Acceptance and Commitment Therapy (ACT)
Deborah B. Grossman
Acceptance and commitment therapy (ACT) is a form of psychotherapy commonly described as a form of cognitive-behavior therapy or of clinical behavior analysis. It is an empirically-based psychological intervention that combines acceptance and mindfulness strategies with commitment and behavior-change strategies, to increase psychological flexibility. ACT was developed in 1982 by Steven C. Hayes and began increasing in popularity in the late 1980s. ACT differs from many other therapies and theoretical orientations in that it does not try to alter the content of the client’s minds. The objective of ACT is not elimination of difficult feelings; rather, it is to help client’s increase their awareness of the present moment and move towards behaving in accordance with their values. Through ACT, clients learn not to overreact to unpleasant feelings, and learn to stop avoiding situations which trigger those emotions. Through ACT, clients learn to differentiate their own skewed perceptions from reality. This is accomplished through a number of techniques, one being recognizing one’s thoughts as thoughts, rather than facts.
ACT believes that pain is ubiquitous and is a part of life, and it is how people look at and perceive their pain, rather than the pain itself, that contributes to the suffering. Through the utilization of metaphor, paradox, and experiential exercises, clients learn how to make healthy contact with thoughts, feelings, memories, and physical sensations that have been previously feared and avoided. Clients gain the skills to recontextualize and accept these private events, develop greater clarity about personal values, and commit to changing behavior in order to live life according to chosen values.
ACT views psychological inflexibility as the cause of human suffering and psychopathology. Clients who spend their lives trying to avoid unpleasant situations or feelings, worry about the past of future, live according to rigid rules of how they should act or behave, believe negative thoughts about themselves to be factual, and have undefined values tend to be unhappy individuals. Through a number of interventions and experiential exercises, ACT attempts to bring about acceptance and, eventually, psychological flexibility. ACT identifies six core therapeutic processes as helping to promote psychological flexibility. The six processes are acceptance, cognitive defusion, being present, self as context, defining valued direction, and committed action. These will be explained in greater detail below.
The first core therapeutic principle is acceptance. Through this principle, the goal for the client is to learn acceptance of private events (including thoughts, feelings, sensations, and memories) as an alternative to avoiding these private events. It involves the active and aware embrace of private events, without unnecessary attempts to change their frequency or form. For example, clients who experience anxiety are taught to feel anxiety as a feeling, fully and without defense.
The second core therapeutic process is cognitive defusion. Cognitive defusion techniques attempt to alter the functions that undesirable thoughts and other private events have, rather than trying to alter their form, frequency or situational sensitivity. In other words, ACT attempts to change the way an individual interacts with or relates to thoughts by creating contexts in which their unhelpful functions are diminished. For example, a person could thank their mind for having such an interesting thought, and label the process of thinking (e. g. , “I am having the thought that I am no good”). Such procedures attempt to reduce the literal quality of the thought, weakening the tendency to treat the thought as a fact. The result of defusion is that clients are able to create some distance between themselves and their thoughts. Thoughts are no longer believed to be 100% true and factual. A popular experiential exercise to promote cognitive defusion is the “milk” exercise. The client is asked to list all the thoughts and associations that come to mind when the word “milk” is heard. Common answers include “white,” “creamy,” “cold,” “cow,” etc. The client is then asked to repeat the word “milk” for 45-60 seconds, as many times as possible for as quickly as possible. Through this exercise, the client will hopefully come to the realization that the word “milk” is a representation of a tangible object, but is not actually the object itself. The client comes to the understanding that the word loses meaning, and eventually just becomes a strange guttural sound. The client is then asked to repeat the exercise with a negative word he/she commonly thinks about him/herself. The goal of this exercise is to help the client learn that thoughts are not facts, they are just thoughts.
The third core therapeutic principle of ACT is being present. ACT encourages clients to stay connected with the present moment with a non-judgmental attitude. The goal is present moment awareness, because when people are in contact with the present moment, people tend to be more flexible, responsive, and aware of the possibilities and learning opportunities afforded by the current situations.
The fourth core therapeutic principle of ACT is self as context. Through this process, ACT strives to help clients view themselves as a context, rather than as conceptual. In other words, ACT helps clients adopt a more holistic and realistic view of themselves as individuals, free to make their own choices. Rather than forcing oneself to act in certain ways that correspond with rigid rules based on their past behavior, ACT helps clients develop a more fluid sense of themselves that encourages clients to see themselves as part of a larger context, rather than a conceptual idea of themselves.
The fifth core therapeutic principle of ACT is defining valued direction, which directly addresses lack of values clarity/contact. Through the therapeutic process, ACT helps clients identify values that are important to them. Values as “chosen actions that can never be obtained as an object, but can be instantiated moment by moment,” (Luoma, Hayes, & Walser, 2007, p. 21). ACT uses a variety of exercise to help clients choose life directions in various domains (such as family, career, spirituality), while undermining verbal processes that might lead to choices based on experiential avoidance, social compliance, or cognitive fusion. For example, “I value X because my mother wants me to,” is an example of a value based on social compliance. Values really get to the core of ACT, because acceptance, defusion, being present, and the other core processes are not ends themselves, but rather they clear the path for a life lived according to one’s values.
The sixth and final core therapeutic process of ACT is committed action. ACT encourages the development of larger and larger patterns of effective action whereby individuals are acting in accordance with chosen values. In this regard, ACT looks very much like traditional behavior therapy, and the majority of behavior change methods can be fitted into an ACT protocol, including exposure, skills acquisition, shaping methods, goal setting, etc. ACT utilizes a number of behavioral interventions that encourage clients to change their behaviors that do not fit with their chosen values. For example, is someone values health, but smokes cigarettes, ACT would encourage that client to evaluate whether or not that behavior is consistent with their values, and will help promote behavior change if it is not.
ACT views all six of these core processes as overlapping and interrelated. They each support each other, and together, all target the goal of increasing and promoting psychological flexibility.
ACT and Adlerian therapy have a number of distinct similarities and differences. From a global level, both theories concern themselves with how people think and behave. ACT theorists want to evaluate whether people are fused with their cognitions or are living according to rigid and inflexible rules, and whether people are acting in accordance with their values. Adlerians evaluate how people view themselves, others, and the world around them. Adlerians then take note of the basic mistakes people have about these areas within their lifestyle, and examine whether people are moving through life with purpose and with useful and socially interested goals. In this regard, both Adlerian therapy and ACT are concerned with how people think and act in the world around them.
Another similarity is that of holism. This is a major principle of Adlerian theory, that people are indivisible units and are not broken into parts. Accordingly, Adlerians treat the entire person, rather than any one group of symptoms, or a part of the person. ACT is also a holistic theory to an extent. While a number of second wave cognitive or behavioral treatments try to fix or correct the symptoms clients are experiencing, ACT sees thoughts and behaviors as part of an individual, and, rather than ridding someone of depressive symptoms (for example), ACT tries to help the client experience a more positive life, overall, not just one free of depressive symptoms. Where these two theories differ within the concept of holism is that Adlerian theory is much more concerned with how a person came to be the way they are, by examining the person’s lifestyle, birth order, family constellation, etc. ACT theorists do not concern themselves as much with the person’s family of origin or past experiences.
An additional similarity between the two is how both view the client’s perceptions. Anecdotally, when I’ve worked with clients from a cognitive-behavioral framework, I often found myself struggling with clients over the reality of their perceptions – does this client’s boss really only pick on him? Is this reality, or is this just part of the client’s maladaptive patterns of thinking? Neither ACT nor Adlerian theories would really question this. Neither theory cares as much about the reality as much as the client's subjective reality. The Adlerian concept of phenomenology, meaning that the theory deals with a person’s subjective reality, rather than physical reality, is similar to the core principles within ACT. Both theories strive to work within the client’s reality, rather than arguing about what is and isn’t truth. In both theories, it is the client’s subjective reality, or their perceptions of their world, that is more important, rather than facts or the truth itself.
The core principles of teleology and movement in Adlerian theory are very similar to two of the ACT core processes of defining valued direction and committed action. Adlerians examine whether a person is moving towards useful or useless goals, which is essentially what ACT is also looking for – whether people have clear goals in their lives and are acting in accordance with their values. As these are both major tenants of both theories, the similarities between the two are quite apparent.
Similar to the previous point, the Adlerian principle of the three life tasks, and examining movement within the work, social, and sexual life tasks is very similar to ACT theorists, who examine valued direction in various domains of people’s lives. If one life task, or life domain, is being unfulfilled, both Adlerians and ACT theorists try to help the client improve their movement, or value-based action, within the life task, or domain.
The last point of overlap points out both a similarity and a difference between the two theories. The Adlerian concept of basic mistakes is very similar to the ACT principle of cognitive fusion. Both view these cognitions as causing a person distress. However, Adlerians see basic mistakes as just that – a mistake that needs to be corrected, or re-written. ACT theorists, however, do not try to correct or fix the cognitions with which clients have become fused. Rather, ACT theorists help clients create distance between themselves and their thoughts, so they eventually see their thoughts as thoughts, rather than facts. Additionally, both theories try to change a client’s behavior. In ACT, this is done if a client is not acting in accordance with their values, and for Adlerians, this is done when a person is not fulfilled in one of the life tasks or is preoccupied with useless goals. However, as previously mentioned above, while both ACT and Adlieran theories try to change a client’s behavior, Adlerian is alone in also trying to change a client’s cognitions.
Ansbacher, H. L. , & Ansbacher, R. R. (1956). The individual psychology of Alfred Adler: A systematic presentation in selections from his writings. New York, NY: Harper Torchbooks.
Hayes, S. , Strosahl, K. , & Wilson, K. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed). New York, NY: Guilford Press.
Luoma, J. , Hayes, S. , Walser, R. (2007). Learning ACT: An acceptance & commitment therapy skills-training manual for therapists. Oakland, CA: New Harbinger.
Manaster, G. J. , & Corsini, R. J. (1982). Individual psychology: Theory and practice. Chicago, IL: Adler School of Professional Psychology.
Mosak, H. , & Maniacci, M. (1999). Primer of Adlerian psychology: The analytic-behavioral-cognitive psychology of Alfred Adler. New York, NY: Routledge.