a rt i c l e

Acceptance and Commitment

Therapy (ACT) with a
learning disabled young
person experiencing anxious Journal of
Intellectual Disabilities
© The Author(s), 2009

and obsessive thoughts Reprints and permissions:

F R E D DY J A C K S O N B R O W N North Bristol NHS Trust,
UK
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vol 13(3) 195‒201
issn 1744-6295(346173)
doi: 10.1177⁄1744629509346173

SIAN HOOPER North Bristol NHS Trust, UK

Abstract This case study describes how the ACT model was
adapted to treat anxious and obsessive thoughts in a young person
with moderate/severe learning disabilities. Using mindfulness and
ACT-based experiential activities, the client learned to notice her
thoughts and distance herself from their literal content. The
negative impact that the client’s anxious thoughts had on her life
was reduced and she was able to return to a part-time college
course. The article describes how the client engaged with some
ACT-based activities, such as mindfulness and defusion exercises.
The outcome suggests that the experiential, activity-based nature
of ACT may offer a more accessible intervention model for
learning disabled people than traditional CBT models based on
verbal reasoning skills. However, the intervention also required
considerable individual adaptation and it is likely that this will be
the case in work with people with learning disabilities.

Keywords Acceptance and Commitment Therapy; mindfulness

Children and young people with learning disabilities are particularly

vulnerable to experiencing mental health difficulties, with around 40
percent having a diagnosable mental health problem – a rate that is six
times higher than for other young people (Dykens, 2000; Emerson and
Hatton, 2007).
Cognitive behavioural therapy (CBT) is an established intervention
model for non-disabled children and young people with mental health
needs (see Carr, 2000). While traditionally CBT has rarely been offered to

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JOURNAL OF INTELLECTUAL DISABILITIES 13 ( 3 )
learning disabled people, there is now emerging evidence that it can be an
effective intervention, particularly for people with mild learning dis-
abilities (Prout and Nowak-Drabik, 2003).
Acceptance and Commitment Therapy (ACT: Hayes et al., 1999) is
part of the ‘third wave’ of cognitive behavioural models. According to
Hayes (2004), the first wave of behavioural therapy sought to apply basic
scientific principles to bring about clinically relevant behavioural change.
The second wave followed the same change agenda while incorporating
cognitive theories to address some of the limitations of the first wave. The
third wave refers to a new generation of cognitive behaviour therapy that
emphasizes issues such as ‘acceptance, mindfulness, cognitive defusion,
dialectics, values, spirituality, and relationship. [Third wave] methods are
often more experiential than didactic; their underlying philosophies are
more contextualistic than mechanistic’ (2004, p. 640).
ACT formulates that mental health problems arise primarily from
people’s efforts to avoid unwanted internal experiences (i.e. cognitions and
emotions).The subsequent impact these efforts have on their everyday lives
are what we see as their ‘psychopathology’. While the avoidance of un-
pleasant experiences makes sense in the external world, when this strategy
is applied to the internal world of cognitions and emotions, it fails to be
effective. Quite the contrary in fact: the literature on thought suppression
shows that the more one tries to avoid, manage or change negative
thoughts, the worse they can become (Wegner and Zanakos, 1994).
In ACT, cognitive fusion refers to when people believe the content of
their thoughts as literally true. Fusing with one’s thoughts has long been
shown to be a factor in the development of mental health difficulties. For
example, Clark (1986) described how a belief in the thought that a slight
breathing difficulty or increased heart rate were in fact the early signs of
an impending heart attack is likely to increase a person’s anxiety. This in
turn will increase their physical symptoms, leading to a vicious cycle that
results in a panic attack. Rather than changing a person’s thoughts, ACT
works to undermine their fusion with the literal content of their thoughts
(i.e. their believability).
In the ACT model, mindfulness and other exercises are used to help
people notice their thoughts as they occur, rather than fuse with them.This
enables people to relate to their thoughts differently (i.e. to recontextual-
ize them) and distances them from the literal content. In addition to
‘defusing’ cognitions, ACT seeks to reconnect people with what is import-
ant to them and supports action in a valued life direction. The aim is to
help the client live the life they want to live, rather than simply avoid the
negative or unwanted aspects of it. To achieve this, ACT employs a number
of exercises to help clarify what the client really wants from life and then

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 J AC K S O N B ROW N & H O O P E R : AC T C A S E S T U DY

uses basic behavioural activation strategies (e.g. goal setting and structured
actions) to bring this about.
ACT itself is based on Relational Frame Theory (RFT), a new theory of
human language and cognition. RFT is a contextual analysis of linguistic
phenomena and provides an account of how novel language relations
emerge from basic learned relations (for more details see Hayes et al., 2001).

The young person

Sarah was 18 years old and she lived at home with her parents. She was
described as having ‘an extremely complex neuro-psychiatric disorder of
unknown aetiology’. Since early childhood she had experienced anxious
and obsessive thoughts and ruminations that had impacted negatively on
her life. In the year preceding the intervention her anxieties were so severe
that she had refused to attend school.
When assessed with the WISC–IV (Wechsler, 2004), Sarah’s full-scale
IQ was 44 (range 41–52), her verbal IQ was 50 (range 46–59) and her
performance IQ was 46 (41–52).The Vineland Adaptive Behaviour Scales–II
(Sparrow et al., 2005) gave an age equivalent score of 5 years 3 months.
These scores indicate Sarah was functioning in the moderate to severe
learning disability range.
A psychological assessment undertaken 2 years prior to the inter-
vention stated that, ‘a cognitive behavioural intervention would not be
suitable for her, due to her impaired verbal reasoning skills’.

Intervention protocol
A 10-session intervention protocol was designed to deliver the core ACT
processes (contact the first author for details). The first session was a pre-
intervention meeting to build rapport, discuss issues of confidentiality,
ensure informed consent and agree a therapy contract.
After the first session, each session began with a simple, body aware-
ness mindfulness exercise (Hayes et al., 1999). The aim of this was to give
Sarah the opportunity to practise mindfulness skills regularly and to
provide a fun and relaxing way to start each session.

The therapeutic process

Building a rapport with Sarah was an unconventional and indirect process.
For instance, Sarah was intensely interested in her therapist and asked a lot
of personal questions. While this did not feel intrusive, it was noted how
different this experience was from working with non-learning-disabled

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JOURNAL OF INTELLECTUAL DISABILITIES 13 ( 3 )
people. Also, in the second session Sarah wanted to go for a walk; while in
itself this was not a problem, it was somewhat unusual and slowed the
overall intervention process.
Each session started with a brief mindfulness exercise based on noticing
aspects of Sarah’s immediate experience (such as what she could feel in her
body and hear).These exercises had the effect of relaxing Sarah and prepar-
ing her for the session. However, she often struggled to maintain her
attention and needed high levels of prompts to stay on task.
Sarah enjoyed the activity-based exercises and she often needed more
than one session to complete them. The following are notes from one of
the defusion activities called ‘River of Thoughts’ (see Hayes et al., 1999):

We constructed the river, coloured in the leaves and then took some time to
relax. I encouraged Sarah to notice her thoughts as they arose and we wrote
them down on a leaf and placed them on the river. At first Sarah wanted the
river to be very fast moving so that the thoughts were bumping into each
other. She called this ‘thinking up’. She explained that this is what she feels
her thoughts do to her. They become tangled up and work against her. She
constructed the first part of the river to look more like a rapid for this reason.
This was a really useful analogy and could become a major part of our future
work. After some practice, she was able to tolerate the thoughts floating on
leaves in front of her. She even described it as ‘peaceful’.

These exercises also revealed the ways Sarah tried to control her thoughts.
By ‘spinning’ her thoughts around quickly, Sarah felt she could stop them
from ‘thinking up’. However, Sarah reported that this mental process was
exhausting and rarely led to a positive outcome.
Sarah was encouraged to use metaphors to understand and defuse her
thoughts and cognitions. For instance, the metaphor of ‘stickiness’ helped
her to understand why she ‘got stuck’ on certain thoughts and why they
can be difficult to get rid of. Sarah liked this metaphor and wondered how
thoughts became sticky. On another occasion Sarah described vacuuming
up her ‘sticky’ thoughts. The therapist found that it was worthwhile
spending time setting up the metaphor using drawings and real objects as
this made the process more accessible to Sarah.
Identifying ‘values’ was difficult for Sarah and she required consider-
able time to clarify her views. In the end Sarah identified that ‘being a
friendly person’ and ‘being a healthy person’ were important to her and
things she wanted to work on. Setting goals in relation to these values was
not straightforward either, though targets such as going for a walk regu-
larly, not eating sweets every day and attending college were agreed and
achieved.

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Outcomes
An adapted version of the Acceptance and Action Questionnaire–9 (AAQ9:
Hayes et al., 2004) was used to evaluate Sarah’s acceptance of her
cognitions and experiential avoidance. To make it accessible the AAQ9
language was simplified and a five-point visual scoring system was used
(i.e. sections in a pie chart). After the intervention Sarah scored lower on
every question (average 1.7 points, range 1–3), indicating that she was less
avoidant of her cognitions and emotions and motives.
Parental reports were that Sarah was generally calmer and her episodes
of rumination were observed to be shorter. Sarah was now able to notice
her thoughts as just thoughts and was less fused with (and confused by)
their content. She was more likely to stop to think before she acted and
was more socially confident. She had a better understanding of other
people’s emotions and recently she had commented that ‘everybody has
bad days’.
Intervention gains were maintained at 4-month follow-up and Sarah had
returned to part-time education. The intervention required 17 meetings over
a 6 month period, which was nearly twice as long as originally planned.

Discussion
To date there has been little published evidence demonstrating the effec-
tiveness of CBT for learning disabled people and none with the ACT model.
What has been published has shown that CBT can be effective for people
with mild to moderate learning disabilities (e.g. Willner, 2004). This case
study indicates that ACT, a ‘third wave’ form of CBT, can help people with
moderate to severe learning disabilities with anxious, obsessive thoughts.
The intervention was originally based on a 10-session protocol, but it
took longer (i.e. 17 sessions) to implement as certain sessions needed to
be repeated and reworked in order to be relevant to Sarah. While adjusting
and tailoring materials and activities is always part of good clinical practice,
it may be that this is more of an issue for learning disabled people. If this
is the case, then interventions may take longer to deliver and require more
time for session planning and revision.
While an earlier assessment had concluded that CBT was not suitable
for Sarah because of her limited language and verbal reasoning skills, this
study showed that she was able to engage in and benefit from ACT. It is
possible that the opinion that Sarah would not be able to gain from CBT
was simply inaccurate. Alternatively it may be that the activity oriented,
experiential basis of ACT enabled Sarah to participate in the therapeutic
process more readily than with a more traditional CBT approach. For

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instance, rather than relying on verbal reasoning skills to reframe
cognitions, ACT employs mindfulness and other experiential exercises to
help clients distance themselves from the literal content of their thoughts
(termed ‘defusion’). It also uses exercises to help identify values and goals
that form the basis of behavioural action in daily life. Further work is
needed to understand the extent to which experiential exercises can
support learning disabled people to engage in CBT.
An important question to consider when using CBT with learning
disabled people is the extent to which an individual’s language and cogni-
tive skills are sufficient to engage in the therapeutic process (Willner,
2006). While limited or impaired language skills will impact on a client’s
ability to participate in a language-based therapeutic process such as CBT,
such difficulties do not preclude the use of CBT per se. Rather the issue is
how these therapeutic techniques are tailored and made relevant to the
individual’s particular needs and profile. Further research is needed to
investigate how language-based therapies should be adapted and developed
to enable learning disabled people to benefit from them.

References
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Willner, P. (2004) ‘Brief Cognitive Therapy of Nightmares and Post-Traumatic

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Correspondence should be addressed to:

D R F R E D DY J AC K S O N B ROW N , Clinical
Psychologist, North Bristol NHS Trust,
Child and Family, Westgate House, Southmead Hospital, Westbury on Trym, Bristol
BS10 5NB, UK. e-mail: Freddy.jacksonbrown@nbt.nhs.uk or
Freddy.jacksonbrown@gmail.com

Date accepted 27/07/09

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