Acceptance and Commitment Therapy

The goal of Acceptance and Commitment Therapy (ACT) is to create a rich and meaningful life, while accepting the pain that inevitably goes with it.

ACT teaches mindfulness skills to handle unwanted private experiences, ie unpleasant thoughts, images, feelings, sensations, urges and memories. It aims to help people to live in the present moment, engaging fully in what they are doing, rather than getting lost in their thoughts, and allowing their feelings to be as they are, rather than trying to control them.

ACT holds that the ongoing attempt to get rid of symptoms creates a clinical disorder in the first place. As soon as a private experience is labelled as a 'symptom' it immediately sets up a struggle to get rid of it. By contrast, ACT aims to change our relationship to our troubling thoughts and feelings so that we no longer perceive them as symptoms. The idea is to see them as unpleasant but harmless and transient events.

ACT assumes that normal psychological processes are often destructive and create suffering for all of us, sooner or later. The root of this suffering is thought, which dwells on and relives painful events, scares us by imagining unpleasant futures, compares, judges and criticises ourselves and others; and creates rules for ourselves that can be constricting or destructive.

Thought creates suffering by setting us up in a struggle with our own thoughts and feelings. When we try to get rid of unwanted private experiences we often create extra suffering for ourselves. It is believed that almost every addiction arises as a result of an attempt to get rid of unwanted experiences such as boredom, low self-esteem, traumatic memories, fear of rejection, anger, grief, loneliness, depression and anxiety. The more energy we expend on avoiding unwanted private experiences the more we will suffer in the long term. The more importance we place on avoiding anxiety the more we develop anxiety about our anxiety. This is believed to be the mechanism behind panic attacks.

People who suffer from loneliness, depression or anxiety seek to avoid these feelings and these avoidance behaviours are themselves harmful. Thus depressed people often withdraw from socialising. In the short term this gives relief, but in the long term it makes them more depressed. ACT aims to replace these avoidance behaviours with therapeutic interventions. It does so by teaching people to reduce the impact of unwanted thoughts and feelings through the use of mindfulness. People cease to struggle with their private experience but expend this wasted energy on taking effective action instead. The two main processes are developing acceptance of unwanted private experiences which are out of our control, and commitment and action towards living a valued life.

The example of a 35-year-old man, Michael, who suffered from significant social anxiety illustrates how ACT works. Michael was asked to identify the ways in which he had tried to avoid being anxious. He had used Valium, alcohol, avoiding social events, relaxation, affirmations, disputing negative thoughts, and self-hypnosis. None of these strategies had reduced his anxiety in the long term. It was impressed on Michael that control is the problem, not the solution. So long as Michael was fixated on trying to control how he felt he was trapped in a vicious cycle of increased suffering. It is analogous to falling into quicksand, where the worst thing you can do is struggle. To survive you should float on your back. When Michael got anxious he struggled against it, arousing additional feelings of anger at himself, sadness, guilt and frustration. These secondary feelings were useless, unpleasant, unhelpful and drained his vitality. Michael was taught to accept his anxiety when it showed up. He was told to not struggle with it but to allow it to rise and fall without wasting his energy on combating it. Anxiety is unpleasant but it is not something terrible. By not struggling with it Michael stopped amplifying its effects.

After his agenda of emotional control was undermined Michael was introduced to the six principles of ACT.

1 Defusion

In a state of cognitive fusion we are caught up in our thoughts, which seem to be the literal truth, or rules that must be obeyed, or important events that require urgent attention, or threatening events that we must get rid of. When we fuse with our thoughts they exercise enormous power over us. Cognitive defusion means stepping back and observing our own mental processes, recognising them as transient private events, an ever-changing stream of words, memories and pictures. To deal with an unpleasant thought we can simply observe it with detachment, or repeat it over and over aloud, until it becomes a meaningless sound. We can thank our mind for such an interesting thought or sing it to the tune of "Happy Birthday". Not one of these techniques involves evaluating or disputing unwanted thoughts. To see how this works, imagine an unpleasant thought such as "I am stupid" or "I am incompetent". Compare how it feels to hold this thought in your mind with the phrase, "I am having the thought that I am stupid." This second form introduces distance from the thought. The thought has been reduced to what it is, just words.

Cognitive defusion is perceiving thoughts, images, memories as what they are - nothing more than bits of language and pictures - as opposed to what they appear to be - threatening events, rules that must be obeyed and objective facts.

Michael said he experienced distress from thoughts such as "I am boring", "No-one likes me" and "I am a loser". Michael was instructed to examine one of these thoughts to see whether it was words he could hear or words that he could see. He was asked to imagine the thought appearing on a karaoke screen, then to change the font and colour, then to imagine a bouncing ball jumping from word to word. By this stage, Michael was chuckling at a thought that only minutes earlier had brought him to tears. His homework consisted of practising various defusion techniques with distressing thoughts in order to see them for what they are - just bits of language passing through.

2 Acceptance

Acceptance means making room for unpleasant feelings, sensations, urges and other private experiences, allowing them to come and go without struggling with them, running from them, or giving them undue attention. Michael was asked to make himself anxious by imagining himself at an office party. He was asked to observe the knot in his stomach as if he were a curious scientist, noticing its size, shape, vibration, weight, temperature, texture, hardness, and even its colour. He was instructed to make room for the sensation, to allow it to be there, even though he didn't like it. He reported feeling a sense of being at ease with his anxiety. Homework was to practise this technique with his recurring anxious feelings, to let them come and go without a struggle.

3 Living in the present moment

This involves bringing full awareness to our here-and-now experience, with openness, interest and receptiveness. It means focusing on and engaging fully in whatever we are doing. Michael was given a simple mindfulness exercise: to eat a sultana in slow motion, with total focus on the taste and texture of the fruit, and the sounds, sensations and movements inside his mouth. He was told to allow distracting thoughts to come and go but to remain focused on eating the sultana. Michael was told of the parallel between eating the sultana and social situations, where he would be so caught up in his thoughts and feelings that he wasn't able to engage fully in conversation, and missed out on its richness. Homework was to practise full engagement with all five senses in his daily routines, such as washing, brushing his teeth or doing the dishes. He also agreed to practise mindful engagement in conversations by keeping his attention on the other person, rather than on his own thoughts and feelings.

4 The observing self

ACT asks us to access a transcendent sense of self, a continuity of consciousness that is unchanging, ever-present and impervious to harm. This allows us to directly experience that we are not our thoughts, feelings, memories, urges, sensations, roles, images, or physical body. These phenomena change constantly and are peripheral aspects of us, but not the essence of what we are. Michael was instructed to close his eyes and to observe his thoughts, the form they took, the way they came and went. He was told to bear in mind that there were two processes going on - his thoughts and the observation of those thoughts. He was reminded of the distinction between his thoughts and the self that observes these thoughts. From the perspective of the observing self no thought is dangerous, threatening or controlling.

5 Values

Values embody what is most important, deep in our hearts. They relate to the sort of person we want to be, to what is significant and meaningful to us, to what we stand for, and to our goals. Michael identified his important values as being connecting with others, building meaningful friendships, developing intimacy, and being authentic and genuine. Michael was asked to be willing to accept being anxious as the price to be paid for pursuing these values.

6 Committed action

This involves setting goals guided by our values and taking effective action to achieve them. Michael set himself the initial goal of going to lunch with a work colleague every day and sharing some personal information on each occasion. In later sessions Michael set himself increasingly challenging social goals and used mindfulness skills to handle the anxious feelings that inevitably arose. At the end of ten sessions Michael reported that he was socialising a lot more, and more importantly, that he was enjoying it. Thoughts of being boring or a 'loser' still occurred but usually he did not pay them much attention. Feelings of anxiety still occurred in social situations, but no longer bothered him or distracted him. Overall, his anxiety levels had diminished considerably.

This illustrates how ACT can result in good symptom reduction without directly aiming for it. A lot of exposure took place, as Michael engaged in increasingly challenging social situations. It is well known that exposure frequently leads to reduced anxiety. The more accepting Michael became of his unwanted thoughts and feelings the less anxiety he had about these thoughts and feelings. Indeed, practising mindfulness of unwanted thoughts and feelings is a form of exposure in itself.