Essentials of Acceptance and Commitment Therapy

Sonja Batten

• Editorial: SAGE Publications Ltd
• Año: 2011
• ISBN:
  9781446242681
• Edición: 1
• Categoría: Medicine
• Categoría: Psychiatry & Mental Health

?The literature on Acceptance and Commitment Therapy (ACT) is vast but if you want to dig down to the essentials of ACT you?ve found the right volume. Nothing central is left out and nothing unnecessary is left in. Written by one of the world?s experts on ACT, this book delivers. Highly recommended.? - Dr Steven C. Hayes, Foundation Professor, University of Nevada

This practical, easy-to-use book introduces the theory and practice of Acceptance and Commitment Therapy (ACT), a key contextual third wave CBT approach. The book takes the reader through the therapeutic stages from start to end, showing how to use acceptance and mindfulness together with commitment and behaviour change strategies to improve mental health. This is a uniquely concise and clear introduction that does not require prior knowledge of the approach. It

"puts the emphasis on practical interventions and direct applicability in real practice

"avoids jargon and complex language

"is full of case examples to translate the theory into practice

"includes key points and questions to test readers? comprehension of the topics covered.

After reading this book, readers will be able to apply basic ACT interventions for common problems, and will know if they are interested in more in-depth training in ACT. This is a must-have overview of ACT for CBT trainees on graduate level courses in the UK and worldwide. It will also be of value to practitioners on ACT workshops and short courses, as preliminary or follow-up reading.

1

The ACT Conceptual Framework

Key Concepts

• Some techniques in ACT may be familiar to therapists from other traditions; it is the contextual behavioural theory that ties ACT together to make it unique.
• The focus within ACT is pragmatic – the emphasis is on what works for a particular person to move toward a valued life.
• From an ACT perspective, much of what is seen as psychopathology in other systems can be conceptualized as resulting from experiential avoidance.

Acceptance and Commitment Therapy (pronounced as the word ‘ACT’) is an innovative behavioural therapy designed to help individuals reduce unnecessary suffering and move forward with building lives that they value. Although ACT has been in development since the early 1980s, most current ACT practitioners have become familiar with the treatment model since the year 2000 and thus see it as a new treatment. Developed originally in the United States, ACT books and trainings are now available in multiple languages and around the world. The goal of this text is to provide a practical introduction to the essentials of ACT that can be utilized as a supplement in psychotherapy training courses, or used by practitioners to reinforce ACT concepts and basic skills before or after attending an ACT workshop or training.

Revolutionary not just for the specific techniques or strategies that are incorporated into the treatment, ACT takes the pragmatic principles of a contextual perspective, along with the commitment to empirical support that is the cornerstone of evidence-based practice, and combines those philosophical assumptions with an existential and experiential sensibility. It is beyond the scope of the current text to address the core philosophy that underlies ACT in great detail. Those who are interested in an analysis of the theoretical underpinnings of this work are referred to the texts listed in the Further Readings section at the end of this chapter (see especially Hayes et al., 1999, 2001). This introductory chapter will provide a very basic overview of those theoretical principles, as well as a guide to the concepts to be covered in the rest of the text. Because the ACT model proposes that the processes at the core of problematic behaviour are common to all humans, the client and the ACT therapist are seen as being on the same level in the therapeutic relationship. Special considerations regarding the therapeutic stance in ACT will be addressed in Chapter 2.

The model upon which ACT is based can be described as having six primary areas of focus: Acceptance, Defusion, Contact with the Present Moment, Self-as-Context, Values and Committed Action. In successful ACT treatment, the therapist and client work together using these processes for the purpose of enhancing psychological flexibility and improving the client’s life. It is important to note that the experienced ACT therapist will work flexibly with all six of these processes throughout treatment – sometimes using all six in one session alone. However, for the purpose of clarity in this text, these six processes will be presented sequentially (in Chapters 3 to 8). In fact, some ACT treatment protocols would have the therapist focus on these six processes in the order in which they occur in this text, and there is good theoretical reason to do so in many cases. However, there are as yet no data to suggest that these processes must be approached in a specific sequence, and many experienced ACT therapists will work through these areas flexibly over the course of treatment and depending on the client’s presentation.

It is important to note that the ACT clinician does not simply move flexibly from one therapeutic target to the next simply based on moment-to-moment whim. The early part of therapy with any ACT client is devoted to a functional analysis – determining the environmental influences on the client’s behaviour. How is ineffective behaviour being reinforced or strengthened, and effective behaviour being punished or weakened in a client’s life, such that the person’s life is not full of the things that he or she values? From an ACT perspective, there are several potential processes that are likely candidates for contributing to a client’s ineffective behaviour, and awareness of these processes is used for hypothesis generation and to guide the development of a fundamental case conceptualization and treatment plan. Although multiple processes have been identified as potentially contributing to ineffective behaviour in the ACT model, such as weak self-knowledge, attachment to the conceptualized self, lack of values clarity and persistent inaction, impulsivity or avoidance (Bach and Moran, 2008), this chapter will focus on two of the most pervasive problems: experiential avoidance and cognitive fusion.

EXPERIENTIAL AVOIDANCE

Experiential avoidance has been defined as a process by which individuals engage in strategies designed to alter the frequency or experience of private events, such as thoughts, feelings, memories or bodily sensations (Hayes et al., 1996), and the resulting model holds avoidance as key in the development and maintenance of a variety of psychological disorders. Although such processes may be reinforced in the short term because they result in reduced immediate distress, they are likely to cause increased symptoms and behavioural problems over time. The concept of experiential avoidance may be best demonstrated through some common examples of major classes of psychopathology as currently categorized.

For example, in what is called Panic Disorder with Agoraphobia, an individual experiences bodily sensations, thoughts and feelings that are evaluated as extremely negative (i.e. anxiety and panic attacks), and thus avoids places, situations and things that may bring on those unwanted sensations and reactions. Gradually, as the person avoids more and more situations in the service of not having to feel anxiety or experience panic, her life becomes much more constricted and ‘disordered’. From an ACT approach, an important aspect of treatment would focus on helping the client to identify the problematic role of avoidance in the development and maintenance of the Panic Disorder, before then moving on to mindfulness and acceptance work to facilitate committed action in valued domains. Similar conceptualizations exist for many other problem areas, including (but by no means limited to) substance abuse, post-traumatic stress disorder (PTSD), depression and suicidal/parasuicidal behaviour.

If experiential avoidance is so pervasive and caustic, then does this mean that all avoidance is bad? Absolutely not. The ACT approach is about flexibility and adaptable patterns of behaviour. It would be an extreme overstatement to say that all forms of avoidance are bad or will lead to psychopathology. The individual who distracts himself with music or positive imagery while having his teeth drilled at the dentist is not automatically going to develop a psychological health problem. The trouble begins when avoidance is the most frequent or characteristic way that an individual chooses to deal with difficult experiences or private events (i.e. thoughts, feelings, memories, bodily sensations) or when the person does not have other, more adaptive, coping skills upon which to rely in times of stress or distress. Chapter 3 provides more information about the assessment and identification of each client’s avoidant behavioural strategies.

COGNITIVE FUSION

Another core process that is believed to be relevant to problematic or dysfunctional behaviour from an ACT perspective is known as ‘cognitive fusion’. As mentioned above, ACT is based on a comprehensive theory of human language and cognition, and this theoretical model is called Relational Frame Theory (RFT) (Hayes et al., 2001). RFT suggests that one of the ways in which humans are different from any other animal is in the ability to arbitrarily relate things and events to each other and in combination, and to change the way we perceive the characteristics of specific events and experiences, simply by relating them verbally to others (Hayes et al., 2006b). Through these processes, words themselves take on the properties of the things to which they refer. This can be helpful, as calling up the word ‘hammer’ or the image of a hammer may help us to solve a problem, even when there is not a hammer immediately present in the environment. However, it also means, for example, that when a rape survivor has thoughts about her trauma experience, it can bring up, in the present, all of the thoughts, feelings and memories associated with the original experience, even if it was many years ago. Thus, this process of ‘fusion’, by which verbal processes come to excessively or inappropriately influence behaviour, may lead one to behave in ways that are guided by inflexible verbal networks rather than by the direct consequences one would encounter in the environment (Hayes et al., 1999). For example, the rape survivor who is fused with the thought ‘I can’t trust anyone’ would be encouraged to try out a variety of interpersonal behaviours to see what happens, rather than having her choices guided by the inflexible rule suggesting that people are not to be trusted. ACT treatment, then, places emphasis on helping individuals not be governed rigidly by the thoughts and rules in their head (e.g. ‘I can’t stand this anxiety anymore’), working instead to find ways to interact more effectively with the directly experienced world, rather than the verbally constructed one in one’s ‘mind’.

It is for this reason that the ACT approach includes a variety of different therapeutic tools in its clinical or applied work. If an overly dominant focus on words and verbal constructions of situations is believed to be part of the problem, then it is easy to see how trying to ‘describe’ solutions or other ways of dealing with problems to clients could be counterproductive. Thus, many of the core methods of working with clients involve the use of metaphors or experiential exercises that are designed to focus people on things in their direct experience or awareness. More examples of working with cognitive fusion will be provided in Chapter 4.

EMPIRICAL SUPPORT FOR ACT

Consistent with the broad model of psychopathology suggested above, ACT has been shown to be an effective treatment for a wide variety of disorders – with much broader effectiveness across diverse conditions than most treatment approaches. Several illustrative studies and literature reviews are highlighted in the text box entitled, ‘Sample of Existing Evidence for ACT’. It is important to note that this is by no means an exhaustive list, and a literature search will provide the most recent data sources. However, it does provide a sense of the breadth of the evolving ACT literature, where ACT has been shown to reduce hospitalization for psychotic disorders, improve quality of life for individuals with chronic pain, increase compliance with a medical regimen for diabetes, and improve functioning across many other domains. Further information on the evidence for ACT with anxiety disorders, depression and substance abuse will be provided in Chapters 9, 10 and 11, along with practical guidance on the application of the ACT approach to these presenting problems.

SAMPLE OF EXISTING EVIDENCE FOR ACT

Literature reviews:

Hayes, S.C., Luoma, J., Bond, F., Masuda, A. and Lillis, J. (2006) Acceptance and Commitment Therapy: model, processes, and outcomes. Behaviour Research and Therapy, 44: 1–25.

Ruiz, F.J. (2010) A review of Acceptance and Commitment Therapy (ACT) empirical evidence: correlational, experimental psychopathology, component and outcome studies. International Journal of Psychology and Psychological Therapy, 10: 125–62.

Pain:

Wicksell, R.K., Ahlqvist, J., Bring, A., Melin, L. and Olsson, G.L. (2008) Can exposure and acceptance strategies improve functioning and life satisfaction in people with chronic pain and whiplash-associated disorders (WAD)? A randomized controlled trial. Cognitive Behaviour Therapy, 37: 1–14.

Wicksell, R.K., Melin, L., Lekander, M. and Olsson, G.L. (2009) Evaluating the effectiveness of exposure and acceptance strategies to improve functioning and quality of life in longstanding pediatric pain – a randomized controlled trial. Pain, 141: 248–57.

Other Health Conditions:

Gregg, J.A., Callaghan, G.M., Hayes, S.C. and Glenn-Lawson, J.L. (2007) Improving diabetes self-management through acceptance, mindfulness, and values: a randomized controlled trial. Journal of Consulting and Clinical Psychology, 75: 336–43.

Lundgren, T., Dahl, J., Melin, L. and Kies, B. (2006) Evaluation of acceptance and commitment therapy for drug refractory epilepsy: a randomized controlled trial in South Africa – a pilot study. Epilepsia, 47: 2173–9.

Psychotic Disorders:

Bach, P.A. and Hayes, S.C. (2002) The use of Acceptance and Commitment Therapy to prevent the rehospitalization of psychotic patients: a randomized controlled trial. Journal of Consulting and Clinical Psychology, 70: 1129–39.

Gaudiano, B.A. and Herbert, J.D. (2006) Acute treatment of inpatients with psychotic symptoms using Acceptance and Commitment Therapy. Behaviour Research and Therapy, 44: 415–37.

HOW CAN ONE THERAPY BE USED FOR SUCH A VARIETY OF PROBLEMS?

For those who are more familiar with a traditional approach to psycho-pathology, it can be curious to imagine how one treatment approach could be used to decrease seizures in epilepsy, as well as improve smoking cessation rates. ACT is also regularly used with anxiety and depressive disorders. Because ACT practitioners focus on the cross-cutting, functional processes that are believed to underlie many different manifestations of problematic behaviour, rather than simply on the overt form or topography of the behaviour, the most important issue is not necessarily a diagnostic category, but the patterns of behaviour that are hindering a client’s successful living. In fact, many ACT-related studies have not only shown that ACT is comparable to or more effective than traditional approaches, but they also suggest that ACT works through different processes than other treatments, such as Cognitive Behaviour Therapy (CBT) (Hayes et al., 2006b).

The extremely high rates of comorbidity among the major categories of psychopathology can then be reconceptualized as the result of crosscutting, transdiagnostic processes, rather than as multiple, co-occurring conditions. For example, if PTSD, depression, suicidality and substance abuse can all be seen as problems resulting from excessive efforts at experiential avoidance, then the clinician facing a client with these four comorbidities does not have to decide which problem to tackle first with separate, targeted treatments, but can instead proceed with one model that addresses the shared processes among all four conditions (Batten et al., 2005). Rather than primarily focusing on decreasing symptoms, the ACT client and therapist can together work on improving the client’s overall life!

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