Acceptance and Commitment Therapy
Acceptance and commitment therapy (ACT) is a model of psychological intervention (See “Psychotherapy”) based on behavioral therapy that applies mindfulness and acceptance processes, together with commitment and behavior change processes, to create psychological flexibility (Hayes et al. 2006). Psychological flexibility refers to patterns of behavior that implies the ability to fully contact the present moment and the inner experiences that are occurring without defenses and, according to the context, persisting or changing in the pursuit of goals or personal values (Hayes et al. 2006).
ACT embraces a functional contextual philosophy of science based on the basic theory of language and cognition, is linked to the applied theory of psychopathology and psychological change (Hayes 2004), is theoretically rooted in the relational frame theory (Twohig 2012), and is one of the most representative therapies of the so-called third wave of behavior therapy (Ruiz 2010) (See “Cognitive Behavioral Therapy”).
From an ACT point of view, psychological problems can emerge from the general absence of relational abilities; a primary source of psychopathology is the way that language and cognition interact with direct contingencies to produce an inability to persist or change behavior in the service of long-term valued ends. This kind of psychological inflexibility is argued in ACT to emerge from a weak or unhelpful contextual control over language processes themselves (Hayes et al. 2006).
The literature on an ACT model of psychopathology is large and growing. Six key middle-level processes, overlapped and interrelated, have been identified and organized into the “model of pathology, intervention, and health.” In this model, the psychological inflexibility refers to patterns of behavior regulated by six repertoire-narrowing processes, and on the other hand, psychological flexibility is regulated by six repertoire-expanding processes, considered positive patterns of behavior or psychological skills (Hayes et al. 2006, 2013). First, cognitive fusion refers to the excessive or improper regulation of behavior by verbal processes; people begin to take their thoughts literally without noticing the process of thinking itself; in contrast, defusion as a treatment process involves the of nonevaluative contexts that diminish the unnecessary regulatory functions of cognitive events, focusing on mindfully noticing thinking as it occurs. Second, experiential avoidance is the attempt to alter the form, frequency, or intensity of private experiences such as thoughts, feelings, bodily sensations, or memories, even when doing so is costly, ineffective, or unnecessary; the alternative is the acceptance; it means the adoption of an intentionally open, receptive, and flexible posture with respect to moment-to-moment experience, implies an active and intentional behavior, and is one of the biggest functional changes possible that often will ultimately change the form of emotional events themselves. Third, the contexts that promote fusion and experiential avoidance often also take an individual out of flexible contact with the present, with dominance of the conceptualized past and feared future, and a weak self-knowledge; in contrast, ACT promotes contact with the present moment; it means attending to what is present in a focused, voluntary, and flexible fashion; a sense of “self as a process” is actively encouraged. Fourth, ACT seeks to undermine an attachment to a conceptualized self (evaluative stories about who we are) and to promote contact with a sense of self, as a locus or perspective, providing a transcendent spiritual aspect to human experience. Fifth, in the context of psychological inflexibility, people may act in a way that is inconsistent with what the environment affords relevant to chosen values and goals, and then the lack of values clarity, values based not on personal choice but on pliancy, and avoidant tracking are not helpful behaviorally; in contrast, the goal of ACT is increasing the ability to persist or change in behavior in the service of one’s chosen values, defined as chosen qualities of purposive action that can never be obtained as an object but can be instantiated moment by moment. And sixth, when people lose contact with what they want in life, the behavioral repertoires narrow, and the persistence and change in the service of effectiveness are less likely, leading to psychological pain, inaction, impulsivity, or avoidant persistence; the alternative is the commitment to action; in this sense ACT encourages the development of larger and larger patterns of effective action linked to chosen values. In this regard, ACT looks very much like traditional behavior therapy, and almost any behaviorally coherent behavior change method can be fitted into an ACT protocol, including exposure, skills acquisition, shaping methods, goal setting, and the like (Hayes 2004; Hayes et al. 2006, 2013).
The six processes – acceptance, defusion, the now, self, values, and committed action – while distinguishable, are understood more fully in the context of the others. Can be further organized, the first two are acceptance and mindfulness processes; the last two are commitment and behavior change processes (Hayes et al. 2006, 2013). Movement in the processes is the functional goal, and any techniques that move these processes can be part of an ACT intervention; in this sense, ACT is not a technology; it is a perspective into which a wide variety of technologies, some identified with ACT and some not, can be deployed in a coherent fashion linked to basic principles (Hayes et al. 2013).
Key Research Findings
ACT has shown to be efficacious in a wide range of problems, in which a common pattern of experiential avoidance, in a context of cognitive fusion, is present (Ruiz 2010). Evidence derived from correlational studies support that experiential avoidance is positively related to a wide range of psychological symptoms (e.g., depression, anxiety, pain, concerns) and negatively related to quality of life and general health measures. Experimental studies mainly focused on the effects of experiential avoidance repertoire in some experimental task, the effects of acceptance coping instructions, and the effects of brief ACT protocols. Instead, outcome studies were focused mainly in clinical symptoms such as depression, anxiety disorders, social phobia, subclinical worries, and psychotic symptoms, among others. Some studies were also focused on health psychology (e.g., abstinence from smoking, epilepsy, cancer, weight loss). Effects of ACT in experimental and outcome studies were relevant; in general, the effect sizes were large and typically even better at follow-up, even when very short interventions were applied (Ruiz 2010). Most studies have used the Acceptance and Action Questionnaire (Hayes et al. 2004).
In old age, ACT has been mainly focused in psychological symptoms, mainly depression, anxiety, and pain. Older adults may be less familiar with depression and anxiety symptoms due to their lower levels of awareness of mental health issues, and ACT framework conceptualizes this problem as the pursuit of value-incongruent goals or failing to pursue value-congruent goals as a reaction to changes and losses that are characteristic of the aging process (Petkus and Wetherell 2013).
ACT shows promise as a therapeutic approach to address symptoms of depression. A study reported that older adults residing in long-term care facilities participated in a structured individual psychotherapeutic program administrated in 12 sessions; the intervention aimed to enhance psychological flexibility and improve daily functioning and was based on ACT core processes and techniques (e.g., mindfulness exercise, acceptance, experiential exercises, defusion, metaphor); the findings indicated that symptoms of depression fell significantly after the intervention (compared to a wait-list control) and remained at lower levels 3 months after ACT (Davison et al. 2016). Similarly, another study reported significant reductions in depressive symptoms in older adults from the general population, who participated in a program based on ACT and administrated as a web-based self-help intervention, the effects were sustained at 6-month and 12-month follow-up, and results also underline the efficacy of ACT in various formats (Pots et al. 2016).
ACT has also been applied on anxiety symptoms in old age. A study recruited older adults with diagnosis of generalized anxiety disorder in a 12 individual session program of ACT; findings suggest that ACT is feasible to use in this population and may be effective in reducing worry and depressive symptoms (Wetherell et al. 2011). Currently the online intervention program “Living the full” (based on ACT core processes) is being implemented to evaluate its cost-effectiveness in reducing anxiety symptoms in older adults; the format combines web sessions, telephone, and face-to-face interviews with mental health counselors; although results has not been published yet, it has already been proven to reduce anxiety in several patient groups (Witlox et al. 2018) (See “Performance Anxiety”).
In older adults with chronic pain, ACT has been effective in increasing the acceptance and enhancing functioning and mental health (Scott et al. 2017). In a randomized trial comparing ACT and cognitive-behavioral therapy for chronic pain, findings support that older adults were more likely to respond to ACT, effects last even at 6 months posttreatment, and besides older adults believed ACT as credible, acceptable, and satisfying (Wetherell et al. 2016). A combined intervention, ACT with selective optimization with compensation (SOC), also finds decline in chronic pain, depression, and anxiety among nursing home residents (Alonso-Fernández et al. 2016). Similar studies report that older adults attending treatment based on ACT showed increases in acceptance to pain with long-term benefits, suggesting that this therapeutic model confers durable benefits and, even more, may further integrate into people’s lives after treatment is complete without the need for further professional input (McCracken and Jones 2012). In sum, ACT is considered particularly appropriate for older adults with chronic pain (Barban 2016), as they may have experienced failed efforts to reduce their pain, and an intervention that focuses on living well with pain as opposed to pain reduction may have more appeal to older adults (Wetherell et al. 2016) (See “Pain”).
ACT has been argued to be particularly valuable in other health conditions in aging. An Internet-delivered intervention for hearing-related distress indicates that ACT might be suitable treatment for individuals that are negatively affected by their hearing difficulties, improving quality of life and reducing depression (Molander et al. 2017). It has been also considered as a valuable and effective resource for stroke survivors experiencing psychological distress and residual disability, in working toward acceptance of a changed reality (Majumdar and Morris 2019).
Future Directions of Research
Future studies may consider more randomized controlled trials involving intention to treat, as a comparison between ACT and other psychotherapies used with people in old age (Kishita et al. 2017). The development of transdiagnostic treatments for older adults should be further studied, particularly for the older population with a high possibility to acquire anxiety or depressive disorders (Petkus and Wetherell 2013).
Although ACT has been delivered in different formats (individual and web-based), more research is needed to analyze their potentials and limitations with older adults, as well as including the evaluation of programs delivered in a group format, and the potential to train non-clinicians to deliver the program, which would enable broader implementation of the therapy and may assist in addressing the current mental health problems in aging (Davison et al. 2016).
Additionally, it is important to examine the appropriateness of ACT evaluation and intervention processes for older adults in a gerontological theory framework, as well as in individuals without depression, anxiety, or pain and living in different contexts (nursing homes and community) and health status (ill, frail, healthy). Future research would benefit from a broader range of outcome measures, to identify additional benefits of ACT in old age, such as adjustment to aging, improvements in quality of life, and promotion of successful and active aging.
ACT is a psychological therapy and aims to dismantle inflexible behavioral repertoires and to increase psychological flexibility, promoting acceptance of the feared private events when the attempt to control them is counterproductive in the long term. Model and core processes imply being able to contact the moment as a conscious human being more fully as it is, not as what it says it is, and based on what the situation affords, persisting or changing in behavior in the service of chosen values (Hayes et al. 2013). ACT is highly suitable for older adults, is centered in the acceptance and commitment to action, and shows significant benefits for older adults in managing symptoms associated to depression, anxiety, and pain among others.
- Molander P, Hesser H, Weineland S et al (2017) Internet-based acceptance and commitment therapy for psychological distress experienced by people with hearing problems: a pilot randomized controlled trial. Cogn Behav Ther 47(2):169–184. https://doi.org/10.1080/16506073.2017.1365929CrossRefGoogle Scholar
- Scott W, Daly A, Yu L et al (2017) Treatment of chronic pain for older adults 65 and over: analyses of outcomes and changes in psychological flexibility following interdisciplinary acceptance and commitment therapy (ACT). Pain Med 18(2):252–264. https://doi.org/10.1093/pm/pnw073CrossRefGoogle Scholar