Acceptance and Commitment Therapy

Distinctive Features

Paul E. Flaxman, J.T. Blackledge, Frank W. Bond

• Publisher: Routledge
• Year: 2010
• ISBN:
  9781136851186
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

What are the distinctive theoretical and practical features of acceptance and commitment therapy?

Acceptance and commitment therapy (ACT) is a modern behaviour therapy that uses acceptance and mindfulness interventions alongside commitment and behaviour change strategies to enhance psychological flexibility. Psychological flexibility refers to the ability to contact the present moment and change or persist in behaviour that serves one's personally chosen values.

Divided into two sections, The Distinctive Theoretical Features of ACT and The Distinctive Practical Features of ACT, this book summarises the key features of ACT in 30 concise points and explains how this approach differs from traditional cognitive behaviour therapy.

Acceptance and Commitment Therapy provides an excellent guide to ACT. Its straightforward format will appeal to those who are new to the field and provide a handy reference tool for more experienced clinicians.

Part 1
THE DISTINCTIVE THEORETICAL FEATURES OF ACT

1
ACT, human suffering, and experiential avoidance

Acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999) was designed as an alternative to more traditional brands of psychotherapy (such as conventional cognitive-behaviour therapy: CBT), which place a primary emphasis on decreasing the intensity and frequency of aversive emotions and cognitions. Rather than direct attempts to decrease such levels, ACT focuses on increased behavioural effectiveness, regardless of the presence of unpleasant thoughts and emotions of varying degrees of intensity. In other words, the ACT therapist does not attempt to change the client’s distressing thoughts or attenuate their distressing emotions—though, perhaps ironically, psychological distress does typically decrease when ACT is successful. While it might at first appear bizarre to design a psychological treatment that does not attempt to make clients feel better and think differently, there is an arguably sound rationale for doing so.

The assumption that marked degrees of psychological distress are a normal part of the human experience is central to ACT. This assumption stands in contrast to the majority view in clinical psychology and psychiatry, where degrees of distress equated with psychological disorders are viewed as statistically deviant. The majority view that distress severe enough to warrant psychological diagnosis is statistically abnormal, however, may well be in error. For example, Kessler et al. (1994) estimated that 50% of the US population between the ages of 15 and 54 qualified for at least one DSM-IIIR diagnosis, with 80% of those qualifying for two or more diagnoses. Moffitt et al. (2009) presented an even grimmer estimate, finding in a longitudinal study that between 57% and 65% of US and New Zealand samples had been diagnosable with at least one psychological disorder by the age of 32. Studies such as these suggest that while a diagnosis of any specific psychological disorder remains statistically abnormal, the marked degrees of psychological distress indicated by psychological disorders as a whole appear to be encountered by most at least once in their lives.

From an ACT and relational frame theory (RFT) perspective, this high prevalence of human suffering is not surprising. Non-human animals appear to require very little in order to thrive and appear relatively happy: food, water, warmth, shelter, a modicum of physical contact, and a relative lack of physical abuse. RFT (see Point 4) describes how normal human language processes dramatically change the human experience by resulting in the ability to readily and frequently evaluate virtually all of its aspects negatively. Once humans develop the uniquely verbal capacity to reflect on their existence, consider its eventual end, compare it to imagined “ideals”, identify personal “flaws”, and use these “flaws” as evidence of “unworthiness”, the potential for psychological distress appears to dramatically increase (even though, as will be discussed in Point 6, many aspects of these “verbal constructs” are literally constructed, rather than serving as immutable reflections of reality). RFT posits that this verbal ability sets up a drive and capacity for experiential avoidance (see, for example, Hayes et al., 1999, pp. 58–69), the act of attempting to avoid unpleasant thoughts, emotions, memories, and other private experiences.

The human capacity for experiential avoidance is significant for at least two reasons. First, many experientially avoidant behaviours either cause physical harm or compound the problem(s) that engendered them in the first place. Drinking, drugging, overeating, and lack of exercise are often prime examples of physically harmful experiential avoidance (EA); behaviours involving procrastination and avoidance of constructive conflict often simply make the precipitating distress even worse. In other words, many instances of EA may offer some initial relief, but make our problems and our distress worse over the long run. Second, many instances of EA prevent us from living life in a meaningful, purposeful, and vital way. If one values a close, caring, and loving relationship, for example, yet consistently disengages from one’s partner when unpleasant emotions arise, one will be unlikely to develop and maintain such a relationship. Or, if one values a fulfilling professional career yet typically balks at the stressful demands entailed, the fulfilling career is unlikely to come to fruition. When life is lived in such a manner, life satisfaction and well-being would be expected to markedly decrease over the long run. The conclusion comes readily: increased degrees of EA, along with typically failing to reduce distress in the long or even short term (see Point 18), move one increasingly away from a meaningful, purposeful, and vital life.

These ACT/RFT assumptions suggest that a different way of approaching human suffering may be indicated. If marked psychological distress is a part of normal human life that can often not be avoided, and if frequent experiential avoidance tends to both exacerbate distress and decrease quality of life, then perhaps psychotherapy should help clients find ways to accept the distress that arises in the course of pursuing a meaningful, purposeful, and vital life. This suggestion is nothing new, and in one form resembles the all-too-difficult-to-follow advice many of us received from our grandparents: keep a stiff upper lip, carry on, and discharge one’s responsibilities. But ACT’s basis in RFT suggests a different prescription more viable and attractive than sheer perseverance. At the core of RFT’s account of language and cognition is the assumption that the kinds of abstract, evaluative words we struggle with that claim to capture reality, in fact cannot. Thus, the acceptance asked of an ACT client is not an acceptance of his experience as he literally perceives it, but rather an acceptance of his experience as it is, and not as his mind says it is. Points on RFT, acceptance, cognitive defusion, and self-as-context later in this book will explain how this distinction is put into action.

2
Developments within CBT: ACT and the Third Wave of behaviour therapy

The behaviourism of John Watson and B.F.Skinner arose, in part, as a reaction to the relatively introspective, non-empirical approach Freud took toward psychology (e.g. Watson, 1913). The principles of operant and respondent (or classical) conditioning relied solely on directly observable variables, and both Skinner and Watson placed primary emphasis on pragmatics. In other words, rather than “explaining” behaviour at multiple levels of analysis, their parsimonious theories of behaviour largely sought to enhance the degree to which one could predict what organisms would do under particular circumstances and control or systematically change those behaviours using operant and respondent principles (e.g. Smith, 1992). Perhaps not surprisingly, exposure-based behavioural treatments for problems like anxiety and fear proved to be relatively brief and effective from early on (e.g. Jones, 1924; Wolpe, 1958), with operant approaches to the treatment of depression (e.g. Ferster, 1973) and a variety of developmental disabilities (e.g. Baer, Wolf, & Risley, 1968) arising as similarly effective treatments later on. This tide of empirically supported behavioural momentum eventually came to be known as the “First Wave” of behaviour therapy (Hayes, 2004a).

Beginning in the late 1950s (e.g. Chomsky, 1959; Ellis, 1957), the tides began to change. Proponents of the newly founded subfield of cognitive psychology had grown increasingly dismissive of the behavioural insistence on confining psychology to the study of only directly observable behaviour. Additionally, the continuity hypothesis (where learning principles observed in the animal laboratory were presumed to hold inviolably for human beings as well) advocated by behaviourists like Skinner and Watson essentially came under question (e.g. White, Juhasz, & Wilson, 1973). Initial objections to the continuity hypothesis, such as Chomsky’s (1959) very negative review of Skinner’s Verbal Behavior (1957), were largely not empirically based, but rather focused on the apparently obvious observation that human language and cognition granted human beings learning and processing abilities far beyond those of other animals. (Ironically, even empirical research produced by behavioural psychologists—such as stimulus equivalence research conducted by Sidman & Tailby, 1982, and research conducted on rule governance cited in Point 4—later began to very strongly suggest that human and animal learning appeared to have some very marked differences.) As a result, cognitive therapy—with the premise that potentially changeable irrational and distorted cognitions produced the lion’s share of psychopathology—began to take centre stage beginning in the late 1970s (e.g. Beck, 1976). Cognitive interventions focused on changing dysfunctional and/or irrational thoughts, attributions, and self-talk began to be provided more or less alongside tried and true behavioural treatment components such as exposure, skills training, and behavioural activation. This marked change in direction came to be called the “Second Wave” of behaviour therapy.

Spurred by a desire to both improve upon the effects of conventional CBT and to parsimoniously extend behavioural principles to account for the apparent effects of human language and cognition (see Hayes, 2004a, for an extended account), Steven C.Hayes and colleagues began formulating relational frame theory (RFT; Hayes & Hayes, 1989) and comprehensive distancing (now called acceptance and commitment therapy; Zettle & Hayes, 1986). RFT posited a relatively unique set of directly observable operant-based learning processes intended to account for the effects of language on human behaviour. The approach avoided criticisms of mentalism (e.g. Hayes & Brownstein, 1986) and the inclusion of unobservable constructs in psychological theories (Wilson, 2001) that have been levelled against cognitive psychology, and at present reportedly over 180 published, peer-reviewed studies (personal communication, S.C.Hayes, 8 September 2009) have uniformly supported its tenets and indicated how RFT-based processes interact with and often supersede conventional operant and respondent conditioning processes. Perhaps more importantly, RFT suggests that a more viable way of addressing problematic thoughts and emotions may involve interventions that help one experience them in a different manner (or within a different context), rather than systematic attempts to change them or reduce their frequency. It is this focus on changing the context in which distressing thoughts and emotions are experienced (rather than conventional CBT’s focus on changing the content of thoughts and feelings) that is perhaps the leading hallmark of the “Third Wave” of behaviour therapy, and defining this “wave” in this manner includes other contemporary brands of psychotherapy, such as dialectical behaviour therapy (Linehan, 1993) and mindfulness-based cognitive therapy for depression (Segal, Williams, & Teasdale, 2002), under the moniker as well.

However, ACT arguably differs from Second Wave cognitive and cognitive-behavioural treatments in an additional way. The developmental trajectory of ACT bears a striking resemblance to the First Wave years of behaviour therapy. ACT co-emerged with a basic experimental account of human behaviour (RFT) and its applications reflect the tenets of RFT to no small degree. Basic lab-based RFT explorations of core ACT constructs like cognitive defusion, self-as-context, acceptance, and commitment to values-driven behaviour have been published and continue to be conducted. These studies, as with RFTbased studies on the effects of metaphorical thinking, have arguably impacted the development of ACT, just as ACT has impacted the research agenda of experimental psychologists well versed in RFT. In other words, the relatively close linkage between basic experimental and applied science evidenced in the First Wave of behaviour therapy is again being evidenced by ACT and RFT in the Third Wave. These similarities are not a coincidence. Rather, they are a product of the assumption that a focused and consistent integration of basic and applied research, as well as explicit empirical assessment of the processes that drive behavioural change, will more quickly move our ability to predict and change human behaviour forward. To put it more succinctly, it is hoped this wave of behaviour therapy can produce a family of treatments “more adequate to the challenge of human suffering” (Hayes, 2008a). Whether these rather enthusiastic goals can be achieved still remains to be seen.

3
Functional contextualism

At the most fundamental level, the scientific method is simply a set of tools and procedures used to find more reliable answers to a great variety of questions. What greater purpose this process should be put toward is a matter of opinion, and what these answers say about the world around us depends, in part, on the different assumptions we make about knowledge and what it can tell us about reality. Philosopher Stephen Pepper (1942) maintained that all scientists make one of four sets of relatively adequate pre-analytic assumptions about how scientific findings reflect or do not correspond to objective reality in an absolute sense. By “pre-analytic”, Pepper meant that these assumptions are not scientifically testable, but rather simply subjective, philosophical beliefs about how knowledge does or does not reflect universal truth. One is free to adopt any of these four sets of goals as the “purpose” of science, given that they are simply assertions about how science can and should be used. Pepper stated that the most common set of assumptions among scientists, mechanisms, iterate that one knows a scientific theory is true when it corresponds accurately to the real world. In other words, a mechanist (or realist) would assume that the ultimate goal of psychological theory and experimentation is a complete understanding of what all the human psychological processes really are and how they really work together, an understanding that would result in perfect prediction of what humans will do under an infinite variety of circumstances

By contrast, Pepper (1942) stated that contextualists assume that an objective reality is not conclusively knowable. Due to a number of factors, such as human perceptual errors, measurement error, errors in data interpretation, and observational effects on subjects of study, contextualists assume that scientific theories cannot capture objective Truth (with a capital “T”), but can organize the way we think about the world in ways that allow us to act more effectively within the theory’s domain. In other words, a contextualist would assume that the ultimate goal of psychological theory and experimentation is to develop ways of talking about human psychological processes that maximize our ability to accurately predict and control (change) human behaviour. The goal is purely pragmatic—use theories and research to find increasingly better ways to change people’s behaviour for the better. While a contextual psychologist would certainly believe there is a...