CHAPTER 1.  ACCEPTANCE AND COMMITMENT THERAPY

Acceptance and Commitment Therapy, or ACT, is a form of therapy that draws from mindfulness practice and cognitive behavioral psychotherapy. It is also known as a contextual psychotherapy because it encourages patients to exhibit values-based positive behaviors even if they are experiencing negative sensations, emotions, or thoughts. In other words, it helps patients increase their psychological flexibility.

As a third wave Cognitive Behavioral Therapy (CBT), ACT (said as one word) is strongly connected to the power of behavioral change. However, ACT differs from CBT. It can change the relationship you have with your thoughts rather than change them directly. ACT promotes the notion that you don't have to do anything with your thoughts to push change in your behavior.

ACT focuses on mindfulness, diffusion of challenging thoughts, and acceptance of unpleasant emotions. With ACT, your efforts are concentrated to moving you towards a momentous life by helping you learn to separate yourself from your thoughts. Your efforts are based on your committed action towards establishing your values.

ACT mindfulness skills have 3 categories:

• Acceptance: enables patients to make room for sensations, urges, and painful feelings, and allowing them to easily come and go
• Defusion: enables patients to let go of and distance from unhelpful thoughts, memories, and beliefs
• Contact with the present moment: enables patients to fully engage, with an attitude of curiosity and openness, with their here-and-now experience

ACT can be delivered in many different ways:

• Ultra-brief ACT - ACT can be highly effective even in one or two twenty to thirty-minute sessions. A good example is treatment by Kirk Strosahl, co-founder of ACT, in primary care medical settings.
• Brief ACT - ACT is done with only four sessions at 1-hour each. A good example is treatment by Patty Bach, assistant professor of psychology at the Illinois Institute of Technology, used on patients with schizophrenia.
• Medium-term ACT - ACT is completed for a total of eight hours. An example is a protocol for chronic pain by professor of psychology at Uppsala University in Sweden, JoAnne Dahl.
• Long-term ACT - ACT takes forty sessions at 2-hour each. This is very effective in treating patients with borderline personality disorder (BPD). One of the only few known users of long-term ACT is Spectrum, the Personality Disorder (clinic) Service in the state of Victoria in Australia.

Note: Therapy Affects the Brain

According to a study published in the American Journal of Psychology in 1998, several decades of research has revealed that all mental processes derive from brain mechanism.

This means that any change in our psychological processes is reflected by changes in the functions or structures of the brain.

It doesn't come as a surprise then that the outcome and effects of these therapies that brings about change in an individual have been studied on the social and psychological levels. Changes in social functioning, personality, psychological abilities, and symptoms were carefully measured. These changes are in a way, brain mechanisms.

One of several strands of Cognitive Behavior Therapy (CBT), Acceptance and Commitment Therapy (ACT) is a unique way of treating a wide range of symptoms. This approach looks for non-physical causes for mental disorders, understanding that experiences such as depression, addictions, obsessive-compulsive disorder, and schizophrenia arise out of multiple complex factors. It considers genetic, epigenetic (not inherited through DNA), psychological, and cultural conditions. As a syndrome strategy, it identifies sets of symptoms as syndromes related to sets of conditions (Hayes and Lillis 2012, 5).

Conceived by Steven Hayes in 1980, it was developed into a full-fledged therapy model by his students and colleagues, especially Kirk Strohal and Kelly Wilson in 1999 (ibid, xv). These researchers were concerned with finding a more successful way to ease human suffering and help people address problems within relationships and daily living. They were puzzled as to why people often suffer even in conditions of affluence. They see human suffering as common despite the high-level accomplishments that any individual may make. Hayes and his students and colleagues thought it best to examine the root causes more than the symptoms. Considering the context of each case, this approach is inductive and process-oriented for comprehending human misery and failure (ibid, 6).

Very few therapists practiced ACT until the new millennium (ibid, 15). That may be because Cognitive Behavior Therapy (CBT) was in vogue until the end of the 20th century. As CBT declined, ACT carried on and grew.

History

As behavioral therapy based on empiricism rose through the 1960s, there was little research on psychological intervention methods. Empirical results were easily measured, and theoretical foundations tended to be weak, according to Hayes and Lillis (2012, 16), based on humanism and psychoanalysis. Misdiagnosis frequently occurred, they say, citing some of Freud's cases where analytical symbolism, revolving around things like defecation and sex, went too far.

Perhaps in a backlash to analytical psychology, reliance spread on clearly measurable empirical evidence observed in controlled conditions. Behavioral principles were rigidly set, and the application of technologies rigidly tested. ACT arose out of behavioral therapy but made concessions to psychoanalytical and humanist approaches. It, thus, began as a less conventional approach which demanded direct and overt modifications to the behavior of the treated person (ibid, 18). Acceptance and commitment therapists want to see behavioral changes, but they also want to explore the underlying human issues to problem behavior. They view social conditions as deep, rich and complex (ibid.).

Behaviorism set great stimulus-response training and behavior choices. It is inadequate because it does not take into consideration language and higher-level cognitive processes -meaning, conceptualization, and symbolism (ibid .). In laboratory experiments, only the external factors that the scientist can manipulate can be altered. Cognition, internal processes of the mind, were harder to decipher. Cognition psychology was likewise insufficient. Models sprouted up, but the evidence for them was lacking. Achieving practical results from cognitive therapy seemed too difficult. By holding conversations with patients, however, Cognitive Behavior Therapy began to develop, teaching clients to acknowledge and self-direct themselves to correct "behavioral errors" (ibid, 20) while tending to abandon evidence-based treatments in the beginning. Alternative approaches started to be put forward.

ACT - Experienced Based Psychotherapy

ACT, expressed as a single word and not phonetic letters, is a new form of CBT that is gaining a lot of attention in recent years. It emphasizes values, acceptance, mindfulness and processes to help people overcome life hurdles.

The concept of human suffering as a natural and unavoidable aspect of humanity is a fundamental assumption of ACT. It also revolves around the attempt of people to take control or avoid their own experiences that could lead to human suffering and other areas that are not working in our lives. ACT can help people learn effective ways of managing pain, practicing mindfulness, obtain clarity on what is really important, and to seek a life with more meaning. The objective of ACT is not to get rid of pain, but instead to learn how to experience life without too much struggle.

ACT is regarded as an empirical psychotherapy because its researchers and practitioners are committed to the progress of science and the empirical assessment of its causes and effects.

As of 2014, ACT has been scrutinized in more than 80 randomized clinical trials for different concerns in studies with more than 5,000 subjects. This form of CBT has also been used to build a non-therapeutic version of the same processes known as Acceptance and Commitment Training, which is focused on the development of values skills, acceptance, and mindfulness.

Relational Frame Theory

The Relational Frame Theory (RFT) frames the fundamental concept of ACT. RFT aims to explore the link between behavior and human language.

Understanding language is crucial in psychotherapy. Many of us use language in private when we think or in public when we speak with the people around us. We use language to think about, read about, write about, talk about, evaluate, relate, categorize, and describe everything around us.

Language is a useful tool in our existence as human beings, and without it we may never had the chance to build our civilizations. For example, without language, we cannot develop laws and societal rules to regulate our behavior.

While human language offers a lot of benefits, it could also have negative aspects. It's like the yin and yang - it has a powerful dark side and the powerful bright side. And based on RFT, language plays a critical role in human suffering. Language is a tool we use to form prejudiced and hateful assumptions about people around us, construct negative thoughts, obsess over things, and revisit events that caused us trauma in the past. Too much use of language and thinking could also make it hard to keep in touch with the present moment. We could spend so much time in thinking about our past and worrying about our future that we end up being unable...