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Acceptance and commitment therapy (ACT, typically pronounced as the word "act") is a form of psychotherapy and a branch of clinical behavior analysis.It is an empirically based psychological intervention that uses acceptance and mindfulness strategies mixed in different ways with commitment and behavior-change strategies, to increase psychological flexibility. The approach was originally called comprehensive distancing. Steven C. Hayes developed acceptance and commitment therapy in 1982 in order to create a mixed approach which integrates both covert conditioning and behavior therapy. There are a variety of protocols for ACT, depending on the target behavior or setting. For example, in behavioral health areas a brief version of ACT is called focused acceptance and commitment therapy (FACT).
The objective of ACT is not elimination of difficult feelings; rather, it is to be present with what life brings us and to "move toward valued behavior".Acceptance and commitment therapy invites people to open up to unpleasant feelings, and learn not to overreact to them, and not avoid situations where they are invoked. Its therapeutic effect is a positive spiral where feeling better leads to a better understanding of the truth. In ACT, 'truth' is measured through the concept of 'workability', or what works to take another step toward what matters (e.g. values, meaning).
ACT is developed within a pragmatic philosophy called functional contextualism. ACT is based on relational frame theory (RFT), a comprehensive theory of language and cognition that is an offshoot of behavior analysis. Both ACT and RFT are based on B. F. Skinner's philosophy of Radical Behaviorism.
ACT differs from some other kinds of cognitive behavioral therapy (CBT) in that rather than trying to teach people to better control their thoughts, feelings, sensations, memories and other private events, ACT teaches them to "just notice," accept, and embrace their private events, especially previously unwanted ones. ACT helps the individual get in contact with a transcendent sense of self known as self-as-context—the you who is always there observing and experiencing and yet distinct from one's thoughts, feelings, sensations, and memories. ACT aims to help the individual clarify their personal values and to take action on them, bringing more vitality and meaning to their life in the process, increasing their psychological flexibility.
While Western psychology has typically operated under the "healthy normality" assumption which states that by their nature, humans are psychologically healthy, ACT assumes, rather, that psychological processes of a normal human mind are often destructive.The core conception of ACT is that psychological suffering is usually caused by experiential avoidance, cognitive entanglement, and resulting psychological rigidity that leads to a failure to take needed behavioral steps in accord with core values. As a simple way to summarize the model, ACT views the core of many problems to be due to the concepts represented in the acronym, FEAR:
And the healthy alternative is to ACT:
ACT commonly employs six core principles to help clients develop psychological flexibility:
Correlational evidence has found that absence of psychological flexibility predicts many forms of psychopathology. A 2005 meta-analysis showed that the six ACT principles, on average, account for 16–29% of the variance in psychopathology (general mental health, depression, anxiety) at baseline, depending on the measure, using correlational methods. 12–13 A 2012 meta-analysis of 68 laboratory-based studies on ACT components has also provided support for the link between psychological flexibility concepts and specific components.:
A 2008 meta-analysis concluded that the evidence was still too limited for ACT to be considered a supported treatment, and raised methodological concerns about the research base.A 2009 meta-analysis found that ACT was more effective than placebo and "treatment as usual" for most problems (with the exception of anxiety and depression), but not more effective than CBT and other traditional therapies. A 2012 meta-analysis was more positive and reported that ACT outperformed CBT, except for treating depression and anxiety.
A 2015 review found that ACT was better than placebo and typical treatment for anxiety disorders, depression, and addiction.Its effectiveness was similar to traditional treatments like cognitive behavioral therapy (CBT). The authors suggested that the CBT comparison of the previous 2012 meta-analysis may have been compromised by the inclusion of nonrandomized trials with small sample sizes. They also noted that research methodologies had improved since the studies described in the 2008 meta-analysis.
The number of randomized clinical trials and controlled time series evaluating ACT for a variety of problems is growing. In 2006, only about 30 such studies were known,but in 2011 the number had approximately doubled. The website of the Association for Contextual Behavioral Science states that there were 171 randomized controlled trials (RCTs) of ACT published as of December 2016, and over 20 meta-analyses and 45 mediational studies of the ACT literature as of Spring 2016. Most studies of ACT so far have been conducted on adults and therefore the knowledge of its effectiveness when applied to children and adolescents is limited.
The Association for Contextual Behavioral Science is committed to research and development in the area of ACT, RFT, and contextual behavioral science more generally. As of 2017 it had over 7,600 members worldwide, about half outside of the United States. It holds annual "world conference" meetings: The 16th will be held in Montreal, in July 2018.
The Association for Behavior Analysis International (ABAI) has a special interest group for practitioner issues, behavioral counseling, and clinical behavior analysis ABA:I.[ citation needed ] ABAI has larger special interest groups for autism and behavioral medicine. ABAI serves as the core intellectual home for behavior analysts. ABAI sponsors three conferences/year—one multi-track in the U.S., one specific to Autism and one international.
The Association for Behavioral and Cognitive Therapies (ABCT) also has an interest group in behavior analysis, which focuses on clinical behavior analysis. ACT work is commonly presented at ABCT and other mainstream CBT organizations.
The British Association for Behavioural and Cognitive Psychotherapies (BABCP) has a large special interest group in ACT, with over 1,200 members.
Doctoral-level behavior analysts who are psychologists belong to the American Psychological Association's (APA) Division 25—Behavior analysis.ACT has been called a "commonly used treatment with empirical support" within the APA-recognized specialty of behavioral and cognitive psychology.
ACT, dialectical behavior therapy (DBT), functional analytic psychotherapy (FAP), mindfulness-based cognitive therapy (MBCT) and other acceptance- and mindfulness-based approaches are commonly grouped under the name "the third wave of cognitive behavior therapy".The first wave, behaviour therapy, commenced in the 1920s based on Pavlov's classical (respondent) conditioning and operant conditioning that was correlated to reinforcing consequences. The second wave emerged in the 1970s and included cognition in the form of irrational beliefs, dysfunctional attitudes or depressogenic attributions. In the late 1980s empirical limitations and philosophical misgivings of the second wave gave rise to Steven Hayes' ACT theory which modified the focus of abnormal behaviour away from the content or form towards the context in which it occurs. ACT research has suggested that many of the emotional defenses individuals use with conviction to try to solve their problems actually entangle humans into greater suffering. Rigid ideas about themselves, lack of focus on what is important in their life and struggling to change sensations, feelings or thoughts that are troublesome only serve to create greater distress.
Steven C. Hayes described this group in his ABCT President Address as follows:
Grounded in an empirical, principle-focused approach, the third wave of behavioral and cognitive therapy is particularly sensitive to the context and functions of psychological phenomena, not just their form, and thus tends to emphasize contextual and experiential change strategies in addition to more direct and didactic ones. These treatments tend to seek the construction of broad, flexible and effective repertoires over an eliminative approach to narrowly defined problems, and to emphasize the relevance of the issues they examine for clinicians as well as clients. The third wave reformulates and synthesizes previous generations of behavioral and cognitive therapy and carries them forward into questions, issues, and domains previously addressed primarily by other traditions, in hopes of improving both understanding and outcomes.
ACT has also been adapted to create a non-therapy version of the same processes called Acceptance and Commitment Training. This training process, oriented towards the development of mindfulness, acceptance, and valued skills in non-clinical settings such as businesses or schools, has also been investigated in a handful of research studies with good preliminary results. [ citation needed ]This is somewhat similar to the awareness–management movement in business training programs, where mindfulness and cognitive-shifting techniques are employed.
The emphasis of ACT on ongoing present moment awareness, valued directions and committed action is similar to other psycho-therapeutic approaches that, unlike ACT, are not as focused on outcome research or consciously linked to a basic behavioral science program, including approaches such as Gestalt therapy, Morita therapy and Voice Dialogue, IFS and others.[ citation needed ]
Wilson, Hayes & Byrd explore at length the compatibilities between ACT and the 12-step treatment of addictions and argue that, unlike most other psychotherapies, both approaches can be implicitly or explicitly integrated due to their broad commonalities. Both approaches endorse acceptance as an alternative to unproductive control. ACT emphasizes the hopelessness of relying on ineffectual strategies to control private experience, similarly the 12-step approach emphasizes the acceptance of powerlessness over addiction. Both approaches encourage a broad life-reorientation, rather than a narrow focus on the elimination of substance use, and both place great value on the long-term project of building of a meaningful life aligned with the clients' values. ACT and 12-step both encourage the pragmatic utility of cultivating a transcendent sense of self (higher power) within an unconventional, individualized spirituality. Finally they both openly accept the paradox that acceptance is a necessary condition for change and both encourage a playful awareness of the limitations of human thinking.
Some published empirical studies in clinical psychology have argued that ACT is not different from other interventions.Stefan Hofmann argued that ACT is similar to the much older Morita therapy.
A meta-analysis by Öst in 2008 concluded that ACT did not yet qualify as an "empirically supported treatment", that the research methodology for ACT was less stringent than cognitive behavioral therapy, and that the mean effect size was moderate.Supporters of ACT have challenged those conclusions by showing that the quality difference in Öst's review was accounted for by the larger number of funded trials in the CBT comparison group.
Several concerns, both theoretical and empirical, have arisen in response to the ascendancy of ACT. One major theoretical concern was that the primary authors of ACT and of the corresponding theories of human behavior, relational frame theory (RFT) and functional contextualism (FC), recommended their approach as the proverbial holy grail of psychological therapies.Later, in the preface to the second edition of Acceptance and Commitment Therapy, the authors clarified that "ACT has not been created to undercut the traditions from which it came, nor does it claim to be a panacea." Psychologist James C. Coyne, in a discussion of "disappointments and embarrassments in the branding of psychotherapies as evidence supported", said: "Whether or not ACT is more efficacious than other therapies, as its proponents sometimes claim, or whether it is efficacious for psychosis, is debatable". The textbook Systems of Psychotherapy: A Transtheoretical Analysis provides criticisms of third-wave behaviour therapies including ACT from the perspectives of other systems of psychotherapy.
Psychologist Jonathan W. Kanter said that Hayes and colleagues "argue that empirical clinical psychology is hampered in its efforts to alleviate human suffering and present contextual behavioral science (CBS) to address the basic philosophical, theoretical and methodological shortcomings of the field. CBS represents a host of good ideas but at times the promise of CBS is obscured by excessive promotion of Acceptance and Commitment Therapy (ACT) and Relational Frame Theory (RFT) and demotion of earlier cognitive and behavior change techniques in the absence of clear logic and empirical support."Nevertheless, Kanter concluded that "the ideas of CBS, RFT, and ACT deserve serious consideration by the mainstream community and have great potential to shape a truly progressive clinical science to guide clinical practice."
ACT currently appears to be about as effective as standard CBT, with some meta-analyses showing small differences in favor of ACT and others not. For example, a meta-analysis published by Francisco Ruiz in 2012 looked at 16 studies comparing ACT to standard CBT. – a heterogeneous class of 14 separate outcome measures that were aggregated into the effect size analysis. This analysis however is limited by the highly heterogeneous nature of the outcome variables used in the analysis, which has the tendency to increase the number needed to treat (NNT) to replicate the effect size reported. More limited measures, such as depression, anxiety and quality of life decrease the NNT, making the analysis more clinically relevant, and on these measures ACT did not outperform CBT.ACT failed to separate from CBT on effect sizes for anxiety, however modest benefits were found with ACT compare to CBT for anxiety and quality of life. The author did find separation between ACT and CBT on the "primary outcome"
A 2013 paper comparing ACT to cognitive therapy (CT) concluded that "like CT, ACT cannot yet make strong claims that its unique and theory-driven intervention components are active ingredients in its effects."The authors of the paper suggested that many of the assumptions of ACT and CT "are pre-analytical, and cannot be directly pitted against one another in experimental tests."
the criticism offered by ACT against CBT is based on a misrepresentation of the empirical evidence. Moreover, the strategies of ACT are not specific to the theory and philosophy underlying ACT. There are considerable similarities between ACT and Eastern holistic approaches, such as Morita therapy, which was developed 80 years ago.
Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to improve mental health. CBT focuses on challenging and changing cognitive distortions and behaviors, improving emotional regulation, and the development of personal coping strategies that target solving current problems. It was originally designed to treat depression, but its uses have been expanded to include treatment of a number of mental health conditions, including anxiety, alcohol and drug use problems, marital problems, and eating disorders. CBT includes a number of cognitive or behavior psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.
Psychotherapy is the use of psychological methods, particularly when based on regular personal interaction with adults, to help a person change behavior and overcome problems in desired ways. Psychotherapy aims to improve an individual's well-being and mental health, to resolve or mitigate troublesome behaviors, beliefs, compulsions, thoughts, or emotions, and to improve relationships and social skills. There are also numerous types of psychotherapy designed for children and adolescents, such as play therapy. Certain psychotherapies are considered evidence-based for treating some diagnosed mental disorders. Others have been criticized as pseudoscience.
Cognitive restructuring (CR) is a psychotherapeutic process of learning to identify and dispute irrational or maladaptive thoughts known as cognitive distortions, such as all-or-nothing thinking (splitting), magical thinking, over-generalization, magnification, and emotional reasoning, which are commonly associated with many mental health disorders. CR employs many strategies, such as Socratic questioning, thought recording, and guided imagery, and is used in many types of therapies, including cognitive behavioral therapy (CBT) and rational emotive behaviour therapy (REBT). A number of studies demonstrate considerable efficacy in using CR-based therapies.
Behaviour therapy or behavioural psychotherapy is a broad term referring to clinical psychotherapy that uses techniques derived from behaviourism and/or cognitive psychology. It looks at specific, learned behaviours and how the environment, or other people's mental states, influences those behaviours, and consists of techniques based on learning theory, such as respondent or operant conditioning. Behaviourists who practice these techniques are either behaviour analysts or cognitive-behavioural therapists. They tend to look for treatment outcomes that are objectively measurable. Behaviour therapy does not involve one specific method, but it has a wide range of techniques that can be used to treat a person's psychological problems.
The Dodo bird verdict is a controversial topic in psychotherapy, referring to the claim that all empirically validated psychotherapies, regardless of their specific components, produce equivalent outcomes. It is named after the Dodo character in Alice in Wonderland. The conjecture was introduced by Saul Rosenzweig in 1936, drawing on imagery from Lewis Carroll's novel Alice's Adventures in Wonderland, but only came into prominence with the emergence of new research evidence in the 1970s.
Relational frame theory (RFT) is a psychological theory of human language. It was developed originally by Steven C. Hayes of University of Nevada, Reno and has been extended in research, notably by Dermot Barnes-Holmes and colleagues of Ghent University.
Mindfulness-based cognitive therapy (MBCT) is an approach to psychotherapy that uses cognitive behavioral therapy (CBT) methods in collaboration with mindfulness meditative practices and similar psychological strategies. It was originally created to be a relapse-prevention treatment for individuals with major depressive disorder (MDD). A focus on MDD and cognitive processes distinguishes MBCT from other mindfulness-based therapies. Mindfulness-based stress reduction (MBSR), for example, is a more generalized program that also utilizes the practice of mindfulness. MBSR is a group-intervention program, like MBCT, that uses mindfulness to help improve the life of individuals with chronic clinical ailments and high-stress lives.
Steven C. Hayes is an American clinical psychologist and Nevada Foundation Professor at the University of Nevada, Reno Department of Psychology, where he is a faculty member in their Ph.D. program in behavior analysis, and coined the term clinical behavior analysis. He is known for devising a behavior analysis of human language and cognition called relational frame theory, and its clinical application to various psychological difficulties, such as anxiety. Hayes also developed a widely used and evidence-based procedure often used in counseling called acceptance and commitment therapy (ACT), which relies heavily on counterconditioning techniques, such as mindfulness, and positive reinforcement.
Functional analytic psychotherapy (FAP) is a psychotherapeutic approach based on clinical behavior analysis (CBA) that focuses on the therapeutic relationship as a means to maximize client change. Specifically, FAP suggests that in-session contingent responding to client target behaviors leads to significant therapeutic improvements.
A clinical formulation, also known as case formulation and problem formulation, is a theoretically-based explanation or conceptualisation of the information obtained from a clinical assessment. It offers a hypothesis about the cause and nature of the presenting problems and is considered an adjunct or alternative approach to the more categorical approach of psychiatric diagnosis. In clinical practice, formulations are used to communicate a hypothesis and provide framework for developing the most suitable treatment approach. It is most commonly used by clinical psychologists and psychiatrists and is deemed to be a core component of these professions. Mental health nurses and social workers may also use formulations.
Jack A. Apsche was an American psychologist who has focused his work on adolescents with behavior problems. Apsche was also an author, artist, presenter, consultant and lecturer.
Clinical behavior analysis is the clinical application of behavior analysis (ABA). CBA represents a movement in behavior therapy away from methodological behaviorism and back toward radical behaviorism and the use of functional analytic models of verbal behavior—particularly, relational frame theory (RFT).
Cognitive behavioral therapy for insomnia (CBT-I) is a technique for treating insomnia without medications. Insomnia is a common problem involving trouble falling asleep, staying asleep, or getting quality sleep. CBT-I aims to improve sleep habits and behaviors by identifying and changing the thoughts and the behaviors that affect the ability of a person to sleep or sleep well.
Experiential avoidance (EA) has been broadly defined as attempts to avoid thoughts, feelings, memories, physical sensations, and other internal experiences—even when doing so creates harm in the long-run. The process of EA is thought to be maintained through negative reinforcement—that is, short-term relief of discomfort is achieved through avoidance, thereby increasing the likelihood that the behavior will persist. Importantly, the current conceptualization of EA suggests that it is not negative thoughts, emotions, and sensations that are problematic, but how one responds to them that can cause difficulties. In particular, a habitual and persistent unwillingness to experience uncomfortable thoughts and feelings is thought to be linked to a wide range of problems.
The Association for Contextual Behavioral Science (ACBS) is a worldwide nonprofit professional membership organization associated with acceptance and commitment therapy (ACT), and relational frame theory (RFT) among other topics. The term "contextual behavioral science" refers to the application of functional contextualism to human behavior, including contextual forms of applied behavior analysis, cognitive behavioral therapy, and evolution science. In the applied area Acceptance and Commitment Therapy is perhaps the best known wing of contextual behavioral science, and is an emphasis of ACBS, along with other types of contextual CBT, and efforts in education, organizational behavior, and other areas. ACT is considered an empirically validated treatment by the American Psychological Association, with the status of "Modest Research Support" in depression and "Strong Research Support" in chronic pain, with several others specific areas such as psychosis and work site stress currently under review. ACT is also listed as evidence-based by the Substance Abuse and Mental Health Services Administration of the United States federal government which has examined randomized trials for ACT in the areas of psychosis, work site stress, and obsessive compulsive disorder, including depression outcomes. In the basic area, Relational Frame Theory is a research program in language and cognition that is considered part of contextual behavioral science, and is a focus of ACBS. Unlike the better known behavioral approach proposed by B.F. Skinner in his book Verbal Behavior, experimental RFT research has emerged in a number of areas traditionally thought to be beyond behavioral perspectives, such as grammar, metaphor, perspective taking, implicit cognition and reasoning.
Cognitive emotional behavioral therapy (CEBT) is an extended version of cognitive behavioral therapy (CBT) aimed at helping individuals to evaluate the basis of their emotional distress and thus reduce the need for associated dysfunctional coping behaviors. This psychotherapeutic intervention draws on a range of models and techniques including dialectical behavior therapy (DBT), mindfulness meditation, acceptance and commitment therapy (ACT), and experiential exercises.
Mode deactivation therapy (MDT) is a psychotherapeutic approach that addresses dysfunctional emotions, maladaptive behaviors and cognitive processes and contents through a number of goal-oriented, explicit systematic procedures. The name refers to the process of mode deactivation that is based on the concept of cognitive modes as introduced by Aaron T. Beck. The MDT methodology was developed by Jack A. Apsche by combining the unique validation–clarification–redirection (VCR) process step with elements from acceptance and commitment therapy (ACT), dialectical behavior therapy (DBT), and mindfulness to bring about durable behavior change.
Compassion-focused therapy (CFT) is a system of psychotherapy developed by Paul Gilbert that integrates techniques from cognitive behavioral therapy with concepts from evolutionary psychology, social psychology, developmental psychology, Buddhist psychology, and neuroscience. According to Gilbert, "One of its key concerns is to use compassionate mind training to help people develop and work with experiences of inner warmth, safeness and soothing, via compassion and self-compassion."
Metacognitive therapy (MCT) is a psychotherapy focused on modifying metacognitive beliefs that perpetuate states of worry, rumination and attention fixation. It was created by Adrian Wells based on an information processing model by Wells and Gerald Matthews. It is supported by scientific evidence from a large number of studies.
Stefan G. Hofmann is a German-born clinical psychologist. He is the Alexander von Humboldt Professor and recipient of the LOEWE Spitzenprofessur for Translational Clinical Psychology at the Philipps University of Marburg in Germany and Professor for Psychology at the Department of Psychological and Brain Sciences at Boston University. He is one of the foremost experts in Cognitive Behavioral Therapy, especially for anxiety disorders