Embracing Your Demons: an Overview of Acceptance and Commitment Therapy RUSSELL HARRIS Acceptance and Commitment Therapy is one of the recent mindfulness-based behaviour therapies shown to be effective with a diverse range of clinical conditions. In contrast to the assumption of ‘healthy normality’ of Western psychology, ACT assumes that the psychological processes of a normal human mind are often destructive and create psychological suffering. Symptom reduction is not a goal of ACT, based on the view that ongoing attempts to get rid of ‘symptoms’ can create clinical disorders in the first place. RUSSELL HARRIS provides an overview of ACT against a background of the suffering generated by experiential avoidance and emotional control. A case study illustrates the six core principles of developing psychological flexibility; defusion, acceptance, contact with the present moment, the observing self, values, and committed action. magine a therapy that makes no pain, the stress of terminal cancer, of barriers, in the form of unpleasant attempt to reduce symptoms, anxiety, PTSD, anorexia, heroin and unwanted ‘private experiences’ butI gets symptom reduction as a by- abuse, marijuana abuse, and even (thoughts, images, feelings, sensations, product. A therapy firmly based in the schizophrenia. (Zettle & Raines, 1989; urges, and memories). ACT teaches tradition of empirical science, yet has a Twohig, Hayes & Masuda, 2006; mindfulness skills as an effective way major emphasis on values, forgiveness, Bond & Bunce, 2000; Dahl, Wilson to handle these private experiences. acceptance, compassion, living in & Nilsson, 2004; Branstetter, Wilson, What is mindfulness? the present moment, and accessing a Hildebrandt & Mutch, 2004). A study transcendent sense of self. A therapy by Bach & Hayes (2002) showed that When I discuss mindfulness with so hard to classify that it has been with only four hours of ACT, hospital clients, I define it as:‘Consciously described as an ‘existential humanistic re-admission rates for schizophrenic bringing awareness to your here-and-now cognitive behavioural therapy’. patients dropped by 50% over the next experience with openness, interest and Acceptance and Commitment six months. receptiveness.’ There are many facets Therapy, known as ‘ACT’ (pronounced The goal of ACT to mindfulness, including living in as the word ‘act’) is a mindfulness- the present moment; engaging fully based behavioural therapy that The goal of ACT is to create a rich in what you are doing rather than challenges the ground rules of most and meaningful life, while accepting ‘getting lost’ in your thoughts; and Western psychology. It utilizes an the pain that inevitably goes with it. allowing your feelings to be as they eclectic mix of metaphor, paradox, ‘ACT’ is a good abbreviation, because are, letting them come and go rather and mindfulness skills, along with a this therapy is about taking effective than trying to control them. When wide range of experiential exercises action guided by our deepest values we observe our private experiences and values-guided behavioural and in which we are fully present and with openness and receptiveness, even interventions. ACT has proven engaged. It is only through mindful the most painful thoughts, feelings, effective with a diverse range of action that we can create a meaningful sensations and memories can seem less clinical conditions; depression, life. Of course, as we attempt to create threatening or unbearable. In this way OCD, workplace stress, chronic such a life, we will encounter all sorts mindfulness can help us to transform 2 PSYCHOTHERAPY IN AUSTRALIA • VOL 12 NO 4 • AUGUST 2006 our relationship with painful thoughts rather than following a manualised feelings, so that we no longer perceive and feelings, in a way that reduces their protocol, ACT allows the therapist them as ‘symptoms’. Instead, we learn impact and influence over our life. to create and individualise their own to perceive them as harmless, even if How does ACT differ from other mindfulness techniques, or even to co- uncomfortable, transient psychological mindfulness-based approaches? create them with clients. events. Ironically, it is through this Another primary difference is process that ACT actually achieves ACT is one of the so-called ‘third that ACT sees formal mindfulness symptom reduction—but as a by- wave’ of behavioural therapies—along meditation as only one way of many to product and not the goal. with Dialectical Behaviour Therapy teach mindfulness skills. Mindfulness Another way in which ACT is (DBT), Mindfulness-Based Cognitive skills are ‘divided’ into four subsets: unique, is that it doesn’t rest on the Therapy (MBCT) and Mindfulness- • acceptance; assumption of ‘healthy normality’. Based Stress Reduction (MBSR)—all • cognitive defusion; Healthy normality of which place a major emphasis on • contact with the present moment; the development of mindfulness skills. • the observing self. Western psychology is founded on the assumption of healthy normality: Acceptance and Commitment Therapy is one of the recent mindfulness-based that by their nature, humans are In stark contrast to most Western psychologically healthy, and given a behaviour therapies shown to be effective with a diverse range of clinical conditions. In psychotherapy, ACT does not have healthy environment, lifestyle, and contrast to the assumption of ‘healthy normality’ of Western psychology, ACT assumes social context (with opportunities that the psychological processes of a normal human mind are often destructive and symptom reduction as a goal. This is based for ‘self-actualisation’), humans will naturally be happy and content. create psychological suffering. Symptom reduction is not a goal of ACT, based on the on the view that the ongoing attempt From this perspective, psychological view that ongoing attempts to get rid of ‘symptoms’ can create clinical disorders in suffering is seen as abnormal; a the first place. RUSSELL HARRIS provides an overview of ACT against a background to get rid of ‘symptoms’ actually creates disease or syndrome driven by unusual of the suffering generated by experiential avoidance and emotional control. A pathological processes. a clinical disorder in the first place. Why does ACT suspect this case study illustrates the six core principles of developing psychological flexibility; assumption to be false? If we defusion, acceptance, contact with the present moment, the observing self, values, examine the statistics we find that and committed action. Created in 1986 by Steve Hayes, ACT The range of ACT interventions in any year almost 30 percent of the was the first of these ‘third wave’ to develop these skills is vast and adult population will suffer from therapies, and currently has a large continues to grow ranging from a recognised psychiatric disorder body of empirical data to support its traditional meditations on the (Kessler et al, 1994). The World Health effectiveness. breath through to cognitive defusion Organization estimates that depression The ‘first wave’ of behavioural techniques. is currently the fourth biggest, most therapies, in the fifties and sixties, What is unique to ACT? costly, and most debilitating disease in focused on overt behavioural change the world, and by the year 2020 it will and utilized techniques linked to ACT is the only Western operant and classical conditioning psychotherapy developed in principles. The ‘second wave’ in conjunction with its own basic research the seventies included cognitive program into human language and interventions as a key strategy. cognition—Relational Frame Theory Cognitive-behaviour therapy (CBT) (RFT). It is beyond the scope of eventually came to dominate this this article to go into RFT in detail, ‘second wave’. however, for more information see ACT differs from DBT, MBCT, www.contextualpsychology.org/rtf. and MBSR in many ways. For a start, In stark contrast to most Western MBSR and MBCT are essentially psychotherapy, ACT does not have manualised treatment protocols, symptom reduction as a goal. This is designed for use with groups for based on the view that the ongoing treatment of stress and depression. attempt to get rid of ‘symptoms’ DBT is typically a combination of actually creates a clinical disorder in group skills training and individual the first place. As soon as a private therapy, designed primarily for group experience is labeled a ‘symptom’, it treatment of Borderline Personality immediately sets up a struggle with it Disorder. In contrast, ACT can be because a ‘symptom’ is by definition used with individuals, couples and something ‘pathological’; something groups, both as brief therapy or long we should try to get rid of. In ACT, term therapy, in a wide range of the aim is to transform our relationship clinical populations. Furthermore, with our difficult thoughts and Illustration: Savina Hopkins PSYCHOTHERAPY IN AUSTRALIA • VOL 12 NO 4 • AUGUST 2006 3 be the second biggest. In any week, and all of these processes rely on are therefore highly adaptive for us as one-tenth of the adult population is human language. Thus in ACT, the humans (and indeed, teaching such suffering from clinical depression, and word ‘mind’ is used as a metaphor for skills has proven to be effective in the one in five people will suffer from it at human language itself. treatment of depression). Given this some point in their lifetime (Davies, Unfortunately, human language is a problem solving approach works well 1997). Furthermore, one in four adults, double-edged