Section 1: The Key Concepts and Techniques of Acceptance and Commitment Therapy

What is Acceptance Commitment Therapy?

An animation that introduces you to Acceptance Commitment Therapy (ACT). 

Watch

Acceptance and commitment therapy, known as ACT (pronounced as the word ‘act’), is an approach to counselling that was originally developed in the early 1980s by Steven C. Hayes, but rose to prominence in the early 2000s through Hayes’ collaboration with Kelly G. Wilson, and Kirk Strosahl as well as through the work of Russ Harris.

ACT seeks to help clients transform their ‘relationship’ with difficult thoughts and emotions. One of the central concepts of ACT is that many of the issues that clients present with in counselling are caused by the avoidance of internal experiences (i.e., thoughts or feelings) that are distressing or uncomfortable. For example, people often find that the process of trying to suppress unwanted thoughts only makes these thoughts more powerful. ACT practitioners do not seek to eliminate or change a client’s thoughts or emotions but instead seek to help the client view these thoughts and emotions for what they are – pieces of language and transient psychological events, not external “truths”.

ACT practitioners encourage clients to approach problematic thoughts and beliefs from a psychologically flexible, mindful, and open perspective to prevent these problematic thoughts from overwhelming the person or determining their actions (Lloyd & Bond, 2015). Known as a third-wave behavioural therapy, ACT practitioners use several mindfulness and acceptance-based strategies and cognitive behavioural techniques. Ultimately, ACT interventions tend to focus on two main overarching goals (Harris, 2019, p. 4):

1. Help clients to clarify what’s truly important and meaningful to them (i.e., values) and use those to guide, inspire, and motivate clients to do things that will enrich and enhance their lives.
2. Teach clients skills to handle difficult thoughts and feelings effectively, so they can fully engage in their actions and appreciate life’s fulfilling aspects.

In a nutshell, ACT gets its name from its core ideas of accepting what is outside of your personal control and committing to action that improves and enriches your life.

Acceptance and Commitment Therapy (ACT)

The presenter in this video, takes you through the development history, theory that underpins ACT: relation frame theory (RFT), and practice of ACT.

Watch

Check your understanding of the content so far!

The ACT model suggests that a couple of core processes commonly contribute to emotional distress and psychological disorders: cognitive confusion and experiential avoidance.

Cognitive fusion

Cognitive fusion is a term used to refer to when an individual is allowing their thought processes (e.g., beliefs, assumptions, thoughts, attitudes, memories, or emotions) to have an excessive influence over their behaviour and awareness to the point that they are caught up in these and become disconnected from the present moment (Harris, 2019). Whilst these thoughts and emotions were never problematic, it becomes problematic when we become overly attached and ‘fused’ with them, believing that they reflect reality. When an individual is ‘fused’ with their thought processes, it can lead them to move away from the present moment and their true values. This often gives rise to experiential avoidance.

Cognitive Fusion and Defusion in ACT 

This animation provides an example of why we get stuck to our thoughts and how we can reduce overthinking. Answer the questions that follow. 

Watch

Experiential avoidance

Experiential avoidance is a term used to refer to the process of engaging in strategies to avoid certain private events, such as unpleasant or unwanted thoughts, feelings, emotions, urges, desires, memories, or bodily sensations (Harris, 2019). Common experiential avoidance strategies include avoidance, suppression, and distraction. Although these strategies seem effective in the short-term, they restrict an individual’s choices and, in the long-term, usually lead to a reinforcement of problematic thoughts, feelings, and sensations, leading to behaviours or decisions where a person must alter their life to avoid them.

The goal of ACT is, therefore, to help clients ‘defuse’ these internal processes and accept their private experiences through using strategies that increase their psychological flexibility.

Headstuck! What is Experiential Avoidance?

This short video explores the concept of experiential avoidance, and how it relates to the idea of career paralysis. Answer the questions that follow. 

Watch

ACT Hexaflux

In his book ACT Made Simple, Russ Harris (2019, p. 8) explains psychological flexibility as “the ability to act mindfully, guided by our values”, which is thought to be facilitated through six core processes – these are often illustrated using the following ACT Hexaflex:

Increasing Psychological Flexibility

This video explores ACT and its powerful impact on psychological flexibility. Answer the questions that follow. 

Watch

Six Core Processes of ACT

Whilst the six are being discussed as separate processes, they are considered as inseparable facets of psychological flexibility (Harris, 2019). As you will learn later, many ACT techniques are set out to promote more than one, if not all, these facets.

The 6 Core Processes of ACT Explained | What They Mean and How to Use Them

This video explains the six Core Processes of ACT as the key in achieving psychological flexibility, where you are able to show up consciously to the present moment and facilitate positive behaviour change.

Watch

Check your understanding of the content so far!

Explaining ACT to Clients

Like other approaches you have learned, helping clients understand how ACT works and what it involves is essential for them to gain the full benefits of such an approach. According to Harris (2019, p. 55), a counsellor should at least cover the following points when obtaining a client’s consent to use this approach (using language tailored to suit each client and context):

• Clients play an ‘active’ role in the process. There are times when they will be encouraged to try new things or learn new skills – the client has a choice on whether to do them. However, it is a collaborative process between the counsellor and the client.
• The counsellor and client work together as a team to help the client build the sort of life they want to live.
• ACT involves the clients learning skills that enable them to ‘unhook’ themselves from difficult thoughts and feelings.
• ACT also involves clarifying the clients’ values and taking action to solve their problems, face challenges, and do things to make life better.
• Clients will likely leave each session with an action plan that enlists practical steps or strategies they will use in life.
• Clients will be asked to try new things out of their comfort zone (and clients can say no).

The following extract is an example transcript of how to introduce the ACT model to clients:

Generally, ACT practitioners use a wide range of exercises, worksheets, homework and metaphors as the central techniques to promote clients’ psychological flexibility. There is no particular order for which of these six core processes needs to be focused on first and which should follow – each can be fostered as a stand-alone intervention or in combination. In addition, the use of techniques in ACT is extremely flexible, with substantial allowances built in for creativity and adaptation. In fact, ACT practitioners are encouraged to create, adapt, and improvise activities for use with clients (Harris, 2019).

Here we will explore some of the most commonly used ACT techniques; however, as you continue reading, keep in mind that there are hundreds of exercises, metaphors, and other techniques that ACT practitioners use. If you wish to use the ACT

approach in your own work, you will need to spend some time developing your toolbox of techniques.

Techniques to Highlight the Costs and Ineffectiveness of Experiential Avoidance

Several ACT techniques can be used to help clients understand that their attempts to control their inner experiences are unworkable and even detrimental to them long-term. This is particularly useful for certain clients who are “excessively experientially avoidant, strongly attached to an agenda of emotional control: I must feel good; I must get rid of these unwanted thoughts and feelings” (Harris, 2019, p. 90). ACT practitioners often refer to this process as “Creative Hopelessness” (a term that isn’t used with clients) or “Confronting the Agenda”.

The goal is to get the client to examine the steps they have taken to control their thoughts/feelings, examine whether it has made things better or worse, and open up the possibility of using alternative methods to handle them (Harris, 2019). Clients who are motivated and open to change may not need as much work on this; however, it is not uncommon for counsellors to work on creative hopelessness across sessions with clients who are strongly attached to their need/desire to control their inner experiencing. Essentially, this group of techniques come down to exploring the following questions with the client (p. 93):

1. What have you tried?
2. How has it worked?
3. What has it cost?
4. What’s showing up?
5. Are you open to something new?

How To Use The Choice Point in ACT

This video describes how to use the choice point is a tool used in ACT. Answer the questions that follow.  

Watch

Join the DOTS

One technique that can be used when helping clients explore Question 1 is called ‘Join the DOTS’ - the counsellor asks the client to discuss the thoughts and feelings that are particularly problematic to them and everything that they have done to get rid of them, avoid, suppress, escape, or distract themselves from these thoughts/feelings (Harris, 2019). Counsellors can use the acronym ‘DOTS’ as a memory aid to assist in this process and prompt the client to think of how they use distraction, opting out, thinking, and substances/self-harm/other strategies to control their thoughts/feelings:

Once the client has identified their control strategies, the counsellor will encourage them to evaluate whether these strategies have worked in the long term (i.e., Question 2). For example, they may ask the client, “Did these strategies get rid of your painful thoughts and feelings in the long run so that they never came back? Or do your thoughts and feelings keep coming back?” In most cases, the client will identify that their control strategies have not worked – after all, they are in counselling seeking assistance. (If a client indicates a particular strategy is working for them in the long-term, it is still possible to invite them to explore the costs of these strategies when used excessively.)

From there, the counsellor will ask the client to consider what their control strategies have cost them (i.e., Question 3). The counsellor may prompt the client to think about its impacts on the various areas of their life. For example, the counsellor might ask, “How much time do you spend on distracting yourself?” or “How much time have you spent in your head, trying to think away your pain? How much did you miss out on?” (p. 97) It is also important to round off this discussion on a validating note, acknowledging the client’s hard work in using these strategies and they are not lazy or stupid.

Join the DOTS – Worksheet

Attempted Solutions and their Long-Term Effect Worksheet

Another technique that can help with this process is asking clients to complete a homework exercise, such as the ‘Attempted Solutions and their Long-Term Effects’ Worksheet and then discuss it during the following session.

This exploration often primes clients to identify the problem by using control strategies. However, some clients may need more help understanding that control is the problem, not the solution. Metaphors are a great way of making this point.

Metaphors

ACT practitioners often use different metaphors when working with clients. Two useful metaphors for highlighting the costs of experiential avoidance are the ‘Struggling in Quicksand’ metaphor and the ‘Tug-of-War with a Monster’ metaphor.

Struggling in Quicksand – Metaphor

The ‘Struggling in Quicksand’ metaphor helps highlight the damage that can be done by trying to control inner processes and is also useful as a way to begin introducing acceptance work with the client (Flaxman, Blackledge & Bond, 2011). An example of how a counsellor can apply this metaphor with a client is:

Tug-of-War with a Monster – Metaphor

The ‘Tug-of-War with a Monster’ metaphor is used to help the client understand how difficult it is to do other things while they are struggling with something and the benefit that can be had by giving up the struggle (Flaxman et al., 2011). An example of how a counsellor can apply this metaphor with a client is:

Examples of Metaphors

Watch the following two videos on examples of using Metaphors. 

Watch

Watch

Thought Suppression – Exercise

Another technique often used to highlight the ineffectiveness of experiential avoidance – and bust the myth that we can control our thoughts and feelings - is a thought suppression exercise. Clients are asked to close their eyes and try hard not to think about a particular object, such as, “Don’t think about a blue elephant” (Hayes et al., 1999, cited in Harris, 2019). This exercise shows that attempting not to think about something does not eliminate that thought (Flaxman, Blackledge & Bond, 2011). Again, this helps clients open up to the possibility of accepting their thoughts and emotions rather than trying to control them.

Techniques to Teach Defusion Skills

Defusion and acceptance are two of the core therapeutic processes in ACT, but how exactly do counsellors assist clients in becoming defused and open up to their difficult inner experiences without needing to change or control them? Again, counsellors can use a wide range of additional metaphors, experiential exercises, worksheets and other techniques throughout the counselling process. We will explore a few of the most commonly used techniques.

Let’s start with defusion. The goal of defusion techniques is to help clients to (adapted from Harris, 2019, pp. 120-121):

• See the true nature of cognitions – they are nothing more or less than constructions of words and pictures.
• Respond to cognitions more flexibly – in terms of how helpful they are, rather than holding on to how true/false or positive/negative they are.

ACT practitioners use a simple technique to facilitate this process: treating the mind as an entity and thoughts as things that the mind is projecting (Harris, 2019). For example, ACT practitioners encourage their clients to use language such as “I’m having a thought that ____________” (e.g., saying “I’m having a thought that I’m not good enough”) rather than saying “I’m ___________ (e.g., “I’m not good enough”). Additionally, ACT practitioners may ask questions like “What does your mind tell you about that?” and refer to thoughts as stories. This type of language helps separate thoughts as external pieces of language, and ACT practitioners will likely get clients to do this repeatedly throughout sessions.

Another interesting technique to promote defusion is singing and silly voices to help defuse problematic thoughts. The basis of these techniques is to have the client concentrate on a negative self-judgement that they are having (e.g., “I am a loser”) for a brief period of time (e.g., 10 seconds). The counsellor will then instruct the client to take that phrase and either silently or aloud sing it to a tune (e.g., Happy Birthday) or repeat it in their head in a silly voice (Harris, 2019). By doing this repeatedly, the client will become distanced from the thought and see it as just a bunch of words in their head than a truth about who they are.

How to Detangle from Thoughts & Feelings

The Psychology Group discusses how to detangle from thoughts and feelings. Answer the questions that follow. 

Watch

Techniques for Acceptance

Mindfulness techniques are also widely used during this part of the ACT therapeutic process. These techniques aim to help the client learn how to observe their thoughts with openness and curiosity and allow them to come and go rather than trying to control them. One commonly used technique is a popular mindfulness exercise named ‘Leaves on a Stream’.

Leaves on the Stream – Exercise

The exercise helps clients learn to take a back seat, observe their thoughts as no more or less than what they are, and let them flow rather than trying to make them disappear. These thoughts can be positive, negative, or neutral. The key is that they no longer dominate the client if they are not being held onto. Clients are often invited to determine their preferred versions, such as clouds in the sky or platters on a sushi train.

Mindfulness exercises are also used to help facilitate clients’ acceptance of emotions. In the following extract, Harris (2019) demonstrates how a combination of different mindfulness techniques (observe, breathe, expand, allow, objectify, normalise, show self-compassion and expand awareness) can be used to facilitate acceptance of emotions (adapted from Harris, 2019, pp. 261-264).

Stop Overthinking: Leaves on a Stream ACT Anxiety Skill

An example of Leaves on a Stream guided meditation. 

Watch

Harris – Exercise

It is common for clients to practice mindfulness exercises focused on accepting difficult emotions as their homework. The more clients practice these techniques, the easier acceptance will become for them.

Besides mindfulness exercises, metaphors are also widely used to help establish psychological acceptance and defusion skills and encourage full contact with difficult psychological content. A commonly used one is called the “Struggle Switch”. As you’d notice, the metaphor is followed by a rating exercise where acceptance is talked in terms of a 0-10 scale. This is to highlight that acceptance is not an “all-or-nothing” concept. Both acceptance and struggle are best assessed and understood in terms of degree.

Struggle Switch – Exercise

^{(Harris, 2019, p. 264-266)}

The Struggle Switch - By Dr. Russ Harris

Dr. Russ Harris, explains  the struggle switch metaphor through this entertaining and educational clip. Answer the question that follows. 

watch

Defusion and acceptance are difficult processes and ones that ACT practitioners usually work on with clients throughout the counselling process. As such, ACT practitioners often assign clients homework to help with these processes. For example, the counsellor may ask clients to complete a worksheet such as the ‘Getting Hooked’ to help facilitate the defusion process or the 'Struggling vs. Opening Up' worksheet to help facilitate the acceptance process (Harris, 2021).

Getting Hooked – Worksheet

Struggling vs. Opening Up – Worksheet

Techniques to Explain and Encourage Self-As-Context

ACT practitioners use various techniques to help clients understand that they are not their thoughts (or feelings, memories, urges, etc.). One commonly used metaphor is the “Sky and Weather” metaphor.

Sky and Weather – Metaphor

Sky Metaphor

This video explains the Sky Metaphor in practical detail. 

Watch

There is also a range of experiential exercises that counsellors can use with clients to help them develop their sense of self-as-context. One of these is the 'Continuous You' exercise.

Continuous You – Exercise

The Continuous You

An example of the continuous you guided meditation. 

Watch

Techniques to Promote Contact with the Present Moment

Mindfulness techniques are central in the ACT approach for helping clients contact with their present-moment experience. Mindfulness can be practiced in sessions with the client and set formally and informally for homework. Whilst there isn’t a consensual definition, formal mindfulness typically refers to setting aside time for mindfulness activities, such as meditation, whereas informal mindfulness involves bringing the concept of mindfulness to daily activities (e.g., mindfully washing dishes, mindfully brushing teeth).

Many of the previous techniques you have learned about encompass mindfulness exercises. All the techniques that require the client to focus on their breathing and allow thoughts to come and go help facilitate contact with the present-moment experience. ACT practitioners also teach clients mindfulness techniques they can use outside sessions to continue connecting with the present moment. One quick and simple mindfulness technique that is often taught to clients is the ‘Take Ten Breaths’ Technique.

Take Ten Breaths – Technique

Mindfulness of breath Meditation

An example of the mindfulness of breath meditation.

Watch

Mindfully Eating a Raisin - Technique

It can also be useful to help the client understand that fully engaging in their experiences leads to increased life satisfaction and fulfilment. One commonly used technique for this is 'Mindfully Eating a Raisin'.

Mindful Eating MEDITATION

An example of mindfully eating a raisin meditation. 

Watch

Techniques to Help to Clarify Values

Clarifying the client’s values is an important step in the ACT counselling process. Some clients may have clearer ideas of what they want and have been engaging in value-driven activities, while others may require help clarifying their values. There are a range of worksheets that ACT counsellors use during this process. One of them is the following downloadable Bull's Eye Worksheet (pdf) (Harris, 2007).

Bull's Eye Worksheet

Life Compass – Worksheet

Another commonly used worksheet is the following Life Compass (pdf) (New Harbinger Publications, Inc.). 

Some clients find it difficult to think about their values in this sort of format, so another technique that is often used to clarify values is the 'Imagine your Eightieth Birthday' technique.

Imagine your Eightieth Birthday – Technique

Once the client is aware of their values, the counsellor and client can focus on using these values to help them set specific goals that can lead to committed action.

Imagine your 80th Birthday

An example of the Imagine your 80th Birthday technique. 

Watch

Techniques to Facilitate Committed Action

Committed action involves any purposeful actions that help the client pursue their values. Depending upon the client's needs, this might involve using some form of traditional behavioural interventions, or it may simply involve committing to valued living. Of course, making changes is a difficult process, so ACT counsellors help their clients anticipate potential barriers and learn how to respond effectively to them.

A Technique to Help Clients Take Action Using ACT

The presenter discusses a common question regarding clients that are stuck, "why can't I get my client to take committed action? Why is it so difficult?". Answer the question that follows.

Watch

HARD – Worksheet

The following ‘HARD” worksheet (Harris, 2021) is designed to help clients clarify their internal barriers to change.

The aim of this worksheet is to clarify your own internal barriers, holding you back from stepping out of your comfort zone, or trying new things, or facing your fears, or tackling your big challenges, etc.

• HARD Barriers Worksheet - Russ Harris (pdf)

There are two ways to fill out this worksheet. One option is to do it for a specific domain of life, for example, work, education, friends, partner, parenting, spirituality, hobbies and health. The other option is to do it as a broad overview of life in general.

Check your understanding of the content so far!

Check your understanding of the content so far!

Like most other approaches to counselling, the therapeutic relationship is considered to be of central importance to the effectiveness of ACT. In ACT, the counsellor is not considered an ‘expert’; instead, the counsellor and client are considered as equals. Counsellors are encouraged to practice the same concepts and techniques that they teach their clients and admit that they, too, have had difficulties with avoidance, fusion, and lack of values clarity (Batten, 2011). Indeed, many ACT explanations and metaphors highlight this by having the counsellor remind the client that they, like the client, are struggling with life’s challenges. For example, the counsellor might say something like:

When working from an ACT approach, it is important to remember that:

ACT is a very ‘active’ form of counselling that requires clients to engage in various mindfulness and experiential exercises. Clients must participate in therapeutic techniques and reflect upon their thought processes. The counsellor guides the client; however, the client must learn to “be present, open up, and do what matters” (Harris, 2019, p. 9).

Check your understanding of the content so far!

The Benefits of the ACT Approach for Suitable Clients

Acceptance and Commitment Therapy (ACT) is a widely recognised counselling approach with proven effectiveness for many clients and various client issues. However, it's important to acknowledge that ACT may not suit everyone. In this context, we will explore the benefits of the ACT approach for clients well-suited to this therapeutic framework.

One of the key benefits of ACT for suitable clients is the enhancement of psychological flexibility. ACT empowers clients to develop greater emotional regulation, adaptability, and resilience. Clients learn to accept and mindfully embrace their thoughts and emotions, reducing the struggle against them. This improves mental well-being as clients gain the skills to navigate life's challenges more easily.

Another significant advantage of ACT is its ability to guide clients toward increased value-based living. Suitable clients engage in the process of clarifying their deeply held values and committing to actions aligned with those values. This shift towards a more values-driven life fosters a sense of purpose and meaning. Clients often experience increased life satisfaction and greater fulfilment as they align their actions with their values.

In addition to psychological flexibility and value-based living, ACT can lead to a reduction in avoidance behaviours. Suitable clients learn to acknowledge how past coping strategies, particularly avoidance, may have cost them. Learning to accept difficult emotions and situations rather than avoiding them. This can result in personal growth, reduced life experience, and suffering related to avoidance. Clients become better equipped to recognise difficulties and accept challenging situations, leading to a more empowered and resilient mindset.

Furthermore, ACT can have a positive impact on interpersonal relationships. Suitable clients often find that their ability to communicate effectively, empathise with others, and navigate interpersonal conflicts improves significantly. This enhancement in interpersonal skills contributes to healthier relationships and greater social well-being.

In summary, the ACT approach offers numerous benefits for clients well-suited to its principles. These benefits include increased psychological flexibility, pursuing a more meaningful and values-driven life, reduced avoidance behaviours, and improved interpersonal relationships. ACT can be a powerful and transformative approach for clients seeking a therapeutic framework that emphasises mindfulness, acceptance, and commitment to valued actions.

Check your understanding of the content so far!

This module section explored the theoretical underpinnings and key techniques of acceptance and commitment therapy. It is important for any counsellor who intends to use ACT techniques to understand these concepts because theoretical understanding is vital for the effective practice of ACT. You will learn more about how counsellors implement ACT in the next section of this module.

1. Batten, S. V. (2011). Essentials of acceptance and commitment therapy. London, UK: Sage.
2. Ciarrochi, J. A., & Bailey, A. (2008). A CBT practitioner’s guide to ACT: How to bridge the gap between Cognitive Behavioural Therapy and Acceptance & Commitment Therapy. Oakland, CA: New Harbinger Publications.
3. Flaxman, P. E., Blackledge, J. T., & Bond, F. W. (2011). Acceptance and commitment therapy. East Sussex, UK: Routledge.
4. Harris, R. (2006). Embracing your demons: An overview of Acceptance and Commitment Therapy. Psychotherapy in Australia, 12(4), pp. 2-8.
5. Harris, R. (2019). ACT made simple: A quick start guide to ACT basics and beyond. New Harbinger.
6. Harris, R. (2021). ACT made simple: The extra bits. https://www.actmindfully.com.au/free-stuff/worksheets-handouts-book-chapters/
7. Lloyd, J., & Bond, F. W. (2015). Acceptance and commitment therapy. In S. Palmer (Ed.), The beginner’s guide to counselling and psychotherapy (2nd ed.). Sage.
8. Luoma, J. B., Hayes, S. C., & Walser, R. D. (2017). The ACT therapeutic stance. In Learning ACT: An acceptance and commitment therapy skills-training manual for therapists (3rd ed.) (pp. 317-319). Context Press.
9. Stoddard, J. A., & Afari, N. (2014). The big book of ACT metaphors: A practitioner’s guide to experiential exercises & metaphors in acceptance & commitment therapy. Oakland, CA: New Harbinger.