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Psychological Flexibility in Practice: A Systematic Overview of Acceptance and Commitment Therapy

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Developed by psychologist Steven C. Hayes in the 1980s, Acceptance and Commitment Therapy (ACT) is a therapeutic approach that helps individuals establish psychological resilience by both accepting their distressing feelings and thoughts and committing to actions that are consistent with their values. ACT focuses on developing the ability to accept and allow complicated feelings and thoughts rather than fight them, and then to take actions consistent with one’s values. A unique, empirically based intervention method, ACT aims to develop psychological flexibility, which means getting in touch with the present moment as a conscious human being and, based on what the situation presents, modifying or maintaining behavior to serve chosen values. In the present therapy sketch, a comprehensive description of ACT will be presented, its application areas will be discussed, and a general understanding of how it works in the therapeutic field will be provided.

What is Acceptance and Commitment Therapy?

Acceptance and Commitment Therapy (ACT) is based on the idea that pain, grief, disappointment, illness, and anxiety are inevitable elements of human life. The therapeutic goal of ACT is to enable individuals to adapt to such challenges by developing greater psychological resilience rather than eliminating or suppressing unwanted challenging experiences (Dindo et. al., 2017). ACT is supported and accepted by organizations such as the American Psychological Association (APA), the World Health Organization (WHO), the UK National Institute for Health and Care Excellence, and the Australian Psychological Society for meeting empirical standards. The proven importance of ACT stems from its transdiagnostic, process-oriented, and flexible nature. ACT, an action-oriented method, teaches individuals to accept that, rather than avoiding, rejecting, or struggling with emotions, deeper emotions are appropriate responses to specific situations that should not prevent them from moving forward in life. Within this understanding, individuals decide to accept the challenges of life and make the necessary changes in their behavior. In addition, ACT allows the individual to clarify their values and to use these clarified values as the basis for their actions. This process brings more vitality and meaning to life and increases the psychological flexibility of the individual (Zettle, 2005). Through ACT, individuals learn that their emotions are a regular part of the human experience and gain the skills to apply different ways of thinking to achieve their personalized goals.

On the other hand, ACT assumes that the psychological processes of a normal human mind are often destructive, in contrast to Western Psychology’s assumption of ‘’healthy normality’’. The ACT approach suggests that psychological human suffering arises from behavioral inflexibility and efficacy inflexibility resulting from experiential avoidance, cognitive entanglement, perspective-taking difficulties, failure to take necessary behavioral steps consistent with core values, and loss of contact with the present (Hayes et. al., 2011). ACT argues that the core of many problems stems from the concepts contained in the FEAR acronym (Powers, 2009):

  • Fusion with your thoughts
  • Evaluation of experience
  • Avoidance of your experience
  • Reason-giving for your behavior

The healthy alternative is to ACT:

  • Accept your thoughts and emotions
  • Choose a valued direction
  • Take action

Research increasingly shows that the same ACT processes can help understand and modify a diverse set of problems and symptoms. Indeed, understanding contextual factors such as individuals’ relationships, values, and goals has been identified as a vital paradigm in the treatment of patients with multiple chronic conditions (Bayliss et. al., 2014). Because ACT teaches individuals how to change the way psychological experiences work, this empowering practice has been shown to help clients cope with a wide range of disorders, including depression, anxiety, stress, substance use, and psychotic symptoms; overcome behavioral challenges related to diet, sleep, exercise, or physical illness; address social issues such as stigma or prejudice; and seek positive outcomes in areas such as relationships, social justice, climate change, gender discrimination, and more. This approach, which manifested itself as a way of dealing with mental health problems by focusing on change processes, is now known as a model for understanding and changing human behavior more generally (ACBS, 2024). Since the ultimate goal of ACT, an evidence-based, modern, and transdiagnostic approach, is to increase psychological resilience, this goal is addressed through six distinct processes while effectively treating the many mental disorders that individuals experience (ACBS, 2024):

Acceptance: Acceptance, taught as an alternative to experiential avoidance, involves actively and consciously embracing the specific events of one’s past without unnecessarily attempting to change their frequency or form. Acceptance is not promoted in ACT as an end in itself, but rather as a method of enhancing values-based action.

Cognitive Defusion: Cognitive defusion techniques focus on changing the unwanted functions of thoughts and other specific events. That is, ACT seeks to change the way an individual interacts with or relates to thoughts by creating contexts in which their useless functions are reduced. In this way, the dysfunctional thoughts that the individual has become less critical, and the individual’s belief in and attachment to dysfunctional thoughts decrease.

Being Present: ACT encourages a continuous non-judgmental contact with psychological and environmental events as they occur. The goal is to allow the individual to experience the world directly so that their behavior is more flexible and therefore their actions are more consistent with their values. This is achieved by allowing malleability to give greater control over behavior and by using language as a tool to note and describe events, not just to predict and judge them.

Self as Context: People develop a perspective of ‘’self’’ through relational frames such as ‘’me-you’’, ‘’now-then’’, ‘’here-there’’. This self is the context in which experiences are recognized rather than their content. This approach is vital for linguistic functions such as empathy, theory of mind, and self-perception. In ACT, this awareness is supported by mindfulness, metaphors, and experiential exercises so that one can observe one’s thoughts without clinging to them.

Values: Values refer to selected qualities of purposeful action that can never be achieved as an object but can be exemplified moment by moment. ACT uses many exercises to help the individual choose a life path in various areas (career, education, family, etc.) while weakening the verbal processes that can lead to choices based on avoidance, social compliance, or fusion.

Committed Action: ACT aims to develop effective action patterns based on chosen values. In this respect, it is similar to traditional behavior therapy and includes methods such as exposure, skill development, and goal setting. While values provide a direction, concrete goals in line with these values can be set and achieved. ACT therapies are usually structured with short, medium, and long-term goals, and psychological barriers are addressed through processes such as acceptance and cognitive defusion.

As is clear from the above information, the six core processes of ACT have a strong function in supporting psychological resilience. These processes are divided into two groups (ACBS, 2024):

  1. Mindfulness and acceptance processes: acceptance, defusion, contact with the present moment, and self as context.
  2. Commitment and behavior change processes: contact with the present moment, self as context, values, and committed action.

Contact with the being present and self as context is included in both groups because all psychological processes involve awareness of the present moment. These six processes work together to enable the individual to act flexibly in accordance with chosen values. So, in what areas does ACT work within these six processes to benefit individuals? Let’s take a look at ACT’s areas of work together!

What are the Working Areas of ACT?

ACT, which can comprehensively address a wide range of mental disorders and offer effective treatment methods, has a wide field of study (Dindo et. al., 2017). In fact, ACT is recognized by the APA as an empirically supported treatment for depression, anxiety disorders, psychosis, chronic pain, and obsessive-compulsive disorder. In addition, it is also approved by the Department of Veterans Affairs as an evidence-based therapy modality in the context of mood disorders. On the other hand, ACT has proven itself not only as a modality that reaches the adult population but also as an approach that offers effective results on young populations. A study conducted by Swain et al. (2015) supports the applicability and effectiveness of ACT for children and adolescents coping with anxiety, depression, and behavioral problems. ACT’s experiential methods, such as metaphors and games, are particularly engaging among children and adolescents and facilitate the treatment process. Below is detailed information on the areas of ACT:

Anxiety and Depression: A 2015 meta-analysis found that ACT is as effective as CBT in treating anxiety and mood disorders (A-Tjak et al., 2015). Moreover, ACT’s emphasis on anxiety acceptance rather than symptom control was found to be particularly useful for clients with chronic or treatment-resistant anxiety (Arch et al., 2012). On the other hand, Twohig and Levin (2017) found that ACT interventions produced significant reductions in depressive symptoms across a variety of formats, including group therapy, individual therapy, and self-help practices.

Chronic Pain: ACT has shown benefit in both improving functioning and reducing distress in individuals with chronic pain (Veehof et al., 2016). Unlike traditional pain management approaches that focus on reducing pain, ACT encourages patients to live a valued life alongside ongoing discomfort, promoting psychological resilience and reducing pain-related interventions.

Substance Abuse: ACT-based interventions can reduce substance misuse and support long-term recovery (Lee et al., 2015). By targeting avoidance patterns and reinforcing value-consistent actions, ACT supports individuals to build a meaningful life that is not centered on substance use.

Psychosis: ACT may enhance recovery and reduce hospitalization in individuals with psychotic symptoms (Bach & Hayes, 2002). Moreover, ACT may reduce distress related to hallucinations and delusions by promoting cognitive dissociation and acceptance (White et al., 2011).

Eating Disorders: Juarascio et al. (2013) found that ACT-based interventions reduced binge eating frequency and body image dissatisfaction by targeting rigid thought patterns and promoting acceptance of uncomfortable bodily sensations.

Workplace Stress and Burnout: Bond and Bunce (2000) found that an ACT-based stress management intervention at work led to reductions in distress and increases in innovation and productivity.

ACT has proven functional with moderate to large effect sizes for numerous conditions with robust improvements in quality of life, functional outcomes, and psychological resilience (Gloster et al., 2020). The strength of ACT lies in its transdiagnostic applicability and its focus on living meaningfully with psychological distress, not without it.

Takeaways:

  1. Acceptance and Commitment Therapy (ACT) is a flexible and scientifically based therapy approach that promotes acceptance of the inevitable challenges of the human experience and supports the individual to live a meaningful life in line with their values.
  2. At the root of psychological problems are dysfunctional processes such as avoidance of experience, fusion with thoughts and behaviors incompatible with personal values; ACT aims to transform these processes.
  3. Instead of mental traps such as FEAR (Fusion, Evaluation, Avoidance, Reason-giving), ACT empowers individuals to accept, choose, and act.
  4. ACT’s six core processes, acceptance, cognitive defusion, being present, self as context, values, and committed action, increase psychological resilience and provide an effective intervention for a wide range of individual and social problems.
  5. The strength of ACT, which has been scientifically validated in many psychiatric conditions such as depression, anxiety, psychotic disorders, chronic pain, and OCD, lies in its flexible, transdiagnostic structure, and in the ability of the person to lead a meaningful life not only free of psychological disorders, but despite them.

References

  1. Zettle, R. D. (2005). The evolution of a contextual approach to therapy: From comprehensive distancing to ACT.International Journal of Behavioral Consultation and Therapy, 1(2), 77–89. https://doi.org/10.1037/h0100736
  2. Powers, Mark B.; Zum Vörde Sive Vörding, Maarten B.; Emmelkamp, Paul M. G. (2009). “Acceptance and commitment therapy: a meta-analytic review”. Psychotherapy and Psychosomatics. 78 (2): 73–80. CiteSeerX 10.1.1.476.7775. doi:10.1159/000190790
  3. About ACT | Association for Contextual Behavioral Science. (ACBS). (2024). https://contextualscience.org/about_act
  4. Bayliss, E. A., Bonds, D. E., Boyd, C. M., Davis, M. M., Finke, B., Fox, M. H., … & Stange, K. C. (2014). Understanding the context of health for persons with multiple chronic conditions: moving from what is the matter to what matters. The Annals of Family Medicine, 12(3), 260-269.
  5. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2011). Acceptance and commitment therapy: The process and practice of mindful change. Guilford Press.
  6. Juarascio, A. S., Forman, E. M., & Herbert, J. D. (2013). Acceptance and Commitment Therapy versus Cognitive Therapy for the treatment of comorbid eating pathology. Behavior Modification, 37(6), 749–777. https://doi.org/10.1177/0145445513478633
  7. Swain, J., Hancock, K., Dixon, A., & Bowman, J. (2015). Acceptance and Commitment Therapy for children: A systematic review of intervention studies. Journal of Contextual Behavioral Science, 4(2), 73–85. https://doi.org/10.1016/j.jcbs.2015.02.001
  8. White, R., Gumley, A., McTaggart, J., Rattrie, L., McConville, D., Cleare, S., & Mitchell, G. (2011). A feasibility study of acceptance and commitment therapy for emotional dysfunction following psychosis. Behaviour Research and Therapy, 49(12), 901–907. https://doi.org/10.1016/j.brat.2011.09.003
  9. Arch, J. J., Eifert, G. H., Davies, C., Vilardaga, J. C., Rose, R. D., & Craske, M. G. (2012). Randomized clinical trial of cognitive behavioral therapy (CBT) versus acceptance and commitment therapy (ACT) for mixed anxiety disorders. Journal of Consulting and Clinical Psychology, 80(5), 750–765. https://doi.org/10.1037/a0028310
  10. Bond, F. W., & Bunce, D. (2000). Mediators of change in emotion-focused and problem-focused worksite stress management interventions. Journal of Occupational Health Psychology, 5(1), 156–163. https://doi.org/10.1037/1076-8998.5.1.156
  11. Gloster, A. T., Walder, N., Levin, M. E., Twohig, M. P., & Karekla, M. (2020). The empirical status of acceptance and commitment therapy: A review of meta-analyses. Journal of Contextual Behavioral Science, 18, 181–192. https://doi.org/10.1016/j.jcbs.2020.08.003
  12. A-Tjak, J. G. L., Davis, M. L., Morina, N., Powers, M. B., Smits, J. A. J., & Emmelkamp, P. M. G. (2015). A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems. Psychotherapy and Psychosomatics, 84(1), 30–36. https://doi.org/10.1159/000365764
  13. Bach, P., & 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(5), 1129–1139. https://doi.org/10.1037/0022-006X.70.5.1129
  14. Lee, E. B., An, W., Levin, M. E., & Twohig, M. P. (2015). An initial meta-analysis of Acceptance and Commitment Therapy for treating substance use disorders. Drug and Alcohol Dependence, 155, 1–7. https://doi.org/10.1016/j.drugalcdep.2015.08.004
  15. Veehof, M. M., Trompetter, H. R., Bohlmeijer, E. T., & Schreurs, K. M. (2016). Acceptance- and mindfulness-based interventions for the treatment of chronic pain: A meta-analytic review. Cognitive Behaviour Therapy, 45(1), 5–31. https://doi.org/10.1080/16506073.2015.1098724
  16. Twohig, M. P., & Levin, M. E. (2017). Acceptance and commitment therapy as a treatment for anxiety and depression: a review. Psychiatric clinics, 40(4), 751-770.
  17. Dindo, L., Van Liew, J. R., & Arch, J. J. (2017). Acceptance and commitment therapy: a transdiagnostic behavioral intervention for mental health and medical conditions. Neurotherapeutics, 14(3), 546-553.
  18. The six Core Processes of ACT | Association for Contextual Behavioral Science. (2024). https://contextualscience.org/the_six_core_processes_of_act