Acceptance
and
Commitment
Therapy
Scott Clark
ACT (Hayes, Masuda & De Mey, in press)
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1950-60s 1st wave: Behaviour Therapy
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focus on direct behaviour change, classical
and operant conditioning
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1970s 2nd wave: Cognitive Therapy
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focus on changing content and frequency of
cognitions
1980s 3rd wave: focus on changing relationship
with thoughts and feelings – using mindfulness and
acceptance strategies
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Dialectical Behavior Therapy, Acceptance and
Commitment Therapy, Functional Analytic Psychotherapy,
Integrative Behavioral Couples Therapy, Mindfulness Based
Cognitive Therapy (Hayes and De May, in press)
ACT (Morris & Oliver 2009)
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Psychotherapy technique that:
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Attempts to expand a person’s behavioural
repertoire by increasing the ability to respond
flexibly in response to the opportunities presented
by each situation for valued living.
Involves a degree of being in the present moment,
connection with the direction given by values,
and a letting go of or distancing from the rules
and assumptions that can function as barriers to
doing what matters.
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Some of these rules and assumptions are a by
product of/ are inherent in the use of language as
thinking and communication.
Attempts to change the social and verbal
contexts that link thoughts and feelings with overt
action
Russ Harris intro video
ACT
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Developed by Stephen Hayes - 1984
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Evolution from behaviourism
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Classical and Instrumental conditioning
Learnt verbal and rule-governed behaviour
Functional contextualism (Hayes, Masuda & De Mey, in
press)
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“ACT conceptualizes psychological events as a set of
ongoing actions of a whole organism interacting with
historically and situationally defined contexts”.
……. Learning Theory…at mercy of learned
associations…focusing on changing cognitions is not
enough or can actually be counter productive by
reinforcing dysfunctional thinking…..
Relational Frame Theory (www.contextualpsychology.org)
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Language allows humans to link neutral stimuli
such as words/thoughts with events.
Pairings/networks can generalise (derived
relationships) with reinforcement to become
relational frames applied in an arbitary fashion.
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Relational networks: If A = B and B = C then A = C
A child experiences seasickness on a boat and then
associates the word boat with seasickness.
The child may then learn at school that a "Car Ferry" is
a type of boat.
Later, on hearing that she is going on a car ferry, the
child may show signs of anxiety despite having had
no direct experience with car ferries.
Respondently acquired (conditioned) function of
"boat" and the derived relation between "boat" and
"car ferry".
The child does not need to experience the possibly
aversive consequences of traveling on a car ferry in
rough seas, in order to show signs of anxiety.
ACT Core Priniciples (Harris 2006)
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Goal is psychological flexibility
Defusion
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Thoughts/language are not truth/rules/threatening
events….person not fused with thoughts….able to observe
them….”leaves in the stream”
versus Fusion (Hayes et al. in press)
Behavior is guided more by inflexible verbal networks than
by the contingencies of reinforcement in the
environment…..reality
 focus on:
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Literality - treating symbols (e.g.“life is hopeless”) as one would
their referents (i.e., a truly hopeless life)
Reason-giving (i.e., basing action or inaction excessively on the
constructed “causes” of ones own behavior, especially when
these processes point to non-manipulable “causes” such as
conditioned private events)
Emotional control (i.e., focusing on proper manipulation of
emotional states as a primary goal and metric of successful
living)…..? In contrast to CBT
ACT Core Priniciples (Harris 2006)
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Acceptance
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Contact with the present moment
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“A transcendent sense of self encourages clients to
experience their own thoughts and feelings and to shift
from identifying with the conceptualized self (“I am a
bad person”, “I am depressed”)”.
Values
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Bringing full awareness to your here- and-now
experience, with openness, interest, and receptiveness
The “Observing Self”
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Moment by moment process of actively embracing the
private events evoked in the moment without
unnecessary attempts to change their frequency or
form, especially when doing so would cause
psychological harm (Vs avoidance)
Clarifying what is most important to you; what sort of
person you want to be
Committed action
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setting goals, guided by your values, and taking
effective action to achieve them
HEXAFLEX DIAGRAM
Contact with the
Present Moment
Acceptance
Values
Defusion
Committed
Action
Self as
Context
HEXAFLEX DIAGRAM
6. … at this time, in this situation?
Acceptance
and mindfulness
2. … are you
willing to have that
stuff, fully and
without defense …
3. … as it is, and
not as what it
says it is …
Contact with the
Present Moment
Commitment and
behaviour change
Acceptance
Values
Defusion
Committed
Action
Self as
Context
1. Given a distinction between Context you and the
stuff you are struggling with and trying to change …
5. … of
your
chosen
values …
4. … and do
what takes you
in the direction
…
HEXAFLEX DIAGRAM
Techniques (Harris 2006)
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Less confrontational manner and less
directive forms of verbal interaction, such as
metaphor, paradoxes, and experiential
exercises, to loosen the entanglement of
language/thoughts and the self.
Identify unworkable behaviours and develop
suitable metaphors
Homework exercises that highlight the cost of
unworkable solutions in respect to valued
living
Stages (Hayes, Masuda, & De Mey (in press))
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Creative hopelessness – explore current strategies in
motivational interviewing style - bring client toward new
options.
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Control is the problem, not the solution
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Man in the hole metaphor
Polygraph metaphor
Acceptance as an alternative agenda
Two scales metaphor
 Imagine an anxiety provoking situation
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Notice its effects on the body
Examine these effects at a distance, “like a scientist”
Allow it to be there regardless of its aversive nature
Highlights the futility of struggle for control and undermines
avoidance
Russ Harris exmples
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Accepting emotions
Demons on a ship
Stages (Hayes, Masuda, & De Mey (in press))
A
transcendent sense of self
 Safe
to expose yourself to fears
 Chessboard metaphor – separated self and avoided
psychological content
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Defusing language and cognition
 Mindfulness
exercises: locate self in here and now
 “AND” not “BUT” (which implies something is wrong)
 Dealing with an unpleasant thought
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Simply observe it with detachment
Repeat it over and over, out aloud, until it just becomes a
meaningless sound
Imagine it in the voice of a cartoon character
Sing it to the tune of ‘Happy Birthday’
Silently say ‘Thanks, mind’ in gratitude for such an interesting
thought
Exercise: Think of a negative self-judgement “(x)” – notice its
effect. Compare to “I am having the thought (x)”
Stages (Hayes, Masuda, & De Mey (in press))
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Values
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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
values x”) (Hayes et al. in press).
The “Bulls eye” (Tobias Lundgren)
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Formal assessment of ability to live life according to ones
values in:
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Work/education
Leisure
Personal Growth/Health
Relationships
Assessment of barriers in each area
Valued action plan addressing each area
I am living fully by
my values
Work/
Education
Personal growth/
Health
I have lost touch
with my values
Leisure
Relationships
Stages (Hayes, Masuda, & De Mey (in press))
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Willingness and commitment
 Development
of larger and larger patterns of effective
action linked to chosen values.
 Identify barriers to achieving values
 Similar to traditional behavior therapy
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Select the appropriate components:
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exposure
skills acquisition
shaping methods
goal setting,
The ACT therapeutic relationship
 Two
mountains metaphor
Studies of efficacy (Powers et al. (2009))
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Metanalysis of 18 (n = 917) randomized controlled ACT trials
Range of conditions:
 Psychosis, worksite stress, chronic pain, anxiety and depression,
smoking, borderline personality disorder, diabetes self
management, polysubstance abuse, weight, drug refractory
epilepsy, trichotillomania, math anxiety.
Mixed comparators and outcome measures
ACT better than control (effect size = 0.42).
 The average ACT-treated participant was more improved than
66% of the participants in the control conditions.
ACT was superior to:
 Waiting lists and psychological placebos (effect size = 0.68)
 Treatment as usual (effect size = 0.42)
ACT was not more effective than:
 Established treatments - e.g CBT (effect size = 0.18, p = 0.13).
Studies of efficacy
Cohen’s convention of small (0.2), medium (0.5), and large (0.8) effects
Studies of efficacy (Powers et al. (2009))
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When viewed individually only 4 studies had confidence intervals not
crossing 0:
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Smoking cessation
Supplementation of TAU for borderline PD
Treatment resistant epilepsy
Trichotillomania
Study quality poor
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Jadad Scale 0-5
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0=1; 1 = 7; 2 = 5; 3 = 5
Studies of efficacy Since 2008 (Smout et al.
2012)
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Improved coherence and competence montoring
Good studies provide Level II RCT evidence for chronic pain, obsessive–
compulsive disorder, and a subset of other anxiety disorders (panic
disorder, social phobia, and generalised anxiety disorder)
The majority of studies demonstrated that ACT significantly improved
primary outcomes but used comparison conditions that did not rule out
therapy-unspecific factors, including use of concurrent treatments, as
explanations for the improvements.
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Use of treatment as usual unmatched for contact and unmonitored for
competence, and unmonitored use of concurrent treatments are the primary
factors preventing the attribution of better outcomes for ACT recipients to
therapy-specific effects
References
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Chris Cullen (2008) Acceptance and Commitment Therapy (ACT): A Third Wave Behaviour
Therapy Behavioural and Cognitive Psychotherapy, 36, 667–673.
Fletcher L, Hayes S (in press) Relational Frame Theory, Acceptance and Commitment
Therapy, and a Functional Analytic Definition of Mindfulness
Harris R (2006) Embracing Your Demons: an Overview of Acceptance and Commitment
Therapy. Psychotherapy in Australia 12 (4): 2-8.
Hayes S, Luoma, J, Bond S, Masuda A, and Lillis J (in press) Acceptance and Commitment
Therapy: Model, Processes and Outcomes.
Hayes S, Masuda A, and De May (in press) Acceptance and Commitment Therapy and the
Third Wave of Behavior TherapyRelational Frame Theory, Acceptance and Commitment
Therapy, and a Functional Analytic Definition of Mindfulness
Morris E & Oliver J (2009)ACT Early: Acceptance and Commitment Therapy in early
intervention. Power point presentation
Powers M, Vörding M, Emmelkamp P (2009) Acceptance and Commitment Therapy: A
Meta-Analytic Review. Psychother Psychosom 78:73–80.
Webster, M. (2011) Introduction to Acceptance and Commitment Therapy. Advances in
Psychiatric Treatment 17:309-316.
Wilson, K. G. & Murrell, A. R. (In Preparation). Values-Centered Interventions: Setting a Course
for Behavioral Treatment. In S. C. Hayes, V. M.. Follette, & M. Linehan (Eds.) (in preparation).
The new behavior therapies: Expanding the cognitive behavioral tradition. New York:
Guilford Press.
The empirically supported status of acceptance and commitment therapy: An update
Smout, M, Louise Hayes, Atkins, PWB, Klausen, J and Duguid, J E (2012) The empirically
supported status of acceptance and commitment therapy: An update. Clinical Psychologist
16 (2012) 97–109
www.contextualpsychology.org
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Relational frame theory simplified
Bulls eye values assessment