What is Acceptance and Commitment Therapy (ACT)?
By Ivy Hall, Ph.D., Clinical Psychologist
Cognitive-Behavioral Therapy (CBT), described in a previous post, is considered to be a “second wave” of therapy approaches (“first wave” approaches consisted of techniques based on behavioral therapy). One of the therapy approaches associated with the “third wave” is Acceptance and Commitment Therapy, or ACT (pronounced just as you see it, “act”). Although ACT is a relatively new approach, there is a strong research base for it’s effectiveness for treatment of depression, anxiety, psychosis, chronic pain, and substance abuse, and has been listed as an evidence-based practice on Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-based Programs and Practices. What makes ACT unique from other approaches is that the goal of therapy is not necessarily symptom reduction, but “to create a rich and meaningful life, while accepting the pain that inevitably goes with it.” (Harris, 2006).
“Pain is inevitable. Suffering is optional.” – Unknown
With ACT, the cause of psychological suffering is thought to be strongly tied to language. Language is useful; it helps us communicate with each other, predict and plan, solve complex problems, and learn from cultures and people. However, language can also be unhelpful, as it creates a way for us to think in relational frames. So in our minds, we are constantly describing, categorizing, relating, evaluating, or thinking about various things. We imagine an idealized future, form negative opinions about ourselves or others, compare ourselves to a particular ideal, develop rules for behaving that may be harmful or ineffective, and so forth.
Different and same
Faster and slower
Bigger and smaller
Worse and better
Closer and further
Mine and yours
Here and there
…and so on.
Our ability to use language to relate ideas can become problematic when we attach emotional content to our thoughts, relationships, and memories. For example, cats, like humans, aren’t fond of needles. They will show signs of distress and resist if they see the needle at the vet’s office. They can be trained to later report (by pushing a lever) whether they experienced a painful experience, but unlike humans, they don’t demonstrate any signs of distress when pushing the lever. They’re not howling at the sight of the lever or trying to avoid that lever. On the other hand, when humans are thinking about or recalling a painful experience, we might experience some distress (e.g., sad mood, tearful, and so forth) because we have attached emotional content to those memories. This leads to what ACT calls “experiential avoidance.”
Experiential avoidance refers to our efforts to avoid, suppress, or get rid of thoughts, memories, or feelings, even when it’s harmful, costly, or ineffective to do so. Avoidance techniques can work well in the external world- for example, avoiding traffic to get somewhere on time. While experiential avoidance can be helpful in certain circumstances, at other times, it creates situations in which people get stuck in painful life experiences. For instance, many people turn towards drugs or alcohol to avoid feeling strong emotions or even reality. This works temporarily, but it’s harmful and costly in the long-term. Avoidance techniques in therapy (e.g., focusing on positive thoughts only, thought-stopping, etc) can also be very useful for people. However, these techniques may not be helpful when individuals feel even more distressed when they try to implement those techniques and are not successful. It’s important to note that ACT only targets experiential avoidance that is unhelpful, useless, or costly to one’s life.
Goals of ACT
As stated before, ACT therapy is not directly geared towards reducing symptoms (e.g., depression or anxiety). Rather, the goal is to help people create a meaningful, values-based life while reducing the impact of the emotional content; decreases in symptoms occur naturally as a byproduct. The tools that are taught in ACT are primarily mindfulness skills that address three areas: defusion, acceptance, and contact with the present moment.
Defusion is the process in which people learn to see thoughts as just thoughts or words, memories as just images or pictures, rather than what they may seem to be due to the emotional content associated with those thoughts and memories. The ACT techniques help people learn to just notice painful thoughts and images, rather than getting caught up and consumed by them.
Acceptance refers to the idea that we can allow ourselves to come into contact with unpleasant thoughts, feelings, and urges that are a natural part of life. Acceptance means letting go of the struggle and allowing those avoided experiences to occur, knowing they will pass. Acceptance is the alternative to experiential avoidance or expending energy being consumed by the thoughts and feelings. A metaphor I like to use to illustrate this is the riptide: when someone gets caught in a riptide, the natural instinct is to fight the waves, struggle, and try to swim to safety. However, fighting the waves actually is detrimental and can pull the person under water. The best way to get to safety is to not struggle but rather, to stay calm and tread water until the rip current strength weakens so they can swim to shore safely.
Contact with the present moment is an important aspect in ACT. When people are struggling, fighting with painful thoughts and emotions, they are often stuck in the past (e.g., remembering those painful experiences) or looking primarily at the future (often with unrealistic expectations based on their past). It is difficult for them to be in the present moment, fully engaged in doing what is important to them. Through mindfulness exercises, people develop skills to be in the here-and-now.
Values and Committed Action
To create a rich and meaningful life, people need to know what is important to them and more so, who it is that they want to be. An important part of ACT therapy is values clarification- what kind of person are you and what do you want to stand for in life? Once values have been clarified, the next step is to set goals that are in line with those values. Committed action means that you pledge to take steps to meet those goals, even when faced with barriers.
Here are some resources to help you get started with ACT and mindfulness.
I highly recommend these books by Russ Harris:
ACT related mindfulness exercises:
- 15-minute Awareness exercise by Jason Luoma
- Leaves on the Stream exercise (female voice)
- Thoughts On The Highway exercise by Julian McNally
- Body Scan mindfulness exercise by Ann Bailey
- Observer Exercise from the 1999 ACT book recorded by Randy Burgess
- Mindfulness of the Hand exercise by Russ Harris
About this Contributor: Ivy Hall is a licensed clinical psychologist working at the California Department of State Hospitals. She graduated from UC San Diego with a B.S. in Psychology and received her Ph.D. in Clinical Psychology from Pacific Graduate School of Psychology at Palo Alto University in 2013. She has extensive experience in treating individuals with substance abuse and dual diagnoses, anxiety, depression and mood disorders, chronic pain and illness, PTSD, and end-of-life issues. She has provided services to a variety of populations (Veterans, dually-diagnosed, Axis II, young adults and families, incarcerated persons), across multiple modalities (inpatient, residential, and outpatient) using a variety of treatment approaches (e.g., cognitive behavioral therapy (CBT), motivational interviewing (MI), acceptance and commitment therapy (ACT), and dialectical behavioral therapy (DBT)). She is passionate about incorporating diversity into her work and personal life. Outside of work, she loves to cook, run, workout, and root for the Giants, Niners, and Warriors!