Lloyd, J. & Bond, F. W. (2015). Acceptance and commitment therapy. In S. Palmer (Ed), Beginner’s guide to counselling and psychotherapy (2nd ed.) (pp. 89-92). SAGE.
Acceptance and commitment therapy (ACT) is best described as a contextual cognitive behaviour therapy (CBT). Contextual CBTs are a recent addition to the cognitive behavioural tradition and are distinct from earlier approaches (e.g. Beck's cognitive therapy) in both their proposed mechanisms of change and core therapeutic techniques. Whilst earlier forms of CBT focus on changing the content, form or the frequency of people's difficult or challenging internal experiences (e.g. thoughts, feelings, physiological sensations, images and memories), contextual CBTs seek to alter the psychological context, or perspective, in which people approach these experiences. Thus, rather than focusing on challenging and disputing problematic thoughts and feelings, contextual CBTs encourage people to approach those internal events from a mindful and open perspective. In so doing, these unwanted events are less likely to overwhelm them and determine their actions.
Steven C. Hayes and his colleagues began formulating ACT during the mid-1980s. It is directly based upon a theory of language and cognition called relational frame theory (RFT), which itself is an extension of the work of B. F. Skinner. Unlike applied behaviour analysis, which was based upon Skinner's work, RFT, and hence, ACT, highlights the potential importance of internal events in influencing mental health and behavioural effectiveness. In this way, it is similar to the CBTs of Ellis and Beck in the 1960s and 70s in emphasising the importance of the relationship amongst thoughts, feelings, and actions. RFT, however, suggests that thoughts cannot reliably be changed or made to occur less frequently; rather, it maintains that the detrimental function of thoughts and feelings on mental health and behavioural effectiveness can be altered, such that they no longer have such negative effects. The goal of ACT, therefore, is to alter the function of these internal events, as opposed to attempting to challenge and change them, as is the aim in Beck and Ellis's CBTs. This is accomplished through enhancing psychological flexibility, or people's ability to fully contact the present moment and pursue their meaningful life directions even when experiencing difficult or challenging internal experiences.
Consistent with this RFT/ACT approach to mental health and behavioural effectiveness, research is increasingly showing that enhancing psychological flexibility serves as the mechanism by which ACT produces its benefits. We now discuss this concept of psychological flexibility, which describes ACT's model of mental health and behavioural effectiveness.
Psychological Flexibility: The ACT Model of Mental Health and Behavioural Effectiveness
ACT posits that mental health and behavioural effectiveness are compromised when people's responses to their difficult or challenging internal experiences reduce their contact with the present moment and prevent them from behaving in ways that are consistent with their meaningful life directions. For example, when carrying out a task at work people may experience engagement, enjoyment and a sense of reward; however, they may also experience worry, nervousness and a degree of apprehension. Whilst the former experiences may be perceived as positive, pleasant and something to be welcomed, the latter may be perceived as difficult, challenging and something to be avoided. If people focus excessively on, attempt to avoid, overanalyse, or otherwise interact unhelpfully with, those latter experiences they may begin to feel overwhelmed and distracted. In turn, this may make it difficult for them to focus on the present moment and work effectively on their task. Eventually this may lead them to lose sight of their meaningful life directions, as well as to an increased risk of emotional and/or behavioural difficulty. In the following section, we will examine these (1) unhelpful responses to internal experiences, when they function (2) to remove people from the present moment, and (3) thwart their ability to pursue their meaningful life directions; in so doing, we hope to explicate how they work together to produce ACT's core process of psychological flexibility.
Unhelpful Responses to Internal Experiences
From an ACT perspective, people's unhelpful responses to their internal experiences derive from two core psychological processes: experiential avoidance and cognitive fusion. Experiential avoidance, or simply avoidance, involves people's attempts to change, control or avoid their internal experiences, even when doing so may lead to psychological and/or behavioural harm. For instance, when suffering from depression people may experience sadness, anger, guilt, shame, or tiredness. Since these are unpleasant, people may engage in practices to avoid, get rid of, or escape from, these experiences. One common avoidance strategy is thought suppression; this involves the use of internal, or thinking-related, strategies to suppress or avoid internal events that are experienced as aversive, or that lead to other aversive experiences. Paradoxically, whilst avoidance may lead to some short-term relief (at least some of the time), when employed on a long-term basis it may have damaging effects. For instance, in the short term, thought suppression may reduce the frequency of aversive thoughts; however, in the long term, thought suppression has been found to lead to a substantial increase in the frequency of the avoided thoughts.
When people feel the need to change, control or avoid their thoughts, it is likely that they are also fused with those cognitive events. Cognitive fusion describes a psychological process in which people are entangled in, dominated by, or enveloped in their internal experiences; a process in which a thought, feeling or memory of an event (past or future) seems 'immediately present and highly likely'; where 'the fearsomeness of the world has been discovered, not constructed'. For instance, when suffering from depression people may be consumed by thoughts that they are inadequate, useless and helpless. Rather than standing back from these thoughts and feelings and seeing them for what they are (i.e. mere products of the mind), people may get caught up in them, believe them, become blinded by them and let them determine their actions.
Removal from the Present Moment
According to ACT, people's unhelpful responses to their internal experiences, in turn, may function to remove them from the present moment; this is characterised by inflexible attention and attachment to the conceptualised self. Inflexible attention involves a reduced ability to allocate one's attention in a voluntary and flexible fashion. That is, rather than thinking, feeling and sensing 'in the moment', people get carried off into a remembered past or imagined future. Avoidance may reinforce this process since the more energy people expend being avoidant, the less they have for paying attention to current inner experiences, as well as what is happening in the world around them. Equally, the more energy people expend being fused, the less they have for being psychologically present. When fused, people tend to dwell on painful memories, ruminate about past events, or worry about a future that has not yet happened.
Attachment to the conceptualised self is where people become fused with, entangled in, or dominated by their self-descriptors. To explain, from a young age we are taught to describe and categorise ourselves according to what we like or dislike, the roles we play and the relationships we have. Whilst these descriptors can be useful for helping us to understand who we are and what we value, if held too rigidly, they can dictate our behaviours and limit our choices. For example, if one holds rigidly to the perception of himself or herself as an outspoken person, then more restrained ways of behaving are unlikely to be considered or chosen even when they may be more appropriate in a given moment. As with inflexible attention, attachment to the conceptualised self is characterised by a lack of psychological presence and attention to the here-and-now, as well as a source of psychological suffering.
Thwarted Pursuit of Meaningful Life Directions
ACT posits that unhelpful responses to internal experiences and removal from the present moment, eventually, may function to thwart people's pursuit of their meaningful life directions; this is characterised by a lack of values clarity or contact, and/or engagement in unworkable action. Starting with the former, as actions become driven by avoidance and fusion, and governed by inflexible attention and attachment to the conceptualised self, people may lose touch with, neglect, or forget their values. For example, people suffering from social phobia may attempt to control, change or suppress internal events that provoke anxiety (e.g. thinking about socialising with friends). Whilst their efforts may lead to a reduction in anxiety (at least temporarily), they will also reduce their awareness of their own thinking and therefore make it difficult for them to contact their valued life directions (e.g. building intimate relationships). Furthermore, they may be fused with self-limiting beliefs (e.g. 'If I go out socialising I won't be able to cope'). These beliefs may loom so large, and over time become so embedded in their conceptualised self (e.g. 'I'm not somebody who has close friendships'), that people cannot see beyond them and contact with values may be lost.
In addition, as actions become driven by avoidance and fusion, and governed by inflexible attention and attachment to the conceptualised self, people may increasingly engage in unworkable action that thwarts their pursuit of their values. For example, whilst people suffering from social phobia may be aware of their valued life directions (e.g. having a meaningful social life), the immediate relief afforded by avoidance strategies may dominate over more reasoned and purposive values-based actions. Also, they may be fused with self-limiting beliefs (e.g. 'If I go out socialising I won't be able to cope') making them inattentive to their external environment and the opportunities it affords them to approach their valued life directions. In such a situation, impulsive, reactive and automatic patterns of avoidant action seem likely to dominate over more considered purposive ones.
We will now consider how ACT attempts to promote greater psychological flexibility and, hence, better mental health and behavioural effectiveness. Broadly, ACT attempts to promote psychological flexibility using acceptance and mindfulness processes in combination with values-consistent commitment and behaviour change processes. Acceptance and mindfulness processes help people to fully contact the present moment and approach internal experiences from a curious and open perspective. Commitment and behaviour change processes help people to fully contact the present moment, clarify and take steps towards their meaningful life directions. These two broad processes emerge from six constituent psychological processes: (1) acceptance, (2) defusion, (3) present moment awareness, (4) self-as-context, (5) values, and (6) committed action. Processes 1-4 produce acceptance and mindfulness processes, whilst processes 3-6 produce commitment and behaviour change processes.
In a recent conceptualisation of the ACT model, the six processes have been further grouped into three process pairs: acceptance / defusion, present moment awareness / self-as-context, and values / committed action. These process pairs represent flexible response styles and are referred to as open, centred and engaged respectively. We will use the three response styles to organise our discussion of the six ACT processes and illustrate how these can counteract the inflexible patterns of behaviour described in the previous section.
Acceptance/Defusion: The Open Response Style
Together, acceptance and defusion support an open response style which helps people to better manage their unhelpful responses to internal events (i.e. avoidance and fusion). Acceptance allows people to engage with difficult and challenging internal experiences without attempting to change, control, suppress or avoid these experiences. It encourages people to approach all aspects of their experience in a mindful, curious and non-judgemental manner, and without struggle and defence. Defusion allows people to step back, separate or disentangle from their internal experiences, and view them as ongoing mental activities that do not need to be believed, analysed, or scrutinised. It involves altering people's relationship with their internal experiences even if the form or frequency of those experiences doesn't change or changes only slowly.
Present Moment Awareness/Self-As-Context: The Centred Response Style
Together, present moment awareness and self-as-context support a centred response style which helps people to make contact with the present moment. Present moment awareness helps people to allocate their attention in a flexible fashion and connect with whatever experience they are having in that moment. Self-as-context allows people to engage with their personal descriptors and conceptualised self without feeling wholly defined (and dictated) by it. This involves establishing a perspective from which people can be in contact with the content of what they are thinking, feeling or experiencing, but nevertheless psychologically distinct from it. Interestingly, the centred response style has been conceived of as a lynchpin between the processes of acceptance and defusion, on the one hand, and values and committed action, on the other. Centredness (i.e. being a conscious person in the present moment) facilitates the use of acceptance and defusion when these are needed to overcome barriers to engaging in values-based action. Equally, centredness facilitates a commitment to taking values-based action when this is needed to justify engaging in the challenging processes of acceptance and defusion.
Values/Committed Action: The Engaged Response Style
Together, identifying one's values and taking committed action towards them represent an engaged response style that helps people to pursue their meaningful life directions. Values describe what people want their lives to stand for and help guide them on a moment-to-moment basis (e.g. being a good father). These are different from goals (which emerge from values) that will end once attainment is reached (e.g. attend your son's football match [the goal] in aid of being a good father [the value]). Committed action involves setting concrete goals and helps move people towards their values. Whilst values are more of a compass-bearing, pointing in a direction that will never be reached (e.g. one can always keep heading west), committed action involves short-, medium- and long-term goals that can be achieved along that course (e.g. travelling to Wales from London on the journey west).
