Acceptance and Commitment Therapy

Published in Oregon Psychological Association Newsletter, May/June, 2006. Suffering, a Dog, and Woody Allen: An Introduction to Acceptance and Commitment Therapy Jason Luoma, Ph.D., & Jenna LeJeune, Ph.D. Client: So you’re saying that I can’t do anything about my anxiety? Therapist: I’m not telling you anything… I’d just like you to check what your experience has to say. As you’ve gone to war with your anxiety, has it gotten smaller and moved off to the side of your life, or have you seen it becoming, unbelievably, even larger and more central in your life? Client: …Central. Therapist: I’d like you to consider the possibility that this battle with anxiety is one you can’t win. It’s like a rigged game, and the way this game turns out is your life… It happens with uncanny predictability; a client comes in to a first session of Acceptance and Commitment Therapy (ACT, said as one word, not the individual letters) and regardless of the content, the form of the complaint is “I don’t want to feel/think/have ‘this’ anymore”, whether ‘this’ is depression, anxiety, anger, memories of a trauma, etc. And often, it’s the client’s very struggle to get rid of this suffering that has consumed the client’s life, and resulted in its current unworkable state. ACT is about letting go of this struggle. When suffering knocks at your door and you say there is no seat for him, he tells you not to worry because he has brought his own stool. Chinua Achebe (1930 - ____) Nigerian novelist Arrow of God, 1967. Dalai has it good Suffering is ubiqitous. And according to ACT, the main culprit is language, which has certain basic properties that serve to amplify suffering to a level unfound in nonhumans animals. The theory on which ACT is based is called Relational Frame Theory (RFT), and is a result of a 20 year program (80+ published studies) of basic research into the nature of language and cognition (Hayes, BarnesHolmes, & Roche, 2001). Informed by this theory, the ACT therapist helps clients see that their struggles largely result from minds and the language they produce, rather than their direct experience. In ACT we seek to help clients disentangle from the futile tug-of-war with their languaging minds. ACT distinguishes between “clean discomfort” (i.e. pain that emerges naturally from the interaction of our history with current circumstances) and “dirty discomfort” (i.e. the additional suffering that results when we try to control, eliminate, or reduce this original pain). Dalai, our dog, doesn’t have language in the way that humans do (by “language” we refer to the ability to do such things as think symbolically). Because of this Dalai only experiences “clean discomfort.” She suffers when she comes into direct contact with a negative event in her environment (e.g. when I remove the bone from her mouth that she has salvaged from the garbage) or something that predicts a negative event (e.g., a scary-looking dog charges her). However, much of human suffering comes from the story we tell ourselves about distressing past or anticipated events (e.g. It is so horrible that I am depressed. I’ll never get out of this) and our entanglement with this story. Because Dalai doesn’t have human language, she is always in the present moment. She doesn’t have the ability/curse of making judgments Published in Oregon Psychological Association Newsletter, May/June, 2006. about not having the bone, worrying about whether the bone will still be there tomorrow, or whether the bone is going to straight to her hips. In this sense she is truly an enlightened being like the one after whom she is named. So suffering is ubiquitous. Sorry, nothing we can do about that. And we don’t want to be dogs, without the abilities that language gives us. So is that the end of it? Collect our money, go home to wallow in our own language-fueled suffering? On the contrary, we would contend that life and therapy can have much more hope, more possibility than simply eliminating of an acute state of discomfort. We ask our clients this essential question “Would you be willing to have what you already have in terms of unpleasant thoughts/feelings, to welcome them willingly into your life, if that meant you could live the life you’ve always wanted to live, if you could be the person you would choose to be if you could write the story?” The goal of ACT is not to eliminate certain parts of one's experience of life, but rather to learn how to experience life more fully, without as much struggle, and with vitality and commitment. What ACT is and what ACT isn’t ACT is one of a “third wave” of cognitive behavioral therapies (Hayes, 2004) that includes Dialectical Behavior Therapy (DBT; Linehan, 1993), mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2001), and Integrative Behavioral Couples Therapy (Jacobson, et al., 2000). What sets these approaches apart from traditional CBT (alá Beck or Ellis) is that rather than trying to directly change the content of thoughts, feelings, sensations, or memories, these therapies seek to change the function of those events and the individual’s relationship to them (Teasdale, 2003). For example, the ACT therapist would not try to identify or change “irrational” thoughts. Rather, through the process of cognitive defusion, ACT helps clients disengage from the struggle with language altogether, to see that winning the battle with language is not only impossible, but also unnecessary in order live a vital life, one of value. In contrast to many traditional cognitive and behavioral therapies, ACT is dominantly experiential. We rely on metaphors, stories, and exercises to step outside of literal language. In this way, ACT shares similarities to Gestalt therapy with its emphasis on in-session “experiments” and experiential exercises. One claim that has been made about ACT is that it is essentially Buddhism dressed up in scientific clothing. Certainly, ACT borrows from many traditions, including Buddhism. However, as ACT is a scientific endeavor rather than one of faith, it must be, and is, based on a cohesive theory that is subject to all the rigors of empirical investigation. While some aspects of ACT, such as mindfulness and acceptance, share commonalities with some forms of Buddhism, it also has unique components which are not found in any Buddhist teachings of which we are aware. In total, ACT owes much more of its theory and interventions to B.F. Skinner than the Buddha. Experiential avoidance as the root of psychopathology Many forms of psychopathology can be conceptualized as unhealthy efforts to escape, avoid, control, or suppress emotions, thoughts, memories, and other private experiences (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). People engage in a broad range of behaviors in order to avoid making psychological contact with negatively evaluated private events, such as engaging in thought or emotional suppression, social withdrawal, drug use, and sexual acting out. Unfortunately, efforts to suppress or eliminate negative thoughts or emotions often result in actually increasing the frequency, intensity, and behavioral regulatory powers of these experiences. ACT seeks to increase psychological acceptance, the ability to contact negatively evaluated private experience, directly, fully, and without needless defense – while at the same time behaving effectively. Published in Oregon Psychological Association Newsletter, May/June, 2006. Acceptance is but one process through which ACT achieves the goal of enhancing psychological flexibility, the process of contacting the present moment fully as a conscious human being, and based on what the situation affords, changing or persisting in behavior in the service of chosen values. The Hexa-what? The hexagon model below (jokingly called the “hexaflex”) illustrates the six processes through which ACT attempts to increase psychological flexibility. Contact with the Present Moment Values Acceptance Psychological Flexibility Defusion Committed Action Self as Context Cognitive defusion involves helping people to step back from their thoughts and be able to respond to thoughts based on their usefulness rather than their literal “truth.” Self as context refers to clients contacting a sense of self as the context, arena, or place where events occur, rather than attaching to the unhelpful self-evaluations and stories about themselves that their minds give them. Contact with the present moment refers to ongoing, non-judgmental contact with psychological and environmental events as they occur in order to help people experience the world in more direct and flexible ways. ACT uses a variety of exercises to help a client choose valued life directions in various domains (e.g. family, career, spirituality) while undermining verbal processes that might lead to choices based on avoidance or social compliance. Finally, ACT encourages committed action through helping clients develop concrete goals that are values consistent and helping clients work toward these goals (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). Utilizing all six components the ACT therapists asks of both ourselves and our clients: “Given the distinction between you and the stuff you are struggling with and trying to change (“Self as context”), are you willing to have that stuff, fully, and without defense (“Acceptance”), as it is, and not what it says it is (“Defusion”), AND do what takes you in the direction (“Committed action”) of your chosen values (“Values”), in this time and this place (“Contact with the present”)? If the answer to that question is “Yes”, then that builds psychological flexibility. ACT as a science Data are emerging rapidly, particularly since the first book on ACT was published (Hayes, Strosahl, & Wilson, 1999). ACT has been delivered in both individual and group psychotherapy formats and has Published in Oregon Psychological Association Newsletter, May/June, 2006. been manualized in specific form for a number of different client problems including manuals for OCD, psychosis, chronic pain, smoking, school problems, panic, depression, and substance abuse. A recent literature review of the ACT model and processes of change (Hayes et al., 2006) found 19 randomized controlled trials with a general between-group effect size at follow up of d=.63 (medium to large effect) for ACT versus other active treatments and d=.71 (large effect) for ACT versus wait list, treatment as usual, or placebo. Targets of intervention included depression, polysubstance abuse, work stress, epilepsy, smoking, social anxiety, borderline personality disorder, psychosis, chronic pain, panic, and burnout/stigma, among others. Numerous case reports and component analysis studies examining specific therapeutic processes have also been conducted. ACT has preliminary evidence for effectiveness across a wide range of disorders and has fairly strong evidence for the general model. One of the unique aspects of the ACT model is the reputed processes of change for ACT are holding up fairly well in mediational analyses, as compared to traditional cognitive-behavioral therapy. For those interested in more up-to-date research information, one can check out www.contextualpsychology.org/state_of_the_act_evidence. ACT resources One of the unique aspects of ACT is the community which supports its development and dissemination. The community of practitioners and researchers working to develop ACT have gone through an intentional process focused on creating an open and nonhierarchical community. The main hub of this work is the contextualpsychology.org website, a changing, living website where members are able to add their own webpages, create their own blogs, and participate in discussion forums. A large range of resources for training, including reading lists, workshops, and discussion/advice can also be found on contextualpsychology.org as well as on Learningact.com. For those interested in learning more about ACT, a great place to start is the client workbook Get Out of Your Mind and Into Your Life (2005) by Steven Hayes and Spencer Smith. Other books can be found by searching an online bookseller for ACT. Locally, there is an ACT consultation group for professionals with varying degrees of experience in ACT that meets twice a month. To learn more about this meeting please contact Jason Luoma at jbluoma@gmail.com. We welcome newcomers to the group. Conclusion To conclude, we’ll leave you with the words of the inimitable philosopher, Woody Allen, who once said “What if everything is an illusion and nothing exists? In that case, I definitely overpaid for my carpet.” If an ACT therapist were working with Woody, he or she might ask “Let’s assume God came down and told you that was 100% true, what would you do then?” References Hayes, S. C. (2004). Acceptance and Commitment Therapy, Relational Frame Theory, and the third wave of behavior therapy. Behavior Therapy, 35, 639-665. Hayes, S. C., Barnes-Holmes, D., & Roche, B. (2001) (Eds.), Relational Frame Theory: A PostSkinnerian account of human language and cognition. New York: Plenum Press. Hayes, S. C., Luoma, J., Bond, F., Masuda, A., & Lillis, J. (2006). Acceptance and Commitment Therapy: Model, processes, and outcomes. Behaviour Research and Therapy, 44, 1-25. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press. Hayes, S. C., Wilson, K., Gifford, E., Follette, V., & Strosahl, K. (1996). Experiential avoidance and behavior disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64, 1152-1168. Published in Oregon Psychological Association Newsletter, May/June, 2006. Jacobson, N. S., Christensen, A., Prince, S. E., Cordova, J., Eldridge, K. (2000). Integrative behavioral couple therapy: An acceptance-based, promising new treatment for couple discord. Journal of Consulting and Clinical Psychology, 68, 351-355. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford. Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York: Guilford Press.