Embracing Your Demons: An Overview of Acceptance and Commitment Therapy
Imagine a therapy that makes no attempt to reduce symptoms, but gets symptom reduction as a by-product. A therapy firmly based in the tradition of empirical science, yet has a major emphasis on values, forgiveness, acceptance, compassion, living in the present moment, and accessing a transcendent sense of self. A therapy so hard to classify that it has been described as an “existential humanistic cognitive behavioral therapy.”
Acceptance and Commitment Therapy, known as “ACT” (pronounced as the word “act”) is a mindfulness-based behavioral therapy that challenges the ground rules of most Western psychology. It utilizes an eclectic mix of metaphor, paradox, and mindfulness skills, along with a wide range of experiential exercises and values-guided behavioral interventions. ACT has proven effective with a diverse range of clinical conditions: depression, OCD, workplace stress, chronic pain, the stress of terminal cancer, anxiety, PTSD, anorexia, heroin abuse, marijuana abuse, and even schizophrenia.1 A study by Bach & Hayes2 showed that with only four hours of ACT, hospital re-admission rates for schizophrenic patients dropped by 50% over the next six months.
The Goal of ACT
The goal of ACT is to create a rich and meaningful life, while accepting the pain that inevitably goes with it. “ACT” is a good abbreviation, because this therapy is about taking effective action guided by our deepest values and in which we are fully present and engaged. It is only through mindful action that we can create a meaningful life. Of course, as we attempt to create such a life, we will encounter all sorts of barriers, in the form of unpleasant and unwanted "private experiences" (thoughts, images, feelings, sensations, urges, and memories). ACT reaches mindfulness skills as an effective way to handle these private experiences.
What is Mindfulness?
When I discuss mindfulness with clients, I define it as: “Consciously bringing awareness to your here-and-now experience with openness, interest and receptiveness. There are many facets to mindfulness, including living in the present moment; engaging fully in what you are doing rather than “getting lost” in your thoughts; and allowing your feelings to be as they are, letting them come and go rather than trying to control them. When we observe our private experiences with openness and receptiveness, even the most painful thoughts, feelings, sensations and memories can seem less threatening or unbearable. In this way mindfulness can help us to transform our relationship with painful thoughts and feelings in a way that reduces their impact and influence over our life.
How Does ACT Differ from Other Mindfulness-based Approaches?
ACT is one of the so-called “third wave” of behavioral therapies—along with Dialectical Behavior Therapy (DBT), Mindfulness-Based Cognitive Therapy (MBCT) and Mindfulness-Based Stress Reduction (MBSR)—all of which place a major emphasis on the development of mindfulness skills.
Created in 1986 by Steve Hayes, ACT was the first of these "third wave” therapies, and currently has a considerable body of empirical data to support its effectiveness. The “first wave” of behavioral therapies, in the fifties and sixties, focused on overt behavioral change and utilized techniques linked to operant and classical conditioning principles. The “second wave” in the seventies included cognitive interventions as a key strategy. Cognitive-behavior therapy (CBT) eventually came to dominate this “second wave”
ACT differs from DBT, MBCT, and MBSR in many ways. For a start, MBSR and MBCT are essentially manualized treatment protocols, designed for use with groups for treatment of stress and depression. DBT is typically a combination of group skills training and individual therapy, designed primarily for group treatment of Borderline Personality Disorder. In contrast, ACT can be used with individuals, couples and groups, both as brief therapy or long term therapy, in a wide range of clinical populations. Furthermore, rather than following a manualized protocol, ACT allows the therapist to create and individualize their own mindfulness techniques, or even to co-create them with clients.
Another primary difference is that ACT sees formal mindfulness meditation as only one way of many to teach mindfulness skills. Mindfulness skills are “divided” into four subsets:
Contact with the present moment
The Observing Self
The range of ACT interventions to develop these skills is vast and continues to grow, ranging from traditional meditations on the breath through to cognitive defusion techniques.
Back to What is Unique to Act?
ACT is the only Western psychotherapy developed in conjunction with its own basic research program into human language and cognition—Relational Frame Theory (RFT). It is beyond the scope of this article to go into RFT in detail, however, for more information see http://contextualscience.org/rft.
In stark contrast to most Western psychotherapy, ACT does not have symptom reduction as a goal.ACT does not have symptom reduction as a goal. This is based on the view that the ongoing attempt to get rid of “symptoms” actually creates a clinical disorder in the first place. As soon as a private experience is labeled a “symptom,” a struggle with the “symptom” is created. A “symptom” is by definition something “pathological” and something we should try to get rid of. In ACT, the aim is to transform our relationship with our difficult thoughts and feelings, so that we no longer perceive them as “symptoms.” Instead, we learn to perceive them as harmless, even if uncomfortable, transient psychological events. Ironically, it is through this process that ACT actually achieves symptom reduction—but as a by-product and not the goal.
Another way in which ACT is unique, is that it doesn't rest on the assumption of “healthy normality.” Western psychology is founded on the assumption of healthy normality: that by their nature, humans are psychologically healthy, and given a healthy environment, lifestyle, and social context (with opportunities for “self-actualization”), humans will naturally be happy and content. From this perspective, psychological suffering is seen as abnormal; a disease or syndrome driven by unusual pathological processes.
Why does ACT suspect this assumption to be false? If we examine the statistics we find that in any year almost 30 percent or the adult population will suffer from a recognized psychiatric disorder.
Organization estimates that depression is currently the fourth biggest, most costly, and most debilitating disease in the world, and by the year 2020 it will be the second biggest. In any week, one-tenth of the adult population is suffering from clinical depression, and one in five people will suffer from it at some point in their lifetime.4 Furthermore, one in four adults, at some stage in their lifetime, will suffer from drug or alcohol addiction. There are now over twenty million alcoholics in the United States alone.5
More startling and sobering is the finding that almost one in two people will go through a stage in life when they consider suicide seriously, and will struggle with it for a period of two weeks or more. Scarier still, one in ten people at some point attempt to kill themselves.6
In addition, consider the many forms of psychological suffering that do not constitute “clinical disorders”—loneliness, boredom, alienation, meaninglessness, low self-esteem, existential angst, and pain associated with issues such as racism, bullying, sexism, domestic violence, and divorce. Clearly, even though our standard of living is higher than ever before in recorded history, psychological suffering is all around us.
ACT assumes that the psychological processes of a normal human mind are often destructive, and create psychological suffering for us all, sooner or later. Furthermore, ACT postulates that the root of this suffering is human language itself. Human language is a highly complex system of symbols, which includes words, images, sounds, facial expressions and physical gestures. We use this language in two domains: public and private. The public use of language includes speaking, talking, miming, gesturing, writing, painting, singing, dancing and so on. The private use of language includes thinking, imagining, daydreaming, planning, visualizing and so on. A more technical term for the private use of language is “cognition.”
Now clearly the mind is not a “thing” or an “object.” Rather, it is a complex set of cognitive processes—such as analyzing, comparing, evaluating, planning, remembering, visualizing—and all of these processes rely on human language. Thus in ACT, the word “mind” is used as a metaphor for human language itself.
Unfortunately, human language is a double-edged sword. On the positive it helps us make maps and models of the world; predict and plan for the future; share knowledge; learn from the past; imagine things that have never existed, and go on to create them; develop rules that guide our behavior effectively, and help us to thrive as a community; communicate with people who are far away; and learn from people who are no longer alive.
The dark side of language is that we use it to lie, manipulate and deceive; to spread libel, slander and ignorance; to incite hatred, prejudice and violence; to make weapons of mass destruction, and industries of mass pollution; to dwell on and “relive” painful events from the past; to scare ourselves by imagining unpleasant futures; to compare, judge, criticize and condemn both ourselves and others; and to create rules for ourselves that can often be life-constricting or destructive.
ACT rests on the assumption that human language naturally creates psychological suffering for us all. One way it does this is through setting us up for a struggle with our own thoughts and feelings, through a process called experiential avoidance.
Probably the single biggest evolutionary advantage of human language was the ability to anticipate and solve problems. It has enabled us not only to change the face of the planet, but to travel outside it. The essence of problem-solving is this:
Problem = something we don't want.
Solution = figure out how to get rid of it, or avoid it.
This approach obviously works well in the material world. A wolf outside your door? Get rid of it. Throw rocks at it, or spears, or shoot it. Snow, rain, hail? Well, you can't get rid of those things, but you can avoid them by hiding in a cave, or building a shelter. Dry, arid ground? You can get rid of it by irrigation and fertilization, or you can avoid it by moving to a better location. Problem solving strategies are therefore highly adaptive for us as humans (and indeed, teaching such skills has proven to be effective in the treatment of depression). Given this problem-solving approach works well in the outside world, it's only natural that we would tend to apply it to our interior world; the psychological world of thoughts, feelings, memories, sensations, and urges. Unfortunately, all too often when we try to avoid or get rid of unwanted private experiences, we simply create extra suffering for ourselves. For example, virtually every addiction known to mankind begins as an attempt to avoid or get rid of unwanted thoughts and feelings, such as boredom, loneliness, anxiety, depression and so on. The addictive behavior then becomes self-sustaining, because it provides a quick and easy way to get rid of cravings or withdrawal symptoms.
The more time and energy we spend trying to avoid or get rid of unwanted private experiences, the more we are likely to suffer psychologically in the long term. Anxiety disorders provide a good example. It is not the presence of anxiety that comprises the essence of an anxiety disorder. After all, anxiety is a normal human emotion that we all experience. At the core of any anxiety disorder lies a major preoccupation with trying to avoid or get rid of anxiety. OCD provides a florid example; l never cease to be amazed by the elaborate rituals that OCD sufferers devise, in vain attempts to get rid or anxiety-provoking thoughts and images. Sadly, the more importance we place on avoiding anxiety, the more we develop anxiety about our anxiety—thereby exacerbating it. It's a vicious cycle found at the center of any anxiety disorder. (What is a panic attack if not anxiety about anxiety?)
A large body of research shows that higher experiential avoidance is associated with anxiety disorders, depression, poorer work performance, higher levels of substance abuse, lower quality of life, high-risk sexual behavior, borderline personality disorder, greater severity of PTSD, long-term disability and alexithymia.
Of course, not all forms of experiential avoidance are unhealthy. For example, drinking a glass of wine to unwind at night is experiential avoidance, but it's not likely to be harmful. However, drinking an entire bottle of wine a night is likely to be extremely harmful in the long term. ACT targets experiential avoidance strategies only when client use them to such a degree that they become costly, life-distorting, or harmful. ACT calls these “emotional control strategies,” because they are attempts to directly control how we feel. Many of the emotional control strategies that clients use to try to feel good (or to feel “less bad”) may work in the short term, but frequently they are costly and self-destructive in the long term. For example, depressed clients often withdraw from socializing in order to avoid uncomfortable thoughts—“I’m a burden,” “I have nothing to say,” “I won’t enjoy myself”—and unpleasant feelings such as anxiety, fatigue and fear of rejection. In the short term, canceling a social engagement may give rise to a short-lived sense of relief, but in the long term, the increasing social isolation makes them more depressed.
ACT offers clients an alternative to experiential avoidance through a variety of therapeutic interventions. In general, clients come to therapy with an agenda of emotional control. They want to get rid of their depression, anxiety, urges to drink, traumatic memories, low self-esteem, fear of rejection, anger, grief and so on. In ACT, there is no attempt to try to reduce, change, avoid, suppress or control these private experiences. Instead, clients learn to reduce the impact and influence of unwanted thoughts and feelings through the effective use of mindfulness. Clients learn to stop fighting with their private experiences—to open up to them, make room for them, and allow them to come and go without a struggle. The time, energy, and money that they wasted previously on trying to control how they feel is then invested in taking effective action (guided by their values) to change their life for the better.
The ACT interventions focus around two main processes:
Developing acceptance of unwanted private experiences which are out of personal control.
Commitment and action toward living a valued life.