Acceptance and Commitment Therapy, or ACT (pronounced as one word, act, not three letters, a.c.t.), is a contemporary, transdiagnostic, evidence-based behavioral therapy that focuses on cultivating greater psychological flexibility through six core therapeutic processes. This article defines psychological flexibility and describes the key processes used in ACT to achieve it.
Last year, I was asked to give a talk to high school seniors for an amazing non-profit called KyleCares. The organizer wanted a presentation that could improve mental health and reduce vulnerability to suicide—in only 20 minutes. This felt like a tall order! After just a moment’s consideration, though, I knew what my focus would be. I thought, if I could give these humans just one thing to change their lives, it would be teaching them to get comfortable being uncomfortable.So that is what I did.
This strategy of ‘getting comfortable being uncomfortable’ is called acceptance or willingness in ACT. Acceptance is a critical element of building psychological flexibility. Psychological flexibility refers to our ability to be in the present moment, aware of and open to all our internal experiences (e.g., thoughts, emotions, physical sensations, memories, images, urges) while consciously choosing to act in ways that are congruent with our values. Values, in ACT, are who and how we most deeply desire to be. They are what we choose when we are choosing a meaningful life (1). Psychological flexibility is at the heart of healthy emotional functioning and is the main goal of ACT.
ACT is a transdiagnostic, evidence-based, behavioral therapy that was developed by Steve Hayes and colleagues throughout the 1980’s and 90’s. Research has demonstrated the benefits of ACT for numerous struggles, including anxiety, depression, tinnitus, chronic pain, body image issues, psychotic symptoms, substance use, smoking cessation, eating disorders, diabetes management, skin picking, and more (2).
Instead of teaching clients to change the content of thoughts and feelings, ACT focuses on changing the relationship to internal experiences. This is done through six core therapeutic processes all aimed at cultivating greater psychological flexibility (1).
- Present moment awareness is an aspect of mindfulness that refers to non-judgmental, present focused awareness. Present moment awareness creates a space between triggers, like self-critical thoughts or anxious feelings, and responses. In that space, a values-based decision, rather than an auto-pilot, avoidant reaction, can be chosen.
- Acceptance/willingness involves making full contact with internal experiences without attempting to escape, change, or control them, what I earlier referred to as ‘getting comfortable being uncomfortable.’ Importantly, acceptance does not mean liking or wanting, nor does it imply giving up, giving in, or resignation. It simply means allowing what is already present or arises to be as it is. At first, people may balk at this seemingly counterintuitive idea, wondering why they would ever choose to accept pain or discomfort. ACT provides two science-based reasons: First, struggling to avoid pain is often ineffective and even backfires, amplifying suffering (3), and second, avoidance, the opposite of acceptance, commonly pulls people away from values (1).
- Cognitive defusion is the process of stepping back from thoughts and observing them for what they are—words, sounds, syllables, images. When we ‘defuse,’ we disengage from our self-talk and merely observe thoughts as entities separate from ourselves. ACT suggests that thoughts aren’t inherently problematic unless we become fused with their content and allow them to dictate our behavior in ways that move us away from values. Defusing allows us to choose whether listening to thoughts will be “workable”—moving us toward our values—or “unworkable”—moving us away from values.
- Self-as-context refers to a self that transcends the content of one’s experiences. In other words, there is a “you” that has thoughts, feelings, urges, physical sensations, and roles but that is also separate and distinct from them. You are not those things, you are the context or arena in which they unfold. When we’re stuck viewing ourselves from the opposite perspective (i.e., self-as-content), we tend to be driven by the scripts we have about ourselves, our lives, and our histories in rule-governed ways that may not be values-congruent.
- Values are personal and freely chosen actions and qualities of actions defined by an individual as important and meaningful. Values define who we truly want to be and what we want to stand for. Moving in valued directions cultivates greater vitality, fulfillment, and meaning in our lives. ACT isn’t about changing internal experiences, it’s about changing behaviors. Values provide the road map for making these changes.
- Committed action is simply walking the talk. Whereas values provide the path or direction, committed action refers to the actual behaviors we choose to engage in (or disengage from).
When I was asked to give that 20-minute mental-health-changing talk, I wanted to talk to my teen audience about living their values, but I knew the real problem was overcoming the obstacles in doing so. I’m not talking about external obstacles like time or bad weather. While those are real obstacles, they can generally be problem-solved with a little creativity. I’m talking about internal obstacles like a loud inner-critic or imposter voice and feelings of anxiety, fear, or self-doubt.
Humans are designed to avoid pain—if you put your hand on a hot stove, removing it will protect you from a serious burn. But often avoiding emotional pain, like fear, in the same way we avoid a hot stove, can mean missing out on cool opportunities or closeness in relationships. Fear sometimes means we are in danger and need to fight or flee, but it is often a false alarm. I like the metaphor of a smoke detector—sometimes it signals a fire, but most of the time you just burned your toast.
Burnt toast is one way we teach the six core processes in ACT. More specifically, ACT involves a heavy reliance on experiential learning through metaphors and active exercises. Psychological inflexibility is thought to arise from an overreliance on language where things like rules, assumptions, judgments, worries, and predictions lead to unworkable behavior (1). So, you will often find ACT therapists engaging in tugs-of-war with their clients or talking with them about smoke detectors as a way to use language, which we of course must do in talk therapy, to put clients in touch with elements of their lived experience.
Think of how many decisions you make, how many things you avoid, because you don’t want to feel uncomfortable. Now, I’m not saying life should be lived with a ‘no pain no gain’ mentality—to be clear, there is no glory in feeling pain for pain’s sake. What I’m saying is that we need to look to the places we avoid and ask: Is there a cost? Is this avoidance consistent with the Me that I most deeply desire to be and the life that I really want to live? Comfort zones are cozy, but they are never where the growth and magic happen. Teaching this is how I thought I might make an impact on those teens. I hope it makes an impact on you too.
Acceptance and Commitment Therapy provides processes for changing our relationship to anxiety, fear, self-doubt, our inner critic, and all the other painful internal experiences we humans are wired to have. And to be sure, we are wired, evolutionarily, to feel and think in these ways as they once offered a survival advantage. When we learn to allow discomfort, detach from thoughts and self-stories, and choose to act in ways that are congruent with our values, we are being psychologically flexible. ACT is not about controlling how we think and feel. Rather, it is about cultivating a rich and meaningful life in the presence of pain, in other words, a life that is truly worth living.
Jill Stoddard
References:
- Hayes, S. C., Strosahl, K. D., & Wilson, K. G., “Acceptance and commitment therapy: The process and practice of mindful change”, 2011.
- Stoddard, J. A., & Afari, N.,“The Big Book of ACT Metaphors: A practitioner’s guide to experiential exercises and metaphors in Acceptance and Commitment Therapy”, 2014
- Campbell-Sills, L., Barlow, D. H., Brown, T. A., & Hofmann, S. G., “Effects of suppression and acceptance on emotional responses of individuals with anxiety and mood disorders”, Behaviour Research and Therapy, 2006.
Leave a Reply