Acceptance and Commitment Therapy (ACT) was first developed in
the late 1980s by Steven Hayes, currently professor of Psychology, University of
Nevada, Reno. Early in his professional career, Hayes was plagued by panic
attacks, especially in professional situations requiring him to speak in front
of his peers or students. He tried Cognitive Behavioral Therapy along with a
number of other self-help strategies, including Eastern meditation and EST.
Three years of CBT led Hayes to the realization that, for him, processing his
thoughts and feelings cognitively actually made them worse. He realized that he
turned his painful fears into suffering whenever he tried various strategies to
get rid of them. Then, in Hayes words,
“Something in that mixture of Eastern thinking and the human potential
movement clicked for me. It was goofy.....But what I saw in what they did, in
there, was the possibility of really pursuing this acceptance side.”
(2006) The Third Wave of Therapy. Time Magazine, Feb
What Hayes had learned was that by relating to his panic attacks with
acceptance, he created a space between himself and the emotions and thoughts of
the attack itself. In this space he could choose to act differently. He didn’t
have to let his panic determine his behavior. Thus what is called the “Third
Wave” of Behavioral Therapy was born.
The Third Wave of Behavioral Therapy
The initial period of Behavioral Therapy emphasized changing behavior alone.
The theory proposed that when behavior was modified, changes in beliefs and
emotions would follow. The “Second Wave” of Behavioral Therapy saw the
introduction of cognition to the process. “Second Wave” therapy emphasized
analyzing beliefs, then consciously changing those that needed changing. CBT
therapists look for the ways in which the client’s thoughts are inaccurate in a
dysfunctional way. The therapist challenges these old inaccurate and problematic
thoughts and beliefs and helps the client replace them with new ones that
accurately reflect the client’s life.
The “Third Wave” takes paradoxical
approach to change. In a strong contrast with CBT, which uses the strategy of
attacking and ultimately changing negative thoughts directly, ACT (along with
other “Third Wave” therapies such as Dialectical Behavioral Therapy (DBT) and
Mindfulness-Based Cognitive Therapy (MBCT)) doesn’t try to control private
experiences (thoughts, feelings, sensations, memories, etc.) “Third Wave”
therapies are characterized more by acceptance and disidentification.
Mindfulness training is the common element in “Third Wave” therapies.
Overview of ACT
ACT has its theoretical grounding in Relational Frame Theory (RFT). RFT takes
the view that much of what we consider to be psychopathology results from
negatively evaluating private events and subsequent internal strategies for
trying to avoid them, both of which are linguistic functions. ACT therapist
Jason Luomo, PhD, a Portland, OR, psychologist, summarizes the RFT/ACT
connection as follows:
“RFT holds that while language has been key in allowing us to dominate the
planet and create amazing levels of wealth and security, it also has a dark
side. Basic properties of language seem to lie behind much of the suffering that
humans experience. ACT, the applied technology resulting from RFT, attempts to
help people circumvent language in those areas of life where it is less helpful,
and strengthen the most useful aspects of language in the domains where it tends
to be most helpful.” Luomo, J. “Acceptance and Copmmitment
In ACT, the client is taught to just notice, rather than evaluate, thoughts
and emotions, accepting them as they are through the application of mindfulness.
For more on the RFT theoretical background of ACT see Yovel, I (2009) Acceptance and
Commitment Therapy and the New Generation of Cognitive Behavioral
Treatments. Isr J Psychiatry Relat Sci 46(4): 304-9.
This mindful approach further involves the recognition that thoughts and
emotions are experiences we have as opposed to being what we are. In this
process the client gets in touch with and identifies with the ongoing witness or
knower of experiences. ACT sees this internal witness as a transcendental sense
of self that is always there. ACT describes this shift as one from “self as
content,” in which we identify strongly with the content of our private
experiences, to self as the context in which private experiences happen. For
example a depressed client would make the shift from “I’m depressed.” to “I’m
having the thought that I’m depressed.” The client with the tendency to be self
critical might shift from “I’m a terrible person” to “I’m having the thought
that I’m terrible.” A patient suffering from psychotic delusions might make the
shift from “I am the Queen of Sheba” to “I’m having the thought that I’m the
Queen of Sheba.” Such a client might continue to hear voices but not feel so
compelled to act on them or take them seriously. This disidentification from
thoughts and emotions and identification with the witness then allows more
freedom of choice in relation to internal experiences. From Hayes’s perspective,
taking a disidentified stance and accepting attitude towards negative thoughts
and emotions also paradoxically weakens them.
From the ACT perspective
challenging thoughts and emotions are inevitable parts of human experience. The
ACT theory takes the view that suffering is intensified by trying to avoid
difficult or unpleasant experiences. We get stuck in unhealthy patterns of
avoidance leaving us inflexible in the face of life’s challenging experiences.
This inflexibility leads in turn to an inability to access and act on our own
As such, ACT combines acceptance and mindfulness skills
with activities to help the client rediscover of their core values and then
commit to changes in behavior that reflect them. Actually just the cultivation
of a willingness to face and feel difficult or unpleasant thoughts and emotions
with acceptance rather than struggling against them ultimately leads to greater
awareness of our deepest values and yearnings. ACT therapists further support
this turning towards core values by employing existential questions such as:
“What do you really want your life to be about?” Other techniques include such
exercises as writing your own epitaph or verbalizing your definition of a good
person. Once core values are identified, clients are helped to identify and
commit to a course of action to actualize them.
The overall goal of ACT
is to choose effective behaviors in accordance with one’s own core values even
in the presence of challenging private (internal thoughts and emotions) events.
For example a client who stays home from work for fear of an impending
confrontation with their boss, learns to be able to go to work even though
The ACT Therapeutic Approach and the Role of
Mindfulness The ACT therapist helps the client develop in six core as follows
- Cognitive diffusion: disidentification from thoughts, feelings other private
experiences. A thought is not what I am but something I have or that happens to
me. Thoughts are just thoughts, not reality.
- Acceptance: Allow private experiences to come and go without trying to
- Contact with the present moment: a “here and now” focus of awareness
accompanied with openness to and interest in whatever is happening
- Observing the self: utilizing and identifying with a transcendent,
unchanging, continuous consciousness that witnesses one’s experiences.
- Values: opening to what are one’s own deepest values.
- Committed action: making goals and plans in accord with those values then
acting to actualize them.
Of these six, the first four are strong
elements of mindfulness practice. Mindfulness has a present moment focus that is
non-judgmental towards all experience including thoughts and emotions. In
mindfulness the practitioner also distinguishes between impermanent thoughts and
emotions and that which knows them. ACT therapists use both metaphors and guided
meditative activities to teach these mindfulness skills to their clients. For a sampling of such approaches see the following:
by ACT therapist Jason Luomo, PhD. The first is a
generic mindfulness meditation exercise guiding the practitioner to be aware or
the full range of present moment experience without judgment. The second is a
standard ACT guided meditation called “Leaves on the Stream.”
Audio of “Thoughts on a Highway
” exercise. Guided
meditation on working with thoughts, emotions and introduction to the observing.
Hayes is careful to point out that although mindfulness is most
commonly associated with Buddhism, all religions have practices that cultivate a
non-judgmental relationship to our inner experiences. He is concerned that
mindfulness is put into a Buddhist box when it is found in all traditions.
The metaphor and imagery are also used extensively to teach the
ACT approach to clients. The following illustrate this intriguing, sometimes
playful side of ACT:
- Video role play presentation of the ACT metaphor “The chessboard” (a
metaphor of the mind and its contents).
- Visual imagery: ACT therapist Joseph Ciarrochi, PhD has developed playful
visual images to illustrate ACT principles like the one below. Six sets of such
images can be found on his website.
“Thoughts about life are not equivalent to life: Sometimes
our minds tells us a mouse is a monster.”
Research on ACT
Compared with older therapies like CBT, there is less research completed to
date on ACT. Nonetheless, ACT is already listed as an evidence-based practice
for depression by the American Psychological Association and is under
consideration for similar listing for treatment of substance abuse by the
Substance Abuse and Mental Health Services Administration. Other mental health
issues for which positive research results have published include obsessive
compulsive disorder, generalized anxiety disorder, social anxiety disorder,
post-traumatic stress disorder, borderline personality disorder, psychosis,
chronic pain, and coping with chronic physical diseases like diabetes or
Most research compares one therapeutic modality to a placebo, a wait list, or
other kinds of control groups. Effective modalities show greater effects than
those demonstrated by the control group. This has been true for ACT as well.
However when effective modalities are tested against one another not so much
difference is usually found. In contrast, ACT has done especially well when
directly compared with other effective therapies. In such head-to-head trials
against other modalities, ACT nearly always does modestly better than the other
modality, no matter what it is.
Here is a recently published summary of research on ACT. For a more
abbreviated overview of ACT research we turn to the website for the Association for Contextual Behavioral Science,
the major professional organization associated with ACT.
Peer-reviewed articles co-authored by Steven Hayes:
Hayes SC, Villatte M, Levin M, Hildebrandt M (2010). Open, Aware, and Active: Contextual Approaches as an Emerging
Trend in the Behavioral and Cognitive Therapies. Annu Rev Clin
Psychol 7: 141-168.
Gaudiano BA, Herbert JD, Hayes SC (2010). Is it the
symptom or the relation to it? Investigating potential mediators of change in
acceptance and commitment therapy for psychosis. Behav
Ther 41(4): 543-54. Epub 2010 Jun 9.
Twohig MP, Hayes SC, Masuda A (2006). Increasing
willingness to experience obsessions: acceptance and commitment therapy as a
treatment for obsessive-compulsive disorder. Behav Ther
37(1): 3-13. Epub 2006 Feb 21.
Other Recent Research Articles
Jurascio, AS, Forman, EM, Herbert, JD (2010) Acceptance and
Commitment Therapy Versus Cognitive Therapy for the Treatment of Comorbid Eating
Pathololgy. Behav Modif 34(2): 175-90.
Lundgren, T, Dahl, J, Yardi, N, Melin, L (2008). Acceptance and
Commitment Therapy and Yoga for Drug-Refractory Epilepsy: A Randomized
Controlled Trial. Epilepsy Behav 13(1): 102-8. Epub 2008 Mar
Forman, EM, Herbert, JD, Moitra, E, Yeomans, PD, Geller, PA (2007). A Randomized
Controlled Effectiveness Trial of Acceptance and Commitment Therapy and
Cognitive Therapy for Anxiety and Depression. Behav Modif
Online audio interview with Steven C. Hayes, PhD,
founder of ACT. This online interview with ACT founder Steven C. Hayes, PhD
covers an overview of ACT and its relationship to RFT. (Running Time: Approx. 30
Harris R (2010). Embracing Your Demons: An Overview of Acceptance and Commitment
Therapy. Psychotherapy in Australia 12(4): 2-8.
Hayes SC (2005). Get Out of Your Mind and Into Your Life. Oakland, CA:
New Harbinger. Hayes’ bestseller for the general public about ACT.