Acceptance and commitment therapy | |
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MeSH | D064869 |
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Acceptance and commitment therapy (ACT, typically pronounced as the word "act") is a form of psychotherapy, as well as a branch of clinical behavior analysis. [1] It is an empirically based psychological intervention that uses acceptance and mindfulness strategies [2] along with commitment and behavior-change strategies to increase psychological flexibility.
This approach was first called comprehensive distancing. [3] Steven C. Hayes developed it around 1982 to integrate features of cognitive therapy and behavior analysis, especially behavior analytic data on the often negative effects of verbal rules and how they might be ameliorated. [4]
ACT protocols vary with the target behavior and the setting. For example, in behavioral health, a brief version of ACT is focused acceptance and commitment therapy (FACT). [5]
The goal of ACT is not elimination of difficult feelings, but to be present with what life brings and to "move toward valued behavior". [6] : 240 Acceptance and commitment therapy invites people to open up to unpleasant feelings, not to overreact to them, and not to avoid situations that cause them.
Its therapeutic effect aims to be a positive spiral, in which more understanding of one's emotions leads to a better understanding of the truth. [7] 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, functional contextualism. ACT is based on relational frame theory (RFT), a comprehensive theory of language and cognition that is derived from behavior analysis. Both ACT and RFT are based on B. F. Skinner's philosophy of radical behaviorism. [8]
ACT differs from some kinds of cognitive behavioral therapy (CBT) in that, rather than try to teach people to 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, "self-as-context"—the one who is always there observing and experiencing and yet distinct from one's thoughts, feelings, sensations, and memories. ACT tries to help the individual clarify values and then use them as the basis for action, bringing more vitality and meaning to life in the process, while increasing psychological flexibility. [3]
While Western psychology has typically operated under the "healthy normality" assumption, which states that humans naturally are psychologically healthy, ACT assumes that the psychological processes of a normal human mind are often destructive. [9] 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. [10] 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: [11]
And the healthy alternative is to ACT:
ACT commonly employs six core principles to help clients develop psychological flexibility: [9]
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. [13] : 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. [14]
The website of the Association for Contextual Behavioral Science states that there were over 1,000 randomized controlled trials (RCTs) of ACT, [15] over 500 meta-analyses/systematic reviews, and 78 mediational studies of the ACT literature as of April 2024. [16]
Organizations that have stated that acceptance and commitment therapy is empirically supported in certain areas or as a whole according to their standards include (as of March 2022): [16]
In 2006, only about 30 randomized clinical trials and controlled time series evaluating ACT were known, [13] in 2011 the number had doubled to more than 60 ACT randomized controlled trials, [17] and in 2023 there were more than 1,000 randomized controlled trials of ACT worldwide. [15] A 2008 meta-analysis concluded that the evidence was still too limited for ACT to be considered a supported treatment. [18] A 2009 meta-analysis found that ACT was more effective than placebo and "treatment as usual" for most problems. [11] A 2012 meta-analysis was more positive and reported that ACT outperformed CBT, except for treating depression and anxiety. [19] A 2015 review found that ACT was better than placebo and typical treatment for anxiety disorders, depression, and addiction. [20] Its effectiveness was similar to traditional treatments like cognitive behavioral therapy (CBT). [20] The authors also noted that research methodologies had improved since the studies described in the 2008 meta-analysis. [20]
In 2020, a review of meta-analyses examined 20 meta-analyses that included 133 studies and 12,477 participants. The authors concluded ACT is efficacious for all conditions examined, including anxiety, depression, substance use, pain, and transdiagnostic groups. Results also showed that ACT was generally superior to inactive controls, treatment as usual, and most active intervention conditions. [21]
In 2020–2021, after three RCTs of ACT by the World Health Organization (WHO), WHO released an ACT-based self-help course Self-Help Plus (SH+) for "groups of up to 30 people who have lived through or are living through adversity". [22] As of July 2023, there are six RCTs of Self-Help Plus. [23]
In 2022, a systematic review of meta-analyses about interventions for depressive symptoms in people living with chronic pain concluded "Acceptance and commitment therapy for general chronic pain, and fluoxetine and web-based psychotherapy for fibromyalgia showed the most robust effects and can be prioritized for implementation in clinical practice". [24]
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 2023 it had over 8,000 members worldwide, about half outside of the United States. It holds annual "world conference" meetings each summer, with the location alternating between North America, Europe, and South America. [25]
The Association for Behavior Analysis International (ABAI) has a special interest group for practitioner issues, behavioral counseling, and clinical behavior analysis ABA:I. [26] ABAI has larger special interest groups for autism and behavioral medicine. ABAI serves as the core intellectual home for behavior analysts. [27] [28] 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. [29] ACT has been called a "commonly used treatment with empirical support" within the APA-recognized specialty of behavioral and cognitive psychology. [30]
ACT, dialectical behavior therapy (DBT), functional analytic psychotherapy (FAP), mindfulness-based cognitive therapy (MBCT) and other acceptance- and mindfulness-based approaches have been grouped by Steven Hayes under the name "the third wave of cognitive behavior therapy". [18] [31] However, this classification has been criticized and not everyone agrees with it. [32] [33] For example, David Dozois and Aaron T. Beck argued that there is no "new wave" and that there are a variety of extensions of cognitive therapy; for example, Jeffrey Young's schema therapy came after Beck's cognitive therapy but Young did not name his innovations "the third wave" or "the third generation" of cognitive behavior therapy. [33]
According to Hayes' classification, 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. [34] [ page needed ] 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. [34] [ page needed ] People's rigid ideas about themselves, their lack of focus on what is important in their life, and their struggle to change sensations, feelings or thoughts that are troublesome only serve to create greater distress. [35]
Steven C. Hayes described the third wave 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. [36]
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. [37] [ page needed ]
The emphasis of ACT on ongoing present moment awareness, valued directions and committed action is similar to other psychotherapeutic 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 others. [38] [39] [40] Hayes and colleagues themselves stated in their book that introduced ACT that "many or even most of the techniques in ACT have been borrowed from elsewhere—from the human potential movement, Eastern traditions, behavior therapy, mystical traditions, and the like". [41]
Wilson, Hayes & Byrd explored at length the compatibilities between ACT and the 12-step treatment of addictions and argued that, unlike most other psychotherapies, both approaches can be implicitly or explicitly integrated due to their broad commonalities. [42] 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. [42]
The textbook Systems of Psychotherapy: A Transtheoretical Analysis includes various criticisms of third-wave behaviour therapy, including ACT, from the perspectives of other systems of psychotherapy, including the complaint that third-wave therapies "display an annoying tendency to gather effective methods from other traditions and label them as their own". [43]
In a 2012 blog post, psychologist James C. Coyne criticized the process and studies initially used by the APA to favorably evaluate ACT for the treatment of psychosis in its labeling system for evidence-based medicine. In particular, it relied on only one full randomized trials, supplemented by a pilot study and a feasibility study, despite the criteria for "strong evidence" requiring a treatment to be supported by many such trials. [44] [45] The main study used (Bach, P., & Hayes, S.C., 2002) was alleged not to have clearly specified its hypothesis, that ACT reduces rehospitalization, in advance (a practice that can allow researchers to retrospectively cherry-pick the metric showing the largest positive change after treatment). [45] In 2016, this and other critiques were cited by William O'Donohue and coauthors in a paper on "weak and pseudo-tests" of ACT and added that while "no doubt there are studies of ACT that are quite good", they had examined three trials of ACT that were "weakened and thus made easier to pass", and they listed over 30 ways in which such trials were "weak or pseudo-tests". [46] Drawing on concepts from Karl Popper's philosophy of science and Popper's critique of psychoanalysis as impossible to falsify, O'Donohue and colleagues advocated Popperian severe testing instead. [46]
In 2013, 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." [47] 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". [47]
Authors of a 2013 paper comparing ACT to cognitive therapy (CT) concluded that "although preliminary research on ACT is promising, we suggest that its proponents need to be appropriately humble in their claims. In particular, 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." [48]
In 2012, ACT appeared 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. [19] ACT failed to separate from CBT on effect sizes for anxiety, however modest benefits were found with ACT compared to CBT for depression and quality of life. The author did find separation between ACT and CBT on the "primary outcome" – 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. A 2012 clinical trial by Forman et al. found that Beckian CBT obtained better results than ACT. [49]
Several concerns, both theoretical and empirical, have arisen in response to the ascendancy of ACT. One 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. [50] In 2012, in the preface to the second edition of Acceptance and Commitment Therapy, the primary authors of ACT clarified that "ACT has not been created to undercut the traditions from which it came, nor does it claim to be a panacea." [6] : x
Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. Cognitive behavioral therapy is one of the most effective means of treatment for substance abuse and co-occurring mental health disorders. CBT focuses on challenging and changing cognitive distortions and their associated behaviors to improve emotional regulation and develop personal coping strategies that target solving current problems. Though it was originally designed to treat depression, its uses have been expanded to include many issues and the treatment of many mental health and other conditions, including anxiety, substance use disorders, marital problems, ADHD, and eating disorders. CBT includes a number of cognitive or behavioral 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, to help a person change behavior, increase happiness, and overcome problems. 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. Numerous types of psychotherapy have been designed either for individual adults, families, or children and adolescents. Certain types of psychotherapy are considered evidence-based for treating some diagnosed mental disorders; other types have been criticized as pseudoscience.
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 behaviorism's theory of learning: 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, cognition, and behaviour. 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 conjunction with mindfulness meditative practices and similar psychological strategies. The origins to its conception and creation can be traced back to the traditional approaches from East Asian formative and functional medicine, philosophy and spirituality, birthed from the basic underlying tenets from classical Taoist, Buddhist and Traditional Chinese medical texts, doctrine and teachings.
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. He is known for developing relational frame theory, an account of human higher cognition. He is the co-developer of acceptance and commitment therapy (ACT), a popular evidence-based form of psychotherapy that uses mindfulness, acceptance, and values-based methods, and is the co-developer of process-based therapy (PBT), a new approach to evidence-based therapies more generally. He also coined the term clinical behavior analysis.
Although modern, scientific psychology is often dated from the 1879 opening of the first psychological clinic by Wilhelm Wundt, attempts to create methods for assessing and treating mental distress existed long before. The earliest recorded approaches were a combination of religious, magical and/or medical perspectives. Early examples of such psychological thinkers included Patañjali, Padmasambhava, Rhazes, Avicenna and Rumi.
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 is deemed to be a core component of that profession. Mental health nurses, social workers, and some psychiatrists 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 avoidance 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, Obsessive Compulsive Disorder, mixed anxiety disorders, and psychosis, and "Strong Research Support" in chronic pain. 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.
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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, examining Cognitive Behavioral Therapy, especially for anxiety disorders.
Though mindfulness- and acceptance-based strategies have not been emphasized in cognitive therapy relative to cognitive change interventions, their general approaches are not inconsistent with the cognitive model, and the approaches are, in many respects, more similar than distinct ... Congruent with this argument, we view these approaches as extensions or complementary components of cognitive therapy and not a "third wave" per se (see Hofmann, 2008a; Hofmann & Asmundson, 2008).
Instead of the familiar litany of behavior analytic-terms and concepts, this book is replete with terms and themes that are more commonly associated with such philosophical and therapeutic traditions as existentialism, humanism, Zen Buddhism, Gestalt, and other experiential-based therapies.
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. ... According to Hayes and colleagues, the principal goal of ACT is to "treat emotional avoidance, excessive literal response to cognitive content, and the inability to make and keep commitments to behavior change" (Kohlenberg, Hayes, & Tsai, 1995, p. 584). This appears to be consistent with many old humanistic therapies and holistic approaches, such as Gestalt therapy (e.g., Perls, Hefferline, & Goodman, 1951). Particularly striking is the similarity between ACT and Morita therapy (Morita, 1928; translated in English in 1998).
I would have to say a lot of what's in ACT is in Gestalt, is in Est, is in mindfulness-based traditions, but I'm not embarrassed by that; I think it's to be expected that things like the wisdom traditions, spiritual traditions, human potential/growth traditions, Gestalt, these things were there because very very creative people put them there. ... The history of psychology would be different if people realized that there was a lot of overlap in the early days between these things that then get put behind walls and students start fighting about and saying, oh, this is very different than that.