. Committed Action: setting goals, guided by your values, and taking effective action to achieve them.

Ultimately ACT aims to create a purposeful and rich life, while simultaneously accepting the pain that inevitably goes with it. ‘ACT’ is a good abbreviation, because this therapy is about taking effective, engaged action guided by our deepest values. Like any worthwhile endeavor, the internal changes in attitude and perspective required take disciplined, focused and sustained effort and work. But it is the most worthwhile work you will ever undertake

Ultimately ACT aims to create a purposeful and rich life, while simultaneously accepting the pain that inevitably goes with it. ‘ACT’ is a good abbreviation, because this therapy is about taking effective, engaged action guided by our deepest values. Like any worthwhile endeavor, the internal changes in attitude and perspective required take disciplined, focused and sustained effort and work.  But it is the most worthwhile work you will ever undertake

References

Bach, P. & Hayes, Steven C. (2002). The use of Acceptance and Commitment Therapy to prevent the rehospitalisation of psychotic patients: a randomized controlled trial. Journal of Consulting and Clinical Psychology, 70, 1129–1139.

Branstetter, A. D., Wilson, K. G., Hildebrandt, M., & Mutch, D. (2004). Improving psychological adjustment among cancer patients:ACT and CBT. Paper presented at the Association for Advancement of Behavior Therapy, New Orleans.

Hayes, Steven C., Strosahl, Kirk D., Wilson, Kelly G. (2012) Acceptance and Commitment Therapy: The process and practise of mindful change. The Guilford Press. New York

Twohig, M. P., Hayes, S. C., Masuda,
A. (2006). Increasing willingness to experience obsessions: Acceptance and Commitment Therapy as a treatment for obsessive compulsive disorder. Behavior Therapy, 37:1, 3–13.