Acceptance and Commitment Therapy

100 Key Points and Techniques

Richard Bennett, Joseph Oliver

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781351056120
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychothérapie

Acceptance and Commitment Therapy: 100 Key Points and Techniques offers a comprehensive, yet concise, overview of the central features of the philosophy, theory, and practical application of ACT. It explains and demonstrates the range of acceptance, mindfulness, and behaviour change strategies that can be used in the service of helping people increase their psychological flexibility and wellbeing.

Divided into three main parts, the book covers the 'Head, Hands, and Heart' of the approach, moving from the basics of behavioural psychology, via the key principles of Relational Frame Theory and the Psychological Flexibility model, to a detailed description of how ACT is practiced, providing the reader with a solid grounding from which to develop their delivery of ACT-consistent interventions. It concludes by addressing key decisions to make in practice and how best to attend to the therapeutic process.

The authors of Acceptance and Commitment Therapy bring a wealth of experience of using ACT in their own therapy practice and of training and supervising others in developing knowledge and skills in the approach. This book will appeal to practitioners looking to further their theoretical knowledge and hands-on skills and those seeking a useful reference for all aspects of their ACT practice.

Part 1

HEAD

1

The head of ACT – philosophy and theory

This first part of this book, the ‘Head’ of ACT, is concerned with setting the philosophical and theoretical context for the practice of ACT. It is our belief that a solid foundation in the principles of behavioural science is vital to the effective practice of ACT as an intervention in any setting. As experienced trainers, we have witnessed the somewhat seductive power of ACT for people coming across it for the first time. It can be easy to be wowed by the creative use of metaphors or an appealing therapeutic technique, such as engaging a client in a game of tug of war. We would want to urge some caution at the outset, in that if practitioners simply lift metaphors or techniques from this book without having a clear understanding of why they can be useful, the functional analytic approach that underpins the practice of ACT will be lost. Despite how it might appear to someone looking in from the outside, ACT is not just a neat bag of tricks. It is an approach to psychological intervention firmly rooted in a functional contextualist account of behaviourism, and it is our assertion that therapeutic precision and impact will be greater if the practitioner has a clear understanding of what this means.

In the service of assisting you, the reader, to locate your understanding of ACT within the wider behavioural tradition, this part will firstly offer a kind of ‘Behaviourism 101’. This will focus on the key principles that have been influential in shaping the theory and practice of ACT as a psychological intervention. Following this, we will introduce you to Relational Frame Theory (RFT); a behavioural account of language that has been a significant theoretical driver of the development of ACT. One might consider RFT and ACT to be like siblings that have grown up together and influenced each other’s growth and development. Lastly, this part of the book will outline the psychological flexibility model central to the aims of practicing ACT. Here we will discuss the psychological flexibility concept itself, as well as the six core processes that contribute to it.

Key behavioural principles

2

The ‘B’ in CBT

Contemporary Cognitive Behavioural Therapy (CBT) is often spoken about as if it is a single entity. It is more accurate to describe it as a combination of models and approaches that have co-evolved and coalesced over time and are likely to continue to do so in ways that are not yet clear. Any model of psychology that attempts to understand the demands of the human condition will inevitably focus both on observable external behaviours, as well as the less immediately accessible internal realm of thoughts, emotions, values, and desires. CBT explicitly attempts to balance attention to these aspects of human functioning, and behavioural science has made a significant contribution to this endeavour.

Behaviourism is an approach to understanding behaviour that emphasises the role of interactions between an organism, the environmental context in which it exists, and its previous learning history. The focus, behaviour, can be defined as something that an organism does (Watson, 1929). Behaviourism primarily sees behaviour as a response to a stimulus within the present environmental context, or as a consequence of previous learning, such as whether that behaviour has previously been reinforced or punished in the presence of the stimulus. The behaviourists of the early twentieth century, notably Ivan Pavlov and John B. Watson, tended to focus only on observable behaviours and events, with a view to measuring, predicting, and controlling behavioural responses. Later theorists, such as Burrhus F. Skinner, expanded the notion of behavioural science to embrace the study of internal events, including thoughts, feelings, and the processes of language (Skinner, 1953). This became known as ‘radical behaviourism’. In terms of the application of this work to clinical psychology, retrospectively, this phase has been referred to as the ‘first wave’ of what we now recognise as the field that became CBT.

The early promise that behaviourism showed with respect to improving the lives of people somewhat dissipated when the field faltered in its attempts to effectively explain these more sophisticated internal aspects of the human experience. Behavioural approaches to clinical psychology were largely dominant in the US and UK until the early 1970s, at which point popular criticisms that behaviourism was too mechanical and reductionist, or that it effectively denied the role of thoughts and feelings, led psychological therapists to look much more towards cognitive science for their inspiration. This increased focus on cognition, along with the development of techniques for modifying thoughts and beliefs, via the work of Albert Ellis and Aaron T. Beck, is often referred to as the ‘second wave’ of CBT (Ellis, 1962; Beck, 1976).

Certain fields of clinical psychology, notably work with people with intellectual disabilities, and work with children, have always maintained a strong focus on utilising basic behavioural principles. Other fields are rediscovering the important contribution that a solid understanding of the central tenets of behaviourism can bring, as well as benefitting from contemporary developments in behavioural theory. The ‘third wave’ of CBT is characterised by a focus on the functional relationship between behaviour and the contexts in which it occurs, with interventions focusing on modifying the way individuals relate to thoughts, behaviours, and events. ACT (Hayes, Strosahl, & Wilson, 1999) and Dialectical Behaviour Therapy (Linehan, 1993) are prime examples of contemporary models of CBT with radical behaviourism at their core. These models have quickly established a scientific evidence base attesting to their efficacy, ensuring that the ‘B’ in CBT remains alive and well.

3

Learning by association

Thanks to Ivan Pavlov and his dogs, respondent conditioning (sometimes known as classical conditioning) is probably the best-known aspect of behavioural theory. This describes the ability of an organism to learn by associating one stimulus with another. In his famous experiments, Pavlov systematically sounded a bell just before presenting food to his dogs. After several repetitions, Pavlov observed that the dogs began to salivate at the sound of the bell, even when the food was not present. A dog needs no training to salivate when food is presented. In the language of respondent conditioning, food is an unconditioned stimulus (UCS) and salivation is an unconditioned response (UCR). Pavlov had trained the dogs to associate a previously neutral stimulus (NS), the sound of the bell, with food. The bell obtained the function of the food and provoked salivation. In this association, the bell became a conditioned stimulus (CS) and the learned reaction of salivating to its sound is referred to as a conditioned response (CR).

The ability to make associations in this way and relate different stimuli together is a key building block of the learning of all organisms, humans included. The process is often so smooth and multi-faceted to the point that we don’t even notice it occurring. However, this form of learning provides countless opportunities for modifying behaviour in the service of adaptation and survival in a wide range of environmental contexts. It can be an incredibly efficient form of learning. Sometimes even one ‘trial’ is enough to form an association that modifies behaviour for an entire lifetime. Imagine a child frightened by the squawk of a parrot at a young age. The association of fear and parrots might subsequently persist for many years. Parrots and their squawks become a CS. The CR of fear can begin to show up consistently around birds, and can even generalise to similar contextual cues, such as other animals, or places like parks where birds or animals are known to be present. Respondent conditioning is so efficient that the fear response described above could even be learned from observing a parent respond with fear around an apparently passive animal.

It is worth noting that whilst behaviourism often emphasises learning in the present or in the history of the organism, biological preparedness for certain associations is also a relevant factor. Not all neutral stimuli are entirely neutral. For example, it is much easier to condition a fear response to a dog bark, a tall building, darkness, physical pain, or social evaluation, than it is to many other commonly experienced stimuli (Ramnerö & Törneke, 2008).

As with all forms of learning that will be described in this book, respondent conditioning can be responsible for the development of very helpful and adaptive behavioural responses, such as the avoidance of dangerous stimuli. It can also be responsible for the development of conditioned responses that are not adaptive at all, such as the avoidance of stimuli that are not dangerous, and which could even be very rewarding to explore if only the fear did not get in the way.

4

Learning by consequence

Learning to relate stimuli by association, as described by respondent conditioning, does not in itself fully explain why behaviours that result from the conditioning process persist over time. For example, why does the child in the previous chapter, frightened by the squawking parrot, continue to exhibit avoidant behaviour long after that initial squawk, particularly when no physical harm was caused? Operant conditioning, or learning by consequence, can help us to formulate an answer to this question. Consider what the immediate consequence of the child’s avoidant behaviour (getting away from the parrot) might be. First, the behaviour serves the function of removing the aversive external stimulus of the squawking noise; and second, as a result, it removes the aversive internal stimulus of anxiety. The child’s action has resulted in a good outcome, thereby increasing the chances that the child will act in the same, or at least functionally similar, way the next time a comparable situation occurs. It is not hard to see how a broad pattern of avoidant behaviour might grow and grow for as long as it continues to produce favourable outcomes. In this way, behaviourists are not only interested in the behaviour, but also in what precedes and follows it, often expressed as follows:

Antecedent (A) – Behaviour (B) – Consequence (C)

The basic point here is that consequences of a certain behaviour can serve to increase or decrease the likelihood of that behaviour recurring in response to particular antecedents in the future. Behaviour is more likely to be repeated if the consequences of it are experienced as pleasant or rewarding, and less likely to be repeated if it has had unpleasant consequences. Given that consequences can be experienced as pleasant or unpleasant, and stimuli can be both added and removed, four basic scenarios exist for modifying the form and frequency of a certain behaviour. Let us imagine we want to increase the frequency with which Jake tidies his bedroom. There are two strategies we could employ:

•Positive reinforcement: Adding a pleasant consequence to the tidying behaviour (e.g. ‘As soon as your room is tidy, we can go to that new Star Wars movie you’ve been asking to see’)

•Negative reinforcement: Removing an unpleasant consequence to the tidying behaviour (e.g. ‘If you tidy your room, I will clean your football boots for you’)

Should we wish to decrease the frequency with which Jake messes up his room, a further two strategies are available:

•Positive punishment: Adding an unpleasant consequence to the untidy behaviour (e.g. ‘If you mess up your room again, you will be on cleaning duty for the whole house for a week’)

•Negative punishment: Removing a pleasant consequence to the untidy behaviour (e.g. ‘If you mess up your room again, there will be no movie trips for a month’)

It is worth noting the use of ‘positive’ and ‘negative’ are often misunderstood in the context of operant conditioning. They are not synonymous with ‘good’ and ‘bad’, rather they are indicative of ‘increase/addition’ and ‘decrease/subtraction’ of a consequence respectively.

Not all behaviours are followed by consequences that function as reinforcement or punishment. Extinction is the term used to describe the situation when a behaviour declines in frequency because it is not reinforced or the reinforcement ceases. For example, Jake is unlikely to continue to tidy his room if he learns that the treats he is promised for doing so never actually materialise.

5

Appetitive and aversive control

There are many ways of describing and classifying behaviour. One of the key behavioural principles that influences the practice of ACT is the notion that the behaviour of any organism can be grouped into one of two broad functional classes: behaviour under appetitive (coming from the word appetite) control; and behaviour under aversive control.

Different behaviours can be classified as having the same function, even though they appear to be quite dissimilar. Imagine a client in therapy who finds the therapist’s focus on the key issue of worthlessness to be very uncomfortable. The client might avoid this discomfort by using humour to redirect the conversation, or, alternatively, he might simply stop attending sessions. These two behaviours appear very different, although they belong to the same functional class, because both are attempts to avoid the unwanted experience of discussing the feeling of worthlessness. In the example, the client can be said to be acting under aversive control, that is, his behaviour is designed, either consciously or not, to diminish contact with an experience that he finds aversive. It is not difficult to appreciate how this client might have acquired a learning history w...