Definition, mindfulness, theoretical basis, core processes, session outline, effectiveness, benefits, reservations, training, resources, relevance for social work, practice approach
Three sections follow:
Background Material that provides the context for the topic
A suggested Practice Approach
A list of Supporting Material / References
What is ACT
Acceptance and commitment therapy (ACT – pronounced as the word ‘act’) is a type of psychotherapy that emphasizes acceptance as a way to deal with negative thoughts, feelings, symptoms, or circumstances. It also encourages increased commitment to healthy, constructive activities that uphold your values or goals. ACT stems from traditional behavior therapy and cognitive behavioral therapy. ACT acknowledges that a lot of pain in life is not easy to alleviate and preventing it from occurring is next to impossible. ACT normalises pain and teaches people to respond differently to it, i.e. to embrace their thoughts and feelings rather than fighting or feeling guilty about them. It is a type of therapy that aims to help patients accept what is out of their control and commit instead to actions that enrichen their lives. Ultimately clients begin to accept their hardships and commit to making necessary changes in their behavior, regardless of what is going on in their lives and how they feel about it (Ackerman, 2022; Clinicians Corner, 2014; Glasofer, 2021; Larmar et al., 2014; Psychology Today, 2022; Smout, 2012).
ACT maximises human potential for a rich, full and meaningful life. It does this by helping people:
develop psychological skills to deal more effectively with difficult thoughts and feelings, to reduce their impact and influence.
clarify how people want to behave as a human being; how they want to treat themselves, others and the world around them. These values are used to guide, inspire and motivate one to take action: to do what matters, face fears, live meaningfully, and change life for the better.
focus attention on what is important and engage fully in whatever one is doing (Harris, 2022).
Mindfulness is an important approach used in ACT. Mindfulness is a mental state of awareness, focus and openness – which allows you to engage fully in what you are doing at any moment. In a state of mindfulness, difficult thoughts and feelings have much less impact and influence over you. ACT gives you a vast range of tools to learn mindfulness skills – many of which require only a few minutes to master. ACT breaks mindfulness skills down into 3 categories:
Defusion: distancing from, and letting go of, unhelpful thoughts, beliefs and memories
Acceptance: making room for painful feelings, urges and sensations, and allowing them to come and go without a struggle
Contact with the present moment: engaging fully with your here-and-now experience, with an attitude of openness and curiosity
These three skills enable a person to “observe self”, i.e. observe both the physical and thinking self. It is actually ‘pure awareness, the part of you that is aware of everything else (Harris, 2022). [Note: Mindfulness is a stand-alone topic on this website at https://www.thesocialworkgraduate.com/post/mindfulness ]
The ACT model predicts people will be most effective when able to:
accept automatic thoughts, sensations and urges
defuse from thinking (i.e. observe thoughts without believing them or following their directions)
experience self as context (i.e. a continuous, stable sense of self as an observer of psychological experiences)
attend to the present moment with self-awareness
clearly articulate their values (i.e. self-chosen, desirable ways of behaving)
engage in committed action (i.e. participate in values-consistent activities, even when psychologically challenging).
In therapy clients are guided through these processes (Brennan, 2021; Smout, 2012).
Relational Frame Theory
ACT is theoretically rooted in relational frame theory (RFT). Central to RFT is the assumption that learning is not separate from one’s context and environment. RFT suggests that the environment shapes our learning via its influence on internal states (such as language and thinking/understanding), and once learning is shaped by the environment, it influences how a person responds to his or her environment. Most learning developed through environmental experiences may be unconscious, so that a person does not realize how the environment has influenced or triggered his or her learning. For example, if a young girl watched her mother being physically abused by every man her mother dated, she might come to believe that all men are physically abusive in relationships. As a result of this ‘relational frame’ she might refuse to trust male adults for fear that they are all abusive (Montgomery et al., 2011). Or a person might relate “worthless” with the ability to perform certain tasks and then, often unconsciously, extend this concept of “being worthless” to the other aspects of life (Ackerman, 2022). ACT guides people to acknowledge these thoughts, objectively accept that they happen, focus on what they want from life (their values) and concentrate on this rather than these thoughts.
Six Core Processes
Six core processes of ACT guide patients through therapy and provide a framework for developing psychological flexibility (Ackerman, 2022; Harris, 2022; Montgomery, 2011;).
Acceptance is an alternative to our instinct to avoid thinking about negative—or potentially negative—experiences. It is the active choice to allow unpleasant experiences to exist, without trying to deny or change them. Acceptance is not a goal of ACT, but a method of encouraging action that will lead to positive results. Clients learn how to drop the struggle with painful feelings and sensations.
Cognitive Defusion refers to the techniques intended to change how an individual reacts to their thoughts and feelings. ACT does not intend to limit our exposure to negative experiences, but rather to face them and come out the other side with a decreased fixation on these experiences. For example, the thought, “I am a bad person” is reframed into “I have the thought that I am a bad person.” Clients learn how to let thoughts come and go, as if they are cars driving past the house. Other techniques to separate the thought from the person include giving the thought a shape, form, weight or colour; watching the thought as if watching TV; or repeating the thought out loud until it simply becomes a combination of words. These interventions allow clients to contextually restructure their thinking without placing blame or judgement on them for having the thoughts.
Being Present can be understood as the practice of being aware of the present moment, without judging the experience. In other words, it involves experiencing what is happening without trying to predict or change the experience.
Self as Context is the idea that an individual is not simply the sum of their experiences, thoughts, or emotions. The “self as context” process offers the alternative concept that there is a self outside of the current experience. We are not only what happens to us. We are the ones experiencing what happens to us. The goal of this process is to foster defusion and acceptance by using mindfulness techniques to engage the self that has existed throughout one’s life.
Values in this context are the qualities we choose to work towards in any given moment; what we want our life to be about; what we stand for. We all hold values, consciously or unconsciously, that direct our steps. Although different clients will draw from alternative values bases (e.g. family, career, spirituality), the goal of ACT is to assist clients in creating choices that are directed by their values.
Finally, ACT aims to help individuals engage in committed action that will assist in their long-term goals and assist them to live a life consistent with their values. Positive behavior changes cannot occur without awareness of how a given behavior affects us. Almost any behaviourally coherent behaviour change method can be fitted into ACT protocol, including exposure, skills acquisition, shaping methods, goal setting, and the like. Unlike values, which is a short process with no end or specific goals, committed action is intended to be fleshed out with concrete short-, medium- and long-term goals.
How and to whom ACT is offered
There is no manualised recommendation of ACT treatment. ACT should be flexibly used to meet the needs of clients. The aim is to assist the client in increased psychological flexibility, i.e. become fully aware of the present moment and the psychological reactions occurring and then to persist or change behaviour depending on the situation and in line with one’s values (Montgomery et al., 2011). Training is discussed more fully in the Practice Approach section below.
ACT can be delivered in many different ways:
long-term therapy – for example, the Spectrum protocol for ACT with borderline personality disorder: forty two-hour sessions https://www.spectrumbpd.com.au/treatment-services/spectrum-treatments
medium-term therapy – for example, JoAnne Dahl’s protocol for ACT with chronic pain: eight hours in total https://www.div12.org/wp-content/uploads/2015/06/ACT-in-the-treatment-of-chronic-pain.pdf
brief therapy – for example, Patty Bach’s protocol on ACT with schizophrenia: only four 1-hour sessions https://contextualscience.org/files/BachHayes2002%5B1%5D.pdf
ultra-brief therapy – for example, Kirk Strosahl’s work in primary care medical settings, where ACT can be highly effective even in one or two twenty to thirty-minute sessions https://thepsychologist.bps.org.uk/volume-29/august/pain-inevitable-suffering-optional
One of the many positives of ACT is the way it can be adapted and made as short or long as it needs to be, to suit the individual needs of the client, group, or organisation (Harris, 2022).
Research on Effectiveness
Harris (2022) suggests there is a growing body of empirical data confirms that cultivating acceptance, mindfulness, and openness to experience is highly effective for the treatment of depression, anxiety disorders, substance abuse, chronic pain, PTSD, anorexia, and even schizophrenia. ACT is also a very effective model for life coaching and executive coaching.
In 2020, Gloster et al. reviewed the meta-analytic evidence on ACT. The 20 included meta-analyses reported 100 controlled effect sizes across 12,477 participants. Results showed that ACT is efficacious for all conditions examined, including anxiety, depression, substance use, pain, and transdiagnostic groups. Results also showed that ACT was generally superior to inactive controls (e.g. waitlist, placebo), treatment as usual, and most active intervention conditions. ACT was generally not statistically different from CBT. These results are consistent with previous studies. Being more specific, results of the review of meta-analyses indicated:
Depression: Six of nine meta-analyses reported significant effect sizes favouring ACT in the small to medium range.
Anxiety: Six out of seven reported significant effect sizes favouring ACT in the small to medium range.
Substance use: Two out of three reported significant effect sizes favouring ACT in the small range.
Chronic pain: One out of two reported a significant and large effect.
Transdiagnostic combinations of conditions: Five out of five reported significant small to large effect sizes favouring ACT
Other conditions: Significant small to medium effect sizes for ACT were reported for eating disorders (1 study), stress (2), somatic complaints (1) and physical conditions (1).
Other outcomes: Three out of six reported significant medium effects in quality of life for ACT, two out of three significantly favoured ACT for psychological flexibility (small to large effect size).
Psychology Today (2022) and Glasorer (2021) suggest ACT can help treat many mental and physical conditions. These include anxiety disorders, depression, obsessive-compulsive disorder, psychosis, eating disorders, substance use disorders, workplace stress, and chronic pain.
Ackerman (2022) provides links to relevant websites and articles that show ACT to be effective in these areas:
General and social anxiety disorders: http://www.anxietyhappens.com/WhyAnxiety/
Chronic pain: three sources are mentioned
Depression: two sources mentioned
Obsessive-Compulsive Disorder (OCD): two sources mentioned
Eating disorders: two sources mentioned
Group therapy: https://hgps.org/newsletter/acceptance-commitment-therapy-in-group-practice/
On the other hand, a search of the Cochrane Library (2022) using the phrase “Acceptance and Commitment Therapy” found seven reviews that compared ACT with other treatments for various ailments. In general the reviews did not find ACT was more beneficial than the other treatments. Three of the recent reviews follow.
Mindfulness for smoking cessation (2022 - Jackson et al.): “We did not detect a clear benefit or harm of ACT on quit rates compared with less intensive behavioural treatments, including nicotine replacement therapy alone (1 study, 102 participants; low‐certainty evidence), brief advice (1 study, 144 participants; very low‐certainty evidence), or less intensive ACT (1 study, 100 participants; low‐certainty evidence) … However this evidence is of low or very low certainty, and further evidence is likely to change our conclusions. Further RCTs of mindfulness‐based interventions for smoking cessation are needed, following up participants at six months or longer.”
Chronic pain management (2020 – de Williams et al.): “We analysed five studies (443 participants). There was no evidence of difference between ACT and active control for pain, disability or distress at treatment end … Evidence from trials of ACT was of moderate to very low quality, so we are very uncertain about benefits or lack of benefits of these treatments for adults with chronic pain.”
Interventions for female drug-using offenders (2019 – Perry et al.): “One study (31 participants) comparing acceptance and commitment therapy (ACT) to a waiting list showed no significant reduction in self‐reported drug use using the Addiction Severity Index and abstinence from drug use at six months … ACT may make little or no difference to reducing drug use/abstinence from drug use in comparison to a waiting list control (low-certainty evidence) … Larger trials are required.”
Benefits and Reservations
ACT allows a person to embrace thoughts and feelings when useful and set them aside when they are not. This allows thoughtful responses to inner experience and avoids short-term, impulsive actions, focusing instead on living a meaningful life. ACT is similar to other forms of therapy, such as CBT. Some consider ACT doesn’t represent a significantly different approach (Glasofer, 2021).
Like any psychotherapy, ACT is not suitable for people whose cognitive functioning is impaired such that they have difficulty comprehending and generating answers to routine assessment questions or virtually no substantive memory of previous conversations. In many trials ACT has been used in conjunction with pharmacotherapy to good effect (Smout, 2012).
Training & Resources
To be proficient as an ACT therapist, training is indicated. For social workers dealing with the broad range of behavioral problems that demand short and empirically based intervention, ACT has a place (Dewane, 2008). Information about ACT and potential training is available at https://contextualscience.org/act and https://psychwire.com/harris
Ackerman (2022) has a comprehensive list of worksheets, pdfs, PowerPoints and other resources that may assist social workers choosing to use ACT. They include:
Triggers, behaviours and payoffs—a worksheet to help the worker or clients identify self-defeating behaviors with the motivation behind them, which can be a first step to recognizing and modifying problematic behavior.
Bulls eye—a worksheet that assists clients to clarify if they are behaving as they want to behave in four areas, work/education, leisure, personal growth/health and relationships.
Psychological flexibility assessment—a tool to evaluate ability to open up, to be present and to do what matters.
Cost of avoidance worksheet—assists clients to become aware of their avoidance strategies and whether they are producing the desired results.
Informal mindfulness exercises (in morning routine and when carrying out domestic chores)—approach to incorporate mindfulness into one’s day.
Values assessment rating form—a matrix to complete with ten life domains (e.g. parenting, intimate relationships, employment) and four columns to complete to help identify where clients are falling short of goals and meeting goals.
Goal setting worksheet—worksheet to assist with developing SMART goals.
What to do in a crisis—an information page on responding to a crisis.
Psychological inflexibility—a .pdf with questions to use to assess a client’s psychological inflexibility.
Writing acceptance exercise—a quick exercise to help clients understand how avoidance can be counterproductive
Two sides of the same coin—an exercise to help one appreciate suffering is an inevitable part of life and, if eradicated, would lead to the elimination of joy.
Mindfulness and emotions—a mindfulness technique that can defuse a strong, negative emotion.
Valued directions worksheet—rating the importance of ten values domains, and their satisfaction with their lives in each area.
The sailing boat metaphor—raising awareness that, when dealing with problematic thoughts, some techniques are better than others, because working desperately to avoid these thoughts blocks us from reaching other important goals.
The mind bully metaphor—a strategy to encourage clients to shift attention away and stop struggling with a particular emotion or diagnosis.
The quicksand metaphor—encouraging the thought that accepting suffering as inevitable can help one survive and come out the other side (rather than struggling against suffering).
Relevance for Social Work Practice
The primary goal of ACT is to help people become more psychologically flexible. Therefore, any intervention that helps people become more mindful, more accepting, and more connected to values is consistent with ACT. Most social workers have these kinds of interventions in their repertoire already.
ACT is applicable across a wide variety of problems. Over 130 randomized controlled trials have been published on everything from anxiety, depression, psychosis and substance use to chronic pain, cancer, diabetes, weight loss, and tinnitus. Social workers tend to work in settings where they have to serve all comers, so a flexible intervention model that is widely applicable is essential. Furthermore, the theory behind ACT suggests that all human beings are prone to unnecessary efforts to avoid and escape pain, including social workers. In many ways, therapists and clients are no different from one another. This perspective is deeply resonant with the social work perspective, which is non-hierarchical and empowering.
ACT is consistent with core social work valuess, which emphasize the way social, political, and physical environments contribute to the problems people face (Boone, 2016).
Using ACT with Clients
Larmar et al. (2014) summaries the ACT process using the acronym ‘ACT’:
Accepting thoughts and feelings as a means of eliminating the challenges associated with reducing, modifying or rejecting cognitive or affective influences.
Choosing future directions that align with the individual’s goals and underlying values.
Taking action through the process of committing to identified areas of the individual’s world that require change.
ACT suits social workers who may only have a few brief contacts with clients. Instilling a sense of acceptance and becoming more mindful can occur with brief interventions. For example, for a person struggling with anxiety one could provide a little psychoeducation about how trying to control anxiety sometimes makes anxiety worse and can prevent a person from doing what matters in her or his life. Then one could bring in values: “In any given moment, while you’re avoiding, procrastinating, or trying to otherwise get away from your anxiety, what might you be doing instead if you were focusing on what’s important to you? What would it look like if anxiety wasn’t in charge?” Pinning down some specific actions to take when feeling anxious could occur. The ultimate message would be, “Don’t wait to stop feeling anxious before you live your life.” A brief intervention like this is not the solution for everybody, but sometimes it gets someone started on a new path (Boone, 2016).
If multiple sessions occur with a client, the following approach, adapted to each client’s situation, appears appropriate (Brennan, 2012; Dewane, 2008; Harris, 2006; Psychology Today, 2022; Smout, 2012).
Allow clients to describe why they are seeking therapy—what do they want to achieve. An aspect of this could be to assess clients’ life context including relationships, work, recreation and health.
Ask clients to identify the ways they have tried to get rid of or avoid unwanted private experiences. They are then asked to assess for each method: “Did this reduce your symptoms in the long term? What did this strategy cost you in terms of time, energy, health, vitality, relationships? Did it bring you closer to the life you want?”
Increase clients' awareness that as long as they're fixated on trying to control how they feel, they're trapped in a vicious cycle of increasing suffering. Useful metaphors here include
“quicksand” – the more you struggle in quicksand the worse the situation becomes
“the struggle switch” – imagine a struggle switch in your mind that you can turn on and off
“clean discomfort” and “dirty discomfort” – Without struggle we experience “clean discomfort”, and this is common in life. Once we start to struggle against it, we move into “dirty discomfort”.
Then assess strengths and weaknesses in the six core ACT processes. Mindfulness plays an important part in these processes. It offers a way to ground oneself in the present by paying attention moment-by-moment to feelings, physical sensations, and outside environment. Instead of trying to change things, rehashing the past, or imagining a future, clients remain in the moment.
Cognitive defusion—Learning to perceive thoughts, images, memories and other cognitions as what they are—nothing more than bits of language, words and pictures—as opposed to what they can appear to be—threatening events, rules that must be obeyed, objective truths and facts. Techniques for cognitive defusion include observing a thought without judgment, singing the thought, and labelling the automatic response that you have.
Acceptance of experiences—Reducing the motivation to avoid certain situations. An emphasis is given to “unhooking”—realizing that thoughts and feelings don’t always lead to actions. Discriminating between thoughts, feelings, and experiences is a salient focus. Allowing unpleasantness to come and go without struggling with it.
Being Present—Developing and practising the ability to give full attention to internal and external environment, in the ‘here and now’; observing thoughts and feelings without judging them or trying to change them.
Self as context—Teaching clients to view their identity as separate from the content of their experience. Clients are taught to get in touch with an observant self—the one that watches, and experiences – yet is distinct from one’s inner experiences.
Values clarity—Develop a clear vision of how clients want to live; clarifying what is important, the sort of people clients want to be, what is significant and meaningful in their life, what they want to stand for. This provides a platform for regaining control of life, not necessarily just control of thoughts and feelings.
Committed action—Setting goals, guided by the clients’ values and taking effective action to achieve them. Ask patients, “What’s the next step you could take to live more like the way you want to in the area of (relationships, work, recreation, health)?” This may involve goal setting, exposure to difficult thoughts or experiences, and skill development.
Supporting Material / References
(Available on request)
Ackerman, C. E. (2022). How does Acceptance and Commitment Therapy (ACT) work? Retrieved from https://positivepsychology.com/act-acceptance-and-commitment-therapy/
Boone, M. S. (2016). Leading with the heart: How ACT is highly successful in social work. Retrieved from https://www.praxiscet.com/posts/leading-heart-how-act-highly-successful-social-work/
Brennan, D. (2021). What is Acceptance and Commitment Therapy? Retrieved from https://www.webmd.com/mental-health/what-is-acceptance-and-commitment-therapy
Clinicians Corner. (2014). Why ACT is so well-suited to social work. Retrieved from https://www.newharbinger.com/blog/professional/why-act-is-so-well-suited-to-social-work/
Cochrane Library. (2022). Search results for the phrase, “Acceptance and Commitment Therapy”. https://www.cochranelibrary.com/search
Dewane, C. (2008). The ABCs or ACT – Acceptance and Commitment Therapy. Social Work Today, 8(5), 34.
Glasofer, D. R. (2021). What is Acceptance and Commitment Therapy (ACT)? Retrieved from https://www.verywellmind.com/acceptance-commitment-therapy-gad-1393175
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 Behavioural Science, 18, 181-192. https://doi.org/10.1016/j.jcbs.2020.09.009
Harris, R. (2006). Embracing your demons: An overview of Acceptance and Commitment Therapy. Psychotherapy in Australia, 12(4), 2-8. Retrieved from https://www.psychotherapy.net/article/Acceptance-and-Commitment-Therapy-ACT
Harris, R. (2022). Acceptance and Commitment Therapy. Retrieved from https://www.actmindfully.com.au/about-act/. This link has list of resources that may be useful for those considering incorporating aspects of ACT into social work practice.
Larmar, S., Wiatrowski, S., & Lewis-Driver, S. (2014). Acceptance and Commitment Therapy: An overview of techniques and applications. Journal of Service Science and Management, 7, 216-221. http://dx.doi.org/10.4236/jssm.2014.73019
Montgomery, K. L., Kim, J. S., & Franklin, C. (2011). Acceptance and Commitment Therapy for psychological and physiological illnesses: A systematic review for social workers. Health and Social Work, 36(3), 169-181.
Psychology Today. (2022). Acceptance and Commitment Therapy. Retrieved from https://www.psychologytoday.com/au/therapy-types/acceptance-and-commitment-therapy
Ruiz, F. J. (2012). Acceptance and Commitment Therapy versus traditional Cognitive Behavioural Therapy: A systematic review and meta-analysis of current empirical evidence. International Journal of Psychology and Psychological Therapy, 12(2), 333-357.
Smout, M. (2012). Acceptance and Commitment Therapy: Pathways for general practitioners. Australian Family Physician, 41(9), 672-676.