The Research Journey of Acceptance and Commitment Therapy (ACT)

Nic Hooper, Andreas Larsson

• Publisher: Palgrave Macmillan
• Year: 2015
• Print ISBN: 9781137440150
• eBook ISBN: 9781137440174
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

In 1986 the first research study investigating Acceptance and Commitment Therapy (ACT) was published. It aimed to determine if an early conceptualization of the ACT model could be used to treat depression. Since this seminal study, further investigations have been conducted across every imaginable psychological issue and the rate at which this research has emerged is impressive. This book describes the research journey that ACT has taken in the past 30 years. It also suggests, in light of the progress that has already been made, how ACT research should move forward in the coming decades.

Part I

Theoretical and Historical Background

1

The Need

If you have been to any ACT trainings or have read any ACT books, you may be familiar with the phrase “the ubiquity of human suffering”. This sentiment suggests that the reason mental health issues are so widespread is that suffering is simply an inevitable artefact of being human. It lies in stark contrast to the mainstream notion of “healthy normality”, which is the idea that it is normal to be psychologically healthy, meaning that if you are not happy, then you are not normal. Many people may not realize that the ubiquity of suffering actually takes centre stage in the ACT model because it provides the space for acceptance; that is, if suffering is normal and common, then maybe acceptance, rather than avoidance, is the way to manage it. Of course, if a major premise of the ACT model is that human suffering is widespread, this would be evidenced by high prevalence rates of mental health disorders.

The World Health Organisation (WHO; Kessler & Üstün, 2008) aimed to determine the likelihood of mental health problems in 17 participating countries (Belgium, Colombia, France, Germany, Israel, Italy, Japan, Lebanon, Mexico, the Netherlands, New Zealand, Nigeria, the People’s Republic of China, South Africa, Spain, Ukraine and the USA). In these studies, people were required to complete a structured interview that screened for diagnostic criteria according to the fourth edition of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-IV; American Psychiatric Association, 1994), both during the past year of the person’s life and during their lifetime. The results were surprising: between 12% (Nigeria) and 47.4% (USA) of people had experienced a mental health disorder in their lifetime. This means, if you live in the USA, that every second person you meet will, at some point, experience enough mental health troubles to warrant a psychiatric diagnosis. The figures for 12-month prevalence were just as startling, with as many as every fourth person reaching the criteria for diagnosis.

These figures provide evidence that there is a need for psychotherapy in helping to manage the growing burden of mental health issues, but this burden is not limited only to those actually suffering. Mental illness is considered the most costly health problem in the Western world (Bloom et al., 2011). In 2010, the direct cost of mental illness (i.e. diagnosis, treatment and care costs) was reported to be 823 billion USD globally. Indirect costs (i.e. housing issues, loss of income, research and sick pay) were 1624 billion USD. Those figures are expected to increase to 1995 billion and 4051 billion USD, respectively, by the year 2030. Additionally, the cost in lost output (i.e. the depletion of a country’s gross domestic product [GDP] due to people being less able to work or manage capital) associated with mental illness is projected at 16.3 trillion USD between 2011 and 2030. Important as the economic burden of mental health is, many of us work within this profession because we want to be able to improve lives at ground level. Therefore, whereas the financial relief that psychotherapy could provide may not totally resonate with us, seeing people suffer does. And, as the aforementioned research suggests, people do indeed suffer. Perhaps this cannot better be illustrated than via statistics about the ultimate act of self-destruction: suicide. According to the WHO (Kessler & Üstün, 2008), suicide, which can often be attributed to mental health issues, is the second leading cause of death among 15–29-year-olds globally; over 800,000 people succeed in suicide yearly and there are many more who fail in suicide attempts. Furthermore, Chiles and Strosahl (1995) put the prevalence rate of serious suicidal ideation over the course of a lifetime at almost 50%. That includes attempted suicide (10%) and suicidal ideation with (20%) or without (20%) a specific plan.

You will find these sorts of chapters in many books about psychotherapy. Often, the words about mental health issues and suicide roll from our tongues and we probably do not fully process the information. But the figures tell a grim story; mental health issues are not something that happen in a far off land, rather they happen all around us. Think about this when you next see your co-workers, your friends, or your family. With ever-growing rates of mental illness, it seems as though suffering is indeed ubiquitous and a part of life. Consequently, many people need help in managing their unwanted thoughts and feelings. With huge concern arising over psycho-pharmaceutical drugs (Whitaker, 2011), the development of psychotherapies has been crucial in the battle to treat mental illness, and finding evidence-based approaches is currently being emphasized the world over. We will now turn our attention to the evidence-based psychotherapeutic models of the middle to late 20th century in an effort to illuminate the roots from which ACT emerged.

2

The Three Waves

The first wave: Behaviour therapy

While the dominant psychoanalytical model of the early 20th century developed mostly from the clinical interactions of Freud and his patients, behaviour therapy emerged from the experimental psychology of John Watson. Watson had come into contact with the work of Ivan Pavlov and, although he was initially of the opinion that Pavlov’s results were more physiological than psychological, he came to employ similar experimental conditions with his work in the USA. Watson viewed psychology as “a purely directive experimental branch of natural science” (Watson, 1913, p. 158) in reaction to the psychoanalytical models of the time. His manifest states that psychology should look at covert behaviour, and not bother itself with introspection and the experience of consciousness (Watson, 1913). The predominant interpretation of Watson’s manifest, which has been debated over time (Barrett, 2012), was that he refused to allow any sort of information not available to the outside observer to be used in psychology. Watson’s importance for behaviour therapy, beyond a first formulation of behaviourism, is in his experiment with “Little Albert” (Watson & Rayner, 1920), a nine-month-old child who was experimentally conditioned to fear a white rat. Watson, who was interested in the mechanisms by which emotional reactions developed, had observed that children seemed to startle at loud noises as a natural reaction. Together with graduate student Rosalie Rayner, Watson conditioned Albert to fear a white rat by striking a suspended metal bar with a hammer whenever Albert touched the rat. Experimentally, the unconditioned stimulus (the noise) occasions an unconditioned response (fear). Since this was performed in the presence of the neutral stimulus (the rat), the rat eventually becomes the conditioned stimulus for fear, which is then called a conditioned response. This means that after conditioning, the white rat itself was enough to cause Albert to become distressed and fearful.

Although the Little Albert experiment has been criticized both for ethical concerns (American Psychological Association, 2002) and for methodological flaws (Harris, 1979), it had clear implications about the development of psychopathology, namely that it could be explained by principles of classical conditioning. Of course, if this is the case, then clinical efforts needed to be developed to help clients re-learn unhelpful associations. Mary Cover Jones (sometimes known as the Grandmother of Behaviourism) was the first to do this. Upon attending one of Watson’s lectures, she went on to design the first desensitization experiment. “The Case of Peter” (Jones, 1960) involved a three-year-old boy, who after having been conditioned to fear a rabbit, successfully had the fear reduced by gradually moving closer to the rabbit in the presence of candy. Although groundbreaking, the study garnered little interest until Joseph Wolpe directed attention to the work. Wolpe, who was both an experimental psychiatrist and a clinician, used the basic ideas of Cover Jones to develop the method of systematic desensitization. In Wolpe’s method, the client is first taken through a progressive relaxation phase to inhibit an anxious response. Second, a hierarchy of feared stimuli is produced in collaboration with the client. Third, the client practices relaxation in the presence of feared stimuli from the hierarchy, starting with the least feared stimulus and moving to the most feared stimulus. To help in this work, Wolpe (1973) constructed the Subjective Units of Distress Scale (SUDS) that is used throughout the world in exposure treatments. The SUDS is a 0–10 scale of distress that involves, in one form or another, asking the client the following question: “On a scale from 0 to 10, 0 being the least distressed you have ever been to 10 being the most distressed you have ever been, how would you rate your current experience?” The measure can be employed in creating the hierarchy by putting stimuli on the hierarchy in ascending order of SUDS ratings. Additionally, in the exposure phase of treatment, clients are also often asked to report their current SUDS level so that it may be tracked.

Systematic desensitization is based on the classical conditioning paradigm and was successful in the treatment of post-traumatic stress patients in the South African army. However, many psychological problems were not treatable through these techniques. Agoraphobia (the fear of small spaces) was one such issue that seemed to benefit from a slightly different approach. Agras, Leitenberg and Barlow (1968) added social reinforcement to the treatment by praising the client upon approaching the feared situation. This use of reinforcement was of course based on the experimental analysis of behaviour by B. F. Skinner, who formulated the operant paradigm in psychology, whereby a behaviour changes in accordance with its consequences (Skinner, 1938). This addition of social reinforcement is one of the success stories in the history of clinical psychology (Barlow, 2004).

The work of Watson, Cover Jones, Wolpe and Skinner all contributed to the development of behaviour therapy, whereby interventions based on the principles of operant and classical conditioning are designed to alter problematic behaviour. However, although behaviourism was the dominant force in psychology in the 1950s, the tide was turning. From the late 1950s, a new interdisciplinary field grew out of neuroscience, linguistics, computer science, anthropology and psychology. It came to be named cognitive science (Miller, 2003) and this approach would eclipse behaviourism as the dominant approach. This eclipse emerged due to the inability of behaviourism to account for language and cognition. Although Skinner developed an extrapolated account in Verbal Behavior (1957), it did not lend itself easily to the development of a research paradigm. The fledgling cognitive studies (the Harvard name for cognitive science pre-1977) criticized Skinner’s account on both linguistic and meta-theoretical grounds (e.g. Chomsky, 1991). Consequently, in psychotherapy, a so-called cognitive revolution occurred through the development of cognitive therapy (CT), which has its own explanation for the advent of psychological disorders (Ramnerö, 2012).

The second wave: Cognitive therapy

Albert Ellis, who was originally a psychoanalyst, developed rational-emotive behaviour therapy (REBT) in 1955 (Ellis & Ellis, 2011). REBT is an active form of psychotherapy, where irrational, negative beliefs are to be restructured so that the client can see their irrationality, self-defeatism and rigidity. Ellis’ focus on irrational cognition caused uproar in psychoanalytic circles and it would be another few decades before the cognitive approach became fully accepted (A. Ellis, 2010). When the change did happen in the 1970s, it was due to the work of Aaron T. Beck, who had also become disillusioned with the psychoanalytical approach. His clients seemed to have dysfunctional and unrealistic negative beliefs about themselves and rapid, difficult to control, negative thoughts. When he explored and challenged these thoughts and beliefs with his clients, they seemed to improve (e.g. Beck, 2011). This led Beck to develop CT, which views negative cognitions as being related to negative emotions and actions. It therefore uses a variety of means, such as cognitive restructuring, to reduce the frequency and intensity of such cognitions, or to change them into more desirable forms, as a way to reduce negative emotions or undesired actions (Masuda, Hayes, Sackett, & Twohig, 2004). Eventually, the Association for the Advancement of Behaviour Therapy (AABT) recognized the impact of CT and renamed itself the Association for Behavioural and Cognitive Therapies (ABCT). According to some, this was not an easy transition; Hayes (2008) recounted Joseph Wolpe saying that cognitions were accounted for already and that cognitive models brought nothing new to the table. Nevertheless, over time the “old” behaviour therapists and the “new” cognitive therapists coined a new approach: cognitive behaviour therapy, or CBT (Hayes, 2004).

This combination seemed to be useful; behaviour therapy, which specialized in behaviour change, now had a complementary approach that targeted cognition. However, even though CBT encompasses a large treatment package, including a number of behavioural techniques, the hallmark mechanism of change is still the modification of maladaptive cognitions or cognitive restructuring (Beck, 1979; Longmore & Worrell, 2007). Judith Beck (2011) explains cognitive restructuring as a method of teaching clients to challenge the absolute truth of maladaptive cognitions. This is approached by training the client to note evidence for and against the thought, to identify thinking errors and to find or develop alternative cognitions that better reflect the full range of their actual experience. Cognitive restructuring, which often takes the format of guided discovery, is thought to teach clients to respond to their dysfunctional thoughts in a more constructive manner, ultimately alleviating their psychological disorder.

CBT has dominated psychotherapy over the past 30 years and part of its success can be attributed to the scores of outcome studies conducted on its effectiveness. The current state of CBT evidence shows it to be the most efficacious treatment for many different disorders, including anxiety and depression disorders, as well as personality disorders and eating disorders (http://www.div12.org/PsychologicalTreatments/treatments.html). CBT even outdoes medical treatments for depression and anxiety (e.g. Butler, Chapman, Forman, & Beck, 2006). Although it is far beyond the remit of the current volume to describe the amount of research behind CBT, a quick search of the literature will substantiate the claim that CBT is the most successful therapeutic approach on the planet.

The aforementioned outcome data made the alliance between the cognitive and behavioural interventions of CBT relatively solid. Still, a number of researchers were curious to see what it was that really made the biggest difference in clients’ lives: the behavioural components or the cognitive components. In 1996, Jacobson and colleagues found that adding cognitive components in the treatment of depression made no difference in outcome compared to just doing behavioural interventions (Jacobson et al., 1996). A few years later, Borkovec, Newman, Pincus and Lytle (2002) made a similar discovery for generalized anxiety disorder (GAD). This made people question the validity and effectiveness of cognitive restructuring for these diagnoses. It was this line of thinking (in combination with the fact that CBT is not always effective for every disorder) that opened up the field for new approaches in the treatment of psychopathology. Some have named this changing tide the third wave.

The third wave

Hayes (2004) includes a number of recent therapeutic models in the third wave, for example, behaviour activation (Kanter, Busch, & Rusch, 2009), mindfulness-based stress reduction (MBSR; Kabat-Zinn & Hanh, 2009), mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2012), dialectical behaviour therapy (DBT; Lin...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• List of Figures and Tables
• Foreword
• Acknowledgements
• Prologue
• Part I: Theoretical and Historical Background
• Part II: Empirical Research
• Part III: The Journey Ahead
• References
• Further Resources
• Index