‘A superb text.

Entertaining, informative, well-written, easy-to-read,

and highly relevant for every ACT practitioner. The authors brilliantly
answer all those common questions that just about everyone grapples
with in their ACT journey, from the technical stuff like functional
contextualism and relational frame theory to the hands-on practical
stuff like how to actually work with self-as-context. I wish I’d had ac-
cess to a book like this when I was learning ACT. It would have saved
me so much confusion!’
Russ Harris, M. D., and Author of ACT Made
Simple and The Happiness Trap

‘I’ve been in and around ACT for over 15 years, and so when I saw the
title of this book, I assumed that I’d already know the answers to the
FAQs. That was not the case. There have been niggling questions over
the years about the ACT model that I’ve semi-ignored, and this book
now gives me the answers to those questions in a comprehensive, clear,
and accessible way. I guess that’s what I find most remarkable about
the book: it will be useful to both a total newbie and to those more
experienced with ACT.’
Nic Hooper, Ph.D., Lecturer in Psychology at
Cardiff University, UK and Author of
The Unbreakable Student

‘Here is a book that could only be written by people with deep knowl-
edge, years of clinical practice and teaching, and direct experience
of living by the ACT model. They home in on the key questions that
really matter to new (and indeed experienced) practitioners. They an-
swer them with clarity, with precision, depth, as well as with warmth
and humour. Above all this is a supremely practical book; not ob-
sessed with people getting ACT ‘right’, but with helping people to be-
come more confident and effective in using ACT to help themselves
and others. It should be on the bookshelf of any new ACT practitioner,
and also anyone who teaches or supervises them. I know my copy will
become well-thumbed.’
Ray Owen, DClinPsy, Consultant Clinical and
Health Psychologist, Peer-reviewed ACT Trainer,
and Author of Facing the Storm and Living
with the Enemy
‘This book is a true gem. Not only does it provide you with the most
useful answers to various ACT questions. It’s well written, wisely or-
ganised, easy-to-read, and very practical too. This book is a must-
have for every practitioner wanting to develop their skills in ACT.’
Rikke Kjelgaard, Psychologist, Peer-reviewed
ACT Trainer, author of Samtal som förändrar:
en Guide till ACT i Praktiken, and chief
rock’n’roller at www.rikkekjelgaard.com

‘This is the book I wish I had while I was teaching and supervising
ACT trainees. A must-have resource for anyone learning or teaching
Acceptance and Commitment Therapy. It will answer all your burn-
ing questions in a thorough yet concise and understandable format.
Highly recommended!’
Jill Stoddard, Ph.D., author of Be Mighty: A
Woman’s Guide to Liberation from Anxiety,
Worry, and Stress Using Acceptance and
Commitment Therapy and The Big Book
of ACT Metaphors: A Practitioner’s Guide
to Experiential Exercises and Metaphors in
Acceptance and Commitment Therapy

‘The book was a real treat to read, both as an ACT practitioner and as
an ongoing student of the model. I found it especially useful because I
often encounter many of these questions in my practice with clients. I
recommend this book to newcomers and seasoned practitioners alike.
It offers a good starting point for learning about the principles of ACT
and at the same time offers the possibility to revisit fundamental the-
oretical and practical ideas. The book is very well structured, so the
reader can jump to any question to get a specific answer.’
Gabriel Roseanu, Ph.D., Cognitive Behavioral
Psychotherapist and Lecturer in Psychology at
the University of Oradea, Romania
‘If you are an ACT practitioner looking to dive more fully into the
ACT model, then this book is for you. It’s jam packed full of pearls
of wisdom, answering all the questions you ever wanted to ask about
ACT but were too afraid to ask. Highly recommended.’
Joe Oliver, Ph.D., Founder of Contextual
Consulting and co-author of The Mindfulness
and Acceptance Workbook for Self-Esteem

‘This is such a useful book! As a quick reference guide, the authors

have created a go-to resource for accessible answers to questions that
you will find yourself asking or find that others ask of you. More than
that, this book is also a really absorbing and stimulating read, inviting
us to think more about the how of ACT rather than the what. It makes
a perfect accompaniment to many other ACT core texts.’
Elizabeth Burnside, DClinPsy, Clinical
Psychologist and Academic Director of North
Wales Clinical Psychology Programme

‘What a great read. This will be very useful for professionals and
teachers who want to learn more than just the Hexaflex. The reader
can dive into the under-the-hood aspects of ACT, deepen their therapy
skills, and they will become more flexible in their work. You’ll find
answers to all your commonly asked questions answered instantly and
be entertained in the process. A great companion to dip into whenever
questions arise.’
Louise Hayes, PhD, Clinical Psychologist and
co-author of Get Out of Your Mind and into
your Life for Teens, Your Life Your Way,
The Thriving Adolescent and What Makes
You Stronger
Acceptance and
Commitment Therapy

Acceptance and Commitment Therapy (ACT) is an evidence-based

contemporary psychological approach to behaviour change that pro-
motes the idea of people living more in line with their values whilst
providing them with practical strategies for managing adversity. In
this book, Dawn Johnson and Richard Bennett have collated fifty of
the questions that have most frequently been put to them whilst deliv-
ering ACT training and supervision to a wide range of therapists and
other helping professionals.
This book is the first of its kind to provide concise answers to a
range of philosophical, theoretical, conceptual, and practical ques-
tions raised by practitioners who are learning ACT. It will be of interest
to psychotherapists, clinical psychologists, counsellors, psychiatrists,
and a broad range of other mental health practitioners and trainees. It
serves as a useful resource for those new to the practice of ACT, and
for more experienced practitioners who might want to consider these
questions themselves.

Dawn Johnson works as a Clinical Psychologist in private practice, of-

fering therapy, teaching, training, supervision, and consultation. She
previously had a long career in the National Health Service and has
extensive experience of adapting ACT to work with people with intel-
lectual disabilities, neurodiversity, and severe mental health problems.

Richard Bennett works as a Clinical Psychologist and Cognitive Be-

havioural Psychotherapist. He lectures at the Centre for Applied
Psychology at the University of Birmingham and works at Think Psy-
chology, the independent psychology practice he founded, which of-
fers therapy, supervision, and training.
50 FAQs in Counselling and Psychotherapy
Windy Dryden PhD is Emeritus Professor of Psychotherapeutic
Studies at the Goldsmiths University of London. He is an international
authority on Rational Emotive Behaviour Therapy and is in part-time
clinical and consultative practice. He has worked in psychotherapy for
more than 45 years and is the author and editor of over 250 books.

Edited by Windy Dryden, the 50 FAQs in Counselling and Psycho-

therapy Series provides answers to questions frequently raised by
trainees and practitioners in a particular area in counselling and
psychotherapy.
Each book in the series is written by experts based on their responses
to 50 frequently asked questions, divided into specific sections.
The series will be of interest to practitioners from all orientations
including psychotherapists, clinical, health and counselling psycholo-
gists, counsellors, psychiatrists, clinically-oriented social workers and
trainees in these disciplines.

Single-Session Therapy
Responses to Frequently Asked Questions
Windy Dryden

Pluralistic Therapy
Responses to Frequently Asked Questions
Frankie Brown and Kate Smith

Acceptance and Commitment Therapy

Responses to Frequently Asked Questions
Dawn Johnson and Richard Bennett
Acceptance and
Commitment Therapy

Responses to Frequently
Asked Questions

Dawn Johnson and

Richard Bennett
First edition published 2024
by Routledge
4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
and by Routledge
605 Third Avenue, New York, NY 10158
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2024 Dawn Johnson and Richard Bennett
The right of Dawn Johnson and Richard Bennett to be
identified as authors of this work has been asserted in
accordance with sections 77 and 78 of the Copyright,
Designs and Patents Act 1988.
All rights reserved. No part of this book may be
reprinted or reproduced or utilised in any form or by any
electronic, mechanical, or other means, now known or
hereafter invented, including photocopying and recording,
or in any information storage or retrieval system,
without permission in writing from the publishers.
Trademark notice: Product or corporate names may be
trademarks or registered trademarks, and are used only for
identification and explanation without intent to infringe.
British Library Cataloguing-in- Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in- Publication Data
Names: Johnson, Dawn (Clinical psychologist), author. |
Bennett, Richard (Psychologist), author.
Title: Acceptance and commitment therapy : responses to frequently asked
questions / Dawn Johnson and Richard Bennett.
Description: First edition. | Abingdon, Oxon ; New York,
NY : Routledge, 2024. | Series: 50 FAQs in counselling and
psychotherapy | Includes bibliographical references and index. |
Identifiers: LCCN 2023010880 (print) | LCCN 2023010881 (ebook) |
ISBN 9781032429380 (hardback) | ISBN 9781032429373 (paperback) |
ISBN 9781003364993 (ebook)
Subjects: LCSH: Acceptance and commitment
therapy— Miscellanea.
Classification: LCC RC489. A32 J64 2024 (print) | LCC RC489. A32
(ebook) | DDC 616.89/1425 — dc23/eng/20230527
LC record available at https://lccn.loc.gov/2023010880
LC ebook record available at https://lccn.loc.gov/2023010881

ISBN: 978 -1- 032- 42938 - 0 (hbk)

ISBN: 978 -1- 032- 42937-3 (pbk)
ISBN: 978 -1- 003-36499-3 (ebk)

DOI: 10.4324/9781003364993
Typeset in Times New Roman
by codeMantra
This is for you. With love and light.
Contents

List of figures xv
List of tables xvii
Acknowledgements xix

Introduction 1

PART 1
Defining the philosophy and theory of ACT 3

1 What is the best way to describe ACT to a client? 4

2 Which kinds of issues can ACT help with? 7
3 What are the basic assumptions that ACT makes? 10
4 How does evolutionary theory apply to ACT? 13
5 What is functional contextualism? 16
6 Why do ACT practitioners answer every question
with “it depends”? 19
7 What is the most important behavioural principle
to remember? 22
8 What on Earth is relational frame theory? 25
9 Why does ACT use so many metaphors? 28
10 What is the relationship between ACT and other
cognitive behavioural therapies? 32
xii Contents

PART 2
Conceptual questions about the ACT model 37

11 What is psychological flexibility? 38

12 What does ‘creative hopelessness’ mean? 42
13 Is ‘contact with the present moment’ the same
thing as mindfulness? 46
14 What is self-as-context and how does it differ from
defusion?49
15 Doesn’t acceptance just equate to giving up and
letting life steamroller you? 53
16 What is meant by ‘transformation of
stimulus functions’? 56
17 How do I tell values apart from goals or rules? 59
18 How can I tell the difference between toward and
away moves when clients are taking action? 62
19 How does the concept of compassion fit with ACT? 65

PART 3
Putting ACT into practice 69

20 Do I need to know RFT in order to practise ACT? 70

21 How do I know whether ACT is the right
intervention for someone? 73
22 Can ACT be adapted for diverse populations? 76
23 Where do I start with introducing ACT to a client? 79
24 Should I show the Hexaflex to my clients?  82
25 How do I explain each component of the Hexaflex? 87
 Contents xiii

26 In which order should I work through the

components of the psychological flexibility model? 91
27 How can I encourage people to tune in to the
present moment? 94
28 How do I actually do self-as-context work with a client? 97
29 How do I promote acceptance in sessions? 100
30 How do I know which defusion procedure to use? 103
31 How do I deal with values conflict? 106
32 So, I just get people to work out their values and
encourage them to do value-driven behaviour all
the time, right? 109
33 Do I have to address all the processes in every session? 112
34 How do I apply ACT with (insert diagnosis here)? 115
35 How many sessions should a course of ACT
intervention include? 118

PART 4
Developing skills as an ACT practitioner 121

36 What do I need in place in order to practise ACT

safely and effectively? 122
37 Should ACT practitioners practise ACT for
themselves?125
38 Why is experiential learning better than didactic
learning?128
39 Why is there no formal qualification in ACT? 131
40 How can ACT practitioners shape their learning? 134
41 Do I need ongoing ACT supervision? 138
xiv Contents

PART 5
Critical questions about ACT 143

42 How strong is the evidence for ACT? 144

43 Traditional CBT has a well-established evidence
base. Why does the world need ACT? 147
44 Isn’t ACT just another case of ‘the emperor’s
new clothes’?151
45 ACT uses a lot of eye-catching tools and
techniques. Isn’t this all just a bag of tricks? 154
46 How does ACT fit within a culture where the
medical model dominates? 157
47 Is it not harmful to encourage people to tune into
and accept their pain and discomfort? 160
48 What if people have harmful or antisocial values? 163
49 The client says, “I’ve done everything you
suggested but it hasn’t taken away my discomfort”.
What do I do next? 166
50 What do I do if a technique does not work out like
it is supposed to? 170

Index 173
Figures

9.1 Relational networks contained in the metaphor of

‘getting straight back on the horse after a fall’ 29
10.1 A comparison of cognitive therapy and
acceptance and commitment therapy
(adapted from Gillanders, 2013a) 34
11.1 The three-column version of the Hexaflex 40
19.1 Compassion and the Hexaflex 66
24.1 The Inflexahex (adapted from Bach & Moran, 2007) 83
24.2 The ACT Matrix (adapted from Polk et al., 2016) 84
24.3 Mapping Hexaflex terms and derived relations
using the Matrix 85
43.1 The five areas model (adapted from Williams &
Garland, 2022) 149
Tables

2.1 Issues for which ACT is recommended in

national guidelines 9
14.1 A comparison of the concepts of defusion and
self-as-context by process, procedure, and outcome 52
27.1 Modelling, evoking, and reinforcing present moment
behaviour in and out of session 96
Acknowledgements

We would like to express our gratitude to everyone within, and con-

nected to, the ACT and contextual behavioural science community
for influencing the development of our practice. Many of the ideas
and concepts presented within this book have been inspired by our
colleagues, as well as the clients with whom we and they have worked.
Due to the collaborative ethos of the ACT community, it is not always
clear from where certain ideas have originated. We have endeavoured
to reference and credit people where possible.
We would like to thank the Responses to Frequently Asked Ques-
tions series editor, Windy Dryden, for giving us the opportunity to
contribute to this range of books. We are also very grateful to Tien
Kuei, Ayesha Shahid, and Fabian Olaz for reviewing our initial book
proposal, and to Grace McDonnell for guiding us through the publi-
cation process.
Introduction

Acceptance and Commitment Therapy (ACT) is a contemporary form

of Cognitive Behaviour Therapy (CBT) that blends cutting edge re-
search into verbal behaviour with the ancient wisdom traditions. It
is a pan-diagnostic approach to behaviour change that has broad ap-
plication across a wide range of settings. It has a rapidly expanding
evidence base, and it is gaining traction in a number of different areas
of healthcare and psychology more broadly. It is recommended by the
World Health Organization and in the national guidelines of several
countries.
We have delivered thousands of hours of ACT trainings across a
range of settings over a period of approximately ten years. During
training and supervision sessions we are often asked questions about
the ACT model, regarding theory, application, and the ongoing learn-
ing and development journey of budding ACT practitioners. In this
book we have selected the 50 questions that we are most frequently
asked. We hope that gathering them together in one clear and ac-
cessible volume will provide a helpful resource for anyone looking
to develop their knowledge and skills as an ACT practitioner. This
book is suitable for anyone working in a helping professional capacity
including psychotherapists, clinical, health, counselling, sport, and
occupational psychologists, counsellors, psychiatrists, coaches, phys-
iotherapists, occupational therapists, clinically oriented social work-
ers, as well as trainees in these disciplines. It will be best suited to
people who have had some prior exposure to ACT, whether through
training or self-directed learning.
The book is divided into five sections, with each part addressing a
different focus for the most common enquiries.

DOI: 10.4324/9781003364993-1
2 Introduction

1 Defining the philosophy and theory of ACT

2 Conceptual questions about the ACT model
3 Putting ACT into practice
4 Developing skills as an ACT practitioner
5 Critical questions about ACT

Each chapter is written as a stand-alone answer to the chapter title, so

you are free to choose whether to read cover to cover, or just dip into
the question at the forefront of your mind.
We have chosen to write in a way that is as inclusive as possible. The
questions will be answered without specific focus on any particular
condition or area of application in order to make it more accessible.
We have referred to the professional role as ‘practitioner’ throughout
the book, and referred to the receiver of the intervention as ‘client’. We
have also used the singular pronoun “they”, which we hope will work
for the majority of readers.
We are honoured to be part of your learning and development.
Many thanks for joining us on this journey.
Part 1

Defining the philosophy

and theory of ACT

Acceptance and commitment therapy (ACT) is a contemporary psy-

chological approach to behaviour change. It has been at the forefront
of the third wave of Cognitive Behaviour Therapy (CBT), blending
cutting edge research into verbal behaviour with ancient wisdom
traditions. ACT represents a transdiagnostic approach to behaviour
change that has broad application across a wide range of organisa-
tional and healthcare settings. This section of the book addresses fre-
quently asked questions about the philosophical and theoretical basis
of ACT. The chapters aim to describe ACT, placing it within the con-
text of evolutionary and behavioural theory, and the philosophy of
functional contextualism. The section also describes relational frame
theory (RFT), the basic science of language that informs ACT’s ap-
proach to intervention. Finally, it explores the relationship between
ACT and other approaches within the cognitive behavioural tradition.

DOI: 10.4324/9781003364993-2
Chapter 1

What is the best way to

describe ACT to a client?

It depends. This is one of the answers that you will see time and time
again when reading this book and hear when talking to ACT practi-
tioners. We will further explore the reason for this in Chapter 6. In
relation to explaining ACT to a client, how you describe it will depend
on factors like their existing knowledge of ACT and other psychologi-
cal concepts, and what they are hoping to gain by discussing the model
with you. Some people may have some psychological knowledge that
they want to check out with you. Others may have had little or no
exposure to psychological models, and therefore they will have a very
different reason for enquiring about the theory behind your sessions
together. So, it follows that there is no one ‘best way’ and any way will
depend on the factors listed above, as well as others like intellectual
ability and level of emotional arousal in the moment.
If you find yourself in a position of having to explain ACT to a client,
it may be more helpful to ask yourself, “What would be most helpful
in this moment, for this person in front of me?” rather than, “What is
THE best way to explain ACT?”. In our experience, explanations that
have the most utility have an experiential element, such that the client
is actively engaged in doing something, rather than passively listening
to the practitioner. The more active the client is in a session, the more
we may be able to move them away from a rehearsed ‘intellectual’ ap-
proach to life, and in the direction of a more ‘felt’ or ‘experienced’ way
of engaging with their world.
Having said all of that, it wouldn’t be a particularly helpful chapter
if we simply left it at “it depends”. So, here are some ideas on how to
approach this question with clients in a more experiential way. The
‘ACT in a nutshell’ exercise (Harris, 2009) is a simple and clear way

DOI: 10.4324/9781003364993-3
 What is the best way to describe ACT to a client? 5

to explain how we humans get stuck by our use of language. ACT

suggests that we have two main strategies that we draw upon when
facing unwanted thoughts and feelings, namely, fusion, and experien-
tial avoidance. ACT in a nutshell demonstrates these strategies using
a piece of paper. You can invite the client to write down a thought
or feeling that they are struggling with; for example, the client might
write “I am worthless” on a post-it note and use this for the exercise. If
you are comfortable enough with self-disclosure, it can be very useful
modelling for you as the practitioner to join in with the exercise by
writing your own uncomfortable thought on a piece of paper too.
Start by holding the paper up to your face, and invite your client to
do the same. Whilst in this position, explore with the client what they
experience. What can they see in their world now the paper is up close,
and what might they be missing out on? If they were to leave your
session in this position, what costs would it have for their life? You
can model the answer too by sharing what you can no longer see, or
safely engage with, as the piece of paper is firmly blocking your view.
You and your client will likely have a good view of the words you have
written on the piece of paper. Is it helpful to have this so close? This
is a demonstration of fusion, and when we allow our fused thoughts
to dominate our life, we end up with a very blocked perspective of the
world.
Conversely, then invite your client to push away the piece of paper.
Hold it at shoulder height, and push it away as hard as you possibly
can. These thoughts and feelings are, after all, unwanted. However
hard they are pushing, ask them to push harder, and really try to make
them be as far away as possible. Now invite the client to notice what is
grabbing their attention. Can they notice the tiredness in their upper
arm or shoulder? What if they were to continue pushing for another
hour!? And in all seriousness, this is what many of us humans do with
our unwanted thoughts and feelings. We exhaust ourselves with work-
ing so hard to keep them away that we are physically and emotionally
spent. And what else have we missed out on whilst we made sure we
were keeping those things at bay? Have we missed out on important
life experiences? Perhaps our children have been through a develop-
mental milestone that we weren’t really able to attend to? What have
been the costs of so heavily investing in keeping these things at arm’s
length? This part of the exercise demonstrates the use we make of ex-
periential avoidance, and its associated costs.
6 Defining the philosophy and theory of ACT

Next invite your client to rest their tired arm, still holding the post-it
note in their lap. What do they notice? Relief? A reduction of tension?
A broader ability to focus their attention on other things? For exam-
ple, they may suddenly make eye contact with you for the first time!
You can curiously enquire about what it feels like to let this set of
words just lie in their lap. Leaving the post-it note there, you can point
out that now you can both move your hands, which, in the demonstra-
tion of fusion and experiential avoidance, you were less able to move
freely. What else could they turn their attention to if they were able to
leave those words gently resting in their lap? What if they were to fold
the post-it note and put it in their pocket? What could they then do in
their lives that they are currently unable to do?
Alternatively, an overarching metaphor can also be a helpful tool
for explaining the ACT model. ‘Passengers on the bus’ is a very com-
monly used metaphor for helping clients to understand the impact of
how our thoughts can direct our behaviour, and how this doesn’t have
to be the case. See Chapter 9 for a more detailed discussion of the use
of metaphors.
Explaining the model to clients and/or helping them experience it
can be an important part of helping them to understand why ACT
practitioners may approach things slightly differently to how they
have experienced them before. However, our focus in doing this is al-
ways about the importance of psychological flexibility. It can therefore
be helpful to explain the model as learning a set of new ‘flexibility’
skills, and that in each session, the focus will be on the development
of these skills. See Chapters 11, 24, and 26 for more on seeing ACT as
six separate skills.
Of course, the urge to engage in ‘explaining’ behaviour may come
from you, and, if so, the question to ask yourself is, “What is the func-
tion of sharing the detail of the model with someone who doesn’t re-
ally need to know it?”. If this is you, see Chapters 7 and 18 on toward
and away moves, and reflect on this in relation to your own behaviour
as a practitioner.
Chapter 2

Which kinds of issues can

ACT help with?

We are frequently asked whether ACT can be useful in situation X,

Y, or Z. There are probably two ways to answer this question, specif-
ically, either from a conceptual or an empirical perspective. This is to
say that there is potentially a difference between the kinds of issues
that processes and procedures within ACT can usefully be applied
to, and the kinds of issues that ACT has been shown to be effective in
helping. Each of these will be dealt with in turn.
From a conceptual point of view, ACT is intended as an approach to
adaptive behaviour change and psychological wellbeing that is broadly
applicable across any situation which people experience. Indeed, in
describing their own ACT-based self-help course, the World Health
Organization states that it is, “suitable for adults who experiences
stress, wherever they live and whatever their circumstances” (WHO,
2022). Thus, it is a reasonable starting point to assume that ACT prin-
ciples might be helpful in any situation that might come to the atten-
tion of people that work in helping roles. Whilst any specific context
will give rise to unique stressors, and the nature of people’s thoughts,
feelings, and behaviours will differ, ACT takes the stance that psy-
chological flexibility and its sub-processes are universally applicable.
Support for this stance can be seen in the diverse range of contexts
where ACT has been applied to date, and in the variety of methods of
its delivery. Whilst individual psychotherapy in physical and mental
health settings is probably where ACT has been most widely used, its
reach is much broader than this. Whilst psychotherapy is most often
concerned with helping people address deficits or problems in their
lives, ACT has also been used to increase performance in otherwise
healthy individuals. Applications in the workplace and in sport are

DOI: 10.4324/9781003364993- 4
8 Defining the philosophy and theory of ACT

examples of the latter. ACT also provides a basis for working on issues
faced by groups of individuals, such as teams of people within organ-
isations or wider community groups (Atkins et al., 2019). One of the
most notable examples of the application of ACT on a larger scale is
in the training of health professionals, community workers, and the
public in Sierra Leone during the Ebola crisis, where the principles
of psychological flexibility were used to foster behaviour change and
reduce the number of new infections (Stewart et al., 2016).
Turning to the second way to answer this question, many would ar-
gue that one can only determine what kind of issues ACT can actually
help with is with reference to evidence from randomised controlled
trials (RCTs) or other types of outcome research. Whatever claims
might be made about the utility or impact of any model, the proof of
the pudding is in the eating. There are also those who say that you can
never really trust the efficacy of a psychological intervention until it
has received a lot of research attention and there is enough evidence
available for researchers to conduct systematic reviews or meta-
analyses of the data from the research trials. Fortunately, ACT has
been the subject of a significant programme of research right back to
the roots of its inception in the 1980s, and in considering this question,
we can draw on a large body of outcome data as well as the findings
from various types of reviews.
One of the problems of answering this as an empirical question in
a book such as this is that any answer that we give will be out of date
by the time the book is out, such is the rate at which new ACT re-
search is published. We find ourselves constantly updating our train-
ing slides on ACT research. Our advice to you if you are wanting an
answer to this question is to try to keep yourself abreast of the latest
research findings. This can be quite a task given that so far in 2022,
RCTs looking at the effectiveness of ACT are being published at the
rate of at least one each week. In terms of useful resources, Hooper
and Larsson’s (2015) very helpful book charting ACT’s research jour-
ney provided a detailed analysis of the empirical literature up until
the time of its publication. However, books are not the best place to
look given their somewhat static nature. Fortunately, the Association
for Contextual Behavioural Science (ACBS) maintains a dynamic list
of RCTs, systematic reviews, and meta-analyses on the ‘research re-
sources’ section of its website (Hayes, 2022). If you want to look at the
state of the ACT evidence at any given point, this is the best resource
that we have found.
 Which kinds of issues can ACT help with? 9

At the time of writing this book, ACT has a significant evidence

base for being helpful across a wide range of physical and mental
health issues, with the three strongest research areas being anxiety,
depression, and chronic pain. It also has utility in organisational set-
tings as an intervention to help manage workplace stress and prevent
burnout (Flaxman et al., 2013). The first review of ACT meta-analyses
(Gloster et al., 2020) covered research on over 12,000 participants and
concluded that ACT was efficacious wherever it was applied, being
superior to inactive control conditions and most other active inter-
ventions. It performed as well as traditional forms of CBT. We will
conclude our answer to this question with the current list of issues for
which ACT is recommended by the national guidelines of several of
the world’s countries (see Table 2.1).
This is not an exhaustive list of the issues where ACT can demon-
strate evidence of its effectiveness. However, it is included as an in-
dication of the range of issues where the evidence base is substantial
enough to have led to the recommendation of ACT at a national level.

Table 2.1 Issues for which ACT is recommended in national guidelines

Australia Generalised anxiety, social anxiety, panic,

borderline personality, depression, health
anxiety, obsessions and compulsions, pain,
psychosis, problematic substance use, binge
eating, body dysmorphia
Netherlands Depression, multiple sclerosis with depressive
symptoms
United Kingdom Chronic pain, tinnitus
United States Depression, chronic pain, mixed anxiety,
obsessions and compulsions, psychosis,
problematic substance use
Chapter 3

What are the basic

assumptions that
ACT makes?

In more recent years, ACT has become synonymous with the Hexaflex
(see Figure 11.1) and the six core skills that support the development
of increased psychological flexibility. However, when these are looked
at in isolation, the essence and complexity of the ACT model is lost.
This may feel disheartening to read. Perhaps you came to this book
with the desire to increase your ability to work on these core skills in
the service of being a more efficient and successful practitioner for the
clients that you serve. When focusing solely on the Hexaflex to effect
behaviour change, there will undoubtedly be some success for many
clients. Research suggests that developing any of the Hexaflex skills
positively impacts psychological flexibility and other wellbeing out-
comes (Villatte et al., 2016a; Levin et al., 2020). However, the precision
of the model comes from having a good grounding in the wider scien-
tific knowledge, theory, and underpinning philosophy, within which
practitioners can embed their work on the ACT core skills to more
finely tune the interventions that they provide.
As is the case for any science-based work, including psychological
models, there are some basic premises that underlie ACT, and practi-
tioners will benefit from understanding these from the outset. These
basic assumptions are not simply points to remember, rather, they are
the very bedrock of the model. They are the foundation from which
the model has expanded, layer by layer.
This chapter alone is too short to cover the detail of the history of
behaviourism, the exact journey of the development of ACT, and the
complex ideas that have been interwoven to contribute to this body
of work. Further chapters aim to offer more detail and suggest fur-
ther reading on many of the points mentioned here. This chapter aims

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 What are the basic assumptions that ACT makes? 11

to offer an overview of the key assumptions that underpin the ACT

model, in order that their importance becomes clearer. It also pro-
vides a rationale for further implementing them into your ACT work,
rather than relying solely on the Hexaflex.
ACT relies on an underlying science of language and the behav-
iour of relating concepts together, known as relational frame theory
(RFT). This is summarised and explored in relation to its intervention
application in Chapter 8. The underpinning philosophy of the model
is based on the world view of contextualism, specifically functional
contextualism. This is further explored in Chapter 5. Arising out of
both of the aforementioned scientific and philosophical foundations,
the following are some basic assumptions that are made from a con-
textual behavioural standpoint, which are therefore central to ACT
practice.

Everything is behaviour
The work of Skinner (1953) advanced the earlier understanding of
behaviourism to also include attention to internal events such as
thoughts, feelings, and language. ‘Radical behaviourism’ formed
the ‘first wave’ of what became CBT. The field moved more in the di-
rection of cognition during the 1970s, forming what is known as the
‘second wave’ of CBT. The ‘third wave’, which includes ACT (Hayes
et al., 1999), focuses on the importance of the relationship between
the behaviour and the context within which it occurs. ACT assumes
that all human experience is behaviour, encompassing both internal
events and externally observable actions. This idea is captured in the
well-known and often utilised tool, the ACT Matrix (see Chapter 24).
Whilst internal and observable behaviours are separated by the hori-
zontal line, with internal behaviours below and observable behaviours
above, the Matrix seeks to describe the impact of all human behav-
iours, and the further behavioural choices that people may have in
response to them.

Behaviour is not random

By accepting a functional contextualist world view, which in summary
holds that all behaviours are acts-in-context, it follows that behav-
iours are not random. They do not occur in a vacuum or appear out
of nowhere. They have a history, and a specific behaviour occurring
12 Defining the philosophy and theory of ACT

would be predictable given the historical context of the person and the
current context within which the behaviour happens. The complexity
of human behaviour may appear to suggest that specific actions are
random. However, a thorough functional analysis would help to iden-
tify complex behaviour patterns that are embedded in a complex his-
tory, which could theoretically explain all of the observed behaviours
presented by an individual.

All behaviour is purposeful

There are no coincidences or accidents with actions. There are only
behavioural patterns that are in an individual’s repertoire because
they have previously been utilised. If the behaviour was effective for
the person with regard to a desired outcome being achieved, the be-
haviour is more likely to be utilised again, and the behavioural pat-
tern will be reinforced. All of the behaviours in a person’s repertoire
are available for them to engage in at any point that the conditions
around the person evoke their occurrence. The likelihood of a behav-
iour happening will increase if the behaviour has previously afforded
them a desired outcome, either moving toward something of meaning
to them, or away from something uncomfortable or unwanted. In re-
lation to either moving toward or away from something, all behaviour
is seen as purposeful and functional.

No absolute truth
One of the most asked questions in ACT-consistent interactions
(training, supervision, or therapy) is, “Is that behaviour helpful?”. The
underlying philosophy of functional contextualism adopts a different
view of ‘truth’ to that which most people are familiar with. Largely
truth is assessed by the similarity between a verbal description and a
lived experience of a situation. Functional contextualism instead fo-
cuses on ‘truth’ as effective action, hence the question about whether a
behaviour is helpful in leading a person toward their intended goal. If
the action was helpful in achieving a specified end goal, the behaviour
would be considered ‘true’. Thus, functional contextualism adopts a
more pragmatic truth stance, rather than one assessing any sense of
an ontological truth.
ACT-consistent interventions require that all of these basic assump-
tions are held in mind as they form the foundation from which any
ACT tools and techniques can be utilised to effect behaviour change.
Chapter 4

How does evolutionary

theory apply to ACT?

Some models of psychotherapy, notably Beck’s (1979) cognitive ther-

apy, are predominantly models of dysfunction in that they start from a
position of the client being ill and aim for recovery, usually measured
by a reduction of distress. ACT is different in that it is a model of
function. As part of the discipline of contextual behavioural science
(CBS), ACT seeks to understand how human beings operate in the
world, and then uses this understanding to explore how they might
fill their lives with meaning and purpose. There is a big emphasis on
helping people develop psychological flexibility to manage the chal-
lenges they encounter in the context of their environment, as well as
the challenges posed by their own thoughts and feelings. Of course,
ACT can be usefully applied to help people who might traditionally
be described as ‘ill’, whether mentally or physically, although it tends
not to lean too heavily on diagnostic frameworks or subscribe to a
medical model of difficulty or distress.
Rather than see people as ill or broken in some way, thereby locat-
ing all of the problem within an individual, ACT prefers to see people
in distress as stuck. This places the emphasis on the interaction be-
tween a person and the context in which they find themselves. Every
psychological model needs a theoretical foundation, and functional
contextualism, RFT, and ACT all lean on evolutionary theory to ex-
plain why it is that people get stuck. ACT views psychological difficul-
ties as adaptive variations to environmental challenges, rather than as
diseases or disorders (Hollon, 2021). Whilst a detailed examination of
evolutionary theory is beyond the scope of this book (see Sloan et al.,
2018 for an in-depth look at the relationship between evolutionary the-
ory and CBS), we will cover the main issue of relevance, namely the
development of human language.

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14 Defining the philosophy and theory of ACT

The human mind is different to that of other animals because of its

much broader cognitive abilities. The precise reason for this is still a
matter of some debate, although it seems clear that human cognitive
and language abilities evolved alongside humanity’s development as a
predominantly co-operative species. We developed the ability to flex-
ibly communicate on a large scale by exchanging speech sounds with
one another. We began to attach sounds to objects in the real world,
enabling the symbolic transfer of information and ideas (Hayes et al.,
2001). We could talk about people who were not present, relive events
that had occurred in the past, and even describe imagined situations
that we had never experienced. Whilst it is easy to take these everyday
abilities for granted, there is no other species on the planet that com-
municates in the range of ways that humans do, or that has the same
powers of imagination. However, the same ability that is responsible
for our seemingly limitless creativity and co-operation is also respon-
sible for most of our suffering. No other animal ruminates over their
past failures or worries about their future. Our cognitive and language
abilities make it very difficult for us to live in the moment. For a mod-
ern human, the normal developmental business of acquiring language
makes a certain amount of psychological suffering inevitable and an
almost infinite amount of suffering possible. To try and cope with the
suffering we experience at the hands of our own thought processes, we
get stuck in unhelpful patterns of fusion and experiential avoidance.
To make matters worse, we frequently heap further self-criticism upon
ourselves for using these strategies. In short, language is both a gift
and a curse for our species.
For the reasons stated above, the theory and practice of ACT is
intertwined with the theory of human evolution. RFT, which is the
theory of language that ACT allies itself with, is interested in relat-
ing (the behaviour of linking stimuli using language, e.g., ‘lions’ and
‘dangerous’) and the subsequent functions of that relating (e.g., the
behaviours of worrying and avoidance that occur as a consequence of
associating ‘lions’ with ‘dangerous’) (Barnes-Holmes & McEnteggart,
2020). The theory of evolution by natural selection (Darwin & Kebler,
1859) offers the most convincing account of why human beings have
developed as they have, and ACT leans on this account of human de-
velopment to explain why we experience psychological suffering in the
way that we do.
The practice of ACT also shares some features of the Darwinian
model in its approach to behaviour change. Nature produces genetic
 How does evolutionary theory apply to ACT? 15

variations in organisms, some of which are selected and retained if

they give that organism an advantage in terms of survival. In much
the same way, ACT practitioners encourage variation and flexibility
in behaviour, inviting clients to notice what behaviour works for them
with regard to navigating the world, and further encouraging them to
select and retain those adaptive behaviours.
A related question here is whether an ACT practitioner needs to
subscribe to the theory of evolution to practice effectively. This is rel-
evant given that the theory runs counter to the beliefs of some clients
and practitioners, particularly those with strong religious convictions.
Our position here would be that whilst some discussion of evolution-
ary development to reinforce the idea that human suffering is ubiq-
uitous and entirely expected can be extremely validating for many
clients, it is not an essential component of how ACT is practiced ‘in
the room’. As with most aspects of ACT practice, some flexibility is
recommended, and practitioners would be wise to tune in to their cli-
ent and the context of their work together to determine if any, and if
so, how much, discussion of evolutionary theory would add value in
any given moment.
Chapter 5

What is functional
contextualism?

Functional contextualism is a philosophical world view. Of numer-

ous world views, Pepper (1942) identified contextualism as one of four
that came close to the ideal level of precision and scope. Every phil-
osophical world view has its own root metaphor and truth criterion.
A root metaphor is a common-sense understanding of an event, and
within contextualism the root metaphor is the act-in-context. A truth
criterion provides the basis by which the accuracy of truth can be as-
sessed and is inextricably linked with the root metaphor. In the case of
contextualism the truth criterion is concerned with the function of an
action, which can be defined as true or valid if there is an achievement
of a goal, not by its reflection of reality.
In essence, the underlying philosophy of ACT is that it is concerned
with exploring the function of any behaviour inside the context within
which the behaviour happens. This reflects the root metaphor of the
act-in-context. This can feel like a tricky concept to fully understand,
so we will use some examples to illustrate the interplay between func-
tion and context, and why, from an ACT perspective, they are una-
ble to be understood in isolation and are wholly dependent on one
another.
To consider the context of a behavioural event is to consider where
the event happens. This can refer to where in a person’s timeline the
event happened, such as whether it is happening in the present, or
whether it can be explained with reference to its historical context,
for example, current avoidant behaviour in the context of an abusive
history. Each of these time points provides us with information about
the behaviour being described and will shape our formulation about
how the event is experienced inside the client’s life. Context can also

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 What is functional contextualism? 17

refer to the physical context, for example, the people and location
surrounding the event, or the psychological context, such as “In the
context of my current struggles…”. Again, the setting of the internal
and external context provides a large amount of information that can
be added to a functional analysis or formulation. Any minor change
to the context can change our understanding of the behaviour, so it is
really important to have a clear understanding of the context for it, in
all of the ways described above.
The function of an event refers to the effect that it had. This is dif-
ferent to intention, and it is important not to confuse these two con-
cepts. Suppose a client informs you that they intended to pay someone
a compliment, however, the receiver of their words took offence.
Whether that was intended or not we would classify the function of
the comment as aversive, from the receiver’s point of view.
Let us further explore the ideas of function and context by look-
ing at a language example concerning the impact of context. Imagine
being in a nightclub and the DJ shouts, “Put your hands in the air!”
just as your favourite song starts. What do you notice? Perhaps you
would smile. You may willingly raise your hands and you may notice
feelings of joy and excitement. Now let us switch the context. You are
in the queue at the bank on a busy Friday afternoon, paying in a large
amount of cash. Someone walks in and shouts, “Put your hands in
the air!”. What do you notice now? You are likely not smiling in this
context. You may raise your hands, although this may not be with the
same vigour and willingness than you had in the above example. You
may notice a wholly different range of thoughts, feelings, and physi-
ological sensations to the ones that you felt in the nightclub scenario.
Whilst the stimulus, in terms of the language used, was the same, and
maybe resulted in the same behaviour (raising your hands), the context
in which that happened evoked very different reactions. Changing the
context leaves you feeling very differently about hearing, “Put your
hands in the air!” because the different contexts changed the function
of the words.
In the above example, the form of the behaviour remained the same
(your hands were in the air) but the function was appetitive in one
scenario and aversive in the other. We can also consider function in a
different way, whereby the form of a behaviour might change whilst
the functions remain the same. This is something that can be tricky to
catch in clients’ behavioural patterns. However, it is an important skill
for practitioners to hone and can increase the precision with which
18 Defining the philosophy and theory of ACT

functional contextualism is utilised in intervention work. Imagine a

client who is struggling to connect emotionally during sessions. Each
time you raise an issue that feels aversive for them, they find a way of
avoiding it, and you find you never really get near the emotional con-
tent underlying their behavioural choices. There are numerous ways
in which this avoidance might manifest. The following list contains
several examples:

• Cancelling a session
• Turning up very late to reduce the amount of time in session
• Using humour
• Asking about you
• Talking about other topics that are less emotional
• Spending a lot of time describing something that could have been
easily summarised
• Showing you photos of their new puppy

All of these are different forms of behaviour, i.e., they each look dif-
ferent to one another. However, the function of all of them is the same
in that they serve to keep you at arm’s length. Whilst each of the above
could genuinely be toward moves in some contexts, it is only when
we identify the common contextual factor (getting close to emotional
content) that we may realise that these behaviours all serve the same
avoidant function.
From a functional contextualist perspective, no behaviour can be
judged as intrinsically right or wrong. Instead of making judgements
about behaviour, we would always encourage ACT practitioners to
ask, “What’s the function?” and seek to explore how workable any
particular behaviour is for an individual within the particular context
in which it occurs.
Chapter 6

Why do ACT
practitioners answer
every question with
“it depends”?

As tempting as it is to simply write “it depends” in response to this

question, we will attempt a fuller answer that gets to the heart of this
admittedly irritating habit, which seems to become part and parcel of
being an ACT practitioner after any significant length of time.
If you’ve read the preceding chapter on functional contextualism,
you will have hopefully taken away the key principle that the function
of a behaviour, and the context in which it occurs, are concepts that
are inextricably linked. The function of any behaviour is dependent on
the context of its occurrence, and it is impossible to truly make sense
of any behaviour in isolation. Removing one’s clothes in the privacy of
one’s own bedroom is one thing. Removing them in the freezer aisle of
one’s local grocery store is something else entirely. It’s exactly the same
behaviour on both occasions, and yet the two different contexts com-
pletely change the function. Doing that same behaviour in those two
different contexts carries a different meaning and will likely lead to
different consequences for the person doing it, not to mention any un-
suspecting shoppers.
Since a functional contextualist perspective tends to reject the no-
tion of absolute truth, it is rarely possible to give an absolutely defin-
itive answer to any question. The answer will always depend on the
context of the question. It has become a feature of the trainings we give
to those learning ACT for the first time to address this issue. When
any of us are new to something it is natural to want a ‘handbook’ or a
step-by-step procedure for how to approach a task or situation. If we
lack experience in something it often feels like it would be useful to be
told exactly what to do. We can experience a craving for rules, and for
a practitioner using a new model there is a certain sense of safety to

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20 Defining the philosophy and theory of ACT

be gained by having a clear set of rules or a defined protocol for how

to practise. Thus, it can be quite disheartening for an ACT trainer to
answer honest questions with “it depends”, although there is a sound
rationale for doing so.
There is experimental research (e.g., Hayes et al., 1986; McAuliffe
et al., 2014) suggesting that teaching people to follow rules has a det-
rimental impact on their ability to react effectively to subsequent
changes in a situation. Those who have been taught to follow a rule
are more likely to continue to try and apply the rule, even when the
situational changes mean that following it has become ineffective. In
contrast, teaching people to figure out for themselves what is going on
in a situation, and to respond flexibly to any changes, tends to produce
a much more agile response style. This is because rules can tend to
take on a life of their own, and following the rule, purely because it is
the rule can become more important than noticing what is happening
in the situation. In short, rigid rule following can reduce our ‘context
sensitivity’, making it more difficult for us to see what is actually hap-
pening around us. To illustrate this, consider the satellite navigation
systems that many car drivers use to get them from A to B. There
have been several news reports of people having to be rescued after
doing things like driving into rivers, because they were following the
instructions issued by their Sat Nav. These are clear examples of how
rule-governed behaviour has reduced context sensitivity, in that those
people only drove into the river because the Sat Nav told them to. They
would have stopped short of the river otherwise.
We can extend the driving metaphor to help us as we come back to
the importance of “it depends”. If you want to drive to a new destina-
tion, it may well be helpful to use a Sat Nav. It will help you answer
the question of how you get from A to B. However, it might also be
useful to hold the instructions from the Sat Nav lightly and be flexible
with the rules that it is issuing. For example, if you see a river in front
of you, it might benefit you to take the left turn ahead of you so that
you don’t submerge your car, even though the Sat Nav is telling you to
go straight ahead. Whilst the Sat Nav is giving you one solution about
how to get from A to B, the reality is that there are usually several
different routes, and which one you ought to take depends on various
factors. For example, it depends on whether you want the quick route
or the scenic route, whether you want to take or avoid the toll road,
and whether the amount of rainfall we have had recently means that
the shallow ford that is usually passable is now a deep river.
 Why do ACT practitioners answer every question with “it depends”? 21

ACT practitioners often say “it depends” because saying so en-

courages whoever is asking the question to be sensitive to the context
around the question. From a functional contextualist perspective it
is preferable to orientate people to the contingencies in their envi-
ronment and invite them to track those contingencies for themselves,
rather than to simply give them advice. This is the case whether it is
an ACT trainer answering a question from someone in a workshop, or
whether it is an ACT practitioner answering a question from a client.
We want to position ourselves as helping others to develop their skill
in tracking what the most workable action might be in any given situ-
ation, rather than simply telling others what to do.
The old adage of ‘give someone a fish and you feed them for a day
but teach someone to fish and you feed them for life’ seems relevant
here. Fishing, like any skill, is not learned solely through a simple set
of ‘do this and then do that’ instructions. Whilst a certain amount of
basic instruction is inevitable, it is much more useful when accompa-
nied by encouragement to be flexible with those instructions, based on
the tracking of variations in the context.
Chapter 7

What is the most

important behavioural
principle to remember?

Tracking the distinction between making toward and away moves is

one of the most useful things that a client can learn about their own
behaviour. The discrimination between these two functionally dis-
tinct classes of behaviour is firmly rooted in the behavioural theory
of appetitive and aversive control. The theory describes the difference
between an organism moving toward a stimulus that it wants or has an
appetite for, and away from something it does not want or finds aver-
sive. Such behaviour has been observed in a wide range of organisms,
including single cell protozoa, suggesting that the survival instinct to
both seek resources and avoid threat precedes the evolution of hu-
man beings, dating as far back as 600–700 million years ago (LeDoux,
2019). Due to its evolutionary history, there is an argument that this
basic discrimination is absolutely central to life. As LeDoux (2020)
puts it, “life is all about not being dead – without life, ‘danger’ would
be a meaningless notion”. Survival requirements predict different sur-
vival tactics for different species, and these biological needs find their
expression in the observable behaviours of approaching or avoiding
different stimuli. These behaviours are associated with emotional and
cognitive responses, but those responses do not tell the whole story.
For example, even amongst humans, whilst danger is universal, the
subjective experience of fear will vary between individuals and across
cultures. In any given moment, based on a complex reaction of biolog-
ical impulses, emotional experience, and cognitive appraisal, humans
produce behavioural responses to stimuli, and we can classify these
responses as either being toward or away moves.
Humans are different to every other species on the planet when it
comes to our ability to communicate at the level of complexity that we

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 What is the most important behavioural principle to remember? 23

do. Our language ability has afforded us great benefits, and as we dis-
cussed in Chapter 4, it has also enabled us to forward plan, imagine,
create scenarios in our minds that may never happen, problem-solve
such scenarios, and worry a great deal about our possible demise with
complete ease. Our ability to do all of the above has certainly been
helpful to our species’ success at staying alive. You may even be able
to bring to mind times in your lives where you have been able to con-
sider possible scenarios or outcomes and prepare for them, or avoid
them altogether. Deciding that something is so aversive that we want
to move away from it is a completely valid option, and will most cer-
tainly have kept us all alive at times. However, an issue arises when
we apply the same logic to our internal or ‘mental’ processes. For ex-
ample, if you have the thought “I am not good enough” as you are
about to do something meaningful, you will likely experience bod-
ily sensations that feel uncomfortable, or perhaps even painful. This
stimulus is screaming loud and clear “do not do that thing, it is big
and scary, and we like to be safe!”. If you tune into those physiolog-
ical cues you could quite easily conclude that you need to back out
of that activity. In the short term, this may feel like a very rewarding
decision to have made. You will experience immediate relief from dis-
comfort as those bodily sensations subside, and may be noticing the
thought, “Phew!”. However, taking an away move to turn down the
volume of internal stimuli can often feel less rewarding in the longer
term, as multiple applications of this cycle of choosing away moves
would very quickly mean rejecting and moving away from anything at
all in life where “I am not good enough” shows up. Just consider for a
moment how many wonderful and meaningful activities you may have
rejected if you responded in this way every time that thought popped
into your head.
Toward moves often feel different in their quality. Instead of relief
at the avoidance, we are often connected to a longer-term sense of ful-
filment that comes with taking the actions that we feel are important.
It is essential to state that toward moves are not easy, and in fact, they
are often harder than away moves. They require us to really consider
our values and the value-driven actions we actively commit to taking.
Helping our clients to learn to track their toward and away behaviours
in line with their own values is a key part of the work from an ACT
perspective.
Any behaviour can be a toward or away move. It is only when we
consider the context that it occurs in that we are able to identify the
24 Defining the philosophy and theory of ACT

function. The functional class of the behaviour can contain many var-
ied and creative forms of behaviour. For example, as away moves, how
many of us have very ‘productively’ tidied our desks, made an ‘urgent’
phone call to a long-lost friend, made a convoluted nutritious meal
that took us many hours, or watched TV when we had something dif-
ficult to engage in? These behaviours could be labelled as ‘productive’,
‘connecting’, or ‘nurturing’. It is only when we understand that the
function is actually more about avoidance of a difficult task that we
can see, from a CBS perspective, that they are in fact away moves. In
the same way, toward moves also include a huge variety of forms of
behaviour. If a client wants to expand their self-care repertoire, they
might act on this by spending time reading a book, having a bath, or
hiking a new trail route through a high mountain enjoying some alone
time and the nature all around them.
We may often meet with our clients and hear summaries of their
behaviour between sessions. It is always helpful to ask them, “Was
that a toward or away move for you?” as it will only be them that really
knows whether they did something that would expand their behav-
ioural repertoire in line with their values, or not.
Chapter 8

What on Earth is
relational frame theory?

What RFT seeks to do is offer a behavioural account of human lan-

guage, in terms of how it functions. It builds on basic behavioural
theory and has attempted to address the earlier criticisms of Skinner’s
verbal behaviour theory (Skinner, 1957), since it seemed inadequate
in describing the functions of language and how it appears able to
transform other types of learning (Hayes et al., 2001). With its em-
phasis on a bottom-up, basic science approach, RFT sets out a way of
empirically testing hypotheses about language. It has built up a rap-
idly expanding research programme over the past 20 years (Montoya-­
Rodríguez et al., 2017), which has been very influential in shaping how
ACT is practised.
The relationship between RFT and ACT is interesting. To use a met-
aphor, one might describe them as cousins, and whilst they may have
grown up in different houses, their frequent meetings have influenced
each other’s development to the point that neither would have ma-
tured in the same way without the other. As a basic science program,
RFT research helps answer questions about what ACT interventions
ought to look like in practical terms. At the same time, the practice of
ACT helps RFT researchers think about what questions they should
be finding answers to.
It is not easy to explain RFT in a short chapter such as this (see
Törneke, 2010 for a well-written and accessible book on the subject).
In brief, it is an attempt to explain the human ability to relate any
stimulus to any other stimulus. Humans can take any two objects,
ideas, or concepts, no matter how random, and form a relation be-
tween them. Let us take ‘birdsong’ and ‘cheese’ and use them as an ex-
ample. If you pause for a moment and notice what you are doing right

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26 Defining the philosophy and theory of ACT

now, you may notice a nagging urge at the edge of your consciousness
to try and relate these two concepts. You might be thinking about
how different they are (birdsong is quite distinct from cheese), ways in
which they are similar (birdsong and cheese both originate from living
organisms), or how they might be associated (birdsong comes before
cheese in an English dictionary). Indeed, once we have suggested the
two things to you in the same sentence, it is really quite difficult not to
engage in the behaviour of deriving relations between them.
This ability to derive relations and the subsequent tendency to en-
gage in this behaviour almost without knowing we are doing it is right
at the core of human language. A relational frame uses the idea of a
frame as a metaphor to describe how two concepts are related to each
other and specifies the nature of that relationship. For example, “This
is cheese” is a co-ordination relation, which specifies that the symbolic
noise “cheese” is the same as that block of yellow stuff in your refrig-
erator. Almost from the moment we are born, humans are taught the
ability to derive such relations, and to use them in ways that they are
persistently reinforced for. Most infant humans very quickly master
the ability to derive relations between stimuli in increasingly complex
ways (e.g., is the same as/is different to/comes before/is next to/is a part
of) and they go on to develop complex language skills in an incredibly
generative and flexible manner.
There are many things about relational framing that are remarkable,
as well as being very important considerations for the practice of ACT.
One of these is that many of the relations that we derive, and then pro-
ceed to completely take for granted, are arbitrarily derived. For exam-
ple, the sound “cheese” has no connection to actual cheese in the real
world, aside from the fact that, in the English-speaking world at least,
we have just decided to agree that it does. However, once the relation
has been formed in your mind, no matter how arbitrary it is, the mere
mention of the sound “cheese” might be enough to make you salivate
(or retch, depending on your history with cheese). The behaviour of
arbitrarily applicable relating produces other behavioural functions,
which is why ACT practitioners are so interested in the kinds of rela-
tions that dominate a client’s thinking. A fuller understanding of why
people do the things they do becomes possible when we know more
about the relations they have made. For example, someone’s risky sex-
ual behaviour might be much easier to understand and develop an
intervention for once we understand that sexual intimacy is strongly
co-ordinated with a sense of feeling cared for. Equally, a strong need
 What on Earth is relational frame theory? 27

to feel cared for might be dictated by a learning history in which that

individual was treated unfavourably, such that they learned that, in a
hierarchical sense, they were worth less than others.
Another remarkable ability of humans is that we can infer relations
between stimuli without directly being taught. A child can learn that
crossing the road is dangerous simply by being told by a parent that it
is. Unlike other species, who largely have to be injured, or witness an
injury, to learn the danger posed by something, humans benefit from
this powerful form of indirect learning, that adds another dimension
to respondent and operant conditioning. Of course, this is not purely a
benefit. Language enables humans to be frightened of things that have
never happened to them, which might be helpful in the case of cross-
ing the road but is much less helpful when someone is experiencing
paralysing anxiety about an interview that they have never actually
experienced.
With its emphasis on the importance of symbolic learning, RFT
helps us understand why humans get distressed simply by relating
words and ideas together, and how we can make use of those same
processes to form our interventions. Human distress is ubiquitous be-
cause almost all of us have the capacity for language. This is a central
claim of both RFT and ACT. RFT research has been able to examine
a range of diverse aspects of human ‘languaging’ behaviour includ-
ing naming, understanding, analogy, metaphor, and rule-following
(Hayes, n.d., a). It holds the view that crucial to understanding all
of these, as well as other verbal activities, is the concept of arbitrar-
ily applicable relational responding. ACT leans heavily on this same
understanding, and close scrutiny of many ACT interventions reveal
that they are built around this and other core concepts of RFT. This
close relationship begs another question, and that is whether an ACT
practitioner needs to really know RFT in order to practise ACT. This
question is addressed in Chapter 20.
Chapter 9

Why does ACT use so

many metaphors?

Nursery rhymes, sea-shanties, and millennia-old folk songs. These are

all examples from human history of using language for storytelling.
The function of the storytelling is often one of learning, whether that
be passing on knowledge or information, to heed the warnings of his-
torical actions, or signposting people in a different direction to pre-
vent previous errors. Within the world of behaviour change practice,
and especially in ACT, the use of metaphors has a similar function.
Simply put, metaphors are used to aid learning.
Learning is transferred from one situation, in which we have an ex-
isting understanding of relational networks, to a novel situation where
the network is comparable (Törneke, 2017). This is RFT at work with
a practical application. When a metaphor is used to describe the situ-
ation within which we feel stuck, it can produce those ‘a-ha’ moments
that help us get a fresh perspective and see that other, more workable,
behavioural responses are available.
Some metaphors may be used as one-off examples; for instance, the
metaphor of ‘getting straight back on the horse’ following a fall is a
common example of how we use metaphors in our day-to-day lan-
guage. We might say the above to someone, meaning not to let the
fear grow before tackling the same challenge again, and even if they
have no experience of riding horses, this meaning will generally be
understood. This understanding can be used to promote insight into
the unhelpful functions of experiential avoidance in the long term.
The verbal relations contained within this metaphor are illustrated in
Figure 9.1.
Other metaphors may be overarching metaphors, that can be used
throughout ACT practice with a client as a means of developing insight

DOI: 10.4324/9781003364993-11
 Why does ACT use so many metaphors? 29

Avoiding riding Experiential

following a fall avoidance

Relation of Relation of
causation Relation of causation
co-ordination

Increased anxiety Increased anxiety

about riding in the long term

Figure 9.1 R elational networks contained in the metaphor of ‘getting

straight back on the horse after a fall’

around more complex sets of relations. As an example, imagine a per-

son experiencing a sense of stuckness in their life using the metaphor
of being lost in the middle of a jungle. They are surrounded by dense
foliage, tall trees, and overgrown, disused paths. There are also hid-
den bogs and a river somewhere out of sight. In addition, there is the
knowledge that out there somewhere in the jungle are many dangerous
animals that could attack and kill for their next meal. It certainly is
a scary place to be. This could be used as an overarching metaphor
for how the client is feeling about life. They feel frightened and over-
whelmed. ‘Fear’ stems from the idea that other creatures know the
territory better than they do. ‘Insecurity’ also comes from not having
the basic things we all need in life to feel safe, such as somewhere to
sleep with ease, friendly company, and connection.
Considering life in this way could make a great deal of sense to a
client who can empathise with the feelings associated with being alone
in a jungle. It is something they would not want for themselves, and
metaphorically, something they have. Imagine if the client’s real life
was privileged in certain ways, and this served to offer reasons as to
why they believed they did not deserve a compassionate perspective
on their predicament. Thoughts like “but I am healthy”, “I have a nice
place to live”, or “I have a nice car” will tend to take them down a
judgemental path, and one that veers away from compassion, under-
standing, and associated value-driven action.
Using the jungle metaphor as a way of talking about their emotional
world (i.e., that they felt alone, unheard, and abandoned) might help
the client consider some of the basic needs that one might have. This
could open a door to a discussion about self-care in a way that seems
30 Defining the philosophy and theory of ACT

much harder when talking about their real life. The metaphor could
be developed as a way to start to discuss self-care. If you were stuck in
the jungle, what would be the first steps you would need to take? Per-
haps it would best for there to be some investment in building a shelter
to provide some safety in your immediate environment. This would
help with surviving the storms and provide respite from the heat of
the sun. This could open a conversation about what self-care in the
client’s life would look like. Sometimes that might be about ‘building
the shelter’ in the sense of investing in their own home. At other times
that might be about hunkering down in the shelter until an emotional
storm passes, perhaps by watching some comforting TV or reading a
book by the fire.
The metaphor could also enable a discussion about acceptance. Let
us say the client imagined that a helicopter would fly over the jungle
and miraculously spot them in amongst the tall trees. This would be
an unlikely event, no matter how much they wished it to be true. It
might help them see that in their real life, no matter how much they
want others to be more supportive, or to take the feeling of respon-
sibility for a while, their current context does not suggest that that
will happen. They might learn that engaging in this wishful thinking
is an away move that is not helping them over the longer term. As an
alternative, they could choose to be more accepting of the uncom-
fortable feelings that arise in their day-to-day life from the realisation
that they can only impact their own behaviour and no-one else’s. They
could ask themselves the question, “What do I need when the jungle
is feeling stormy, when the shelter is falling down, or when I am tired
of hacking away at the overgrown foliage?” By thinking in this met-
aphorical way, they could defuse from the judgement that arrives in
their actual life in the form of thoughts like “Why can’t I cope like
everyone else?” and “Why can’t I just get on with things?”.
The metaphor of life as feeling like being stuck in a jungle might
enable the client to see that whilst they enjoy certain privileges, they
are nevertheless emotionally stuck in a place where they feel unsafe
and unconnected. Using the metaphor enables a visual image of them
choosing their responses to the inhospitable jungle environment. Do
I have the energy today to take the overgrown path? Will I stay in the
shelter today or will venture out and harvest some food? The client
can then translate this decision making into their real life, and choose
more value-driven actions as a result.
 Why does ACT use so many metaphors? 31

Metaphors are helpful because they simplify the complex into a

known or imagined (as above) situation within which the client can
more easily see (and feel) the relational networks at play. In the above
situation, the client may be able to empathise with someone being stuck
in a jungle, and therefore are able to offer genuinely compassionate re-
sponses such as “That’s really hard, it’s no surprise you’re struggling”
and “Struggling doesn’t equal failure, look how hard you’re working”.
For any metaphor to work, it is important that it holds resonance
for the client. There are some excellent resources full of ‘off the shelf’
ACT-consistent metaphors (e.g., Stoddard & Afari, 2014), although
the best metaphors are often the ones that come from clients them-
selves. We would encourage you to listen intently to your clients’ sto-
ries and ensure you take advantage of any metaphorical gems that
they contain. Active listening can also help you identify areas of a
client’s knowledge, interest, and expertise that can be used as the basis
for a metaphor that will resonate with them.
Chapter 10

What is the relationship

between ACT and other
cognitive behavioural
therapies?

Which is better, CBT or ACT? This is a common question for people

to ask when first learning about ACT, and the moment the question
is asked, one is invited to bring ‘ACT’ and ‘CBT’ together in a rela-
tional frame. Whilst it is tempting to get into the “it depends” spiel
once again, there might be a range of intentions behind the question,
and so, genuinely, the answer does depend on what is meant by ‘ACT’,
‘CBT’, and ‘better’. If ‘better’ is about effectiveness, then this is an
empirical question, which we have addressed in Chapter 2. However,
‘better’ may also be about personal fit with the values or philosophy of
the practitioner, or the satisfaction of the client, and both may have a
bearing on effectiveness. It’s complicated.
A further complication, which brings us more squarely to the ques-
tion we want to address in this chapter, is what is meant by ‘ACT’ and
‘CBT’. We are going to assume that having been attracted to this book,
you probably don’t need a lengthy definition of what ACT is. And…in
brief, ACT is an approach to behaviour change and well-being aimed
at helping people to live life more in the present, with more attention
to important values and goals, and with less attention on unwanted in-
ternal experiences. It promotes engagement with unwanted thoughts
and feelings through acceptance and mindfulness techniques, with the
aim of developing more flexible responding, to help build more func-
tional patterns of behaviour. It offers a way of managing suffering
via encouraging people to choose to live a life based on what matters
most (ACBS, n.d., a). ACT is based on functional contextualism as a
philosophy of science, and on behavioural and evolutionary theory as
expanded by RFT. Consequently, ACT does not specify a particular
set of techniques or adhere to any explicit protocol.

DOI: 10.4324/9781003364993-12
 Relationship between ACT & other cognitive behavioural therapiess 33

‘CBT’ is a little more difficult to define. Whilst it is often spoken

about as if it is a unitary thing, it is more accurate to describe CBT as
a school of thought or as a psychotherapeutic tradition. In the modern
era, CBT is best viewed as a combination of models and approaches
that have evolved and come together over time and are likely to con-
tinue to do so. Approaches within the CBT tradition tend to share
an interest in explicitly attempting to balance attention between ob-
servable behaviour, and internal phenomena such as thoughts and
emotions. Different approaches within the CBT tradition might place
greater emphasis on behaviour (e.g., behavioural activation (Martell
et al., 2001)) or cognition (e.g., rational emotive behaviour therapy
(­Ellis, 1962)), although all are concerned with the interaction between
a person’s thoughts, emotions, behaviours, physiological sensations,
and the environmental or historical context in which these experi-
ences occur.
CBT is often retrospectively described as having three distinct
‘waves’ in its evolution. The ’first wave’ had a focus on observable
behaviours and events, with a view to measuring, predicting, and
controlling behavioural responses. This gradually expanded to em-
brace the study of internal events, including thoughts, feelings and
the processes of language (Skinner, 1953). Responding to criticism
that an approach focussed mainly on behaviour was too reductionist
led clinical psychology to look more toward the emerging cognitive
sciences. An increased focus on cognition, alongside the development
of techniques for modifying thoughts and beliefs marked the ‘sec-
ond wave’ of CBT (e.g., Ellis, 1962; Beck, 1976). The ‘third wave’ of
CBT is typified by a focus on the relationship between behaviour and
the contexts in which it occurs, with techniques focussing on mod-
ifying the way that individuals relate to thoughts, behaviours, and
events. Characteristically, third wave CBTs place greater emphasis
on modifying the context in which thoughts and feelings are experi-
enced, rather than aiming to change their content. As a consequence,
these more contemporary forms of CBT harbour little interest in the
primary concerns of ‘second wave’ practitioners, such as cognitive
restructuring or symptom reduction. ACT (Hayes et al., 1999), Mind-
fulness Based Cognitive Therapy (Segal et al., 2002) and Dialectical
Behaviour Therapy (Linehan, 1993) are among the most prominent
examples of ‘third wave’ CBT.
In terms of specifying the relationship between ACT and other
cognitive-­behavioural therapies, it is sufficient to describe it as a ‘third
34 Defining the philosophy and theory of ACT

wave’ CBT that has developed from the behavioural elements of the
tradition. Comparing ACT and CBT as if they are two entirely sepa-
rate approaches is like comparing apples and fruit and is not a helpful
comparison (Bennett & Oliver, 2019). It is more intellectually honest
to view ACT as one form of CBT, just like apples are one form of fruit.
A complicating factor in such comparisons is the dominant role of
cognitive therapy (CT; Beck, 1976) within the CBT landscape. Because
of its large body of outcome research, and its adoption of a more med-
ical model of psychological distress, it has become so prominent that
it is almost synonymous with CBT itself. Thus, it seems that when
people draw comparisons between ACT and CBT, what they often re-
ally mean to do is compare ACT (a newer ‘third wave’ CBT) with CT
in its position as the most widely known approach within the more
traditional ‘second wave’ iteration of CBT. This is a justifiable thing
to do in that the two approaches have several notable similarities and
differences. Practitioners trained in both approaches can offer clients
a choice between the two, or even a hybrid method that incorporates
concepts and techniques from both.
Figure 10.1 illustrates how ACT and CT differ significantly in terms
of their philosophical assumptions, with ACT resting on a functional

CT ACT

Techniques & Techniques &

Interventions Interventions

Concepts and Concepts and

Theory Theory

Philosophical Philosophical
Assumptions Assumptions

Figure 10.1 A comparison of cognitive therapy and acceptance and

­c ommitment therapy (adapted from Gillanders, 2013a)
 Relationship between ACT & other cognitive behavioural therapiess 35

contextualist foundation and CT drawing its inspiration from mecha-

nistic metaphors and the logic and reason of Stoicism. That said, the
closer one gets to the level of technique, the more the similarities be-
gin to emerge, particularly when it comes to the use of behavioural
techniques, such as exposure or behavioural activation. Whilst these
techniques might look the same it is important to remember that ACT
and CT practitioners might be doing them for different reasons and
with different goals in mind.
Part 2

Conceptual questions
about the ACT model

As is the case with any psychological model, practitioners new to ACT

are faced with the challenge of learning, understanding, and applying
a number of novel concepts. Building on the philosophical and theo-
retical foundations of the first section, this section of the book seeks to
outline and further define a number of concepts that are key to ACT.
It begins by defining the core construct of psychological flexibility,
before addressing frequently asked questions about the six compo-
nents of the psychological flexibility concept, namely, contact with the
present moment, self-as-context, acceptance, defusion, values, and
committed action. This section also devotes chapters to describing the
technical term ‘creative hopelessness’ and exploring how the concept
of compassion fits with ACT.

DOI: 10.4324/9781003364993-13
Chapter 11

What is psychological flexibility?

ACT is centred around the notion of helping people develop greater

psychological flexibility. It may surprise you to know that the Hex-
aflex was a later addition to ACT, implemented to visually represent
the component skills that people can develop to move toward being
more psychologically flexible. However, the ACT model is not just the
Hexaflex per se. So, let us turn to the heart of the model and consider
exactly what psychological flexibility is.
When we speak of psychological flexibility, we are referring to an
ability to connect with the moment you are presently in, and mak-
ing an active choice about how you would like to respond to your
experience, choosing behaviour in line with the person you would
like to be. When we look at how to do this, we can draw on the Hex-
aflex in identifying six core components, with each promoting a skill
that can increase our repertoire of psychologically flexible choices.
A quick recap of the six core skills within the model might be helpful
at this point:

• Acceptance is often a really difficult word for people to swallow. It

can be referred to as a person’s willingness to allow an emotional
state to be present in their lives. This is not about encouraging
people to accept the situation per se. For example, we are not
wanting people to say, “I’m being abused, and now I have to learn
to accept it”. This skill is more about supporting people to have
the willingness to acknowledge the impact of their given situation
on their internal world, and learning to accept whatever thoughts,
emotions, or sensations that are present. Emotional flexibility is
the key to the acceptance process.

DOI: 10.4324/9781003364993-14
 What is psychological flexibility? 39

• Defusion focusses on expanding a person’s cognitive flexibility.

The target process (‘fusion’) is evident when we observe people
taking the language of their thoughts literally, despite the result-
ing behaviour not being workable for them, and sometimes even
being harmful. Defusion can be summarised as getting some
space between you and your thoughts.
• Contact with the present moment skills are about expanding peo-
ple’s attentional flexibility. Our minds are often drawn to future
planning, or past worries, and living in the present moment is a
skill that can be developed so that we are better able to act in
the present. Attentional flexibility can be honed to enable people
to move their attention around. We might learn to focus our at-
tention like a useful torch-beam, rather than an overbearing and
unhelpful light that constantly shines in the least helpful places
(such as the past or future, where taking action is less available).
• Self-as-context is a simpler concept than the language might sug-
gest. It refers to developing the skill of seeing alternative perspec-
tives to the often ‘fixed’ views we hold of ourselves. We are the
thinker and not the thought. Any kind of container metaphor
does a good job of helping us to see that we are more than the
things we struggle with. When we can see the world from this
broader perspective, we learn to free ourselves from the control of
the narratives that keep our world small.
• Values identification is about choosing who we are and how we
want to be in the world. This work helps us select the qualities
that we want to embody, whilst holding each lightly, so we can
flexibly choose which value we want to respond to. Our values
provide a stimulus for flexibility in our choice of action in any
given moment.
• Committed action is about putting our feet down and moving in
the direction that we decide, based on our chosen values. This
skill is about widening the behavioural repertoire that we have for
ourselves, so we become open to more and more opportunities in
our lives.
Psychological inflexibility can result in a narrow behavioural rep-
ertoire, making our world smaller, and leading to a sense of feeling
stuck. Psychological flexibility provides us with a set of skills that start
to open us up to alternative possibilities, with the aim of bringing us
closer to a more purposeful and meaningful life.
40 Conceptual questions about the ACT model

The ACT model can also be simplified into three columns, ‘open’,
‘aware’, and ‘active’ (see Figure 11.1). The open column encapsulates
the skills pertaining to being open to your experience. Are you willing
to have this experience, and can you get some space between you and
‘it’? The aware column focuses on being in contact with the present
moment and developing the skill of observing oneself in a hierarchical
fashion – after all, if you can observe yourself noticing that you are ‘in-
competent’ you cannot BE incompetent, as it is a separate concept to
you. You can however be the place where some ‘incompetent’ thoughts
and behaviours happen. The ‘active’ column pertains to identifying
one’s values and taking steps in line with those. This simplification
of the Hexaflex into these three columns can be helpful; however, it is
also important not to forget that each column has more than one skill
that contributes to the development of psychological flexibility.
One of Steven C. Hayes’s many wise one-liners about ACT is,
“the only mistake you can make in ACT is to get stuck” (Bennett,
2017–­present). We invite you to recall a time you painted a room. Most
likely, the can of paint had a solid tin lid, and to access the paint you
would have had to use something flat like a screwdriver or the end of a
spoon to lever the lid away from the can. If you pick one single point,
stick to it, and force the lid open from there alone, you will likely
have to work really hard to remove the lid, and probably ruin the lid

OPEN AWARE ACTIVE

Contact with the

Present Moment

Acceptance Values

Psychological
Flexibility

Defusion Committed
Action

Self as Context

Figure 11.1 The three-column version of the Hexaflex

 What is psychological flexibility? 41

in the process of trying. However, by applying gentle pressure, then

stopping, twisting the can around slightly, and applying gentle pres-
sure somewhere else, the lid will eventually lift off without damage.
In the same way, developing psychological flexibility requires us to
move around the various ACT components, just like you would move
around the lid of a paint can, rather than focussing on just one area.
Next time you feel stuck with a client, imagine a paint can with a Hex-
aflex drawn on the lid. Consider which aspect of psychological flex-
ibility you might need to direct your attention to in order to create
some movement and try not to get stuck at any one point.
Of course, these skills are utilised in the context of the broader foun-
dational science and philosophy that underpins the entire ACT model,
discussed in earlier chapters, which also contributes to increasing psy-
chological flexibility.
Chapter 12

What does ‘creative

hopelessness’ mean?

There are anecdotes to suggest that the originators of ACT now wish
that they had used some different terms to describe various concepts
and procedures within the model. ‘Creative hopelessness’ is very pos-
sibly one of them, since the word ‘hopelessness’ carries undesirable
connotations for many, notably a sense of despair. Given that creative
hopelessness procedures are often suggested as one of the first things
that an ACT practitioner should engage a client in, the aversive func-
tions of the term can make it feel like an odd place to start. Far from
being a procedure that induces despair, it is intended to be validating
of the position that someone finds themself in at the point that they
first reach out to a practitioner for help. It refers to the process of
validating a client’s experience of being caught in a struggle with their
own thoughts and feelings, helping them recognise the futility of this,
and setting the stage for creatively identifying more workable ways
forward (Luoma et al., 2007). A creative hopelessness conversation or
activity is about opening up to the new possibilities for taking value-­
driven action, once a client can face up to the reality that whatever
they have been doing to try and rid themselves of their distress up to
this point has not worked.
The experience of psychological distress is highly aversive for most
people, and there is a logic behind wanting to get rid of the internal
experiences (unwanted thoughts, emotions, urges, or sensations) that
comprise that distress. An agenda of wanting to control internal ex-
periences is often a prominent feature of a client’s presentation at the
start of intervention, and highly rehearsed methods of eliminating,
suppressing, or avoiding them are commonplace. At best, such strat-
egies tend to only confer some short-term benefits, and at worst they

DOI: 10.4324/9781003364993-15
 What does ‘creative hopelessness’ mean? 43

can form the basis of ingrained behavioural patterns that cut people
off from opportunities for reinforcement or cause genuine harm over
the long-term. As an example, someone experiencing significant social
anxiety might use several avoidant strategies to reduce the chances
of having to risk experiencing negative evaluation from others. This
is understandable, although controlling anxiety in this way is a be-
havioural process that maintains it: if we avoid engaging with others,
how will we ever learn that they might not judge us negatively? The
practitioner needs a procedure that can validate the client’s desire to
reduce their anxiety without unhelpfully reinforcing the behaviours
that are feeding it. Creative hopelessness procedures are designed to
help the practitioner carefully and sensitively navigate this difficult
terrain early in the therapeutic process.
There are many ways that creative hopelessness can be approached,
and, as with everything in ACT, the function of the dialogue is more
important than its form. In the very first ACT textbook, Hayes et al.
(1999) described creative hopelessness as focussing on three main
questions in respect of the client’s lived experience of the issues they
are seeking help with:

1 What does the client want?

2 What has the client tried?
3 How has that worked?

These questions are designed to draw out example ‘problem-solving’

strategies from the client’s history to ascertain if these reflect any un-
derlying rule. They then help the client contact the short- and long-
term consequences of following that rule. Rules that underlie control
strategies (for example, “If I don’t get close to other people then I
won’t get hurt”) often dictate behavioural responses because they feel
beneficial, at least in the short-term. Following the above rule is likely
to be negatively reinforced by a reduction in anxiety and it is impor-
tant that functions such as this are recognised and validated. People
engage in avoidance because it works for them. This can then be con-
trasted with the long-term costs of rule-following, shining a light on
its limitations. Doing this can engender a sense of hopelessness about
the current strategies, which, whilst uncomfortable for the client, also
provides the impetus to consider doing something different. It is help-
ful for the practitioner to functionally cluster previous strategies as
44 Conceptual questions about the ACT model

various manifestations of the same rule-following so that it is clear

that something new and creative is required (Bennett & Oliver, 2019).
The over-arching rule that many people follow is that controlling in-
ternal experiences is equivalent to living successfully. The long-term
workability of this can be challenged using creative hopelessness pro-
cedures, and this paves the way for standard ACT interventions to
be introduced. Our experience of supervising numerous ACT practi-
tioners is that where ACT interventions fall flat with their clients, it is
often because not enough time has been spent doing the work outlined
above.
As stated previously, creative hopelessness work can take many
forms, using stories, metaphors, discussions, or experiential exercises,
and most introductory ACT practitioner books and trainings will in-
clude examples of these. Metaphors like Chinese finger traps, strug-
gling in quicksand, or engaging in a tug of war match with a monster
(Hayes et al., 1999) essentially describe a rigged game, whereby no
matter how hard the client tries to rid themselves of the adverse as-
pects of the situation, doing so will simply make the situation more
and more difficult. The procedure we most frequently use and recom-
mend is adapted from Strosahl et al. (2012), which involves having a
conversation with a client based around five key questions. Once the
nature of the issue that client is seeking help with is ascertained, the
following questions can be explored:

1 In the context of this situation, what really matters to you?

2 What is getting in the way of you pursuing what really matters?
a) External obstacles (e.g., lack of time or other resources)
b) Internal obstacles (e.g., the uncomfortable thoughts and feel-
ings that arise when the client tries to pursue what matters)
3 What have you already tried in the service of overcoming the in-
ternal obstacles?
4 How have those things worked out for you?
a) In the short-term
b) In the long-term
5 What has doing those things cost you?
a) In the short-term
b) In the long-term
 What does ‘creative hopelessness’ mean? 45

This procedure involves touching on several concepts relevant to

ACT’s psychological flexibility model. The first question essentially
elicits values, whilst the second and third obtain information about fu-
sion and experiential avoidance. Questions four and five enquire about
the workability of existing strategies for managing the discomfort that
almost always arises when people try to engage in value-driven ac-
tions. This conversation usually orients people to the function of their
efforts to avoid discomfort, helping them see that whilst avoiding dis-
comfort generally works in the short-term, it reduces the likelihood of
contacting reinforcing consequences in the long-term. In turn, this of-
ten reduces the appetitive functions of avoidant behaviour, and opens
people up to the idea of approaching their distress differently going
forward. As such, creative hopelessness is an important part of the
engagement process in ACT and worth devoting significant considera-
tion and time to, prior to introducing other interventions.
Chapter 13

Is ‘contact with the present

moment’ the same thing as
mindfulness?

Mindfulness has become a commonly used, and perhaps over-used,

word in recent years. Its growth in popularity has enabled many peo-
ple to experience the benefits of its practice. However, its popularity
and the misunderstanding around its practice has also now taken on
a different function, and one that seems to be aversive to many lay
people. How many times have you had a client say, “I’m not doing any
mindfulness stuff, that doesn’t work”? What they often really mean
is “I did an exercise once and I still felt anxious afterwards”, ergo,
“because my anxiety remained, tuning in to my experience again will
not be helpful”.
Mindfulness practice can take many forms. Its origins lie in the his-
tories of Eastern religions, namely Buddhism and Hinduism. Formal
mindfulness practice has been used in these contexts for millennia.
From a Buddhist perspective, mindfulness is considered to be the first
step to enlightenment. The practice and principles of mindfulness be-
came more well-known and used in Western societies following the
introduction of this work in therapeutic treatment programmes for
stress and mood. Examples of such programmes include Mindfulness-
Based Stress Reduction (MBSR; Kabat-Zinn, 2013) and Mindfulness-
Based Cognitive Therapy (MBCT; Segal et al., 2002), both of which
have significant empirical support.
When considering ACT’s position on mindfulness, a Venn diagram
is helpful (see Figure 13.1). There is undoubtedly some crossover with
formal mindfulness practice, as is there within other forms of psy-
chotherapy and other practices such as yoga and body meditation.
However, ACT procedures facilitate a lot of work outside of mindful-
ness, related to the other components of the Hexaflex. Even the skill

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 Is contact with the present moment the same thing as mindfulness? 47

Body
Meditation
Yoga
ACT
Mindfulness
Spiritual
practice
MBCT
MBSR

Figure 13.1 The relationship between mindfulness and related practices

of ‘contact with the present moment’ does not have to include formal
mindfulness practice. When we think from a functional perspective,
the purpose of a client being able to be in the present moment is the
clarity this can offer them. We often work with clients who get caught
up in the busy-ness of day-to-day life, where seconds, days, weeks,
months, and years all roll away from them in a way that feels inevita-
ble, and where they live an existence in which they feel like they miss
out on much of their own experience. The human brain can operate
on a kind of auto-pilot setting, which is time-efficient and can reduce
cognitive demand. However, being stuck in auto-pilot for all of our in-
teractions and our most precious connections can have a detrimental
impact on the quality of life we experience.
As illustrated by the Hexaflex diagram (see Chapter 19) each of the
six core skills are linked to one another. Strengthening one of those
skills enables a stronger foothold to further improve each of the oth-
ers. Being in contact with the present moment is a pre-requisite for de-
veloping all the other skills on the Hexaflex. The skill here is being able
to tune in to one’s experience, often simultaneously inviting a process
of slowing down and noticing more. This can increase our connection
with ourselves, other people, and the wider world, which in turn can
offer greater choice about how we want to respond in any moment. We
have often asked people, “If you do not notice your own emotion, how
can you choose how to respond to it?”. This can help people to un-
derstand why tuning in to their internal world can open a whole new
choice of actions. For example, imagine discussing a situation with
48 Conceptual questions about the ACT model

a client in which they reported anger toward their partner, who was
feeling sad and frustrated about the inequality of tasks done within
the house. The client describes feeling angry that their partner had
raised this, stating that it felt like a “low blow”, and a way of having
a go at them when they were happy. The ACT practitioner might en-
quire about how their conversation had evolved, asking questions like,
“If you recall your partner’s face during your interaction, what do you
notice?”. This might enable the client to see that they had spent their
entire interaction responding from their mind, driven by thoughts like
“I must be heard”, “They are being unfair raising this”, and “I want
this to stop”. When the process is slowed down, the client might be
able to see that they had not really responded to their partner standing
in the kitchen in front of them, rather they had moved to a metaphor-
ical battle zone and were responding from there. If they were actually
responding to their partner’s tear-stained face, they might have taken
a calmer, more compassionate perspective, and genuinely listened to
why their partner was so sad. In this case, turning up the ‘present
moment’ skill could increase their acceptance of the discomfort of the
situation, their connection with their values (who they want to be in
the face of relationship difficulties), their chosen action, their ability to
see alternative perspectives on the situation, and an ability to defuse
from the idea of needing to be heard. All of that could enable them to
move to a position of wanting to listen when concerns are raised by
their partner.
A helpful metaphor in relation to our present moment awareness
is that of a torch beam. Imagine holding a torch. Switching it on is
like turning on our awareness. We now have our eyes on the thing in
front of us. And this is very helpful because we get to see more than we
could before. By practicing this noticing skill, we can start to help our
clients to broaden or narrow their beam of attention, just like some
torches allow us to broaden or narrow the beam of light they yield.
This can have a direct link with achieving a sense of self-as-context, in
that when we broaden that beam of attention, it is possible to see ad-
ditional perspectives than we previously could, and allows us to take
action in the service of our values.
Chapter 14

What is self-as-context
and how does it differ
from defusion?

This is a very good question and if someone asks it, it is usually evi-
dence that they are a keen student of ACT and have been paying atten-
tion to the nuances of the underlying theory. It feels like a challenge to
come up with an answer that is as good as the question, partly because
the concepts of defusion and self-as-context are closely linked, as in-
dicated by the line that connects them on a Hexaflex diagram, partly
because they have evolved with time (Harris, 2013; Blackledge, 2015),
and partly because they are not very clearly delineated within ACT
literature. This chapter will address these issues as well as presenting
what we hope is a workable way to discriminate each of these terms
from the other.
The issue of the lack of clarity in defining these terms needs to
be addressed up front. ACT has received some justifiable criticism,
mostly from RFT researchers and applied behaviour analysts, for its
reliance on ‘middle-level terms’. This refers to its use of concepts that
are not empirically grounded, and thus lack precision or clear utility
at a functional analytic level. They act as a bridge between a scientific
way of speaking about something, and how a practitioner might speak
about something to a client. As Wilson (2016, p. 70) stated, “Middle-­
level terms are “middle level” in the sense that they are more precise
than lay language, but less precise than technical ways of speaking”.
‘Self-esteem’, ‘beliefs’, or ‘therapeutic alliance’ are examples of middle-­
level terms. They lack accuracy in any empirical sense (for example,
one cannot clearly define and observe the behavioural processes of
‘self-esteem’ in an experiment), although they are useful shorthand for
communicating a broad concept to another person. If a client says to a
practitioner that their ‘self-esteem’ is low, both parties will likely have

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50 Conceptual questions about the ACT model

a workable sense of what this means in the context of the work they
are doing together.
The problem is that when ACT theory evolved to include middle-­
level terms (see Hayes et al., 2006), arguably making it more acces-
sible to greater numbers of people, it sacrificed some precision, and
concepts like defusion started to become used in different ways to
the point that their meaning can become difficult to pin down. Many
ACT practitioners, ourselves included, have probably used defusion to
mean each of the following three things at some point:

1 A process (as in a problematic behaviour pattern that we want to

work on with a client: “I think we could spend the next session
working on defusion”)
2 A procedure (as in an intervention we engage a client in: “I want
to introduce you to some defusion exercises”)
3 An outcome (as in an endpoint we want to achieve by using a
procedure with a client: “Your ability to stand back from your
thoughts about worthlessness really demonstrates your defusion
skills”)

This process/procedure/outcome distinction (Barnes-Holmes &

McEnteggart, 2020) provides a helpful framework that illustrates just
how slippery middle-level terms can become because of their impre-
cise nature. Like defusion, self-as-context is used differently across
ACT literature, both to mean something akin to the Buddhist no-
tion of a transcendent sense of self (e.g., Hayes, 2019) and as flexible
perspective-­taking (e.g., Harris, 2013). From a functional contextual-
ist perspective, some of this is no surprise in that the function of any
term depends on the context in which it is being used. From a scientific
or practical point of view however, it is not very helpful for any theo-
retical model to have any one concept meaning different things at the
same time. It is probably fair to say that ACT might have some work to
do in this area, and that more care with the use of both concepts would
lead to less confusion. At the very least, one practical step that ACT
practitioners could take when they hear someone else using terms like
defusion and self-as-context, is to enquire whether they are using it to
refer to a process, a procedure, or an outcome.
Having acknowledged the difficulties with ACT’s adoption of
middle-­level terms as part of its core model, we can return to the initial
 What is self-as-context and how does it differ from defusion? 51

question regarding how best to define and differentiate defusion and

self-as-context. In our view, regarding the process/procedure/outcome
discrimination, both are best thought of as referring to outcomes.
That is, they provide ways of talking about patterns of behaviour that
we generally want clients to produce more of. It is only useful to use
them to describe behaviours that have been observed to have estab-
lished themselves (usually post-intervention) as ‘real’ environmental
variables (Wilson et al., 2022). The target processes relevant to these
outcomes might best be referred to as fusion and self-as-­content re-
spectively. Table 14.1 shows how procedures might be applied to each
of these processes with a view to achieving the desired outcome. If
we are attempting to be precise here, ACT, as a model that relies on
RFT, should only be concerned with the behaviour of forming verbal
relations, and other behaviours that occur consequent to that relat-
ing (Barnes-Holmes & McEnteggart, 2020). Once we attempt this, it
is evident that whilst the two concepts can be differentiated, they are
somewhat similar, and one might even argue that they overlap, with
self-as-content representing a subset of fused relations.
As a footnote to the above, we should come clean and admit that
we may be slippery in our use of these terms, even in this book. This
is because it is genuinely quite difficult to talk about the various con-
cepts used in ACT without also falling into the trap that the ACT
literature has built for itself with its reliance on middle-level terms.
We will endeavour to try and make the process/procedure/outcome
discrimination clear whenever potentially ambiguous meanings might
be inferred.
52 Conceptual questions about the ACT model

A comparison of the concepts of defusion and self-as-

Table 14.1 
context by process, procedure, and outcome

As applied to defusion As applied to self-as-context

Process Fusion: observable Self-as-content: observable

behaviour is rigid and behaviour is rigid and
regulated by adherence regulated by excessive co-
to the literal meaning ordination of the self with
of language internal language about the
E xample: A client inhibits self
emotional expression E xample: A client turns down
because of the rule “It’s a potentially benef icial
weak to show emotions” opportunity because the
thought “I am worthless”
dictates that they are
undeserving of it
Procedure Interventions that ‘de- Interventions that promote
literalise’ language, a hierarchical relationship
such that there is a between self and internal
loss or weakening of language about the self, such
the meaning of that that the self can be seen as
language containing any such content
E xample: Practicing E xample: Introducing container
repeating “It’s weak to metaphors, such as ‘the sky
show emotions” out loud and the weather’
in the voice of a cartoon
character
Outcome Defusion: flexible Self-as-context: flexible
patterns of behaviour patterns of behaviour
are enacted that are are enacted that are
independent of the independent of internal
literal meanings of language about the self
language E xample: Tuning into the
E xample: Noticing the experience of noticing having
thought “It’s weak to the thought “I am worthless”
show emotions” whilst whilst choosing whether or
choosing to open up not to take up a potentially
emotionally to a friend benef icial opportunity
Chapter 15

Doesn’t acceptance just

equate to giving up and
letting life steamroller you?

A common misconception from both early career ACT practitioners

and clients alike is that acceptance equates to giving up and submit-
ting to being steamrollered by life events. This is a far cry from the
purpose of acceptance within ACT, and helpful to address in the early
stages of a practitioners’ training, and a client’s experience with ACT.
As we have discussed in many of the chapters of this book, language
is a powerful and evocative tool. In this case, the mere use of the word
‘acceptance’ often lands awkwardly with clients, as a common collo-
quially used definition of this word is indeed akin to rolling over or
giving up. So, here is an invitation as we work through what accept-
ance is and is not: notice the different ways that you can use language
with clients so as to help evoke a meaning for them that may feel more
useful, and that is ACT-consistent.
A well-spoken ACT phrase is, “The problem is not the problem,
the solution is the problem”. Clients often come to seek support be-
cause they are experiencing an internal struggle, or because their life
is feeling that it lacks the importance and emphasis they would like
it to have. This has often happened as a result of their behavioural
attempts to avoid uncomfortable internal (and external) stimuli, thus
making life feel easier in the short-term as they do less and take fewer
risks. ACT refers to this pattern of choices as ‘experiential avoidance’.
This essentially moves us away from difficult internal struggles, re-
sulting in short-term gains, although often at the cost of longer-term
suffering. From an ACT perspective, we would only address experi-
ential avoidance when it is having a detrimental impact on a person’s
life. For example, there is nothing too concerning about occasion-
ally binge-watching a TV series when you have a difficult task to do.

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54 Conceptual questions about the ACT model

However, engaging in experientially avoidant behaviours such as

drinking alcohol or taking drugs to block out the emotional struggle
one experiences about similar tasks is more problematic. Such behav-
iour, particularly if sustained over time, would be more akin to the
patterns of experiential avoidance that warrant a therapeutic inter-
vention. The focus here is on whether it is workable in the long term to
live life in this way. Is the ‘smaller sooner’ reward of avoiding discom-
fort worth the ‘larger later’ cost of limiting one’s life and missing out
on the reinforcement that often comes with value-driven action (see
Chapter 12 for more on workability).
One error often made is that people think ACT is about wanting
people to accept the external circumstances that may be causing
suffering. We are not suggesting that anything external needs to be
blindly accepted, for example, someone being bullied at work. There is
no tolerance required, or passive ‘acceptance’ of, “This is just the way
life goes”. Instead here, the more ‘engaged’ parts of the Hexaflex (val-
ues and committed action) would be utilised to consider how someone
would like to respond to their circumstances.
It is helpful then to consider what ACT practitioners are inviting
someone to accept as part of the therapeutic process. The focus on ac-
ceptance from an ACT stance is more directed at an internal process.
In the above example of workplace bullying, we would instead look to
invite someone to connect with how they feel in that situation, and to
consider their willingness to make space for the emotions that arise,
instead of pushing them away. This is a deliberate choice to undertake
an action, not about experiencing an event as a passive bystander. It
is one that involves leaning right into the discomfort (fear, terror, or
worry) that will inevitably arise as they move through their day-to-day
existence. The function of acceptance is to help people to really tune
in to their life experiences (there is a link here with ‘contact with the
present moment’) and to consider whether they would like to continue
to make their current choices, or to take different steps in response to
the situation they are experiencing. In the above example, we would
argue that tuning into the reality of the experience of being bullied
is more likely to facilitate a committed and effective response, as op-
posed to trying to avoid feeling the true pain of it, which is more likely
to fuel minimisation and inaction.
In this way, acceptance is very much linked with an individuals’
values. A question often asked of clients is, “Are you willing to experi-
ence that discomfort, in the service of the things that really matter to
 Doesn’t acceptance just equate to giving up 55

you?”. This is a helpful question to link the experience of, and purpose
of, internal suffering. It makes suffering part of valuing. It is a valid
response for a client to say no to an invitation of accepting their inner
discomfort. It is our job as practitioners to help clients to weigh up
the costs to their life experiences of their behavioural choices. It is not
our job to decide whether a client should or should not tolerate any
particular felt emotion or physiological sensation. Thus, the function
of acceptance is always about helping people to consider their valued
action, and whether they assess the costs (the internal discomfort) to
be worth experiencing in order to take steps in line with their values.
Some things are just not worth suffering for. Some things, we suddenly
realise, are absolutely worth experiencing discomfort for because do-
ing so will ultimately fill our lives with richer and more meaningful
experiences, and broaden our behavioural repertoire in the service of
experiencing a more fulfilling life.
Chapter 16

What is meant by
‘transformation of
stimulus functions’?

Like most other approaches within the CBT tradition, ACT adopts the
view that cognitive processes, such as reasoning, or making rules and
judgements, are responsible for much of the suffering that humans ex-
perience. Most of what we do, we do because our cognitions tell us to,
and this includes all of our unhelpful attempts to cope with adversity.
Whilst, like other animals, we learn through respondent and operant
conditioning, symbolic learning via our cognitive and language abili-
ties is an additional and powerful influence over our behaviour. There-
fore, CBTs have sought to develop interventions that target cognitive
processes with a view to weakening the control they exert over behav-
iour. Second-wave CBTs attempt this by challenging the logic, utility,
or empirical validity of thoughts (e.g., Dryden & Branch, 2008). Such
interventions are aimed at changing the form or content of an individ-
ual’s thinking and encourage them to arrive at more logical, helpful,
or ‘true’ thoughts as a consequence. ACT takes a different approach
for several reasons. Aside from the evidence from certain studies that
so-called ‘cognitive restructuring’ techniques add little to CBT over
and above behavioural interventions (e.g., Jacobson et al., 1996; Dim-
idjian et al., 2006; Lorenzo-Luaces & Dobson, 2019), there is a philo-
sophical rejection of the notion of absolute truth. This means that a
search for ‘true’ thoughts via empirical disputation is incompatible
with the contextualist philosophy that underpins ACT. Rather than
challenge the content of thoughts, ACT interventions seek to modify
the context that thoughts are experienced in, so that the stimulus func-
tions of those thoughts are transformed.
The concept of ‘transformation of stimulus functions’ comes from
RFT and refers to an event where, “The functions of one stimulus alter

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 What is meant by ‘transformation of stimulus functions’? 57

or transform the functions of another stimulus in accordance with the

derived relation between the two, without additional training” (Dy-
mond & Rehfeldt, 2000, p. 239). It is probably helpful to use an example
to deconstruct the meaning of the previous sentence, so let us imagine
that you are someone who eats an exclusively vegan diet due to holding
firm principles around animal welfare. You are in a restaurant where
you have ordered a vegan pizza, which you have eaten and thoroughly
enjoyed. As you are contemplating ordering dessert, the waiter attends
your table and offers a profuse apology because they have just been
informed that due to some confusion in the kitchen, your pizza may
have contained regular cheese rather than the vegan cheese that you
expected. You are horrified to discover that you may have eaten an
animal product, and furious at the restaurant for their incompetence.
With reference to understanding this event from an RFT perspective,
the functions of the pizza have been transformed. Any positive feel-
ings of enjoyment that you might have experienced upon eating the
pizza will have long disappeared and any memory of eating it is likely
to now provoke feelings of anger and disgust instead. Following the
waiter’s intervention, which has introduced doubt about what you
might have eaten, you will have derived a stimulus relation between
the pizza and consuming an animal product, between the restaurant
and anger, and possibly several other relations that didn’t exist in the
same way previously. Once a novel stimulus relation has been derived,
it is not possible to ‘un-derive’ it, and we will respond to the relation,
even though the stimulus itself has not changed. Although the pizza is
still the same pizza, and there is only the suggestion of regular cheese,
your conception of it and the restaurant you ate it in will be altered
forever. In RFT terms, the stimulus functions of the pizza have been
transformed, despite nothing about the actual pizza having changed.
Transformation of stimulus functions is the process by which stimuli
or events with certain functions acquire new ones (Törneke, 2010). It is
a characteristic feature of the way that language works, and numerous
ACT interventions harness this capacity to focus change efforts on the
function rather than the form of unwanted or unhelpful thoughts. Far
from being an obscure theoretical notion, transformation of stimulus
functions is central to the practice of ACT. Altering the way that stim-
uli function, be they thoughts, emotions, memories, or physiological
sensations, is an identifiable aim of a variety of ACT interventions, as
can be seen in the examples below.
58 Conceptual questions about the ACT model

Values and committed action

An ACT practitioner can work to increase the appetitive functions of
an exposure exercise that a client might be anxious about engaging
with by relating it hierarchically to the client’s values. If doing some-
thing that is presently co-ordinated with the prediction of fear can
be seen as part of taking value-driven action, this may increase the
likelihood of the client engaging with it. Relating the exposure activity
to valued action can transform something that is scary into something
that is scary, and worth being scared for.

Defusion
Classic ACT procedures such as taking an unwanted thought and
changing the way it is presented are clear examples of utilising transfor-
mation of stimulus functions. Singing a thought, or saying the thought
in a humorous voice, often results in clients laughing at the thought or
seeing a lighter side to their experience. Relating the thought to the ex-
perience of lightness or humour by repeating such an exercise provides
a very portable way of transforming the way it functions.

Acceptance
Co-ordinating values with painful experiences is another staple of
ACT practice. When clients express distressing thoughts and emo-
tions, it can be helpful to explore how those experiences relate to the
things that they care about. For example, grief about losing someone
often speaks to how much that person was loved. Co-ordinating val-
ues and pain in this way often provides people with a reason to suffer,
thus transforming the function of suffering. Whilst the experience is
still painful, the pain has been connected to a sense of purpose.
Chapter 17

How do I tell values apart

from goals or rules?

Values are often metaphorically referred to as a compass, in that they

are a helpful guide to choosing a direction in life. Since they are always
with us, they can be drawn upon at any moment to help us choose be-
haviours that best fit with the person we want to be. Sometimes these
behaviours are not the easy option, for example, being compassionate
to someone who you feel has wronged you. They can be described
as the meaningful life choices we make when fusion and avoidance
are not in the driving seat. When we connect with our values, we are
reminded of our reason to accept discomfort. In the service of our
values, we are often able to realise that the discomfort we experience
along the way is manageable, and simply part of what happens when
we pursue a life of meaning and purpose.
We often work with clients who confuse values for goals, or even
rules that they must follow. One of the principles that defines a value
is that it represents a freely chosen direction. In any given moment,
we can be aware of the value driving our behaviour. This present mo-
ment awareness of our values can enable our choices to have a more
flexible quality, in the sense that behaviour becomes something that
we choose rather than feel compelled to do. When we lose this flexible
quality, we can slip into confusing values with goals or with rules.
What do we mean by goals? Well, in this comparison, the easiest
distinction to make is that a goal can be ticked off on a to-do list,
whereas a value is not something that you achieve and then stop enact-
ing. For example, it is possible to set a goal of being kind to the person
who serves you in the coffee shop tomorrow morning. This meets the
criteria for being a SMART goal (specific, measurable, achievable, re-
alistic, and time-limited). However, if kindness was a value that you

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60 Conceptual questions about the ACT model

want to live by it would not be consistent to be kind to the person in

the coffee shop but then really mean and short-tempered with every-
one else you encounter for the rest of the day. Goals are generally ei-
ther in front of or behind us, whereas values are ever-present, and if
kindness is a value for you, there are any number of ways in which you
could choose to be kind, both tomorrow morning and for the rest of
your life.
When compared with the flexible quality of value-driven behav-
iour, rule-governed behaviour suggests increased rigidity. When we
behave in line with rules, we start using language like, “I am…”, or “I
must…”. It is often the justification that is given for a behaviour that
can help identify if the behaviour was value-driven or rule-governed.
For example, “I was told in my childhood to be nice to people, so I
was nice to the person in the coffee shop” would suggest a rule is being
followed, rather than a value being freely chosen on each visit to the
coffee shop.
When looking at value-driven choices, it is not simply a question
of, “Is this a toward or away move?”. It is very much about identifying
the value from which you are operating. We all have a range of values
that we may act upon in any given moment. Imagine sorting through
a pack of values cards. There are many cards to choose from, and we
each have our own priorities. We may wish to act on little-practised
values in some contexts, whilst others feel much more rehearsed and
consistent in our day-to-day lives. For example, we might not practise
assertiveness very often, despite it being an important value. However,
it is in our repertoire when we need it, such as when chairing a diffi-
cult meeting at work. Conversely, values like kindness and compas-
sion might be much more ‘front and centre’ in life, and we choose to
embody these in almost all of our daily interactions.
It can be helpful to consider values as if they are a menu, because
just like a food menu in a restaurant, not everything on it is avail-
able all of the time. As an example, consider a client who works in
the armed forces. The context of their training means that they will
have been more highly reinforced for their choice of behaviours driven
by a value of ‘cooperation’, as opposed to ‘autonomy’. The client re-
turns from a combat zone talking about having seen horrific atrocities
against fellow human beings and yet they stood by and did nothing
because they were following orders. This evokes guilt, shame, and
judgement of their actions. Not only does the context matter (they
were following orders in a war zone), it is also a matter of exploring
 How do I tell values apart from goals or rules? 61

whether the individual had their whole values menu available to them
at the time they acted as they did. If you jointly identify with the client
that the values most highly reinforced during combat are compliance
and cooperation, the client may see that in that context, their personal
values of justice, assertiveness, and autonomy were highly unlikely to
have been available to them. Such discussions can help clients appre-
ciate the influence of contextual factors on their choice of behaviours,
and mitigate against values being treated rigidly, as if they are hard-
and-fast rules.
Each value can be thought about as having an associated skill
set. If the skill set associated with the value feels new, or it is under-­
rehearsed, one may need to learn a whole new skill set in order to be
able to carry out value-driven actions. This process takes time. Whilst
behaviours may be within someone’s value set, it does not mean they
do not incur costs of discomfort. For example, a war veteran living in
line with their value of autonomy after having lived for so long under
conditions of compliance may find the period of adjustment very chal-
lenging. As practitioners, we can flexibly move around the Hexaflex
to utilise other ACT skills to help the client manage this. We can help
them notice their discomfort and this repetitive pattern (contact with
the present moment), unhook from any resistance (defusion), identify
that this is a part of themselves that they would like to bring to the fore
in this particular moment (self-as-context), reconnect with their value
and chosen associated behaviours (committed action), and try again
at embodying something that feels difficult to them in the service of
said value (acceptance). As a practitioner, working to consistently no-
tice and reinforce the use of these skills, and bringing clients’ aware-
ness to the development of their new skill set is key.
Chapter 18

How can I tell the

difference between toward
and away moves when
clients are taking action?

The theory of appetitive and aversive control is described in more de-

tail in Chapter 7, and in our view, is one of the most important ideas
that ACT practitioners can impart to their clients. To briefly recap,
the theory is concerned with discriminating between different func-
tional classes of behaviour. Based on basic survival needs, the behav-
iour of humans, as well as a whole host of other organisms, can be
seen as either moving toward stimuli that have appetitive functions,
or away from stimuli that have aversive functions. In short, organisms
approach (or move toward) what they want and avoid (or move away)
from what they do not want. Discriminating between toward and away
behaviour in non-verbal organisms is relatively straightforward. For
example, plankton drift toward sunlight and away from toxins for rea-
sons that are obvious. Dogs will approach sources of food and retreat
when threatened, in a manner that is similarly transparent. When it
comes to applying the toward and away discrimination to humans,
whilst the principle is the same, the added complexities of cognition
and language can make the functional classification of behaviours
somewhat less straightforward to discern. This leads practitioners to
the question posed by this chapter, and to the very practical concern
of how to identify the function of between-session behaviours once the
client has described their form. The client will almost certainly know
what they did. Why they did it, and whether it was an adaptive move in
the direction of the goals of intervention often requires a closer func-
tional analysis.
One of the complicating factors when it comes to human behav-
iour is that almost nothing that a person can do could be intrinsically
considered as a toward or away move. Almost any behaviour that one

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 How can I tell the difference between toward and away moves? 63

could mention can be either. Even something basic like eating, which
on the face of it looks like a toward move since it involves a person
approaching a stimulus for which they have an appetite, might be an
away move. Someone might be ‘comfort eating’ to reduce their dis-
tress, eating a meal they really do not want to avoid the disapproval
of the person who made it, or finishing up leftovers when they have
already eaten enough because, “It would be a waste just to throw it
away”. In each of the above scenarios, the behaviour of eating bears all
the hallmarks of functioning as an away move. Alternatively, a client
might report that they have visited the gym every day since your last
session. This might have been a toward move, serving values around
health and fitness, and, it might have served the function of getting
them out of the house, and therefore away from a tense situation with
their partner.
So, how can we tell the difference? The first thing to say is that we
should not be trying to tell the difference simply to promote toward
moves and eliminate away moves, even if reducing reliance on away
moves might be consistent with the overall trajectory of the interven-
tion. Both are important for successful functioning – we can all benefit
from knowing when to move toward our values and when to avoid
pain. It is important to remember that ACT only targets repertoires of
experientially avoidant behaviour when they are problematic. An ACT
practitioner needs to be able to tell the difference between toward and
away moves because part of their role is about helping clients to get
better at tracking their own behaviour and tuning into its functions.
This is in the service of clients improving the frequency with which
they engage in behaviour that is workable, and consistent with a life
well-lived in the context of their values and aspirations.
One of the main differences between toward and away moves is in
the flexibility of the behaviour. Let us use the behaviour of running
through a country park as an example. As a toward move, perhaps in
the pursuit of fitness, running can be a very flexible activity. Someone
might choose to follow a running programme or not, vary the pace
and duration of their run, take different routes through the park, or
even stop for a while to enjoy the view. If that same person was run-
ning through that same country park because they were being chased
by an assailant, their run will not have the same flexible quality. It is
likely that they will run as fast and as far as they can in one direction
only, namely away from their attacker. Many away moves are like this
since they often do not feel like a choice. Think of it as the difference
64 Conceptual questions about the ACT model

between doing something because you want to and doing something

because you have to. The latter condition tends to produce much more
rigidity. Thus, exploring the flexibility/rigidity of a behaviour with a
client is a useful step to take.
Another way of spotting the difference is in the client’s psychologi-
cal experience of their behaviour. If you are reading this book because
it represents a toward move for you, the act of doing it will likely elicit
certain psychological states. You might notice feeling interested, en-
gaged, or even excited as you develop insights that might be useful
to you in your practice. Reading it might represent a committed ac-
tion as part of a repertoire of behaviour that serves the value of being
helpful to others. If you are reading it because it’s on a reading list for
an assignment that you’ve been set as part of a training course that
you’re not that into anyway, and you wish your manager had not sent
you on, the experience will feel quite different. Encouraging clients to
notice the experience of enacting a behaviour can help you both access
internal events like emotions and physiological sensations. These dif-
ferent feelings offer a clearer sense of whether any given behaviour is
a toward or away move. Only the client can really know the functions
of their behaviour, so helping them learn how to notice, track, and
describe their inner experience is crucial to effective ACT practice.
Chapter 19

How does the concept of

compassion fit with ACT?

Firstly, let’s start by clarifying what we mean by compassion. Who

better to consult for this than our Compassion Focused Therapy
(CFT) colleagues? The Compassionate Mind Foundation (n.d.) de-
fines compassion as “…a sensitivity to suffering in self and others with
a commitment to try to alleviate and prevent it”. If we take this as a
starting point to explore compassion within the ACT model, it feels
immediately clear to us that there is a huge overlap between the thera-
peutic aims of both ACT and CFT. If we were to draw a Venn diagram
relating these third-wave CBT models, the commonalities would in-
clude their focus on human suffering and a desire to alleviate this, the
idea of a common humanity, the inclusion and importance of the self
and other (compassion and acceptance are both principles that have
a focus on the self and others), and their emphasis on the teachings of
evolutionary science. The difference in the models is more about their
points of origin, with CFT drawing on attachment theory, Buddhism
and developmental approaches, and ACT coming more from the be-
havioural science tradition, and ultimately holding psychological flex-
ibility as the foremost important tenet.
With the increase in scientific support around the importance of
compassion, including research studying the effects of compassion
practice on the brain (Lutz et al., 2008), it is predictable that these two
approaches will continue to co-exist and work alongside each other.
There is much to learn from each. ‘The ACT Practitioner’s Guide to
the Science of Compassion’ (Tirch et al., 2014) is a very helpful and
eloquent guide about how to incorporate more of the CFT model and
its learnings into your ACT practice.

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66 Conceptual questions about the ACT model

It is often a misconception of people learning ACT that it is some-

how void of compassion, and that an ACT approach is more a set of
‘forced’ experiential exercises than anything compassionate. This
could not be farther from the truth when ACT intervention is prac-
tised in a manner faithful to the model. The name of the model is
certainly evocative of ‘doing’, of ‘action’. The words ‘acceptance’ and
‘commitment’ are indeed guiding people undertaking this work to be
aware of its active approach. However, it is an injustice to the entire
body of work to attempt to undertake ACT intervention without the
complete and transparent presence of compassion.
In our training and supervision of other therapists, we have long
been talking about wrapping the word compassion around the Hex-
aflex (see Figure 19.1). The visual representation of the entire ACT
model being encompassed by compassion suddenly seems to evoke a
renewed perspective of the ‘what’ and ‘how’ of the work.
Compassion is something we endeavour to bring to all human in-
teraction as practitioners, in whatever capacity we work with people.
When considering how to turn up the volume of compassion in your

Contact with the

Present Moment

Acceptance Values

Psychological
Flexibility

Defusion Committed
Action

Self as Context

Figure 19.1 Compassion and the Hexaflex

 How does the concept of compassion fit with ACT? 67

ACT work, it can be helpful to hold compassion as a stance that we

take in how we choose to behave in the world, both toward ourselves
and to those we engage with. The idea of doing something compas-
sionate with another person implies that this would then stop when
the exercise is over. However, the idea of being compassionate to them
and their needs, as well as toward you and your own needs is some-
thing that can be consistent and sustained throughout the work.
From a behavioural perspective, we know that there are three main
ways to help someone to acquire a new skill. For example, if the goal of
our work together were to be that you learn to swim, we could model
how to swim, we could invite you into the water and evoke swimming
behaviours, and we could reinforce your efforts to move around in the
water. The principles of modelling, evoking, and reinforcing behav-
iour to effect behaviour change are something we can hold in mind
in relation to compassion as well. If we consider how this would be
helpful in our intervention work regarding compassion, we can liter-
ally model compassion to our clients in every single interaction we
have with them. We can then strategically choose how to evoke more
compassionate behavioural choices from our clients, and reinforce
any compassionate choices that our clients make.
A helpful metaphor to bring this to life is driving a car. Imagine
yourself in the driver’s seat, hands on the steering wheel, backside
in the chair, feet on the pedals. To even move the car forward a few
metres you need to take a number of strategic actions. Just consider
what is involved – your hands will change gear, your feet will move
the pedals, your entire body will be making minor movements and
adjustments to action the required events that will get the car to move
forward. And then you’re off! Driving down the road at speed. But
what about awareness? You don’t suddenly pull over and think, “Oh
now it’s time to do the awareness” (we hope!). You need to drive with
awareness all the time, and even if this has become second nature to
you through practice, you would still notice someone walking into the
road, the movement of other cars, and other features on the environ-
ment in which you are driving. Compassion is just the same at that, it’s
a skill and a quality that we aim to bring to all of the work we do. It’s
not something ‘extra’ that we offer on top of our ACT knowledge and
skill. It is how we do ACT.
Part 3

Putting ACT into

practice

Once practitioners understand the philosophical and theoretical ba-

sis of ACT, they can begin to turn their attention to learning how to
apply its concepts in practice. Attempting to meet the challenge of
how to apply the theory to the complexities of the real-life situations
brought by clients is when the most questions about the model tend to
be generated. The largest section of the book is devoted to answering
frequently asked questions about putting ACT into practice. Several
chapters in this section answer questions concerning interventions
and techniques for addressing the six components of the psychologi-
cal model, as well as related questions about assessment, formulation,
and how to structure and order ACT interventions. Questions about
the applicability of ACT with diverse populations and different diag-
nostic presentations are addressed, as is the issue about to what extent
ACT practitioners need to be familiar with the finer points of RFT.

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Chapter 20

Do I need to know RFT in

order to practise ACT?

There is a simple and honest answer to this question, which is ‘no’. You
do not need to know RFT inside out to practise ACT. And…there is
a lot more nuance in a considered position of the relevance of RFT to
ACT, which we would like you to think about before coming to your
own view.
A useful metaphor for this issue is that of a musician and whether
they need to know musical theory or have an in-depth knowledge of
their instrument to play it. Clearly, once again, there will be many mu-
sicians around the world who can play proficiently without this knowl-
edge. They might have been self-taught and simply figured things out
as they went along, drawing on their own experience of what works as
they progress in their musical development. However, one could argue
that there may be times in their practice of music when a knowledge
of musical keys, scales, and time signatures, or an understanding of
how their instrument is constructed would be of great use. Perhaps
that lack of knowledge will limit them in terms of the music they are
able to write and play, or perhaps the instrument develops a fault that
they will not know how to correct. Of course, they can turn to other
people for help at any such times, and maybe there will always be ways
in which they are at a disadvantage to another musician who has that
additional theoretical understanding.
We always include a significant section on RFT in our ACT train-
ings, particularly at an introductory level when people may be coming
across ACT for the first time. Our view is that it is very important for
ACT practitioners to understand at least the fundamental concepts of
RFT. It is fair to say that it is not everyone’s favourite part of the train-
ing, yet without it, it feels difficult to root ACT’s core assumptions

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 Do I need to know RFT in order to practise ACT? 71

in anything solid. As stated by Dixon and Hayes (2022, p. 5), “ACT

makes no sense without RFT”. Learning ACT procedures (the how
of ACT) without learning the theory behind why you are using them
feels very much like giving people a bag of tools without passing on
any understanding of what each one of them is for. How would they
choose which one of them to use and when?
In our experience of supervising ACT practitioners, this issue
frequently presents itself in the questions asked by those with little
training or interest in RFT. For example, they might have run into
obstacles trying to help a client defuse from an unwanted thought. In
good faith, they might have tried several different procedures drawn
from the ‘defusion’ section of a textbook, and then brought the issue
to supervision, because none of them have helped weaken the behav-
ioural control exerted by the thought in question. Part of the problem
here relates to the imprecise nature of some of ACT’s concepts and its
reliance on middle-level terms (see McEnteggart, 2018), as discussed
in more detail in Chapter 14. In noting the client’s thought, the prac-
titioner has observed a process that they recognise as cognitive fusion
and applied procedures aimed at reducing that fusion. However, fu-
sion is not a precise concept, and saying that the client is fused with a
thought says nothing about the specific relations involved. We would
argue that an understanding of RFT can provide greater specificity in
this situation and would enable the practitioner to target their inter-
ventions with greater precision.
For illustrative purposes, let us assume that the thought in ques-
tion is, “I’m just not who I was before. I’m less able than others. I’m
worthless”, and the client has been plagued by this thought ever since
they experienced a life-changing physical injury. The thought has the
function of lowering the client’s mood and narrowing their behav-
ioural repertoire. They have become withdrawn and lack motivation
to engage with valued activity. An RFT formulation of this thought
would specify certain relational frames that are contained within it,
as follows.

“I’m not who I was” – ‘I-NOW’ is in a frame of opposition with

‘I-THEN’
“I’m less able than others. I’m worthless” – ‘I’ is in a frame of
hierarchy with ‘others’ in which ‘I’ is inferior (worth less) than
‘others’
72 Putting ACT into practice

Many of ACT’s defusion procedures aim to create a frame of distinc-

tion between the noticing part of a person’s consciousness and the
content of their thoughts that the noticing part notices. For example,
the ‘leaves on a stream’ exercise creates a distinction between thoughts
that are placed on the leaves as they float down the stream and the
person on the riverbank watching them come and go. However, as
demonstrated by Barnes-Holmes (2015), the exercise might also be
considered to contain elements that target values, acceptance, and
self-as-context outcomes. It is a somewhat scattergun procedure, and
whilst it may well have some benefit in terms of helping with the issues
the client is facing, it is probably not the most efficient way to work and
cannot really be said to be utilising a functional analytic approach.
With reference to the RFT formulation above, it might be more ef-
fective to specifically target the opposition and hierarchical relations,
since neither of these suggest that a distinction procedure is indicated.
The opposition relation could be addressed by using procedures that
promote co-ordination (or continuity) between ‘I-NOW’ and ‘I-THEN’.
Whilst acknowledging that there are some differences between now
and before, it would be useful to orient the client to ways in which they
are the same. What about them has not changed? Do they still aspire
to the same values? Is there a sense of who they are that is more than
just the things that they can or cannot do? The hierarchical relation,
whereby the client sees themselves as less than others could be targeted
by perspective-taking interventions and/or self-as context procedures
such as container metaphors. For example, would the client judge
someone else with the same physical injuries as worthless in the same
way? Would they see something that is part of a person’s experience as
being equivalent to the whole of them? (e.g., does one bad deed, blonde
hair, or a physical injury define a person in their entirety?)
Whether interventions that pay attention to the specifics of RFT
fare better than more generic ACT interventions is an empirical ques-
tion that remains to be answered. The field is in its relative infancy
regarding this question and cutting-edge interventions firmly rooted
in ‘clinical’ RFT (e.g., Barnes-Holmes et al., 2020) are only now be-
ginning to establish themselves. In the interests of balance, we should
state that our belief that a knowledge of RFT can benefit the practice
of ACT does not go unchallenged and there are those of the opinion
that the links that are claimed between RFT and ACT are empiri-
cally premature and somewhat oversold in the ACT literature (see
McLoughlin & Roche, 2022).
Chapter 21

How do I know
whether ACT is the
right intervention
for someone?

There are many ways to answer this question. One could take an em-
pirical approach and examine the evidence-base for using ACT with a
client’s presenting issue, or one could look more intra-personally, both
at the client and ourselves. We will reflect on each of these approaches
to the question in turn.
When starting to use ACT in your practice, it is certainly helpful
to familiarise yourself with the evidence-base for the efficacy of the
model (see Chapter 2 for more on this). There is a growing evidence-
base for the use of ACT with a wide range of presentations. This
includes applications with people who may present with diagnostic
mental health labels, such as depression, anxiety disorders, and prob-
lematic substance use, as well as applications of the model to several
physical health diagnoses like chronic pain, cancer, diabetes, and
bowel diseases (Hayes, 2022). Thus, it is advisable to turn to the litera-
ture to see whether there is evidence that ACT would be of benefit with
reference to any given issue that someone seeking help might bring.
For some of these diagnoses, there are also specific protocols available
(see Hayes, n.d., b), as well as an array of books on specific application
to a particular presentation.
More broadly, there is also a growing evidence-base for the psycho-
logical flexibility model itself. There are studies that look at whether
individual ACT procedures are indeed doing what the theory claims
they should. For example, does introducing a defusion procedure ac-
tually help a client to have more distance from their thoughts, and
achieve an outcome characterised by defusion? One helpful overview
of this work is the meta-analysis of laboratory-based component stud-
ies by Levin et al. (2012). This meta-analysis identified that numerous

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74 Putting ACT into practice

component studies did suggest that individual ACT procedures were

helpful in increasing psychological flexibility via the component pro-
cess they stated they were acting upon. These component studies, as
well as the outcomes from meta-analyses, reinforce the idea that the
model is not only suitable in the context of a few specific diagnostic
labels. Rather, they suggest that this is a flexible model that can be
applied in different ways to various aspects of human functioning,
either to alleviate suffering or to promote adaptive change. Taken in
the round, ACT research data suggest that the specific context within
which human suffering takes place is less relevant, and that the model
is applicable whatever the cause of distress or ‘stuckness’. This can
be observed in the variety of studies that support the use of ACT in
non-clinical settings, including studies on relationship difficulties
(e.g., Rahimi et al., 2020; Amini et al., 2021), staff burnout in work
environments (e.g., Hayes et al., 2004; Montaner et al., 2022; Prudenzi
et al., 2022), and coaching (e.g., Hochard et al., 2021; Potts et al., 2022).
Aside from the evidence-base, there is of course an intra-personal
perspective as to whether ACT is the ‘right’ therapy for someone.
There are a number of therapeutic approaches out there, and as indi-
viduals we each bring personal choice to the type of support we may
wish for at any given moment in our lives. ACT is an active interven-
tion, and one that requires to some degree that the client takes at least
an equally active role to that of the practitioner. A good metaphor
here is rowing a boat. If the practitioner and the client each hold an
oar and the practitioner rows hard whilst the client takes a more laid-
back approach, the boat will turn in circles. The client is required to
be willing to engage in an active therapeutic model (and row at least as
hard as the practitioner) to achieve the forward momentum of behav-
iour change. Of course, at times, clients may wish for a more person-
centred, non-directive counselling approach. There is validity to this
choice and it is likely that this choice will suggest ACT is not the most
helpful approach for your client at this moment in their lives. An-
other factor that might suggest that ACT is not the best fit for your
client is a desire to explore childhood issues in great depth, which may
lean more toward a psychodynamic psychotherapy model. Equally,
another contraindication for ACT might be where a client requests
another specific model, for example, traditional CBT, because they
like the structure of thought diaries, or want a practitioner to directly
challenge their thoughts. Of course, you can provide information
about ACT to all of these people and even advocate why you think
How do I know whether ACT is the right intervention for someone? 75

psychological flexibility could be a helpful approach for them. It may

indeed be a more helpful approach than the one they are requesting,
although it is also important to respect a client’s choice and be honest
with them about what you will and will not be able to offer them.
There is also an important question around whether ACT is an ap-
propriate match with your clients’ needs and abilities. There are some
basic cognitive functions that people need to have to enable them to
access talking therapies of any kind. These include the ability to com-
prehend the relevant language being used, to be able to encode and
retain relevant information and engage in a basic exchange of lan-
guage using both listening and communication skills. ACT is unlikely
to be best suited to people who are intoxicated or require emergency
care (Smout, 2012). ACT is used with a variety of human populations,
including people who have diagnoses of intellectual disability, autis-
tic spectrum disorder, and acquired brain injury. Some of these dif-
ferences will impact the way you would explain the concepts of the
model, or whether you are able to effectively use abstract concepts
like metaphors. Whilst the evidence-base for these populations is still
small, clinical experience from practitioners around the world is in-
dicative of its efficacy. The important question here is not, “Can my
client understand the model as explained in a textbook?”, but rather,
“Do I understand the science and philosophy of the model enough to
adapt the application, so my work is still ACT consistent?”. Sometimes
asking this question suggests a different perspective from the question
in the title of this chapter, in that goodness of fit might be just as much
about a practitioner’s skill set, than it is about the suitability of the
client.
Chapter 22

Can ACT be adapted for

diverse populations?

This question can be approached in two ways, namely, a consideration

of the interest in applying ACT among diverse populations, and the
evidence of the effectiveness of the same. We will consider the second
of these issues first.
A significant problem for all scientific literature is the bias toward
collecting data from what can be referred to as ‘WEIRD’ nations.
WEIRD is an acronym utilised by Henrich et al. (2010a) to refer to
Western, educated, industrialised, rich, and democratic nations. It is
suggested that up to 85% of the world’s scientific studies come from
WEIRD nations, whilst at the same time, only 12% of the world’s
population are resident there. The problem applies to psychological
research, as reported by Arnett (2008) in a paper looking at studies
published in prominent psychology journals between 2003 and 2007.
Arnett found that 74% of the authors and 96% of the participant sam-
ples were American, whilst only 5% of the world’s population are
American. Consequently, it would be wise to always approach psy-
chological research data with some caution, particularly in respect
to generalising any findings to groups of people who may have been
under-­represented in the studies. It is evident that the extant data
within behavioural science is drawn from a small percentage of all
human diversity and whilst many people might assume that any find-
ings from WEIRD nations generalise to all humans, there is a strong
argument to suggest that this is not the case. People vary enormously
in terms of psychological processes like visual perception, memory,
spatial reasoning, fairness, and co-operation, and WEIRD people are
not typical of the species as a whole. In short, the fact that a huge
majority of studies utilise WEIRD participants presents a significant

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 Can ACT be adapted for diverse populations? 77

challenge to our understanding of human psychology and behaviour

(Henrich et al, 2010b).
So how does ACT research compare in respect of these limitations?
As has already been suggested (see Chapter 2), any answer we can pro-
vide about research data at the time of writing may well be out of date
within a few months, such is the rate at which new ACT studies are
published. That said, at the present time there are just short of 1000 ran-
domised controlled trials attesting to the efficacy of ACT as an inter-
vention for a wide range of behavioural issues. Of these, approximately
250 originated in low and lower middle-income regions, as defined by
the World Bank (ACBS, 2022). These include studies published in Alge-
ria, Egypt, Ethiopia, Gaza Strip, India, Indonesia, Iran, Nigeria, Sierra
Leone, South Sudan, and Uganda. Whilst this figure does not come
close to addressing the over-representation of WEIRD people in the
ACT outcome data, it does give some indication of the broad applica-
bility of ACT across cultures. As always, firm conclusions about appli-
cability cannot be achieved by counting studies, and practitioners are
encouraged to seek out individual studies to examine their quality and
relevance to any population that they might be providing a service to.
In addition, it is important to interrogate studies to find out more about
the demographics of the participants in their samples and the overall
cultural competence of the researchers (Woidneck et al., 2012).
Another indicator of the diversity of interest in ACT comes from the
fact that ACBS, the worldwide organisation overseeing the development
of ACT, has chapters in Asia, Australia/Oceania, Europe, South Amer-
ica, and North America. There are ACT textbooks in more than 20 dif-
ferent languages and ACT measures in over 40 languages (ACBS, n.d.,
b). One influence on this worldwide interest might be that ACT draws
inspiration for its theory and practice from both the East and the West.
It is interested in both ideas from ancient wisdom traditions (e.g., mind-
fulness, acceptance, and a transcendent sense of self) and modern sci-
ence (e.g., behaviourism and an emphasis on evidence-­based practice).
The active research programme in Iran and the growing interest in ACT
training and literature in China are just two examples that attest to the
appeal and applicability of the model outside of WEIRD nations. As a
note of caution, we should underline that interest and applicability is
not hard evidence of efficacy in terms of culturally diverse applications.
The WEIRD issue is only one way of thinking about diversity. Hays
(2016) uses the ADDRESSING acronym to help practitioners think
78 Putting ACT into practice

about the ways in which people identify and are diverse. The acronym
indicates the following influences on cultural diversity.

• Age and generational influences

• Developmental disabilities
• Disabilities acquired later in life
• Religion and spiritual orientation
• Ethnic and racial identity
• Socioeconomic status
• Sexual orientation
• Indigenous heritage
• Gender

These are not discrete categories, and the notion of how they might
intersect for any given individual or group is important to consider
when thinking about how applicable ACT procedures might be to
them. Something of use to an ACT practitioner considering intersec-
tionality in this way is the proposed universality of ACT as a model for
approaching human behaviour. Whilst every client brings a different
specific context for the practitioner to work within, the ACT model is
the same everywhere, since the processes are intended to be universal.
Of course, certain contextual concerns will need to be given more prom-
inent consideration when any of Hays’s above list of cultural influences
are a significant feature of a client’s presentation. Thankfully, there is a
significant body of ACT literature already available that practitioners
can look to in these circumstances. There are books and/or research
papers on ACT with older adults (Davison et al., 2017), developmental
disability (Byrne & O’Mahony, 2020; Williams & Jones, 2022), disa-
bilities acquired later in life (Owen, 2013), religion and spiritual orien-
tation (Nieuwsma et al., 2016; Robb, 2022), racism and racial trauma
(Matsuda et al., 2020; Payne, 2022), low-income countries (Geda et al.,
2021), gender and sexual identity (Skinta & Curtin, 2016; Stitt, 2020),
and indigenous populations (Dousti et al., 2021).
As a footnote to this chapter, it feels important to stress that the ef-
fectiveness of using any psychological model with diverse populations
relies on an interaction between the skills of the practitioner and the
model they are using. Using an ‘ACT for X’ protocol is unlikely to be
enough on its own, and it is incumbent upon all ACT practitioners to
seek to equip themselves with knowledge and skills for working in a
manner that is informed by the principles of intersectionality.
Chapter 23

Where do I start with

introducing ACT to
a client?

We could answer this question from a number of perspectives; where

you are at in your ACT practitioner training, where your client is in
relation to their presentation and the issues they are bringing to your
work, or, by considering what the model would suggest as a ‘good’
place to start. We will address each of these in turn.
Much about where you might start with introducing ACT to a client
will depend on where you are in your own ACT practitioner journey
and how skilled you feel with each of the components of the Hexaflex.
It will also be impacted by what other CBS knowledge you have guid-
ing your interventions, such as the underpinning science and philoso-
phy of ACT, notably functional contextualism, behaviourism, and the
clinical application of RFT. If you are reading this book, it is likely
that you have some experience of ACT. It may also be possible that
you have previous training in other psychological models or behav-
iour change approaches, like CBT, psychodynamic psychotherapy, or
coaching. If that is the case, then it can be helpful to reduce some of
the pressure brought by the thought, “How do I change from X to
ACT in my next session?”, and instead start to ‘flavour’ your existing
work with more ACT consistent ideas and strategies. One example of
this is to increase the focus on values work within your existing prac-
tice, to help people turn up the volume on what is important to them in
their lives. You might do this via a specific strategy. For example, you
could alter existing exposure interventions to include a value-driven
perspective, or you could utilise a specific tool such as values cards
(e.g., Nikolic, 2019). If that goes well, you might feel increasingly mo-
tivated to want to explore what your next intervention steps might be
from an ACT perspective. In this way, your learning experience can
feel more like a natural integration of new and existing knowledge.

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80 Putting ACT into practice

If you are in the early stages of learning ACT and are looking for
additional structure to follow, it can be helpful to draw on the various
session-by-session protocols that are available (e.g., Zettle, n.d.). These
give you scripts for exercises and even timed breakdowns of entire ses-
sions. Each protocol has its own starting point and will therefore in-
troduce you to a variety of helpful strategies for you to implement into
your developing practice.
An alternative place to start introducing ACT to a client is picking
up on where the client is at. This is often the flexible approach that
more advanced practitioners take. This may involve identifying the
client’s strengths in relation to psychological flexibility skills and ex-
panding on them in an ACT-consistent manner. For example, if peo-
ple can access their existing values menu, further work on values can
be a great way to build on their strengths and increase the appetitive
functions of the work to come. Alternatively, you may start by focus-
sing on their struggle, helping them to use this to inform therapeutic
goals, aims, and desires. Giving airtime to hearing someone’s struggle
and validate their experience is a valid choice as long as it does not
excessively function as an away move for either the practitioner or the
client. The starting point with every client can differ, based on several
factors, and making choices around selecting the most helpful first
step is a skill that you can hone with practice.
With regard to where the model would tell you to start, there is no
rigid rule to follow about which component comes first. As described
above, you may wish to start where someone holds some existing skill,
or at the place of greatest deficit. This will usually become quite clear
to you during your initial assessment conversation.
Irrespective of which part of the Hexaflex you choose to focus on
first, there are some helpful tools to use to assist the sharing of the
model with clients. As discussed in Chapter 12, creative hopelessness
is a strategy to aid clients to buy into the function of addressing diffi-
culties in a new and novel way. Highlighting the futility of the struggle
that clients may have been stuck in for years is one key to increas-
ing motivation for behaviour change. Another strategy to explain the
model in a client-friendly manner is the use of an overarching or in-
troductory metaphor (see Chapters 1 and 9 for more on metaphors).
‘Passengers on the Bus’ is a common ACT metaphor that encompasses
all the Hexaflex components. Bennett and Oliver (2019) describe this
metaphor, and how to enact it within a group setting. As this meta-
phor includes each of the six aspects of the psychological flexibility
 Where do I start with introducing ACT to a client? 81

model, it is not only a helpful overview of ACT’s perspective on the

world, it is also a helpful tool to repeatedly return to in supporting
clients’ learning of each Hexaflex skill.
If, at the start of sessions, clients specifically ask, “What is ACT?”
or, “How is it different to CBT?”, it can be helpful to summarise some
of the following. In brief, ACT can be described as a third wave CBT,
meaning that it still acknowledges the links between thoughts, behav-
iours, emotions, and physiological sensation. It also utilises mindful-
ness and acceptance practices from ancient wisdom traditions. It is a
values-based model, meaning that the client will be invited to tune in
to what matters most to them, and take active steps to move in that
direction. It is a very active model for a client to engage with, so whilst
we, the practitioner, will offer them our dedication and support, the
active change process will come from them being willing to take dif-
ferent actions based on greater clarity around their values. Chapter 1
offers some further thoughts on socialising clients to the ACT model.
Chapter 24

Should I show the

Hexaflex to my clients?

When learning ACT, whether through an introductory training or

a basic ACT textbook, practitioners will almost invariably be intro-
duced to the Hexaflex. This diagram, which is a way of visually ex-
pressing ACT’s psychological flexibility model, has been referenced
in various previous chapters and the diagram itself can be found in
Chapter 11. The concept of psychological flexibility, described more
fully in Chapter 11, comprises six components, namely acceptance, de-
fusion, contact with the present moment, self-as-context, values, and
committed action. Whilst these components are often referred to as
processes, with reference to the process/procedure/outcome discrimi-
nation described in Chapter 14, they are perhaps better thought of as
outcomes, in that they represent aspects of the behaviour of a more
psychologically flexible individual. For example, we want our clients
to be mindfully in contact with the present, in touch with the part of
themselves that can notice and choose responses, willing to accept
discomfort, able to stand back from unhelpful thoughts, clear about
what values are important to them, and taking meaningful action. As
opposed to that description, the target processes indicating that an
individual might benefit from ACT procedures relate to a state of psy-
chological rigidity or inflexibility. These processes are also sometimes
represented on a similar hexagonal diagram, known colloquially as
the Inflexahex (see Figure 24.1).
The Inflexahex is a useful conceptual tool to help an ACT practi-
tioner map and describe the target processes when arriving at a for-
mulation of a client’s situation. It is helpful in providing an overview
of some of the main issues of stuckness, and in guiding the selection
of interventions. Both the Hexaflex and the Inflexahex diagrams have

DOI: 10.4324/9781003364993-28
 Should I show the Hexaflex to my clients? 83

Rumination
and worry

Experiential Lack of values

avoidance clarity

Psychological
Rigidity

Fusion with
unhelpful Inaction or
thoughts, rules, unworkable action
and judgements

Attachment to a
conceptualised
sense of self

Figure 24.1 T
 he Inflexahex (adapted from Bach & Moran, 2007)

been used as the basis for worksheets that practitioners and clients can
complete together in the service of gathering information about the na-
ture of presenting difficulties and organising it with reference to ACT’s
theoretical framework. The ‘ACT Advisor’ assessment worksheet is a
good example of this, combining both process and outcome as a means
of formulating and tracking progress over time (ACBS, n.d., c).
We do not have any issue with the Hexaflex or Inflexahex as useful
ways of visually representing the component parts of psychological
flexibility. They are useful conceptual tools in ACT training, and in
organising assessment information. However, we would argue that
their practical utility is limited insofar as they do not depict functional
relationships between processes and outcomes or illustrate how the
concepts translate into observable behaviour. For that reason, we do
not recommend sharing them with clients. That is not to suggest that
we do not think it is important to communicate a shared psycholog-
ical understanding of the client’s experience. We do. It is just that we
think that there are more functional tools available for achieving this.
Clearly, this position begs a second question, concerning which tools
we would recommend ACT practitioners to use to share their formula-
tions. Whilst there are several candidates, in our view, the one with the
84 Putting ACT into practice

OBSERVABLE BEHAVIOUR

What might we see you do What might we see you do

when this discomfort is when you are acting on
present? what is important to you?

YOU
AWAY TOWARD
NOTICING

What discomfort shows up to What is important to you

get in the way of you acting in this situation?
on what is important?

INTERNAL EXPERIENCES

Figure 24.2 The ACT Matrix (adapted from Polk et al., 2016)

most practical utility in the widest number of situations is the ACT Ma-
trix (Polk et al., 2016). It is a versatile tool that emphasises the functional
discrimination of observable toward and away moves, and links this to
the components of the Hexaflex in a very accessible manner.
The Matrix diagram (see Figure 24.2) comprises two intersecting
lines, thereby creating four quadrants. The vertical line represents
the discrimination between behaviour under appetitive or aversive
control, and the horizontal line creates a further distinction between
internal, covert experiences (e.g., values, thoughts, or emotions) and
observable behaviours. These distinctions enable several functional
relations to be specified.
Considering the bottom half of the Matrix, the bottom left quad-
rant captures the discomfort that can show up in response to pursu-
ing one’s values in the bottom right quadrant. This serves to helpfully
illustrate the co-ordination relation that exists between valuing and
suffering (for example, anxiety coming hand-in-hand with the expe-
rience of being courageous) and is helpful in emphasising the utility
of accepting discomfort in the service of enabling valued action. This
co-ordination relation is useful to build into a client’s understanding
since clients often come to ACT practice with an opposition relation
regarding values and discomfort (e.g., the notion that they would like
to act more in line with their values, but they can’t because their anx-
iety stops them). The understanding that discomfort is not the enemy,
 Should I show the Hexaflex to my clients? 85

and that it can be seen as simply the ‘price tag’ of holding something
to be really important, is often revelatory.
The left side focusses on unwanted internal experiences and the ob-
servable away moves that characterise experiential avoidance. This
can be used to illustrate the appetitive nature of away moves, and
how discomfort often serves as the automatic cue for them. The left
side can further illustrate how away moves are perpetuated through
a maintaining cycle of negative reinforcement (e.g., reducing anxiety
through avoidant behaviour becomes an ingrained pattern precisely
because it works in achieving its aim). However, no matter how effec-
tive these away moves are at reducing discomfort, they rarely, if ever,
help someone pursue their values, and this understanding can help
create a frame of opposition between the two, thus also helping away
moves acquire aversive functions.
The right side of the Matrix focuses on specifying a client’s values
and the observable toward moves associated with taking value-driven
action. It helps to show how one’s behaviour can look quite different
when it is motivated by moving toward values, as opposed to moving
away from discomfort. The behaviour specified in the top right quad-
rant often has appetitive functions, so taking time to explore it is an
important part of completing a Matrix.
The Matrix is most often drawn with a circle in the middle, which
represents the observing part of the client’s self, and speaks to the
OBSERVABLE BEHAVIOUR

Experiential Committed
OPPOSITION
avoidance action
OPPOSITION

HIERARCHY

AWAY
Self-as- TOWARD
context

Fusion CO-ORDINATION Values

Acceptance

INTERNAL EXPERIENCES

Figure 24.3 Mapping Hexaflex terms and derived relations using the Matrix
86 Putting ACT into practice

ACT concepts of present moment awareness and self-as-context.

From this part of themselves, the client can see all the quadrants of
the Matrix and how they fit together as different parts of their overall
experience. The client is often invited to notice the different functional
choices specified in the top two boxes and to work toward seeing their
discomfort as the cue to mindfully choose a response in any given
moment, rather than the ‘auto-pilot’ response of their usual pattern
of away moves.
Figure 24.3 illustrates how the middle-level terms of the Hexaflex,
and the derived relations outlined in previous paragraphs, can be
mapped onto the Matrix. We use the Matrix so often because it sum-
marises lots of RFT and ACT concepts in one accessible diagram. It
can also be used to address specific situations or much more general
formulations of repeating behaviour patterns. Its applications include
individual psychological wellbeing (e.g., Oliver & Bennett, 2020), or
with teams of colleagues in organisations (e.g., Atkins et al., 2019). In
our view, it offers much more to such situations than versions of the
Hexaflex can.
Chapter 25

How do I explain
each component of
the Hexaflex?

ACT training and intervention work is experiential in nature as it uti-

lises the learning experience of fully engaging in an exercise, rather
than it solely being verbally explained. Take a moment to reflect on
your own experiences of ACT. What moments in your training stand
out in your mind as memorable? Which were particularly poignant for
you? Were those moments halfway through a long didactic explana-
tion, or were they during an experiential exercise that you were invited
to do, and then reflect upon? We would take a punt that for most peo-
ple at least, it was the latter. It is for this reason that ACT also makes
its intervention work experiential, and our best advice would be to en-
gage the client in experiencing each component of the Hexaflex, rather
than getting caught up in a long-winded verbal explanation. That said,
sometimes a client may want a little more information about the work
they are about to embark upon, so below are short narratives for each
component, and an associated exercise or metaphor that can be useful
to further embed the learning in a more experiential manner. Note
that in each of the sample narratives below, the ACT term is omitted.
The aim here is to provide a functional definition of the skills, not to
impart technical ‘middle-level’ terms to the client.

Acceptance
Narrative:

One of the skills that is helpful to develop is our willingness to

allow all our experiences to simply be with us, without judging
them or trying to make them go away. The reason we can benefit

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88 Putting ACT into practice

from this is that we are then often more able to decide how we
would like to respond to an experience, rather than focussing our
attention on how to change it, or make it hurt less.

Metaphor: A useful metaphor for helping explore the futility of strug-

gle, and therefore the utility of acceptance as a means of expanding
behavioural responses is ‘Room full of duct tape’ (Vuille, 2013, as
cited in Stoddard & Afari, 2014, p. 39). This describes the scenario of
a leaking pipe, to which a person’s response is to cover the small crack
with duct tape to stop the dripping water. The problem is solved, mo-
mentarily. Inevitably the water finds its way through the tape and the
dripping continues. If we limit our behavioural response to using duct
tape each time the pipe leaks, we will eventually have a room full of
duct tape and still the water will drip. Acceptance would involve the
willingness to acknowledge the leak, and choose a response that feels
most effective, even if this is a more difficult task.

Defusion
Narrative:

Sometimes it can be helpful to catch our minds in flight and notice

the tricky thoughts that affect the decisions we make in life. Step-
ping back from our thoughts allows us to see that they are simply
that, thoughts. They don’t actually have to guide our behaviour.

Exercise: There are various categories of defusion exercises as de-

scribed in Chapter 30. One involves creating distance from our
thoughts, effectively providing space to look at them, rather than from
them. An example of this is imagining thoughts as if they appeared as
text on a computer screensaver. One can invite the client to imagine
seeing them like this and explore whether this would influence the pro-
cess of choosing how to respond to them.

Contact with the present moment

Narrative:

It is helpful for us to develop the skill of tuning in to our internal

and external worlds. Once we improve our ability to notice what
 How do I explain each component of the Hexaflex? 89

we are experiencing in any moment, we have a better chance of

being able to choose how to respond. For example, it is hard to
think how we can respond differently to our anger if we don’t even
know we are feeling angry.

Exercise: Helping people tune in to the present moment can be as sim-

ple as asking them, “What are you noticing right now?”. Longer, more
focussed, guided mindfulness scripts are also available. The ‘Observ-
ing Thoughts’ exercise (Kates, 2013, as cited in Stoddard & Afari,
2014, p. 92) invites clients to notice the movement of their thoughts,
akin to noticing their breathing. This non-judgemental noticing in-
vites developing the ability for thoughts to simply come and go, like a
bubble or a passing cloud.

Self-as-context
Narrative:

We can often describe ourselves by using the words, “I am ___”.

This can be helpful in some circumstances. For example, saying,
“I am hungry” can efficiently lead to a fairly obvious solution.
However, when we use “I am” to describe qualities of ourselves,
like “I am worthless”, we can often end up reducing our own life
experiences in order to fit the ‘worthless’ story we have told our-
selves. It is helpful to us to see that our stories are often quite
skewed, and that when we have a different way of seeing them, we
often have a different response.

Metaphor: Reducing fusion with self-stories is part of self-as-context

work. We can target exercises that challenge a self-as-content perspec-
tive, broadening a client’s willingness to see that they are more than
any one narrative they may hold about themselves. The ‘Sky and the
Weather’ (Harris, 2009) is a helpful self-as-context container metaphor.

Values
Narrative:

In our work together we will talk a lot about the qualities you
would like to bring to your life, to be the person you would most
90 Putting ACT into practice

like to be. These qualities often bring us a feeling of vitality and

meaning, and they feel intrinsically good when we embody them,
even when that might be a difficult or unpopular choice to make.
It is not about focussing on goals (like getting a car or a bigger
house), and more about focussing on qualities we bring to our ac-
tions. We are often able to summarise these qualities in one word,
for example ‘courage’, ‘independence’, or ‘integrity’.

Exercise: Activities that include perspective taking can be useful to

help clients grasp the kind of person they would like to be, for exam-
ple, ‘Writing Your Autobiography’ (Stern, 2013, as cited in Stoddard &
Afari, 2014, p. 136). This exercise invites the client to reflect on the con-
tent of their autobiography, including what they would like to be able to
write about themselves and what they would feel most proud of.

Committed action
Narrative:

We know that if we do what we’ve always done, we’ll get what we

always got, so one of the important parts of our work together is
to commit to putting our feet down differently in the world, in
order to get different results. What actions you choose to take will
be linked to the qualities you would like to embody, and the aim
of committing to these actions will be to bring you a greater sense
of living a life of vitality and meaning, even when it feels difficult.

Exercise: The ‘The Rope Bridge’ (Gillanders, 2013c, as cited in Stod-

dard & Afari, 2014, p. 163) invites the client to consider their choices
when faced with the scenario of being on a high cliff and seeing the
life they desire on the other side of the canyon. The route to access that
life is across a rope bridge, which looks a little unsafe. The choice for
the client is to decide whether the life on the other side of the canyon
is worth crossing the rope bridge for, and if so, to take steps across
the bridge with purpose in the service of accessing the life they desire.
Chapter 26

In which order should I work

through the components
of the psychological
flexibility model?

This chapter should be read in conjunction with Chapter 23 since the

questions addressed here and there often arrive together. That said,
whilst the questions of where to start and how to proceed are related,
they are sufficiently different that a separate chapter feels warranted.
As we discussed previously regarding the starting point, it is not help-
ful here to give a single definitive answer about the order of ACT
interventions. The model is designed to be flexible, and the context
presented by each practitioner-client interaction will be different.
However, from a functional perspective, our aim in this chapter is to
offer some guiding principles.
If you are the kind of person who likes clear structure and direc-
tion, there are numerous ‘manualised’ ACT protocols available, such
as have been developed for research trials, standardised individual
and group-based interventions, and self-help literature. These can be
particularly helpful for those new to ACT, much like a map or a Sat
Nav are helpful when going somewhere for the first time, since they
walk you through a whole intervention programme step-by-step. Each
such protocol will have been designed with different contexts in mind
and will move through the components of the Hexaflex in a different
order. Thus, it is not possible to reproduce a generic guide here based
on their content, although it is helpful to know that they are available.
At the same time, it is perhaps equally helpful to know that there is no
set order in which you should conduct your ACT interventions. You
can make decisions based on whatever the situation indicates, safe in
the knowledge that you will not be doing it ‘wrong’, as there is no such
thing. It is not even a pre-requisite to address all the components of
the Hexaflex during a course of intervention, since there is research

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92 Putting ACT into practice

(e.g., Levin et al., 2012) indicating that procedures that address any
one of ACT’s processes have an impact on psychological flexibility.
Thus, it seems permissible to build an ACT intervention based on a
functional analysis of the client’s presentation, and as long as the se-
lected procedures target the key processes, there is no single prescrip-
tion for whether particular procedures are included, or for how they
are ordered.
Given how different people are in their attitude toward structure,
whilst there are likely to be practitioners reading the above who are
contacting a liberating sense of freedom in this moment, there will be
others looking for firmer guidance on how to structure their work. If
you are in the latter camp and you work in a way that involves offering
a series of sessions, you might find the following principles helpful.

1 It almost goes without saying, but it makes sense to begin working

with a client by assessing the issues that have prompted them to
seek help. Many practitioners will have a preferred method for
eliciting the information that they feel is relevant to this. We do
not have a strong view about exactly what practitioners should ask
about, although our guiding principle is that less is more. Many
clients only ever attend one session so we need to think carefully
about how we use that first contact. Interrogating clients about
every aspect of their life is probably not necessary and might even
feel quite aversive. Without entirely neglecting a client’s history,
keep the focus on the processes that are maintaining their difficul-
ties in the present.
2 Work on developing a shared formulation of the behaviours key
to the client’s presentation, as seen through an ACT lens. At this
stage you might use a tool such as the Matrix (see Chapter 24),
which might help communicate the information more effectively
than an open conversation alone. Whatever method you choose,
the formulation should be firmly rooted in the principles of func-
tional analysis (see Ramnerö & Törneke, 2008) so that clients de-
velop insight into the function of their behaviours, as well as their
form.
3 Engage the client in a creative hopelessness procedure (see Chap-
ter 12 for a detailed description of a useful technique). This will
help to address the workability of the client’s current strategies
for managing their difficulties, and hopefully build willingness for
finding new ways of responding that are less reliant on experiential
 In which order should I work – psychological flexibility model? 93

avoidance. This stage of the work also lays the foundations upon
which subsequent interventions can be built.
4 The client’s new direction should be charted with reference to
the things that bring them meaning and purpose, so some val-
ues work is often indicated at this point. This goes hand-in-hand
with building acceptance skills, since pursuing valued directions
is likely to mean that the client is about to get out of their comfort
zone.
5 Secure a commitment to engaging in valued actions both within
and between sessions and begin the process of planning and im-
plementing behaviour change. In each session, the concept of
committed action needs to be reinforced. This comprises new be-
haviours, as well as using ACT procedures to manage fusion and
experiential avoidance when they threaten commitment.
6 In this later stage, the work is likely to involve the purposeful re-
cycling of stages 3–5 as the client practices the flexible pursuit of
value-driven living, learning and utilising new skills across every
component of the Hexaflex.
7 Lastly, when the client has learned what they can from attending
sessions regularly, some discussion about how they will use what
they have learned going forward is useful, as is some considera-
tion of how they might manage the inevitable setbacks when they
eventually come along.

If you work in a setting that involves shorter contacts and/or fewer

sessions with clients, the above stages might need to be collapsed or
selected from, as fits the context of the work.
Whether you work within a structure or adopt a more fluid ap-
proach (moving around the model in relation to what is happening in
the room, as more experienced ACT practitioners tend to favour), a
willingness to practice with a degree of flexibility is central to ACT. We
like the sentiments expressed by Steven C. Hayes when talking about
the development of a practitioner’s ability (Bennett, 2017–­present). He
suggested that with any client we should be able to move from any
point on the Hexaflex to any other point at any time, and with all the
options that the model presents, getting stuck in one place is really the
only way that you can go wrong.
Chapter 27

How can I encourage

people to tune in to the
present moment?

One could propose that this skill underlies all of the other aspects
of psychological flexibility. We know from the Hexaflex (see Figure
19.1) that each of the skills is linked to one another. However, it seems
inconceivable that anyone would be able to practise any of the other
skills without being able to tune into their internal world at least a
little. How can anyone identify their values if they are not able to turn
inward and explore what is important to them? And how can one un-
hook from their thoughts if they have no ability to notice thoughts
come and go?
The key to developing any skill is practice, and being aware of the
present moment is no different. As discussed in Chapter 13, there are
both formal and informal practices that can be undertaken, and any of
these could be done under the guidance of a practitioner or completed
by a client alone as part of between-session work. It is important to
ensure a good balance of practice in both of these contexts, especially
as in-session practice allows the practitioner to give live feedback to
the client, enabling the skill to be shaped.
Some ACT practitioners favour starting each session with a mindful
pause or exercise, enabling the practitioner and client to each land
together in the space they are sharing. The precise nature of any such
exercises may differ from client to client, depending on their existing
skill and preference. However, the joint acknowledgement of arriving
in a new context together can prove to be a connecting way to begin
working together.
Regarding how we encourage clients to tune into the present mo-
ment, noticing their internal and external worlds, we can turn to
the work of Kohlenberg and Tsai (1991) and the notion of effecting

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 How can I encourage people to tune in to the present moment? 95

behaviour change by modelling, evoking, and reinforcing target be-

haviours. Table 27.1 suggests some ideas for both in-session and out of
session options for encouraging people to better hone this skill as part
of developing psychological flexibility.
The concept of modelling, evoking, and reinforcing behaviour in
relation to a getting present exercise might appear simple in theory.
However, as we know when we introduce language into any situation,
the complexity increases, and the same is true here. For example, in
Table 27.1 we have discussed saying, “Thank you for slowing down
with me in this moment” as a reinforcing behaviour. This may indeed
increase the likelihood that your client will be more willing to repeat
this behaviour again in future sessions, hence it being described as
a reinforcer. However, you may also be modelling to them by your
own actions, pace, and tone of voice how to slow down, which will
hopefully continue to evoke and reinforce their behaviour of slowing
down. Whilst it is unhelpful for us to get too caught up in labelling our
behaviour as modelling, evoking, or reinforcing of our client’s behav-
iour, it is important to keep your eyes clearly on the function. Inviting
a client to tune into their body during a session or inviting the comple-
tion of present moment exercises between sessions is one thing. With
regard to the development of psychological flexibility it is much more
meaningful if the practitioner then uses this noticing to help the client
to develop their skills in relation to other components of the model.
From an ACT perspective, honing the ability to contact the present
moment is important, although connecting this with implementing
other psychological flexibility skills is what will effect long-term be-
haviour change in line with a client’s goals and values.
 96 Putting ACT into practice

M odelling, evoking, and reinforcing present moment behaviour in

Table 27.1 
and out of session

In-session Out of session

Modelling Anything where you notice Providing examples of what

behaviour your own body or internal you do in your daily life to
world in the session. You encourage your own practice
could say, “I’m noticing it of tuning into your own
is really warm in here”, or, experience
“I’m noticing I’m feeling
anxious about raising this
topic with you”.
Evoking Inviting people to tune Set homework tasks to hone the
behaviour into their bodies in the ‘getting present’ skill. These
session. This can be could be basic exercises that
especially useful when practise the skill of noticing,
you notice that they have like noticing the temperature
responded to something of the washing up water, or
with strong emotions, emotions as they ebb and flow
or in a manner that is whilst doing a familiar task.
different to their previous Alternatively, you may agree
responses. with clients that they will
utilise apps, watch YouTube
videos, or engage in other
‘mindful’ practices between
sessions.
Reinforcing You may reinforce a client’s Ensure here that the client is
behaviour ‘present moment’ skill in a not just being compliant with
number of ways. between-session tasks. In the
Verbally: e.g., “Thank you next session, it is imperative
for slowing down with to explore any task that they
me in this moment”, or, engaged in and reinforce the
“It looks like you are moments when they were able
considering this differently to tune into their experience.
right now” (and then They may have not noticed the
further evoke a response temperature of the washing up
such as, “Can you tell me water, however, they may talk
what is going on for you about noticing their feelings
right now?” to further of anger and upset when their
develop the practice). partner shouted at them. We
Gesturally: e.g., smiling, want to be hot on reinforcing
a gentle nod, a visible the skill, not any one specific
slowing down of your own behaviour. This is definitely
pace of interaction to about function over form.
gently meet them in their
present moment.
Chapter 28

How do I actually do
self-as-context work
with a client?

In our experience of providing ACT training and supervision, it is

consistently the case that if there is one concept within the model that
practitioners struggle to grasp, it is that of self-as-context. It follows
that the subject of this chapter, how to deliver procedures that promote
self-as-context repertoires, is also one that perplexes many students of
ACT. Whilst Chapter 14 deals with the issue of defining self-as-context
in some depth, it is worth briefly re-stating a working definition, since
it is something of an abstract idea.
ACT literature has traditionally described the self as being com-
prised of three parts, the self-as-content, the self-as-process, and the
self-as-context. Content is a term used to describe internal experiences
like thoughts, images, memories, emotions, and sensations, and self-
as-content suggests a pattern of relating whereby observable behav-
iour is rigid, and regulated by excessive co-ordination of the self with
this content. For example, taking the thought, “I am useless” literally
is likely to narrow an individual’s behavioural repertoire. It equates
“I” with “useless”, such that the functions of each word become in-
terchangeable. A healthier psychological state in respect of the rela-
tionship between self and content is self-as-context, in which “I” is the
context within which internal experiences (such as “I am useless”) oc-
cur. It is not equated with such experiences, rather, it is differentiated
from them as the container that holds them, much like the sky is the
container for the weather. Thoughts do not notice themselves; there is
a part of the human mind that does the noticing. It is this ‘observing
self’ that self-as-context is trying to capture. The final term, self-as-
process, is used to refer to the part of an individual’s experience that is
neither content nor context, but is the process of noticing, in the sense
of ongoing, moment-to-moment awareness.

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98 Putting ACT into practice

At a practical level, if an ACT practitioner is working in this area

with a client, the intention is likely to be to widen the client’s behav-
ioural repertoire, helping them to enact flexible patterns of behaviour
that are not controlled by internal experiences, even highly salient
ones like, “I am useless”. The aim is usually to foster a sense of the
self as the context from which those experiences can be heard or felt.
A practitioner might say something like, “There is a part of you that
is the thinker, rather than the thought”, or, “You are the place where
your thoughts and emotions happen”. Such interventions are a kind of
defusion procedure, structured hierarchically (Foody et al., 2013) to
create a discrimination between the whole (the self) and a part of the
whole (the experiences that the self has). Consistently speaking in this
hierarchical manner, taking care not to reinforce relations of equiva-
lence between the client and their content is crucial to good work in
this area.
Using language carefully and consistently to support the work is
probably more useful than trying to explain the concept to the client.
It is so abstract that clients can get hooked by trying to figure it out in
a way that detracts from their direct experience. Kelly Wilson once of-
fered an excellent example of this kind of dialogue in a conference ses-
sion (Holman et al., 2015) when describing talking to a client who was
very fused with the content of self-critical thoughts. He described say-
ing to the client, in response to their negative global self-­evaluations,
“I wish you could see all that I see when I look at you”. This statement
takes a little unpacking. It sets up a frame of distinction between prac-
titioner and client, and suggests that there is another perspective (the
practitioner’s), different from the client’s, from where the client can
be seen and experienced. It also implies that whilst the practitioner
can see the client’s distress, they see them as being more than that,
thereby reinforcing the hierarchical relation between the client and
their self-critical content. Villatte et al. (2016b) offer a detailed anal-
ysis of how interactions between practitioner and client can be struc-
tured to make the most impactful use of hierarchical relations, such as
have been described above.
In addition to representing the concept using language, specific
techniques can be employed to help clients to better relate to a sense of
themselves as containers for their experience. A classic ACT metaphor
(e.g., Harris, 2009) uses the phrase, allegedly of Buddhist origin, “You
are the sky. Everything else is the weather”. With reference to RFT,
this metaphor creates a hierarchical relationship between the sky and
 How do I actually do self-as-context work with a client? 99

the weather in that the sky is bigger than the weather and acts as its
container. The phrase further establishes a frame of co-­ordination be-
tween ‘the sky’ and ‘you’, and the same between ‘the weather’ and the
client’s content. It suggests the notion that ‘you’ are bigger than any
thoughts and feelings that you might have, and that ‘you’ can and do
contain them, without being defined by them. This same hierarchi-
cal relation can be used as the basis for any container metaphor. As
always, the precise form of the metaphor is less important than the
functions that it conveys. One of our favourite ways to physicalise this
relationship is to use a glass jar since it literally functions as a con-
tainer. Session by session, the jar can slowly be filled with post-it notes,
each containing statements detailing the kind of thoughts, emotions,
and behaviours connected to the reason that the client has sought
help. It can also be filled with post-it notes containing the client’s val-
ues, qualities, achievements, or indeed anything else that forms a part
of their experience. In this physical metaphor, the client is the jar, and
the post-it notes are their content. Whilst each note is a valid part of
their experience, no single one defines their whole self, and any notion
of the self is better thought of as comprising all of them.
Chapter 29

How do I promote
acceptance in sessions?

Acceptance can often feel like one of the hardest Hexaflex skills to di-
rectly target because of the intangible nature of what it is. Remember,
ACT’s perspective on acceptance is a focus on internal experiences
rather than accepting an external set of stimuli or events. For this rea-
son, acceptance can often end up being woven into other tools and
strategies used to target the other parts of the Hexaflex, all with the
ultimate outcome of increasing psychological flexibility. A very simple
example of this is that when discussing values, it is common to ask,
“In the service of pursuing this value, are you willing to accept (insert
discomfort)?”. Given that there are few elongated exercises that work
on the skill of acceptance alone, it is important to ensure that it is not
neglected in our work with clients.
From a behavioural stance, we suggest that it is possible to effect
behaviour change by either modelling, evoking, or reinforcing the be-
haviour that we would like to see the client do more of (Kohlenberg
& Tsai, 1991). All three options can be used as ways of promoting ac-
ceptance behaviour. We will look at each of these in turn in relation to
promoting acceptance in a behaviour change setting.
Practitioners can model acceptance in the way they conduct their
own behaviour and what they demonstrate to the client in all of their
interactions. Problematic experiential avoidance is the process we are
targeting in acceptance work, since this is what narrows the client’s
repertoire of behaviours, thereby making it harder for them to live a
value-driven life. Oftentimes, clients turn down the volume of difficult
internal events (thoughts, memories, emotions, and physiological sen-
sations) by avoiding the discomfort that they elicit, and consequently
also turn down the opportunity to select value-driven choices. As

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 How do I promote acceptance in sessions? 101

practitioners, we can model acceptance of our own thoughts, for ex-

ample, “I feel anxious about raising this subject”. With this behaviour
we are modelling that we can experience discomfort and still function
well in the situation. We are noticing our own discomfort and choos-
ing to engage in the behaviour of raising a sensitive topic anyway,
thus demonstrating to the client that we can experience unwanted
thoughts, notice our emotional responses, and opt for the choice that
is value-driven, even in the context of feeling uncomfortable. The
value-­driven choice in this example illustrates raising a difficult topic
because it would be in the best interest of the client’s behaviour change
journey. The experiential avoidance option would be to avoid doing
this because you would rather escape your own discomfort.
It is also possible to model acceptance in sessions via the pace and
rhythm that you bring to your work. Sometimes, your conversation
will be free-flowing, and it is helpful to retain a pace to the conversa-
tion that may feel more like any other kind of conversation. However,
the pace of your work can also be a way in which you can model ac-
ceptance to clients. Skilfully knowing when to slow the conversation
down is a way of inviting acceptance into the room with you. ACT
practice is going to be full of moments where people contact discom-
fort, whether in the context of discussing painful histories, current
stressful situations, or talking about what they most care about. When
distress shows up in the room with you, lean into it. These are golden
acceptance moments. A well-timed slower pace of the work is a gentle
invitation to the client to pause. By not speeding past upsetting things
in session, you are able to model how to ‘be’ in the presence of some-
thing that feels difficult. You can hold that jointly with your client, and
you can model to them how they can generalise this behaviour outside
of the consulting room too. In these ways, you as the practitioner can
use yourself in a very live way in the behaviour change process for
your clients.
It is also possible to evoke acceptance in others, which serves the
function of inviting them to notice their own discomfort and ultimately
decide about how they would like to respond to it. We can do this by
verbally drawing people’s attention to discomfort to elicit descriptions
of it (e.g., “What’s going on for you right now?”) when we notice the
client experiencing a difficult thought, emotion, or sensation in front
of us. This move illustrates the direct link between acceptance and
contact with the present moment as seen in the Hexaflex. Once we
have invited the client to notice what they are actually sitting with, we
102 Putting ACT into practice

are then able to continue to shape their behaviour by bringing to the

fore the choices they have available in response to it. The discomfort
that us as practitioners may feel in bringing clients’ attention to their
own discomfort is addressed in Chapter 47. In brief, it is safe to say
that their uncomfortable internal experiences are present with them
anyway, so us holding a safe space in which they can learn to do some-
thing different in the presence of them is more of a gift than it is harm-
ful. Inviting clients to then make a more aware and active choice about
what to do next is helping them to develop the skills of tuning in to
the present moment, noticing the content, and choosing a toward or
away move, dependent on the context. It is important to remember
that making an away move is a valid choice, it is just unlikely that it
will lead to long-term adaptive behaviour change. The key word here
is choice, and we want to bring that to the fore, which is why evoking
acceptance is an important practitioner skill.
The final behavioural strategy to effect behaviour change is to re-
inforce the client for behaviours that they have stated they want to do
more of or behaviours that are clearly helpful to them. Reinforcement
needs to be a personalised strategy, as what will be reinforcing or aver-
sive for one client may differ wildly from what would be reinforcing or
aversive to someone else. However, the key point here is that you can
note a client’s level of acceptance of discomfort and use this in future
sessions to reinforce any changes that have occurred. For example,
you might say to a client,

I notice that we are talking about something quite difficult right

now, and I see that you are staying with me on this. It feels like
you are able to tolerate this more than in previous sessions. It is
wonderful to see you being more able to sit with this when it shows
up for you.
Chapter 30

How do I know which

defusion procedure
to use?

As has been stated previously in this book, the term ‘fusion’ is used
to describe a situation where people respond to their thoughts as if
they represent literal truths. It is a normal by-product of the devel-
opment of language and there is nothing intrinsically problematic
about it. If the owner of a blue car has the thought, “My car is blue”,
and takes the thought literally, such that they consistently treat their
car as if it is blue in colour, it is unlikely that this will cause them
any problems. The same cannot however be said of the thought, “I
will never achieve anything”. Thus, the first task of an ACT practi-
tioner picking up on fusion within a client’s language and behaviour
is to determine whether it is in any way problematic, and therefore,
whether it should become a target for procedures aimed at defusion.
Indicators of unhelpful fusion can normally be found in the client’s
behavioural responses, for example, rigidity or narrowing of their rep-
ertoire, excessive reliance on experiential avoidance, or where acting
in line with the thought restricts or prevents the client pursuing their
values. Identifying problematic fusion is about pinpointing where cer-
tain thoughts exert undue regulation over behaviour to the extent that
other stimuli or events in the client’s environment have little or no in-
fluence (Bennett & Oliver, 2019). In short, fusion is problematic when
the client is responding solely to internal events and is not responsive
to direct environmental contingencies.
Where unhelpful fusion is apparent, ACT procedures aim to change
the relationship between the person and their thoughts, such that they
might no longer require a response or are experienced as less threaten-
ing. ACT and RFT literature suggest numerous procedures for creat-
ing distance from and/or deliteralising unhelpful thoughts, so it can be

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104 Putting ACT into practice

a challenge for the practitioner to choose between them in any specific

situation. Given the importance of context in any such decision, there
is no simple rule that we can give you to follow. That said, there some
things that are important to consider. Chief amongst these is giving
careful thought to the function of any chosen procedure. What is the
outcome that you are trying to achieve? Blackledge (2015) provides
a helpful structure for differentiating between defusion procedures,
grouping them by function. We will look at each of the groups below
and illustrate each with an example.

• Procedures that change language parameters

• Example: Word repetition (Hayes et al., 1999). The client and
practitioner excessively repeat a neutral word together (e.g.,
“milk, milk, milk…”), perhaps for about 30 seconds. The cli-
ent is invited to notice what shows up for them as they do so.
People frequently report that the meaning seems to drop away
as they start to tune into the physical properties of the sound
of the word. The procedure can then be repeated with a word
or phrase that carries functions related to their distress or the
reason they are seeking help (e.g., “loser, loser, loser…”).
• Procedures that create distance from thoughts
• Example: Hands as thoughts (Harris, 2009). The client is asked
to liken their hands to their uncomfortable thoughts and notice
how their experience of the world changes when their hands
are held right up in front of their face, dominating their vision.
They are asked to slowly move their hands away and down from
their face and are invited to notice changes in their experience
as they do so. This is followed by a discussion of the potential
benefits of trying to create distance between thoughts and the
part of us that notices them, perhaps by calling to mind this
physical metaphor as a means of achieving that.
• Procedures that undermine verbal rules and narratives
• Example: Disobey on purpose (Hayes, 2019). The client is in-
vited to perform an action, such as holding their arms above
their head, whilst repeating the opposite out loud (e.g., “I can-
not raise my arms above my head”). This exercise illustrates that
it is entirely possible to have a repertoire-narrowing thought
whilst engaging in the action anyway, and it can be slowly gen-
eralised to behaviours relevant to the client’s presenting issue.
 How do I know which defusion procedure to use? 105

We might return to the problem of middle-level terms here. Broadly

speaking, all these groups of procedures are aimed at creating defu-
sion, although each group has a different specific function. Thus, good
work in this area should always be based on a sound functional anal-
ysis. ACT practitioners should have a clear sense of what relations
and functions they are targeting, and what outcomes would be help-
ful. This will help in selecting procedures with greater precision. For
example, if a client reports finding it hard to resist the power of their
thoughts, procedures that ‘de-literalise’ language, such that there is a
loss or weakening of the meaning of that language might be indicated.
Conversely, if a client seems to be reacting to thoughts or rules in an
‘auto-pilot’ fashion, without even realising they are doing so, proce-
dures that slow thinking down and promote distinction between self
and content would be more appropriate.
Another relevant issue in selection of defusion procedures is that of
trying to match them, as far as is possible, to the presentation and the
needs of the client. It is important to tune in to your client and assess
how each exercise might land for them. Some defusion procedures are
effective because they introduce humour or a lighter tone to the work.
However, to some clients at certain times, this might feel somewhat
frivolous or inappropriate, and could end up having a very different
function to that which the practitioner intended. Therefore, we would
advocate careful thought over choice of procedures, picking your cli-
ent and your moment carefully.
Chapter 31

How do I deal with

values conflict?

One of the myths about values is that we get stuck when our values are
in conflict with one another. This is rarely, if ever, the reality. Instead,
what is often limited is our time, and that means that we end up feeling
a sense of conflict by being pulled in different directions. For example,
we may want to be attentive and loving partners, and we may want
to be dependable and reliable colleagues. When both of these areas
of our lives provide a sense of demand, and both are important to
us, we can feel like our ‘loving partner’ value and our value of being
a ‘dependable colleague’ are in conflict. However, from an ACT per-
spective, we would instead suggest that you are a single individual who
literally cannot be in two places at any given moment. We do not cease
caring about the thing we are currently not attending to, and unless
our partner is also one of our colleagues, we simply cannot attend to
the two different things at any one time.
A ‘globe’ metaphor is often used to explain this. Imagine a globe
and the country you live in. We live in the United Kingdom. We also
have very dear friends who live in Australia, which is literally on the
other side of the globe. If we were to visit them in Australia, we would
have to leave behind our families, friends, and responsibilities in the
United Kingdom for the time that we were away. We could spend our
time in Australia learning new things about the world, connecting
with our wonderful friends, and taking on new challenges. Whilst we
were doing those things in Australia, we simply could not be attending
to our families, or connecting with our friends in the United Kingdom
in the same way, although they would never cease to be important to
us. Because of the nature of the globe, we can only be in one place at
a time. The context does not support us attending to both in the same

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 How do I deal with values conflict? 107

way, and one must take priority. Values, and how we decide to focus
our attention on them, can be viewed in the same way. If we are in
work, we don’t stop caring about our families, wherever they are, and
vice versa. We can only attend to the value-driven task at hand.
It can be helpful to move clients away from the idea of values con-
flict and toward the notion of choice. As in the above example, one
can choose to either be in one country or another, or attending to one
specific task or another, and we can help clients to see those options
as representing value-driven choices. Tuning in to the values behind
their work and home lives can help people to prioritise one over the
other in a way that feels functional. There are a number of key skills
that may be helpful to strengthen, for example, we can help people to
notice when their choice to work or fulfil the role of a loving partner
is a toward or away move. As we know, any behaviour could be either,
so really tuning in to why we are choosing to focus on one task over
another can be helpful. Working all the time at home to avoid chores
is an away move; working at home because you have a tight deadline
may be a toward move, and one that you choose to do for a time-­
limited number of days or weeks.
When considering our values, and the priority we may give each
of them, it can be helpful to draw a distinction between micro- and
macro-­examples of such situations. We may, for example, talk with
clients about how we focus on our values within a microscopic inter-
action in our life, for example helping them to explore how they want
to be in an upcoming work meeting that evokes anxiety. They may se-
lect values such as honesty, openness, assertiveness, and compassion.
Tuning in to values in this specific context can help the client to select
behaviours that would honour their chosen values, and best represent
them as the kind of person they want to be. Alternatively, sometimes
our discussion with clients about values is more on a macro-level of
life. For example, clients may be embarking on goals around a new job
or a new career pursuit, which will involve a much longer-term com-
mitment. Whilst we can have several micro-level discussions about
how they want to be along their aspirational journey, we can also high-
light how they hold an overarching value as a broader guide. A client
might have moved location to access a university course, and this may
feel like it brings their home and work life values into conflict. In this
scenario, we can invite the individual to consider that this period of
their life may be more directed toward the pursuit of one value over
another, and as such, they might live away from the family home for
108 Putting ACT into practice

the duration of the course. It is also important to help them to see that
any shift in context can be greeted with a corresponding shift in which
of their values is prioritised. For example, should a family member
need their support, they would be able to switch their attention back
to their home setting and make choices accordingly. In this way, we
are able to promote the flexible nature of values, and the importance
of clients having clarity about their internal and external influences,
when choosing value-driven behaviour. This is very neatly summa-
rised by the Zen proverb, “Obstacles do not block the path. Obstacles
are the path” (LeJeune & Luoma, 2019, p. 133).
Chapter 32

So, I just get people to work

out their values and encourage
them to do value-driven
behaviour all the time, right?

Wrong. This is something that is quite easy to misunderstand when

learning ACT, partly because of the potentially seductive nature of
values work. In our experience of training and supervising other
people, we have worked with a large number who have come to ACT
with a solid background in other models that tend to have more of a
problem focus. Beck’s (1976) cognitive therapy is a notable example.
Aside from its commendable commitment to evidence-based practice,
part of the success of cognitive therapy is due to the way it has allied
itself to the medical model, adopting a disorder-specific focus to its
research programme. Thus, a course of intervention tends to begin
with some form of diagnostic assessment to inform the selection of a
disorder-specific formulation and intervention protocol. ACT is dif-
ferent in that it seeks to identify process-based procedures rather than
symptom-­driven protocols. Connecting people to their values is a large
part of this endeavour. In looking at the values of the client, ACT steps
into positive psychology territory and away from a symptom-based or
problem-focussed orientation. This can often feel like a revelation for
practitioners, and it can be exciting to be given permission to talk to
clients about things that lie outside of their presenting problem. We
have observed something of a ‘halo’ effect with this, and the values
part of the work can sometimes be given too much energy and em-
phasis. In answering the question posed by this chapter we would like
to both underline the importance of values work, and caution against
overstating its role in ACT intervention as a whole.
The first thing to be clear about is that the kind of toward moves
associated with value-driven behaviour are no more or less valid than
the away moves associated with avoiding the more aversive things in

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110 Putting ACT into practice

life. To do well in life, most organisms, human beings included, need

to engage in both toward and away moves. Approaching or avoiding
all stimuli in your environment are both sure-fire ways to find yourself
in an early grave. The real skill in living a successful life is working
out what to approach, what to avoid, and, most importantly, when to
do either. Thus, an ACT intervention focussed solely on promoting
value-driven behaviour would be problematic. Whilst it is important
to work to widen repertoires of valued action, this should not be done
at the expense of attending to the important functions of things like
downtime, saying ‘no’ sometimes, or the simple protection afforded
by avoiding or escaping stress. Whilst it is unlikely that a life focussed
solely on away moves would be rewarding, it is critical that ACT prac-
titioners promote flexibility in their work with clients, and balancing
attention between toward and away moves is a key part of this. In-
deed, one of the most useful things that a client can learn is the ability
to track the consequences of their own behaviour in order that they
improve their toward/away choices in any given moment.
Another crucial point is that whilst toward and away moves are easy
to discriminate in non-verbal organisms, the notion of values, relating
as it does to verbally mediated behaviour (LeJeune & Luoma, 2019),
muddies the water somewhat. For example, is a person who acquiesces
to the wishes of an abusive partner making an away move (giving in to
avoid their partner becoming violent) or a toward move (prioritising
the value they place on their own wellbeing)? This is a complex ques-
tion without a definitive answer, although if there is any resolution to
be found, one needs to consider the context. If the context is a value
of independence, then the above behaviour could be construed as an
away move. If, however, the context is valuing self-preservation, per-
haps it could be seen as a toward move. Thus, in any discussion of
values and valued actions, we would encourage ACT practitioners to
spend time on clarifying the context. The Matrix (see Chapter 24) is a
useful tool for achieving this clarity.
Another misconception related to the overall question is the idea
that a life filled with value-driven behaviour will also be full of joy
and free from distress. Nothing could be further from the truth, since
choosing to prioritise one’s values can often make things harder, rather
than easier. One of the most useful ACT-isms, which we find ourselves
repeating all the time is, ‘in our pain we find our values and in our
values we find our pain’. Taking a value-driven stance is often a diffi-
cult and costly thing to do, and valued action requires a willingness to
 So, I just get people to work out their values, right? 111

experience discomfort. To return to the previous example, if a person

decides to prioritise their overall wellbeing and autonomy with a deci-
sion to leave an abusive partner, this can come at great personal cost,
particularly in the short-term, even if it is in their long-term inter-
ests. We should all be honest with our clients about the relative costs
and benefits of valued action and allow them the flexibility to decide
against taking it should they so choose. The overall workability of an
action in the context of a client’s life is important to attend to.
Lastly, another useful ACT-ism is the idea that we can all strive to
pursue our values vigorously whilst ‘holding them lightly’. Even the
most apparently benign value, like kindness for example, can become
problematic if held too tightly, and turned into a rigid rule. If an indi-
vidual being abused by their partner is relentlessly kind to them and
about them, it will not serve that individual’s long-term interests. We
probably all know someone who has prioritised other people to the
point that it has become unhelpful to them, so learning when to relax
one’s grip on a value is a useful skill. A useful metaphor here is that
of using a pen to write or draw. One only needs to hold it lightly for it
to be at its most effective, and the tighter it is gripped, the less useful
it becomes.
Chapter 33

Do I have to address
all the processes in
every session?

ACT is often conceptualised using the Hexaflex. This visual rep-

resentation of the model outlines six core components, with each
having an associated skill that can be developed. In the centre of the
Hexaflex lies a circle. This represents the main aim of the ACT model,
which is to help clients develop greater psychological flexibility. See
Chapter 11 for more information on this.
Sometimes, in the process of first learning the model, we spend a large
proportion of our time learning what each of the six components is about.
We focus on finding a definition of each that would be suitable to share
with clients, a list of tools, techniques, and resources for developing that
particular skill, and even learning what to do when we get stuck in each
area. However, the bigger picture is always about p ­ roviding clients with a
wider repertoire of psychologically flexible behaviour, and this is best de-
veloped by using a fluid approach that interweaves attention to all the com-
ponents of the Hexaflex, proportionate to what is relevant to the client.
In Chapter 11 we introduced the idea of opening a paint tin being
a metaphor for the flexible approach of ACT. The main aim is to get
the lid off the tin. The most efficient and safe way of doing this is by
applying gentle pressure at one point, and then moving the paint tin
around, and applying pressure again. Repeating this pressure-move-
pressure-move routine creates a gap between the tin and the lid in var-
ious places, until it can be easily removed. Developing psychological
flexibility skills is somewhat similar in a number of ways.

• Firstly, we are unlikely to most efficiently develop psychological

flexibility if we only focus in one place. Just like with the paint tin,
it is unlikely that you will achieve your end goal by only working
in one part of the Hexaflex.

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 Do I have to address all the processes in every session? 113

• Secondly, clients come to us with existing skills, and so we are not

required to spend the same amount of time focussing on each part
of the Hexaflex with every client. Imagine if we were trying to open
a paint tin where the lid was already slightly ajar. We would not ap-
ply the same pressure to the part that was already free. We would
just focus our attention on the parts of the lid that were more stuck.
• Lastly, when working around the Hexaflex processes, we might
discover that clients need gentle reminders of skills that they have
already developed. For example, in our intervention, we may
have covered some work targeting fusion. Subsequently, the client
might be invited to take some committed action, only to respond
by saying, “Well maybe, but I think I am just too worried today.
I might think about doing it tomorrow”. This indicates that in
order for the client to take action, we might have to revisit fusion.
Thus, ACT work can involve purposeful recycling of work target-
ting a number of processes in a cyclical fashion.

There are a number of factors that will depend on what processes are
covered in a session. One of those factors is our own sense of compe-
tence with the ACT model, and this may be reflected by the stage of
our learning journey. For early career practitioners, or those exploring
the model in relation to new behavioural presentations, ACT proto-
cols can be a useful resource to give guidance as to which process to
focus on in any given session. Across a course of sessions, all processes
will be touched upon, with the idea being that each contributes to a
shift in psychological flexibility.
More advanced practitioners rely less on a rigid structure for ses-
sion content. Instead, in the course of a free-flowing conversation, it
is likely that a skilled practitioner would move around the Hexaflex
quite naturally. Even in a targeted piece of work, for example a values
card sort, an experienced practitioner would bring in other processes,
with the function of having a greater impact on the client’s psycholog-
ical flexibility. In the example of a values card sort we might touch on
the other processes as below.

Acceptance
During the values discussion, it is likely we would enquire about
whether the client is willing to accept the discomfort that arises when
moving toward the things that matter to them.
114 Putting ACT into practice

Defusion
During the exercise the client might say, “I am not up to being the
loving partner that I want to be”. We might respond with, “Thanks
mind!”, as a way of evoking their reflection on the fusion they have
with this thought.

Contact with the present moment

We can set up a values card sort in a very present moment-based way,
for example, by helping clients to notice any judgement they feel for se-
lecting chosen values as they engage with the exercise. It can be helpful
to introduce the exercise with something like, “If we were to do this ex-
ercise on a different day, you may select slightly different values. Let’s
tune in to what calls out to you in this moment as we work through
these cards”. We can also use moments where the client pauses to
check in with how they are feeling and what they are noticing as they
complete the exercise.

Self-as-context
Sometimes values that people identify may feel strange or new to
them, albeit that they represent qualities that they would like to bring
more to their attention when choosing their actions. For example, ‘as-
sertiveness’ might be a quality they would like to display more of, al-
though they infrequently feel able to. We can invite them to consider
that they contain the capacity for behaviours that align to the qualities
of assertiveness, as well as being a person who can be passive. This can
help them to see there are a range of behaviours in their repertoire and
highlights the importance of choice.

Committed action
We would conclude the exercise with some discussion about how the
client will take steps in the direction of their identified value(s).
Chapter 34

How do I apply ACT with

(insert diagnosis here)?

In most of the ACT trainings that we offer, we take a universalist

approach to its application. Sometimes, however, organisations re-
questing training, or individuals that we supervise, ask about specific
applications of ACT, and often these enquiries relate to the use of the
model with people with specific physical or mental health diagnoses.
This chapter will address the issue of how one might approach the
application of a universal model to a specific presentation.
It is important to remember that ACT is an approach to behaviour
change founded on a specific philosophical and theoretical position.
It concerns itself with the verbal behaviour of relating, and the im-
pact of that relating on other behaviours. Where language processes
and their functions are unhelpful to an individual or group, ACT
practitioners intervene with procedures aimed at achieving adaptive
change. Therefore, any ACT procedures or protocols that one might
employ are, “instances of a general intervention strategy which is de-
signed to be flexibly employed” (Hayes, n.d., b). This being the case,
ACT cannot be defined as any one specific set of techniques or exer-
cises, and it is perhaps better to describe any example of these as being
an ‘ACT-consistent’ intervention rather than an ‘ACT’ intervention.
Another consequence of this overall position is that there is no one
true version of ACT for any given problem or presentation, although
there are instances of ACT-consistent interventions being organised
into specific protocols. In such cases, what tends to happen is that the
psychological flexibility model and the general strategy of ACT is ap-
plied to a particular challenge, and a tailored protocol emerges. Such
protocols include specific procedures designed to provide a best fit to
the needs of the given population and the context in which the work

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116 Putting ACT into practice

is being delivered. Dependent on the context for their development,

some such protocols are very detailed and specific, for example, the
‘ACT for Life’ group intervention for psychosis manual (Oliver et al.,
2011) whilst others are designed to be more flexible, allowing for crea-
tivity and idiosyncratic variation, such as the ‘Togus Intensive Outpa-
tient PTSD Program’ (Polk, 2008).
The pairing of the flexibility of the ACT model with the creativity of
the CBS research and practitioner community means that a wide range
of specific ACT protocols are available, each tailored to a particular
presentation. These include protocols for numerous diagnosable phys-
ical and mental health conditions, as well as non-clinical applications
such as workplace stress (Flaxman et al., 2013) and athletic perfor-
mance (White et al., 2021). Specific ACT protocols can be found on the
ACBS website (Hayes, n.d., b) and there is a large and growing body
of journal articles and books devoted to a wide variety of specific ap-
plications of ACT. With all that is now available, we would encourage
readers with questions about using ACT in the context of particular
diagnostic presentations to interrogate the available literature. Since
the publication of the first book (Hayes et al., 1999), the growth in
ACT literature is such that there is a very good chance that if you are
asking the question about ACT and presentation X, someone else will
have already asked it, researched it, and written about it.
That answer is all very well if we are right about someone getting
there before you. And what if we are wrong? Or, what if you don’t have
the time or resources to search for articles and buy books? Luckily,
all is not lost, and the flexibility of the model will come to the rescue
if you trust it enough. It is useful to keep in mind the basic principle
that even though each client that an ACT practitioner works with will
present a unique context, the relevant processes of the psychological
flexibility model are universal. If one retains a functional contextual
approach to understanding behaviour, it should be possible to make
sense of any presentation, whatever diagnostic label it might have
attracted.
By way of illustrating this, let us imagine that you are asked to
help someone who is struggling with an apparent addiction to petty
theft. This is not something that you have any prior experience of,
and you find yourself asking, “How do I apply ACT for this?”. The
client does not need the items they steal, and after the initial high of
the theft fades, they tend to feel guilty and become besieged by self-­
critical thoughts. As these uncomfortable experiences build over the
 How do I apply ACT with (insert diagnosis here)? 117

subsequent days, they find themselves in desperate need of something

that will lift their mood, so they go out and steal again. You could
respond to this referral in several ways, including by saying you do
not have sufficient expertise in relation to stealing problems to help,
by scheduling an urgent supervision session for help and advice, or by
frantically searching for literature on ‘ACT for stealing’. Each of these
responses would be valid, and we would argue that seeing the client’s
situation through the lens of basic ACT principles might well give you
all that you need. If we take out the specific behaviour of stealing from
the above description, and think functionally about the situation, it
starts to look very familiar. Here is a person experiencing some dis-
comfort and engaging in a behaviour that has the short-term function
of making the discomfort go away. We can formulate the behaviour as
an away move, or in ACT terminology, as experiential avoidance. It is
negatively reinforced by the reduction of discomfort, making it more
likely to be repeated. The person does indeed repeat it and soon finds
themself stuck in a maintaining cycle, where their behaviour becomes
increasingly regulated by the desire to reduce discomfort. If you read
back the last three sentences, does this look familiar to you? Does
it remind you of any clients with whom you have worked? Maybe it
describes a pattern that you have been in yourself at some point? It’s
actually quite hard to think of a client we have worked with to whom
those three sentences do not relate. In summary, we would argue that
you do not need to be an expert in stealing, or in presentation X, Y,
or Z, to help someone using ACT, as long as you keep the focus on
the functions of behaviour and do not become too distracted by their
form.
Chapter 35

How many sessions

should a course of ACT
intervention include?

This question suggests that there is some flexibility as to how many

sessions of ACT intervention are offered, and of course, within some
settings there is little choice. For example, insurance companies and
healthcare providers often dictate the maximum number of sessions
that can be offered, depending on the population that their service
aims to support. In addition to identifying the target population, and
the severity of a client’s struggle at the point that they make contact
with a specific service, the decision-making is also influenced by sev-
eral systemic factors. These include budget availability, waiting list
times, contextual political focus, and guidance from advisory bodies
like the National Institute for Health and Care Excellence (NICE) and
the WHO. To that end, the context within which an ACT interven-
tion is offered may limit the choice about the total number of sessions
available.
Given the pan-diagnostic nature of ACT, it has the potential to be
safely and effectively applied to a range of behavioural presentations
and other issues pertaining to psychological inflexibility. The reason
that a client is seeking out ACT intervention will impact the number of
sessions that may be required to help them make progress, with more
entrenched difficulties taking longer to address. The empirical data
are still growing in relation to the application of the model, for exam-
ple, single-session work (Dochat et al., 2021) and group interventions
(Ferreira et al., 2022), as well as more traditional 1:1 intervention. As
more data are gathered, there will be more information available as to
the research base for how many sessions are required for interventions
to be effective.
Given the many contextual factors that can impact the number of
sessions available to the practitioner, it is more helpful to focus on

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 How many sessions should a course of ACT intervention include? 119

issues around planning ACT interventions, allowing for a more

functional approach to the work. The modal number of sessions at-
tended by clients is one (Brown & Jones, 2005; Hoyt & Talmon, 2014).
Given that, it is helpful to make that first session as useful as possi-
ble. The work of Kirk Strosahl and Patricia Robinson on Focused
ACT (FACT) helps in considering how first sessions are conducted,
and can really help practitioners focus on how to maximise their effi-
ciency. One example of this is their shortened version of an assessment
process, whereby they limit questions to four main life domains: love/
connection, work, fun, and health (Strosahl & Robinson, 2015). Aside
from specific risk questions that may be required, these questions
gather enough information about an individual to begin a wholistic
formulation of their life and identify areas impacted by psychologi-
cal inflexibility. Whilst further assessment information will likely be
gathered in other sessions, this more focussed approach leaves time
for an intervention to be delivered within the first session, meaning
that the client will also leave the session with a practical ACT tech-
nique for making change in their life.
Should you work in a time-limited service model, protocolised man-
uals may help to provide a structured ACT intervention to fit the num-
ber of sessions available. The ABCS website is a very helpful resource
for such manuals, providing guidance on where to start the interven-
tion work and on how to move through each of the processes.
ACT can also be utilised for much more complex psychological in-
flexibility work, such as targeting issues around childhood trauma,
pervasive problems with self-acceptance, or difficult relational issues.
These presenting issues will necessitate longer pieces of intervention
work, such as might be more commonly seen in longer term service
settings, like private practice. With longer-term work, it can be useful
to provide your assessment, formulation, and interventions within a
structure that you can purposefully recycle. One of these is the ACT
Matrix, which is discussed at length in Chapter 24. This is a very use-
ful tool due to its flexibility as an assessment, formulation, and inter-
vention aid, and its ability to help translate some complex RFT ideas
into something accessible for the client and the practitioner to share.
Longer-term work needs to move flexibly around all of the compo-
nents of the Hexaflex. This flexible approach is often referred to as
‘riding the ACT bicycle’, which describes the need to lean to both the
right and left sides of the Hexaflex to keep the client moving forward.
When riding a bike, if you lean to the right (or target the values and
120 Putting ACT into practice

committed actions components in the ‘active’ column of the Hexaflex)

you need to counterbalance yourself by then leaning to the left (by
moving to the ‘open’ components, namely acceptance and defusion).
The constant recycling of small movements to the left and right propel
you forwards, much the same as leaning into values and committed
action and then acceptance and defusion keep the client making pro-
gress toward greater psychological flexibility. Whatever the number of
sessions available, it can be helpful to hold the ACT bicycle metaphor
in mind, ensuring that the ‘aware’ components of self-as-context and
present moment work are also incorporated.
Part 4

Developing skills as an
ACT practitioner

As well as learning about the theory and practice of ACT, practition-

ers interested in developing their ACT practice over the longer-term
often have questions about how best to structure their journey. This
section of the book addresses frequently asked questions about devel-
oping as an ACT practitioner. It includes questions about the rationale
for ACT having no formal route to certification, how best to structure
the development of one’s practice, and what practitioners need to put
in place to ensure that they can practise safely and effectively. This
section also answers questions about ACT’s emphasis on experiential
learning, whether that be through training courses, ongoing supervi-
sion, or the personal practice of ACT in practitioners’ own lives.

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Chapter 36

What do I need in place

in order to practise ACT
safely and effectively?

This is a difficult question to answer definitively given the wide var-

iation of contexts that ACT practitioners work within, although it is
included in this book because it is a question that we often get asked.
The question relates in part to the stance currently taken by ACBS re-
garding there not being any formal process for accrediting as an ACT
practitioner. Whilst this position is explored in greater detail in Chap-
ter 39, suffice it to say here that the lack of clear rules and regulations
around practicing ACT, and the somewhat ‘open source’ nature of the
ACT community, often leads newcomers to feel unsure about the re-
quirements for establishing oneself as someone practicing ACT. This
chapter represents our thoughts on this issue, although we should be
clear at the outset that what follows is unlikely to apply to absolutely
everyone who offers ACT as part of their practice. As ever, it depends
on the context.
If you are in the business of offering ACT in any substantive way to
members of the public, it is important that you have a solid ground-
ing in the practice of psychological interventions. This might come
from a professional training, as in the case of clinical psychologists or
counsellors, or via some other co-ordinated programme of study, such
as a coaching qualification. It is our view that reading about ACT or
attending a few ACT workshops will not be sufficient to practise safely
without some professional background training. This kind of prior
training also usually brings with it some form of accountability, such
as membership of a professional organisation or being a signatory to
a specified code of conduct. Regarding creating a sense of safety, it is
important that clients know that you are accountable to someone else
and that they have somewhere to go if they are dissatisfied with the

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 What do I need in place to practise ACT safely and effectively? 123

service they receive. In terms of our values as practitioners, issues like

accountability and clear boundary setting feel like they are an impor-
tant part of offering services to the public.
As well as being connected to the organisation that represents your
profession or working role, an ongoing connection to the ACT com-
munity in some form feels like a pre-requisite to offering a quality ser-
vice. Given the relative youth of the model and the fast-paced nature
of the ACT/RFT research programme, connecting with other ACT
practitioners and researchers is a great way of keeping pace with de-
velopments. Whilst we are avid consumers of ACT books, research,
training, and conferences, there is always something new that we
miss, and conversations with colleagues are very helpful for catching
up. ACBS itself is the mothership of all things CBS, ACT, and RFT,
and it serves as the central point of contact for the community, with
a well-resourced website, social media presence, and worldwide email
groups for both public and professionals. It also organises an annual
world conference, as well as many other regional conferences, local
chapters, and special interest groups.
Connection with other ACT practitioners is an important way to
keep your practice true to the principles of the model. In particular,
finding an ACT supervisor is of utmost importance. We have probably
all had the experience of exposure to stimulating new ideas through
reading or training, only for the impact of them to quickly evaporate
after a few days back in the workplace. Regular supervision helps to
keep us on track, and can function as quality control, a place to fur-
ther learn and develop, somewhere to take difficult issues, as well as
providing an opportunity for nurturance and support. We would urge
you to find a supervisor who knows their stuff when it comes to ACT,
someone who is open to using experiential methods of supervision
with you, and someone who will strike a balance between being sup-
portive and challenging you to push yourself. ACBS maintains a list
of peer-reviewed ACT trainers (ACBS, n.d., d), many of whom offer
supervision themselves or who will be well connected to help you find
someone else with a good reputation for providing ACT supervision.
Whilst all of the above rely on connecting with others, there are
things you can do using your own resources to aid you in practic-
ing ACT safely and effectively. It is important to keep learning, and
fortunately there is a wealth of ACT literature available to help you
develop your knowledge of the model and your application of it in
practice. Journal articles, books, podcasts, blogs, and videos are
124 Developing skills as an ACT practitioner

widely available, and we recommend a regular diet of these as being

helpful in keeping your ACT practice alive and in good shape. Your
own private study can of course be supplemented by regular training,
which is again widely available, particularly since the development of
more online training as a consequence of the COVID-19 pandemic.
Chapters 39–41 of this book are also relevant to this question, where
some of the issues touched upon here are explored in greater detail.
Chapter 37

Should ACT practitioners

practise ACT for themselves?

The word ‘should’ may feel a bit contentious here. We are not here to
tell you what you ‘should’ or ‘should not’ do in your lives. However,
there is a heartfelt question that we keep coming back to in our think-
ing in relation to this question, which is, “Why would you not practise
ACT for yourselves?” ACT is a model of human functioning. Yes, it is
most often utilised in our intervention work with clients at a point of
distress or stuckness in their lives, and ACT is a model that provides
us all with tools that help us consistently take steps in our own value-­
driven directions. To that end, there is no distinction between what
we might find helpful and what our clients might find helpful, it may
simply be different content that we apply the model to. Unlike physi-
cal surgery, which one would hope is only carried out for people who
are sick or injured, ACT proposes skills, tools, and techniques for all
of humankind to benefit from. Therefore, one does not need to be in
a place of ‘illness’ or ‘dysfunction’ in order to also reap the rewards of
increased psychological flexibility.
Imagine that you want to improve your health, and you seek out the
guidance and expertise of a personal trainer. They have a certificate
on the wall to say that they have the required skills. However, this par-
ticular trainer generally adopts a very ‘do as I say’ approach to health,
rather than modelling and living by what they preach. Let us assume
that you give them the benefit of the doubt, and after a few initial ses-
sions, you see some progress in your own health by following their in-
structions. Sometime into this personal journey, you start to hit a few
blocks and your progress plateaus. Your trainer shouts louder at you
to work harder, all whilst sitting on a chair and eating their favourite
snacks. Your motivation fades, your frustrations build and you notice

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126 Developing skills as an ACT practitioner

a growing reluctance to continue to follow the instructions. You sub-

sequently leave their service and find a personal trainer with exactly
the same qualifications, and they are someone who passionately lives
by what they preach. They exercise, they are considered in their die-
tary intake, they are knowledgeable about supplements, and they are
actively engaged in the sessions they run with you. You see results.
Everything is great until then you hit some blocks and plateaux again.
This time, your trainer is right next to you, talking you through each
moment of the last few repetitions of your exercises. You know that
they too have sweated hard and felt the burn of every muscle group in
the service of their fitness, and this spurs you on, giving you the energy
you need to finish the session. You might do this on repeat, trusting
in your personal trainer because you know that they too have experi-
enced what you are going through. There is no convincing to be done
here. The questions are simply, “What kind of personal trainer would
you rather work with?” and, “What kind of practitioner do you want
to be?” The answers to those questions are yours and yours alone.
From a learning perspective, the suggestion would be that ACT prac-
titioners (and their clients) benefit from engaging experientially with
the model as students. As outlined in Steven C. Hayes’s (n.d., c) four-
step plan for learning ACT (further discussed in Chapter 40) the first
step for students is to experience the impact of psychological flexibility
in their own lives. This explains the experiential nature of ACT train-
ing sessions, whereby attendees are invited to engage with their own
personal content as a means of applying the theory being taught. This
approach follows other CBT models in utilising self-exploration tech-
niques in what is commonly known as ‘Self-Practice/Self-Reflection’
(SP/SR; Bennett-Levy et al., 2001). Research into this approach found
that the experiential engagement of students increased the attunement
between practitioner and client in the psychotherapeutic relationship
(Gale & Schröder, 2014). When using ACT as a therapeutic model with
a client, it is helpful to have prior experience of active engagement in
the exercises yourself. We would never invite a client to do an exercise
we had not done ourselves, the reason being that we want to know
how it might feel to be in the ‘client’ seat when being invited to do
any specific exercise. This is not because we are presumptuous enough
to know how the exercise will make the client feel, since we cannot
really know how an exercise will land for a client until they accept
the invitation to try it out. However, it does help us to connect with
our own emotional experiences through the lens of the exercise. This
 Should ACT practitioners practise ACT for themselves? 127

can help develop our sense of compassion and empathy as we will not
only be offering the exercise to a client, we will be re-remembering
what our own experiences of that exercise were for us too. Spendelow
and Butler (2016) identified that increased compassion, empathy, and
therapeutic presence were reported by therapists who had undertaken
the SP/SR approach to learning the therapeutic model. Our number
one piece of feedback from participants at our ACT training sessions
is that they have gained as much from the training personally as they
have professionally. So, it would seem that both empirical and an-
ecdotal reports suggest the usefulness of this way of engaging with
the work. The book ‘Experiencing ACT from the Inside Out: A Self-­
Practice/Self-Reflection Workbook for Therapists’ (Tirch et al., 2019)
is a fantastic step-by-step guide to experiencing the model personally.
It can be worked through alone, although working through it with
other practitioners is the preferred route suggested by the authors.
Whilst this will not be a substitute for any live training you are able
to attend, engage in, and receive feedback from, it is a wonderful re-
source to enhance your experiential learning and practice of ACT.
As a final point, this experiential approach has also been integrated
into an experiential model of ACT supervision (Morris & Bilich-Eric,
2017). This model is further discussed in Chapter 41.
Chapter 38

Why is experiential
learning better than
didactic learning?

The word ‘better’ within the above question is possibly somewhat con-
tentious and would benefit from clarification. ACT training often in-
volves a significant amount of experiential learning, and students of
ACT are encouraged to utilise experiential methods in their practice
with clients. This is largely because doing so is consistent with the
behavioural focus of the model, as this chapter will explore in more
depth. Whether experiential learning is ‘better’ in the sense of lead-
ing to more desired outcomes is really an empirical question best an-
swered by research.
Whilst a thorough review of the evidence for the utility of expe-
riential learning is beyond the scope of this book, there is a body of
research to suggest that learning through doing has benefits over and
above simply being didactically taught. A classic study by Heffer-
line et al. (1959) showed that when people are consciously aware of
a rule, they follow it less consistently than when they are responding
to actual environmental contingencies, even though these might be
described by the rule. In the study, participants efficiently worked out
how to turn off an aversive stimulus by making small thumb move-
ments. On a second trial, when they were explicitly told that making
these thumb movements was how they could turn off the stimulus,
their performance deteriorated significantly. The authors concluded
that experiential learning was more effective than didactic teaching,
and similar results have been found in applied health and social care
settings (e.g., Stiernborg et al., 1996; Weaver, 1998). When conducting
a meta-analysis of ACT interventions, Levin et al. (2012) also found
larger effect sizes for conditions including experiential methods,
rather than conditions where participants were given the rationale for
doing something without the actual practice.

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 Why is experiential learning better than didactic learning? 129

When addressing a problem that someone is seeking help for, giving

advice or providing a set of instructions for a client to follow is easy for
an ACT practitioner to do. Unfortunately, it is unlikely to be of great
benefit to the client because a simple rule, such as might be contained
in advice or instructions, will not be useful in all the circumstances
that the client might face. It will not be flexible to variations in the
client’s context, and thus is not a particularly functional way to pro-
ceed. Helping a client get better at tracking their experiences, includ-
ing the consequences of their own behaviour, is much more likely to
be useful to them long-term. This is what ACT practitioners are doing
when they organise experiential exercises in session. They are invit-
ing clients to contact the contingencies of their behaviour, rather than
just talking about what those contingencies might be. For example,
engaging a client in a tug-of-war exercise where the practitioner takes
the role of their anxiety (see Hayes et al., 2011) involves the client phys-
ically experiencing the consequences of fighting against anxiety. Exer-
cises such as this make the functions of the problem and any existing
responses to it present in the session, if only in a metaphorical sense
(Ramnero & Törneke, 2008). This is much more difficult to achieve by
talking about the struggle, rather than actually engaging in the strug-
gle. Talking about problems can be helpful up to a point, although it
does not bring things alive in quite the same way. To draw a compar-
ison, most people would agree that going on holiday is a much more
vivid experience than listening to someone else talk about what the
destination might be like if only you were to go there yourself.
ACT puts a strong emphasis on experiential learning, both in prac-
titioner training and in client sessions, because it is consistent with
the principles of functional contextualism. It is about actively learn-
ing through experience about what works in the real world. Didactic
teaching, without attention to direct experience, can lead to ‘pliance’,
which is a state whereby an individual follows a verbal rule simply be-
cause it is the rule (Villatte et al., 2016b). Blind or rigid rule-­following
is often problematic, and in many cases is the reason why clients have
ended up seeking help in the first place (e.g., allowing the rule ‘show-
ing emotions is weak’ to regulate behaviour, leading to feeling discon-
nected from others). If rule-following is identified as the problem, it is
very unlikely to be able to provide the solution. Thus, it is largely un-
helpful for ACT practitioners to encourage more rule-following, which
tends to be what didactic teaching and advice-giving leads to. As sug-
gested previously, the more useful thing that ACT practitioners can
130 Developing skills as an ACT practitioner

do is help clients notice their experience and learn to track it, along-
side tracking the consequences of their behavioural responses. This is
best achieved through experiential procedures, for example, noticing
the consequences of what happens to you when you fight and struggle
with anxiety in an effort to make it go away. Experiential learning
helps a client figure out for themselves whether their responses work.
When they learn to track successfully, any rules that might arise from
their direct experience can continually be revisited, considered, and
updated in line with changes in the context. Since rigid rule-following
can interfere with tracking, procedures that reinforce the importance
of noticing, describing, and responding to direct experience are gener-
ally much more useful.
If you ever find yourself needing to help clients understand the
value of experiential learning, we suggest that this too is achieved best
through experiential means. Consider the following exchange.

PR ACTITIONER: (drops pen on the floor) Oh no! I’ve dropped my pen!

Whatever will I do?
CLIENT: Just pick it up
PR ACTITIONER: Huh? What do you mean?
CLIENT: It’s easy, just lean over to your right and pick it up with your
hand.
PR ACTITIONER: How do I do that?
CLIENT: Are you serious?
PR ACTITIONER: Let’s suppose I am serious. Talk me through it.
CLIENT: Well, you’ll have to bend at the waist, reach down with your
arm, and grab it.
ME: But that’s what I’ve got to do. I’m asking how I do that?
CLIENT: What? Well, I guess your brain tells your arm what to do.
ME: So how do I get it to do that?

After all this, the pen is still on the ground, and it becomes obvious
that verbal instructions are not really cutting it as an explanation of
what needs to happen. Showing this difficult practitioner how to pick
up the pen and inviting them to copy the movements might work bet-
ter. When learning to ride a bike we learn much more from the phys-
ical feedback we get from balancing or falling off than we do from
the verbal instructions we receive. In just the same way, whilst verbal
explanations of ACT practices can help orient someone to what they
need to attend to, ACT works best through doing.
Chapter 39

Why is there no formal

qualification in ACT?

The ACT community lives by its underlying philosophy of science and

the principles of the model, so the decision to not create a formal qual-
ification in ACT is based on the values that the community holds as
important. The main intention behind not introducing a formal qual-
ification process was to avoid, or reduce, a hierarchical structure. One
desire of the ACT community has been to continue the growth and de-
velopment of science in the service of alleviating human suffering. The
community includes researchers and practitioners from around the
world and has seen collaboration and co-operation between different
parties interested in how this science can benefit humanity. The intro-
duction of a rigid hierarchical structure would inevitably restrict and
slow down the development and dissemination of the model, due to
the associated vetting of work that would be required. This approach
has been modelled by the originators of ACT from the outset, as these
words in their first textbook demonstrate: “We have little interest in
our approach as a finished product or brand name, and we encourage
the reader to apply and modify our work” (Hayes et al., 1999, p. ix).
The founders of ACT continue to model openness and evoke in-
teraction from other practitioners, scientists, and researchers by ask-
ing questions like, ‘What does the science tell us?’ and ‘Where can
we go next?’. Contributions of any form are also highly reinforced in
the community, for example, questions posted on the ‘ACT for Profes-
sionals’ listserv are generally answered with a willingness to support,
develop conversation, and provide guidance. This humbling and open
invitation to contribute to, and develop, the body of science for the
benefit of the human population is an inspiring approach within the
often more hostile environment of psychology. It can be contrasted

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132 Developing skills as an ACT practitioner

with other professional circles where a more hierarchical approach is

taken and contributions from the wider professional network are more
limited.
In line with the values of flattening the hierarchy, the ACBS website
directly states, “There is no such thing as an officially certified ACT
therapist” (Long, n.d.). This can feel like a double-edged sword in that
whilst there are benefits to the community in adopting this approach,
it is often comforting, especially for early career practitioners, to have
a more certain development path, and a definitive end point. That
said, ACBS is not void of tools in helping practitioners to develop their
competency skills. There are tools shared in the community that help
practitioners to reflect on their own skill sets and identify strengths, as
well as areas of their practice that they would like to further develop.
If you are a member of ACBS, there is free access to these resources
via the website. One such example is the ACT Core Competency
Self-Rating Form (Luoma, n.d., b), which is a helpful guide to under-
standing competencies attached to each of the Hexaflex processes. It
enables practitioners to identify how they utilise or demonstrate dif-
ferent competencies in interventions sessions. It can also be helpful to
take to supervision as the basis for reflection and discussion around
how to develop additional competencies and advance a practitioner’s
application of the model.
As practitioners are unable to advertise themselves as being certi-
fied in ACT, it can raise the question of how to find a reliably quali-
fied person to consult for ACT intervention work. Given the values
of the organisation, one place to find people who sign up to the same
values as ACBS is the membership. Observing how connected practi-
tioners are to the ACT community, and whether they are working by
the values upheld by the organisation can be a helpful marker of their
commitment and dedication to the work. That is not to say that every
person who uses ACT in their work must be a member of ACBS, and,
a question might be raised regarding the knowledge and competence
of someone who chooses to practise ACT whilst unconnected to the
community within which it grows and develops so rapidly. Perhaps
this could be a point of self-reflection. If you are currently not a partic-
ipating member of the ACT community, what barriers get in the way
for you? What would it mean to you to become someone who more
actively contributes to developing the science and practice of ACT?
Would doing so fit your values in terms of the kind of person and
 Why is there no formal qualification in ACT? 133

practitioner you would like to be? And if so, what step could you take
today to further embed yourself in the community?
ACBS membership offers a number of ways to develop your knowl-
edge and experience within a community of like-minded individuals.
The values-based membership contribution affords you access to
many shared resources including those related to research and clinical
work, intervention protocols and assessment measures, articles in the
Journal of Contextual Behavioural Science (JCBS), numerous special
interest groups, and email forums related to a variety of topics.
Should you wish to further develop your training skills and gain
some form of recognition of your expertise, one option is to become
an ACBS peer-reviewed ACT trainer. This system has a quality con-
trol function, ensuring that the dissemination of ACT is conducted
by people who have undergone rigorous scrutiny from their peers.
Peer-reviewed ACT trainers also take responsibility for contributing
to the development of colleagues who also aspire to train others in
ACT. As part of the peer review process, there are a set of values that
one must agree to uphold. These include:

• Competence
• Beneficence
• Nonmaleficence
• Responsibility
• Integrity
• Respect for People’s Rights and Dignity

In addition to agreeing to the above values, there is a requirement

to hold a terminal degree in a relevant behavioural field of study, be
known to be of good character, provide a number of pieces of work
as evidence of competence as a practitioner and trainer and to pro-
vide evidence of knowledge of the basic science and philosophy of the
model.
Whilst the training route is not a mandatory process, it is the only
version of anything ‘accredited’ within the organisation and affords
trainers the ability to honour their training and experience.
Chapter 40

How can ACT practitioners

shape their learning?

If you have read the previous chapter, you will be aware that at present
there is no single formal route for ACT practitioners to follow should
they wish to develop their expertise. From an accreditation or certifi-
cation point of view, there is no such thing as an ACT practitioner, and
yet there are many thousands of people practising ACT all around the
world. It is interesting to consider what the learning journeys of these
practitioners might have comprised, and highly likely that no two will
have taken the exact same route. This is great from the point of view
of practitioner flexibility, although does present some challenges for
someone new to the practice of ACT. Many of the people we have
trained have expressed concern about whether they are allowed to say
that they practise ACT, or at what point in their learning journey it
feels like a justifiable claim to make. More frequently, people simply
ask what they should do next in terms of additional training, super-
vision, or other means of ensuring fidelity to the model. This chapter
will attempt to address these issues.
It is probably fair to state that the lack of any established consensus
about exactly what the route to becoming a proficient ACT practi-
tioner should comprise leads to a level of heterogeneity in the delivery
of ACT that might not always be helpful. It has also led to the pro-
liferation of one- or two-day ACT workshops at the same time as to
a relative scarcity of long-form ACT training programmes. Courses
that include assessments of competence are rarer still. Whilst there
has been some good work done around developing measures of prac-
titioner competence (e.g., O’Neill et al., 2019), progress toward the
meaningful integration of such measures within systematic training

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 How can ACT practitioners shape their learning? 135

programmes has been limited. Our hope is that as ACT becomes more
established within the mainstream of psychological interventions,
alongside the ever-growing evidence base and the inevitable inclu-
sion of ACT in more national guidelines, more rigorous training pro-
grammes will emerge. Until such time as this happens, practitioners
are left to make their own choices about how to achieve competence
in their practice of ACT.
Having attended and delivered thousands of hours of ACT training
and developed long-form ACT training programmes ourselves (e.g.,
Bennett & Johnson, 2021) we would like to use this chapter to suggest
on outline for the structure and content of a programme of study that
aspiring practitioners could choose to follow. In describing this, we
will make use of Steven C. Hayes’s (n.d., c) four-point plan for learn-
ing ACT. We should state at the outset that what follows ought not to
be read as a rigid prescription, and rather as a suggested method for
structuring an approach to learning ACT.

Experience the impact of flexibility processes

in your own life
As we explained in Chapter 38, when it comes to ACT there is no
substitute for experiential learning. The best place to start is to learn
something about the model from the inside out. Methods for achieving
this could include attending an experiential introductory training or
working through an ACT self-help book. Reading a book is one thing,
and actually making behaviour change whilst tracking the processes
and outcomes described by ACT’s psychological flexibility model is
something else entirely. Thus, we would recommend experiential
trainings, self-help workbooks, and self-help books in that order. In
terms of books with a guided experiential component, Hayes (2005),
Oliver et al. (2015), and Tirch et al. (2019) are excellent options.

Understand the theoretical and philosophical

foundations of the ACT model
Whilst we fully appreciate that learning about theory and philosophy
are not what excites everybody, we are of the view that these topics are
fundamental to understanding the stance that ACT takes on human
136 Developing skills as an ACT practitioner

suffering, and why it looks the way it does in the consulting room.
Whilst it is not a pre-requisite to be able to explain every nuance of
RFT or functional contextualism, a grasp of the basics feels impor-
tant. Taking things back a stage, RFT and functional contextualism
probably will not make a huge amount of sense to someone who does
not have a decent grounding in the fundamental concepts of behav-
iourism, so it is wise to start there. Written from a functional contex-
tualist standpoint, a helpful text to use as a starting point is Ramnerö
and Törneke’s (2008) practical overview of how respondent condition-
ing, operant conditioning, stimulus control, and relational framing
are relevant to the day-to-day work of behaviour change practitioners.

Learn to identify the flexibility processes and

“read” them in a person’s behaviour
There are numerous texts available for practitioners wishing to de-
fine and understand the components of ACT’s psychological flexi-
bility model. Recommended ‘beginning ACT’ books include Hayes
et al. (1999), Luoma et al. (2007), Harris (2019), and Bennett and Oliver
(2019). These and many more ACT learning resources are listed on Ja-
son Luoma’s (n.d., a) comprehensive list, which, at the time of writing,
continues to benefit from regular updates. However, reading books or
watching videos will only get you so far, and it is important at this stage
of your journey to attend more experiential training, with a focus on
practicing assessment and formulation skills in ‘real-play’ situations,
preferably including live feedback. Peer consultation groups with a
practice element, such as the Portland supervision model (Thompson
et al., 2015) are another good way of gaining this kind of experience.

Gain the practical skills to use ACT methods,

as well as methods you already know, to make
the processes move
It goes without saying that the regular practice of ACT is crucial to
development at this stage of the learning journey. This should be done
with the guidance of an ACT-trained supervisor with sufficient ex-
perience of the model to support and guide the practitioner. Ongo-
ing supervision, experiential training focussed on practicing specific
ACT-consistent techniques and interventions, reading about the latest
developments, and connection to a community of ACT practitioners
 How can ACT practitioners shape their learning? 137

are all important aspects of one’s development. We would recommend

that only at this stage should you seek out presentation-specific ACT
trainings (i.e., ‘ACT for X’), since it is important to understand and
competently practice the universal features of the model, before learn-
ing about how it might be adapted to specific populations.
Chapter 41

Do I need ongoing
ACT supervision?

Supervision is often stipulated as a mandatory responsibility of be-

ing a practitioner, whatever one’s professional background. It can be
broadly defined as a process of professional development that pro-
vides space for reflection as well as the continuing development of
knowledge, skills, and competence. Given the broad nature of this
definition, there is little direction as to what needs to take place dur-
ing the process of supervision, how often someone ought to engage
with this process, for how long, or with whom. It is possible to differ-
entiate between types of supervision, for example, the content of line
management supervision might focus on the more practical aspects of
a job role, such as caseload, annual leave, or sickness. In contrast, this
chapter pertains to ACT-specific supervision, which is more focused
on the above description of reflecting on and developing ACT knowl-
edge and skills.
Across the many professions practicing around the world that uti-
lise the ACT model, there will be differing professional guidelines, or
perhaps none at all, about supervision requirements. Whether or not
your particular profession provides specific guidance on supervision,
it can be helpful to consider the function of the supervisory process,
rather than whether or not engaging in it is it a rule-governed behav-
iour dictated by an external agency. Our own perspective on this is
that we would strongly encourage ACT practitioners to think about
the helpful functions of engaging with ACT-consistent supervision,
and seek regular supervision if it is at all practicable to do so.
The difficulties, traps, pitfalls, and missteps that we might encoun-
ter as we embed and practice our ACT knowledge and skills are plen-
tiful and varied. Even from within a ‘comfort zone’ where we feel very
skilled in our work, supervision can still be helpful to ensure that we

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 Do I need ongoing ACT supervision? 139

are not becoming entrenched in specific well-practiced exercises at the

cost of forgetting about the function of why we may apply them. Su-
pervision can also help us to constantly expand and review the work
we are offering within our practice settings.
Despite supervision having been an important part of behaviour
change work for many decades, it lacks the investment of research
that intervention work has afforded (Milne, 2009). The introduction
of a more experiential and self-exploratory form of training within
the CBT arena in the 1990s (Bennett-Levy et al., 2001) opened up the
idea of integrating personal experience into the theoretical learning
of a model. Advancing this work into the supervision arena, Mor-
ris and Bilich-Eric (2017) developed a model of supervision that
included more experiential factors and is firmly grounded in the un-
derlying philosophy of contextual behavioural science. Whilst it is a
very ACT-congruent model because of its underlying principles, the
authors intended it to be applied to support the integration of the-
ory and experiential application across any number of psychological
approaches.
Each of the features of their SHAPE model is included in the frame-
work in order to increase the psychological flexibility of the practi-
tioner and their use of experiential learning. The five features of the
model are as follows.

Supervision values
Values clarification as part of the initial supervision contracting phase
can increase the likelihood of value-driven behaviours occurring dur-
ing sessions where either party connect with uncomfortable experi-
ences. Perhaps the supervisor would like to share a concern about
the supervisee’s work, or the supervisee is connected with a feeling a
shame and criticism. Having a basis of qualities that both have agreed
to work in line with enables more open and honest conversations about
the client work, and the learning and development of the supervisee.

Holding stories lightly

This feature of the model brings light to the language used within su-
pervision and draws on the CBS idea that what is ‘helpful’ is more im-
portant than what is ‘true’. That is not to say that the stories told about
the client would be untruthful, rather, the focus here is on whether the
140 Developing skills as an ACT practitioner

language used to describe the client is the most helpful way of telling
their story. As with the aim of any supervision model, the aim is to
increase the helpfulness of the supervisee’s learning, so that their work
has a greater impact upon the client’s behaviour change journey.

Analysis of function
As is the case with client sessions, the use of functional analysis is key
to the practice of supervision. The authors outline three main areas to
focus upon:

• The client’s presenting problems and life circumstances

• The therapeutic relationship (i.e. the client and supervisee in
session)
• The supervisory relationship

Functional analysis will include the broader context and support an

understanding of the functions of behaviours that show up in each of
the above areas.

Perspective-taking
Utilising perspective-taking skills in supervision can increase the em-
pathy and compassion of the supervisee for the client’s content, con-
text, and presenting situation. This can be especially important when
there is a disconnect from emotion, or where the supervisee is fused
with judgements about the client’s situation. Perspective-taking can be
enhanced by considering various perspectives on the client (i.e., con-
sidering other people’s experiences of the client), and other temporal
or spatial perspectives in relation to the client’s situation.

Experiential methods
This feature focuses on the promotion of learning by experience. This
may be initiated by the supervisor via an invitation for the supervisee
to engage in role-plays, or by reviewing live recordings of the supervi-
see’s therapy sessions. In-session experiential techniques used by the
supervisor may also include the use of imagery, perspective-taking, or
metaphors to encourage the supervisee to connect with the emotional
 Do I need ongoing ACT supervision? 141

content of the client’s situation and evoke workable strategies for the
supervisee to utilise in practice.
Whilst the SHAPE model can be used by practitioners using any
psychological model, it is certainly a helpful addition to supervision
sessions that are aiming to have a more ACT-congruent focus to them.
Part 5

Critical questions
about ACT

In order to provide a balance in the text, which is largely oriented

toward advocating for the utility of ACT as an empirically supported
approach to behaviour change, the book concludes by addressing
some critical questions that have been raised about the model. These
include an analysis of the quality of the evidence base that ACT has
amassed, and a discussion about whether ACT offers anything gen-
uinely new or adds value over the more traditional forms of CBT.
Concerns about how ACT can be integrated within cultures where the
medical model dominates, and where clients might expect to be ‘fixed’
are also explored. The issue of how the moral relativist stance adopted
by ACT and functional contextualism might impact how values work
is conducted is addressed, as are technical questions about how to
proceed when ACT interventions do not work in the way that they are
intended to.

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Chapter 42

How strong is the

evidence for ACT?

The past 20 years have seen significant growth in all areas of research
related to ACT, and the speed of growth is accelerating year on year.
Of particular interest to the question posed by this chapter is the
growth of outcome research, which is concerned with the effective-
ness of ACT as an intervention. To use RCTs of outcomes as a metric,
by the turn of the century there had been four studies, by 2010 there
were 44 studies, and by 2020 there were 731. At the time of writing in
late 2022 there are 949 (Hayes, 2022). However, whilst this growth is
clearly encouraging from the point of view of research interest in ACT
and the development of a wide-ranging evidence base, quantity does
not equal quality, and one needs to interrogate the literature further
before any conclusions can be drawn about the strength of the ev-
idence. There is an advantage to having a large number of trials in
that it makes it possible for other researchers to conduct systematic
reviews or meta-analyses of the combined data produced by the in-
dividual studies. This kind of analysis has allowed for a more robust
exploration of the ACT outcome literature, wherein conceptual, meth-
odological, and statistical issues such as design, measurement, attri-
tion, effect sizes, and bias have received greater scrutiny. To date there
have been well over 300 such reviews, and more recently, meta-meta-­
analyses (meta-analyses of meta-analyses) have started to appear (e.g.,
Gloster et al., 2020; Cheng et al., 2022).
The first comment to make about quality is that ACT research suf-
fers from many of the same problems that plague almost all areas of
research into the effectiveness of psychological interventions. Chief
amongst these is the reliance on self-report measures as a proxy of the
dependent variable in a study. For example, most research trials that
seek to measure the impact of an ACT intervention on psychological

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 How strong is the evidence for ACT? 145

flexibility are not measuring psychological flexibility itself, but partic-

ipants’ self-report of their psychological flexibility, which is not quite
the same thing. Whilst there have been ACT outcome studies that have
measured more objective variables (e.g., rates of re-­hospitalisation;
Bach & Hayes, 2002, or violent re-offending; Zarling & Russell, 2022)
such studies are relatively rare. Another common problem in out-
come research is the extent to which one can be sure that the change
in the dependent variable (e.g., psychological flexibility) is due to the
independent variable (e.g., the ACT intervention). Whilst hundreds of
ACT RCTs have demonstrated a correlation between receiving ACT
intervention and an increase in scores on measures of psychological
flexibility, proving that the intervention is solely responsible for the
change is difficult.
Another issue that has received widespread attention in the discus-
sion of the problems with the quality of psychological research con-
cerns the so-called ‘replication crisis’. This refers to the difficulties
associated with being unable to reproduce the same results when a
given study is repeated (e.g., Open Science Collaboration, 2015). An-
other related problem, which some ACT research has been criticised
for (see Cihon et al., 2021) is that published articles sometimes do not
contain sufficient detail in them to enable the studies they are report-
ing on to be replicated.
Bias in psychology outcome studies is also a significant issue, and
one that also impacts the extant outcome data for ACT. Most schools
of thought in psychotherapy go through a similar developmental tra-
jectory. Initial research is almost always conducted by the originators
of a model, and as well as often being smaller and less robust in design,
any such studies are likely to suffer from researcher bias. Subsequent
studies are often conducted by those connected to the originators (e.g.,
other researchers in the ACT community who also have a vested in-
terest), and it takes time for larger, well-designed studies undertaken
by independent researchers to emerge. It is almost always the case
that when these later studies are eventually published, they report
smaller effect sizes than the early studies did. Since ACT is still a rel-
atively young approach it has not fully progressed to this later stage
of development.
As well as concerns that are generic to most studies of psychological
interventions, attention has been given to issues that are specific to
ACT research. Two of these are clearly summarised by Mcloughlin
and Roche (2022). Firstly, they argue that the link between RFT and
146 Critical questions about ACT

ACT has not been empirically established to the degree that many
ACT practitioners imply that it has. Whilst the conceptual links are
clear, it is suggested that the claim that ACT interventions benefit
from the findings of laboratory based RFT research has been over-
stated, and that any conception of ACT as ‘clinical RFT’ involves get-
ting ahead of the data. Secondly, the authors express concern over
the measurement of psychological flexibility. Whilst various psycho-
metric tools are available to measure ACT’s core concept, most ACT
research has used iterations of the Acceptance and Action Question-
naire (the AAQ; Hayes et al., 2004, or the AAQ-II; Bond et al., 2011).
They report several studies that have indicated that neither version of
the AAQ properly represents the supposed six-factor structure of the
psychological flexibility model, and that the questionnaire might be
better described as measuring other concepts, such as neuroticism.
The quality of the data on the effectiveness of ACT is impacted by
all of the above issues, as well as issues related to the dominance of
WEIRD authors and participants, as discussed in Chapter 22. How-
ever, despite this, the data set does contain studies of sufficient rigour
for ACT methods that have been validated by leading scientific in-
stitutions, such as the WHO and other organisations that have rec-
ommended the use of ACT at a national level, as detailed in Chapter
2 (Dixon & Hayes, 2022). From a diversity perspective, it should be
noted that most scientific praise and criticism that ACT research has
received also comes from WEIRD nations. Context matters, and in
giving primacy to rigorous scientific method as the means to judge the
strength of the ACT evidence base, we should remember that science
is only one of many perspectives on what is useful. In attempting to re-
tain a functional contextualist perspective, it is important to remem-
ber that anything that adds to the overall body of knowledge about
ACT has some utility, whether that is to advance the scientific rigour
of the evidence base, to provide information about the acceptability of
ACT among diverse populations, or something else entirely.
Chapter 43

Traditional CBT has a

well-established evidence
base. Why does the world
need ACT?

Human history is full of examples of different groups with similar

aims spending significant time and energy competing with each other
when their aims might have been better served by co-operating. Un-
fortunately, the fields of psychology and psychotherapy are not ex-
empt from this phenomenon. Devotees of newer models will often
loudly proclaim how they offer advancements over older ones, whilst
followers of more traditional ideas will roll their eyes at the claim that
anything original or better is genuinely on offer. Whilst not the case in
all corners of the field, these kinds of exchanges have certainly taken
place between advocates of traditional forms of CBT, and so-called
‘third wave’ models, such as ACT. It is certainly true that scientific
progress necessarily involves healthy debate and frank exchanges of
views; however, denigrating other approaches is rarely useful to this
debate. In our view, this kind of adversarial discourse is largely un-
helpful to the client groups that behaviour change practitioners serve,
and to use a metaphor, if we have any spare bricks, maybe it is better
to use them to build bridges rather than walls.
Second wave CBT does indeed have a very established evidence base,
particularly in respect of outcome data from research into the effec-
tiveness of Beck’s CT, as used with people who have attracted various
mental health diagnoses. Meta-analytic reviews have described the
strength of the outcome data for traditional CBT (e.g., Hofmann et al.,
2012), although further research is needed to clearly identify its spe-
cific cognitive and behavioural processes of change, beyond generic
therapeutic factors such as the practitioner-client alliance and the use
of between-session assignments (Kazantzis et al., 2018). However, as
successful as it has been, it cannot be considered as an endpoint in

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148 Critical questions about ACT

the evolution of psychological interventions, particularly when rates

of recovery amongst individuals receiving CBT remain as low as 50%
(NHS Digital, 2022). As technology always moves forward, the field
of psychotherapy constantly attempts to improve outcomes for clients
through its endeavours in research and practice.
In some ways, ACT has emerged as a viable alternative to the
methods of traditional CBT precisely because it addresses some of
its shortcomings. It offers a different option in the face of some of
the common criticisms of CT, notably the reliance on a medicalised,
disorder-­specific model of human distress, and the apparently limited
utility of cognitive restructuring (e.g., Jacobson et al., 1996; Longmore
& Worrell, 2007), which is arguably its main intervention strategy.
ACT offers a model focussed on human function rather than assuming
a starting point of illness or dysfunction. It also places much greater
emphasis on value-driven behaviour change, thus including a ‘posi-
tive psychology’ emphasis lacking in diagnosis-driven approaches. In
short, it offers some different things. As much as we are advocates
for ACT, we do not think that advocating for ACT needs be done at
the expense of traditional CBT. Indeed, that would be an intellectu-
ally dishonest position, given that rigorous comparisons of ACT and
traditional CBT tend to point to them being equally effective (e.g.,
Arch et al., 2012a; Öst, 2014; A-Tjak et al., 2015, 2021; Gloster et al.,
2020). Rather, we would like to advocate for ACT as being an effective
alternative to traditional CBT, which, for a number of reasons, be-
haviour change practitioners might want to consider using in certain
circumstances.
All CBTs, ACT included, share a basic formulation, in that they
position cognition as a mediating variable between a stimulus and
an emotional response. Something happens, our minds interpret that
something, and that interpretation influences how we feel and behave.
Where ACT diverts from traditional CBT concerns how best to ad-
dress cognitions if they result in psychological distress or unhelpful
behavioural responses. Traditional forms of CBT would advocate
working to change the content of thoughts in such circumstances,
whereas ACT would promote the use of procedures aimed at changing
the relationship that a person has with their content. The differences in
these approaches can be illustrated with reference to Williams and
Garland’s (2002) ‘five areas’ model, which is a standard formulation
model used within traditional CBT (see Figure 43.1). With regard to
cognition, traditional CBT targets the ‘thoughts’ box by explicitly
 Why does the world need ACT? 149

Traditional CBT target

Situation/context

ACT targets

Thoughts

Physical sensations Emotions

Behaviours

Figure 43.1 T
 he five areas model (adapted from Williams & Garland, 2022)

working toward cognitive change, whereas ACT offers procedures

for targeting the arrows, thereby weakening the regulation that cog-
nitions have over the other aspects of a person’s experience (Gilland-
ers, 2013b). Both traditional CBT and ACT offer interventions for
directly targeting behaviour change, albeit sometimes with differing
rationales.
In our experience of direct intervention work, different clients vary
in their response to these contrasting ideas about how to deal with
unhelpful thoughts. Some people like the idea of learning to think dif-
ferently, whereas others do not respond well to attempts to challenge
thoughts, finding the process invalidating, and leading to potential di-
vision between practitioner and client. Therefore, it feels important to
consider the context of your work in deciding which method provides
the best fit. An approach that resonates with the client is likely to be
more effective. The same is probably true for the practitioner, in that
if ACT resonates with them personally, they will probably be a more
effective practitioner using ACT than they would if they attempted to
use a different approach.
ACT provides a different route to achieving similar ends. To use a
decorating metaphor, a paintbrush and a roller both provide useful
methods for painting walls, although the choice of either one will be
150 Critical questions about ACT

determined partly by personal preference and partly by the specifics

of the situation. Maybe it is useful to have both in the box of decorat-
ing tools. If traditional CBT does not provide a good fit in any given
situation, whether due to practitioner or client preference, the nature
of the presenting issues, or the broader context for the work, ACT is an
empirically validated alternative, and vice versa. Practitioners inter-
ested in offering evidence-based interventions can serve their clients
by learning techniques from each wave of CBT (Hayes & Hofmann,
2017). In the service of being flexible in how best to meet the needs of
clients, we would argue that the development of ACT has given prac-
titioners a greater number of options.
Chapter 44

Isn’t ACT just another

case of ‘the emperor’s
new clothes’?

To agree with this assertion, which we have heard people make, would
be to take the position that ACT has offered nothing new or valuable
to the worlds of psychology, psychotherapy, and behaviour change. It
would be to suggest that the people that have benefitted from the work
of ACT practitioners could just as easily have benefitted from older
technologies and that ACT is simply a re-hash of pre-existing ideas.
We do not agree with this assertion, and this chapter will outline why
we think that it is not a reasonable stance to take.
In the service of being clear from the outset, whilst we would argue
against the idea that ACT has brought nothing new to the science of
behaviour change, neither would we argue that it is wholly original.
Psychology, like other scientific endeavours, is an iterative process,
and any new developments inevitably stand on the shoulders of older
ideas. Other authors have justifiably pointed out that some of the key
features of ACT can be traced back to other models, both inside and
outside of the cognitive behavioural tradition. For example, it is im-
possible to imagine ACT looking the way it does without the previous
work of Titchener (1916), Skinner (1953), or Rogers (1961), all of whom
were referenced in the first ACT textbook (Hayes et al., 1999). Indeed,
the following quote from that same text acknowledges this very point:

ACT is a collection, with components borrowed from many tra-

ditions…if there is anything novel about ACT, it is in the specific
way it combines philosophy, theory, and practice.

(Hayes et al., 1999, p. ix)

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152 Critical questions about ACT

Aside from those referenced above, one can see significant echoes of
Ellis’s (1962) REBT in ACT’s emphasis on the importance of having
a philosophical basis to its model of change, as well as stressing the
centrality of acceptance and committed action. There are also nota-
ble similarities with Morita therapy (1928/1998)1 around the focus on
encouraging clients to take meaningful action even in the presence of
internal discomfort. There are those who have been vocal in their cri-
tique of ACT literature as a consequence of such similarities, as well
as the perceived failure of certain ACT authors to give credit where it
is due. For example, Velten (2007) suggested that ACT could be seen
as having re-used ideas from modalities as diverse as general seman-
tics, person-centred counselling, fixed-role therapy, logotherapy, val-
ues clarification, multimodal therapy, Morita therapy, CT, and REBT
without its originators properly acknowledging those influences.
Whether those that have been influential in the development and
dissemination of ACT have been unwittingly influenced by other the-
ories or have consciously replicated elements of them is not for us to
judge. In any case, it seems clear that ACT theory and practice has
developed in part out of what has gone before it, although a look at the
history of psychological science would suggest that this is not unusual
or even undesirable. The metaphor of waves, as used in describing the
history of CBT, is a useful one. Each new wave is carried to the shore
by the efforts of the previous one, and when it lands, it makes a mark
that changes the shore forever (Hayes & Hofmann, 2017). We would
support the view that ACT, alongside other third wave approaches,
has brought sufficient originality and innovation, such that the field
of behaviour change has changed markedly in a way that cannot be
reversed.
At its most basic, this change can be seen in the way that CBT is
practised and written about. Staple ACT interventions that were once
seen as somewhat ‘left-field’ by the behaviour change community as a
whole (e.g., mindfulness and acceptance-based procedures, cognitive
defusion exercises, or focussing on a client’s values) have been assim-
ilated into the mainstream. Outside of what could be defined as ACT,
such procedures now form part of standard evidence-based interven-
tions for a range of presentations (e.g., Barlow et al.’s unified protocol,
2017). It is now common to see practitioners adding components of
the psychological flexibility model to their theoretical discourse and
practical work in fields as diverse as psychotherapy (e.g., Craske et al.,
2014; Cotterell, 2019), applied behaviour analysis (Tarbox et al., 2020),
 Isn’t ACT just another case of ‘the emperor’s new clothes’? 153

and organisational psychology (Flaxman et al., 2013). If ACT was a

simple re-hash of old ideas, its concepts would not have been able to
exert such an influence upon these areas of practice.
The central importance of such procedures seems unlikely to have
been highlighted without the novel contribution of ACT. However,
arguably the bigger influence of ACT has been felt in the greater at-
tention to the psychological processes that those procedures operate
upon. With its pan-diagnostic approach, ACT has spearheaded an
evolution away from symptom-based protocols toward process-based
procedures, and this change seems to be rapidly gaining pace. ACT
has been a leading contributor to the conversation about which cog-
nitive and behavioural processes are central to psychopathology, and
therefore what the most effective interventions should comprise. The
research evidence from moderation (e.g., Wolitzky-Taylor et al., 2012)
and mediation (e.g., Hayes et al., 2022; Arch et al., 2012b) studies is
increasingly pointing to the important role of psychological flexibility
and its component facets as being central processes in understanding
health and wellbeing. None of this would have happened without the
ACT conceptualisation of human function, a research programme that
has attempted to link the basic science of RFT with what is observed
in the consulting room, and the application of a pan-­diagnostic inter-
vention model supported by a significant body of outcome literature.
As a consequence of the third wave, with ACT and RFT at its fore-
front, the changed shore of cognitive and behavioural intervention
science has a sharper focus on the processes, moderators, and medi-
ators of change, as well as the development of procedures that align
with them. It remains to be seen how this shift toward a process fo-
cus, alongside the slowly waning influence of the psychiatric model,
will impact behaviour change practices in the coming years. However,
at the present time, the term ‘process-based therapy’ (e.g., Hofmann
et al., 2021) is starting to be spoken about more and more, perhaps
suggesting that a fourth wave might be about to hit the shore.

Note
1 The ground-breaking behavioural work with anxiety of Shoma Morita,
whilst written in Japan in the 1920s, was not translated into English until
the 1990s, hence the inclusion of two different publication dates.
Chapter 45

ACT uses a lot of

eye-catching tools and
techniques. Isn’t this all
just a bag of tricks?

ACT certainly uses a vast array of creative experiential activities,

which are designed with the function of maximising the client’s learn-
ing. The intention is that this experiential learning leads to effective
behaviour change for the individual, and a life that feels more rich,
vital, and meaningful to them.
Given there are no formal training routes that categorically certify
anyone as ‘an ACT practitioner’, the disparate nature of some people’s
training journeys does mean that their practice might resemble a bag
of tricks picked up from here, there, and everywhere. YouTube videos
and half-read book chapters do not an ACT practitioner make! The
generosity of the ACT community means that a lot of the useful tools
and resources are freely accessible via Facebook, email lists, YouTube,
and Twitter. Additionally, the values-driven nature of the community
means that ACBS membership and associated training events are of-
ten available at affordable rates. However, learning bits of ACT from
each of these is unlikely to help you learn and embed the underlying
science and philosophy of the model.
The skill of being an ACT practitioner comes from the complex
theoretical knowledge behind applying the ‘simple technique’. It con-
cerns the when and why around using ACT procedures, and not just
the how. Consider something like the experiential metaphor, ‘tug-of
war’, (Hayes et al., 1999) as an example. This is a commonly used ex-
ercise that involves the client getting out of their chair and interacting
with the experience of being hooked by their thoughts. In summary,
the practitioner embodies the client’s distress (e.g., their anxiety, or
their low mood), and engages them in a ‘tug-of-war’ with their difficult
content. Each time the client struggles with their content by pulling on
the rope, the practitioner will pull back, which ensures a to-ing and

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 Isn’t this all just a bag of tricks? 155

fro-ing of the struggle. The harder the client pulls to try and win, the
harder the practitioner pulls back. Through the exercise, it is possible
to see the futility of this struggle and engage the client in a discussion
about trying other useful strategies. One such strategy would be to
drop the rope. If the client opts for this, the practitioner can soon start
to gently coax the client into picking it back up again, returning to the
back and forth of the struggle.
Exercises such as this will likely make for a memorable session,
which is great if you utilise the exercise functionally, and it leaves
the client with some new and effective learning. For example, the key
points in this exercise could be:

1 To help the client see (and experience) the futility of struggle

2 To help the client see how easily they become engaged in their
struggle again, without directly meaning to
3 To learn that there are alternative strategies for responding to dif-
ficult thoughts and feelings
4 To work with the client around identifying what any alternative
strategies would look like and ways of implementing them

On the surface of it, when observing a skilled practitioner execute this

exercise, it could be understood as a way of encouraging clients to just,
‘Drop the rope!’, as if the exercise has a clear and pre-determined end
point. However, clients are not predictable. They are unlikely to have
read our textbooks, and they may not experience the exercise in any
one particular way. Maybe they will resist the idea that acceptance is
a useful strategy, and this exercise alone will not convince them oth-
erwise. Or perhaps, for them, how they might ‘drop the rope’ in their
own life requires some considered thought. They may have questions,
or a different perspective that they want to share and explore. Per-
haps this exercise would be wonderfully complimented by following
up with a values clarification procedure, to help people consider what
they could pursue more of if they were to give up some of their struggle.
If you have only scripted ACT techniques in your toolkit as a bag of
tricks, you will fall flat on your face in a session when someone does
not respond as the textbook said they would, or as you observed when
demonstrated to you in some training that you attended. Utilising
interventions in a scattergun fashion, without being able to theoreti-
cally tie them together, may have some effectiveness, for some clients.
However, using them in this way misses the main point of ACT, in
156 Critical questions about ACT

that it offers a framework for a functional and contextual analysis of a

client’s situation. ACT is not equivalent to any of its procedures, and
using any of the procedures associated with ACT without using them
in the context of a functional analysis is not really ACT. Throwing tech-
niques at clients without a clear process-procedure-outcome structure
to the work is unlikely to be particularly effective. We want clients
to be consistently moving forward, making workable behavioural
change, as assessed through a functional contextual lens. If ACT in-
terventions are treated like a bag of tricks the strength of the model
will be lost, and moments where your work could have evoked clear
learning points will represent missed opportunities, keeping clients
stuck in unhelpful patterns of behaviour for longer.
One of our concerns around ACT not currently having any struc-
tured path to practitioner certification is that anyone can watch some
Instagram videos, learn some exercises, and then state that they use
the ACT model, in a way that does not feel legitimate. This kind of
practice has the potential to damage the reputation of ACT and un-
dermine public confidence in it. We would invite you to consider your
own values when advertising yourself as ‘an ACT practitioner’, and
suggest that you only do that when doing so genuinely is a fair reflec-
tion of your knowledge and skill in the use of the model. The wider
ACT community offers a number of ways to support you in your ACT
journey, both personally, and in your work with clients. The ACBS
website is a great place to start for resources, information, connecting
with others, seeking out high quality training opportunities, finding
a supervisor, and developing your own input to the ever-growing field
of CBS.
Chapter 46

How does ACT fit within a

culture where the medical
model dominates?

This question arises from what, at face value, seems to be a clear and
irreconcilable disagreement between the fields of medicine and ACT
on the view that is taken of psychological distress. The medical model,
the practice of psychiatry, and some psychological models tend to see
distress as symptomatic of some form of disorder or mental illness.
Diagnostic classification systems like DSM-5 (American Psychiatric
Association, 2022) or ICD-11 (WHO, 2019) cluster such symptoms
into separate diagnostic categories that are used to guide interven-
tions, usually in the clear direction of symptom reduction. The view
that ACT takes of psychological distress is radically different in that
what psychiatry might see as a symptom, ACT would see as behaviour,
occurring as a consequence of an individual’s present and historical
context. Whilst ACT and psychiatry might agree on this behaviour
being problematic, particularly if it seems rigid and repetitive, ACT
will see it as being functional within its context, rather than as in-
dicative of some underlying disease process. Of course, part of any
individual’s context is the language that is used to describe any such
behaviour, including labelling an experience of painful emotions as a
‘symptom’. If it is treated as if it is bad, and part of a disease, this will
transform the way that the experience functions, and, more often than
not, it seems that relating to painful emotions as symptoms exerts a
repertoire-narrowing effect. For example, if the internal experience of
anxiety is related to as if it is indicative of illness, it seems likely that
one might work hard at trying to get rid of it, thereby fuelling patterns
of experiential avoidance.
Medical language such as ‘negative thoughts’, ‘anti-depressant’,
and ‘anti-psychotic’ frequently reinforces the idea that reduction,

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158 Critical questions about ACT

avoidance, or elimination of these so-called symptoms is the only way

to go. Clearly, ACT adopts a different stance, in that its goal is to
promote behavioural responses to distressing thoughts and emotions
that are variable, flexible, and value driven. The large and growing evi-
dence base that ACT has amassed suggests that building such patterns
of responses benefits longer-term functioning more than experientially
avoidant behaviour does on its own. ACT encourages clients to stand
back from the diagnostic labelling or the symptom reduction advice,
and focus on what works, whether that is making a move toward val-
ues or away from pain, with both being equally valid responses.
An initial analysis of the above could easily lead to the conclusion
that there is too much divergence here, and that ACT is not a good
fit for any culture where the medical model dominates. However, our
view is that there is room for these approaches to operate alongside
each other, without the need for one to ‘win’ or preclude the other. It
is highly likely that ACT practitioners, wherever they work, will find
themselves having to find ways to address the question of how this
might be achieved. The medical model is so embedded within many
cultures (especially so in WEIRD nations) that the idea of getting
rid of unwanted experiences will be at the forefront of lots of clients’
minds when they first engage with ACT. Wanting to feel happy or not
wanting to have anxious thoughts are common goals expressed by
clients, in part because they will likely have learning histories with
healthcare systems where both client and practitioner are working to-
ward a ‘cure’ for the ‘symptoms’. We would argue that it is rarely help-
ful to respond to a client holding this expectation by denigrating the
medical model. Rather, it seems preferable to find a way of positioning
the ACT stance as an additional or alternative perspective that might
be worth considering if symptom reduction approaches have proved
unproductive. Equally, it is probably not very helpful to come straight
out and say that ACT will not help to reduce unwanted experiences.
It is usually more beneficial to describe ACT as an approach that will
focus on helping the client develop new skills to manage their thoughts
and feelings more effectively, thereby reducing their impact and in-
fluence. It is important to remember that ACT is not against people
experiencing fewer unwanted experiences, and there is nothing intrin-
sically problematic about someone feeling sad or anxious less often. It
can be helpful to communicate this to clients. At the same time, it is
also useful to communicate that this reduction will probably not come
about by waging war on discomfort and trying to make it go away.
 How ACT fits within a culture where the medical model dominates 159

After all, if that was going to work, it probably would have worked
before now. It has a better chance of happening via learning the skills
of psychological flexibility.
The concepts of workability and flexibility, both pivotal to ACT
practice, are also central to the idea of resolving any disagreements
between ACT and the medical model. As an example, imagine a client
who has been given a diagnosis of depression. They are taking pre-
scribed anti-depressant medication and they are also seeing an ACT
practitioner. Despite the apparent contradiction, there is no reason
why the client should not be able to engage with both approaches,
if doing so works for them. If anti-depressant medication is helpful,
there is no reason why this means of managing the experience of low
mood cannot be used alongside learning some useful skills around
mindfulness, acceptance, and valued action. They could be invited to
track the utility of both approaches, and make decisions about when,
and how much, to invest in either going forward.
One final thing to note is that in many of the outcome studies of
ACT, whilst the interventions focus on increasingly psychological
flexibility rather than reducing symptoms, some degree of symptom
reduction, as measured by participants’ self-report, usually occurs
nevertheless (see Gloster et al, 2020 for a review). Therefore, a useful
message for clients who want to get rid of unwanted experiences is that
one of the most useful things they can do in the service of that is to
stop trying to get rid of them.
Chapter 47

Is it not harmful to
encourage people to tune
into and accept their pain
and discomfort?

This is not intended as an introduction to how to manage a client’s

discomfort in the room. The caveat to everything that follows in this
chapter is that it is for each of us to work within our own professional
competence and boundaries. It is possible to exacerbate a person’s
struggle and trauma if there is no underlying expertise to receive it
in a way that is helpful and containing. In Chapters 36 and 39, we
discussed the journey of most ACT practitioners as a process of ad-
ditional learning following a professional training programme. Our
individual professions are then directly linked with an associated code
of ethics and standards of practice, within which we all agree to work.
So please, if this is not your training route, be responsible for your
work, the services that you provide to clients, and ensure you have the
necessary expertise to effectively manage distress. From here on in,
this chapter pertains to the worries we experience as clinicians about
our own discomfort around other people’s pain.
A helpful distinction to make here is between ‘hurt’ and ‘harm’. We
know from neuroscience that our emotions hurt and have similar neural
pathways to how we experience physical pain. The poetic description
of a ‘broken heart’ is not simply poetic; it is indicative of pain and a
requirement of needing time to heal. By that understanding, when we
are talking with people about experiences they have found difficult, we
are directly walking into territory characterised by pain and discom-
fort. This can be described as hurt, since the pain experienced by the
client genuinely will hurt. However, the definition of the word ‘harm’,
implies more of an intention to cause injury. Therefore, when we con-
sider whether encouraging people to tune into and accept their internal
emotional pain is harmful, we suggest that whilst it may hurt, if man-
aged well by the practitioner, it will not cause damage or be harmful.

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 Encourage people to tune into & accept their pain and discomfort? 161

Let us utilise a metaphor to develop this answer. Imagine that we all

acknowledge our past difficulties as ‘skeletons in the closet’. For most
of us, most of the time, the majority of those skeletons are keeping
themselves to themselves, perhaps even asleep on the other side of that
firmly closed closet door. We may have little knowledge that they are
there, or perhaps they are only woken in certain circumstances, and,
in the small ways that they ever bother us, they do not warrant any
significant attention. However, for some of us, some of the time, those
skeletons rattle loudly, banging on the door and we fear their immi-
nent arrival, bursting out from the closet to terrorise us. We worry
what they will do and how they will harm us when they appear. Our
fears grow, and our response to manage them is to begin to pile up
other furniture in front of the closet doors. This enrages the skele-
tons and they push harder, and rattle louder, and in response, we pile
up more furniture and start to cover our ears to block out the noise.
This is a clear pattern of experiential avoidance. Around and around
it goes.
What would happen if the skeletons were to suddenly be in the room
with us? What would they do? If we believe the skeletons to be ‘harmful’
we might imagine they would somehow attack us and inflict physical
pain. When we talk about tuning in and accepting pain and discom-
fort as being ‘harmful’ we are essentially judging that the skeletons
themselves are the harmful concept. It would surely then make logical
sense for the practitioner to help the person manage those skeletons by
lending their own body weight to help barricade the door. However,
whilst it may stop the skeletons’ fingers from reaching the door handle
on the outside, it doesn’t stop them from making one mighty racket
on the inside, and the problem remains unchanged. They’re still there,
still feeling big, still scary, and still having all the same consequences
of making the person’s life get smaller and smaller in the service of
trying to manage them.
One of the aims of ACT is to break this experiential avoidance
loop. This enables us to respond differently to the presence of pain
and discomfort and provide a safe place for those big, scary, angry,
demanding, and terrifying skeletons to join us in the consulting room.
Within the relational safety of the practitioner-client dyad, encourag-
ing someone to tune into their pain is not harmful. What if we were
able to offer the gift of creating a shared space in which we can talk
to those scary creatures? Perhaps listening to what they have to say
might even be helpful?
162 Critical questions about ACT

As always, the question would be, “What’s the function?”. We

would never encourage people to contact their emotional pain and
leave them in suspended animation with no strategies to manage their
discomfort. So, why would we consider that tuning into and accept-
ing their pain could possibly be something of use in our intervention
work?
ACT utilises a number of psychological flexibility skills to help peo-
ple to manage the presence of their loud, scary skeletons. It is our job
as practitioners to provide a place where we can help people to see that
they are bigger than any of their content. The self-as-context arena
does this brilliantly, since it helps people to see that their content is ex-
actly that; it is a part of what they contain. Values and committed ac-
tion skills help us to work with people on how they want to grow their
lives, and who they want to be in the world whilst being a person who
contains some painful content. Tuning in and developing acceptance
around painful content are like keys to all the other aspects of psycho-
logical flexibility. So, from that perspective, we would have to say that
helping people to tune into and accept their pain and discomfort is not
harmful. Rather, it can be a gift.
It is important to remember that we are only inviting people to work
toward accepting discomfort. We cannot make them, and neither
would we want to. The invitation is for the client to develop accept-
ance in the service of their values, not just as a discrete exercise in ex-
periencing pain for the sake of it. We have to ask the question, is this
value worth suffering for, and the client has to be the one to honestly
answer that.
In knowing that this work will evoke hurt in the client, we can ready
them for this by helping them develop self-compassion skills as part of
the work. This enables them to have a skill set within which they can
be more nurturing in the presence of their own pain and discomfort.
Chapter 48

What if people have harmful

or antisocial values?

Whilst this question is often asked by ACT trainees and supervisees,

it rarely arises as a genuine concern when engaging in values clarifica-
tion work with clients. It seems to be something that many practition-
ers new to discussing the concept of values seem to worry about, and
the question pre-supposes a scenario whereby clients express a desire
to improve their skills in engaging in harmful or antisocial behaviour,
because to do so would be consistent with their values. Obviously, this
is not completely improbable, as some ACT practitioners might work
with clients with histories of engaging in such behaviour. However,
it does not seem to be an issue that makes its way into the consulting
room very often. Since it is a question that has sometimes been posed
by critics of ACT, this chapter will reference the underlying philoso-
phy of ACT and the conceptualisation of values, before considering
some useful responses in the event that practitioners find themselves
facing the scenario imagined by the question.
ACT has faced some criticism in respect of values work because
it leans on functional contextualism as its philosophical basis. The
reason for this criticism is that functional contextualism can be con-
strued as a position of moral relativism in which there are no definitive
moral principles. Essentially, a moral relativist, whilst having their
own moral principles, will hold the view that another person might
have a different set of moral principles and there can be no absolute
position on who is ‘right’ (Harris, 2012). From a moral relativist per-
spective, moral judgements are made relative to any given individual
and their principles, whether personally or culturally defined (Whit-
tingham, 2022). Thus, the argument goes, that this gives rise to the
possibility, however remote, that a client could espouse antisocial

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164 Critical questions about ACT

values and want to work with a practitioner on pursuing goals consist-

ent with them. Furthermore, critics suggest that if ACT practitioners
were really staying true to their functional contextualist roots, they
would have to permit this and support such work to take place. It
has been argued (e.g., McLoughlin & Roche, 2022) that this provides
evidence that functional contextualism is an amoral stance that could
lead practitioners to be unconcerned with what is right or wrong. In
our view, such criticism confuses amorality (not having any moral
principles) with moral relativism (the idea that different people will
define their moral principles differently) and imagines a theoretical
scenario that is somewhat far-fetched. We also think that, in reality,
almost all practitioners who faced such a situation would address the
issue head-on, and simply decline to support a client who wanted to
develop their repertoire of antisocial or harmful behaviours. When-
ever we put the question posed by this chapter back to those that ask
it, they generally respond by saying that their personal and/or profes-
sional codes of conduct would preclude such work.
It is certainly true that human beings can subscribe to a range of
antisocial beliefs and behave in a variety of ways that are problematic.
However, almost without exception, the clients that we have worked
with engage in harmful behaviours when under aversive control,
rather than because doing so representing a toward move for them.
Our experience includes working with incarcerated individuals who
have committed serious violent offences, as well as those who have
behaved in harmful ways to others in the context of intellectual disa-
bility, addiction, or trauma. None of these behaviours were driven by
values in the sense that ACT uses the word. Of course, it is possible
that people may genuinely hold antisocial values. We just have not met
anyone like this in the course of our ACT practice. Our sense is that
even if we did, there would be significant problems in respect of the
other aspects of psychological flexibility, whether that be fusion with
dogmatic ideas, extreme avoidance of discomfort, or an inability to
extend perspective-taking across time, place, and person. If we were
to ask you to recall someone you know, or have heard of, who seems
to value harming others, we could ask you to consider whether they
appear to you to be someone skilled at psychological flexibility. We
think it unlikely that you would say that they do. You might even look
at your own history and the times that you have behaved destructively
(Harris, 2018). Were you mindfully acting in line with your values in
 What if people have harmful or antisocial values? 165

those moments, or were you hooked by fusion with your thoughts and
engaging in experiential avoidance?
The goal of values work in ACT is to help people contact and expe-
rience the patterns of living they might choose if they were completely
free to choose. From an evolutionary perspective, the inherently
prosocial and co-operative nature of human beings makes it unlikely,
if people could genuinely be freed from the control exerted by their
histories, that they would freely choose antisocial or harmful values.
If clients choose words to name their values that seem antisocial, Le-
Jeune (2021) has outlined some useful reflective questions that practi-
tioners might ask themselves:

• When you experience a client talking about a ‘value’ that you

would label as harmful (e.g., racism/power/oppression), what is
the quality of that conversation?
• If you were to look beyond the words being said, what might you
notice?
• Is there a sense of free choice present?
• Is there willing vulnerability in the room?
• Does the energy in the room suggest liberty and vitality, or rigid-
ity, fear, and disgust?
• What is the body posture of the client? Does it suggest openness?

The questions above feel very ACT-consistent, and they are useful in
trying to move past the language that people use when describing their
values, to a deeper exploration of the motives that lie in their hearts.
Motivations that appear antisocial will often be reflective of rules that
have developed for survival, rather than of deeply held values. We
would refer the reader back to Chapter 17 for a more detailed explora-
tion of the difference between rules and values.
Chapter 49

The client says, “I’ve done

everything you suggested
but it hasn’t taken away
my discomfort”. What do
I do next?

As we outlined in Chapter 3, ACT views everything as behaviour. That

internal little scream that happens inside when clients say the above?
That’s behaviour too! May we take this opportunity to reinforce your
noticing skills and say “good noticing” to that little scream, and to
any of the sensations of frustration or panic that ensue. Of course,
our response to this statement depends on the context, and it might be
different if we hear this in session two, versus at the end of session 43.
This is a common statement, even from those clients that seem more
engaged in the ACT model. Ultimately it is a demonstration that the
client has still been holding onto a ‘fix it’ strategy in some capacity.
A point to reflect on when we hear it is where the most helpful place
to direct our attention might be. Often, it can be helpful to recap the
work that has been done already, thereby reinforcing the learning
about ACT as a model of behaviour change, rather than a model that
is driven by reduction of symptoms. We can look at this through the
different components of the Hexaflex and how they interact.

Values and committed action

So where do we start with our response? It may not be as drastic as
we might imagine. A helpful question to explore is whether, having
utilised some ACT techniques, the client is doing more of their value-­
driven activities. Logically it makes sense that we want to rid our-
selves of the discomfort of anxiety or low mood. It feels horrible in
both mind and body, and we observe that our world feels worse when
such feelings are around for us. In response, a common solution is to
run away, aiming to get as far away from the discomfort as possible.
This is an experientially avoidant pattern and suggests a difficulty or

DOI: 10.4324/9781003364993-55
 What do I do next? 167

unwillingness to be present with the content of our internal world.

Avoidance as a strategy works well for physical threats. Leaving the
room via the nearest exit is a completely workable strategy to avoid a
lion that may have strolled into your office. This strategy would work
time and time again. Each time the lion comes in, we make a sharp
exit to avoid the danger the lion presents. However, when we use this
same pattern of responses with internal stimuli, it is less effective be-
cause we cannot actually get away from whatever is going on inside
of us. Ultimately, avoidant behaviour results in our world becoming
smaller, and we get less and less reinforcement, either internally or
from the environment. The irony here, and where ACT differs from
other psychological models, is that we would fully expect anxiety to
increase if someone were to start doing more of what they care about.
It can therefore be a helpful starting point to enquire about their
value-­driven actions, because if they are committing to doing more of
them, it would be understandable that their discomfort has increased,
rather than gone away.

Acceptance
Should the client say that they are doing more in their lives that brings
them vitality, we might then spend time working on their understand-
ing of the frame of co-ordination that exists between values and dis-
comfort, checking that the client does not hold them in a frame of
opposition. As described in Chapter 24, what if the discomfort could
be seen as the price tag for doing the things in life that matter to them?
Would they be prepared to pay it? For example, is having a loving
relationship worth the feelings of insecurity and jealousy that might
show up from time to time? This conversation helps the exploration
of the client’s willingness to accept discomfort, which is an important
psychological flexibility skill.

Defusion
When clients say that they have tried everything we suggested and they
still feel discomfort, it can also be helpful to explore what thoughts
or narratives they may be fused with. Whilst there are many, one of
the most common words to look out for is ‘should’. When people use
this word, it suggests that they have rigid views about how the world
‘should’ work for them (Ellis, 1962). This demanding viewpoint can
168 Critical questions about ACT

often lead to a sense of frustration, injustice, or unfairness if the world

does not appear to be following the rule as it ‘should’. If someone has
suffered significant loss and bereavement it would be completely un-
derstandable if they felt that the world had dealt them a ‘bad hand’.
The thought, “No-one should have to go through this” may be the
consequence of many complex and unfathomable experiences. How-
ever, one might question whether being fused with this view of how
the world ‘should’ be is helpful to them living the life they want to
live? Assisting people to get some distance between their demanding
thoughts, tuning into their direct experience, and seeing the way the
world actually is can be a helpful skill to practice. Standing back from
such judgements, and choosing not to buy into them, is more likely to
facilitate movement toward greater value-driven living.

Contact with the present moment

One thing to check out with ‘discomfort’ is whether clients can consist-
ently be present with it, and accurately identify it for what it is. Some-
times, utilising the skill of contacting the present moment can help
people identify more nuance than perhaps they may initially notice.
Helpful ways of exploring this can include questions such as, “Is the
discomfort the same as it previously has been?”, “Is it permanent?”,
“Does it change at all? And if so, when, and how?” Acknowledging,
labelling, and exploring the discomfort, and therefore being present
with the experience of it can help clients with identifying the nuance of
it, moment by moment. Such present moment awareness can also pave
the way for the effective use of acceptance and defusion skills.

Self-as-context
Tuning into the observing part of the self can help clients see that their
whole self is bigger than any amount of discomfort they might feel.
Furthermore, developing a sense of self that includes a part that can
notice and choose how to respond to discomfort can enable a sense of
containment. This ‘noticer’ part might be encouraged to tune into the
values that are contained within the client’s experience, in addition to
the pain. The client could be prompted to consider what a value-driven
response to the thought, “I’ve done everything you suggested but it
hasn’t taken away my discomfort” might be.
 What do I do next? 169

It is important to remind ourselves that as practitioners we are not

there to steer someone’s responses to their thoughts in any specific
direction, or to judge whatever they might choose to do. We are simply
there to help them to have a different relationship with their thoughts,
emotions, and physiological sensations, and to make their own behav-
ioural choices from there. This has to be a workable solution for them,
and not one that we perceive as ‘better’. Ultimately, clients are free to
pursue a ‘fix it’ strategy, even if it means that they probably will not
gain much from ACT interventions.
Chapter 50

What do I do if a
technique does not work
out like it is supposed to?

Firstly, it would be helpful to explore a few of the key words in the

question. What do we mean by ‘does not work’, and, what do we mean
by ‘supposed to’? We can look at the first of these questions from two
different perspectives: a functional contextualist perspective, and the
perspective of a practitioner who experienced a different response
from the client than the one they predicted.
From a functional contextualist perspective, the idea of something
‘not working’ concerns it being unhelpful to the client’s goals. It sug-
gests that the chosen technique did not result in an outcome that
helped the client clarify the functions of their behaviour or find a help-
ful response within the context that they find themselves in. From a
functional contextualist point of view, there is no categorical ‘right’
or ‘wrong’ response in any given moment. There is only the consider-
ation of whether the person doing the behaviour was able to choose a
value-driven response, and whether their chosen action was helpful in
them making an effective toward or away move.
When most practitioners ask this question in an ACT training ses-
sion they are not doing so from a functional contextualist standpoint.
What they are more often referring to is the question of what to do
if a client gives a response to a technique that they were not expect-
ing. This requires us to explore what we mean by ‘supposed to’. This
speaks more to fusion on the part of practitioners. Our minds can lead
us to feel mighty stuck when we are comfortably working through a
technique only for it not to go to plan. The client’s response can sud-
denly lead to anxious thoughts like, “You weren’t meant to say that!”.
They were. Behaviour is not random. They were meant to say exactly
what they said. Their response was absolutely what was meant to hap-
pen because their current and historical context will have shaped their

DOI: 10.4324/9781003364993-56
 What do I do if a technique does not work out? 171

response to the world to be exactly what it was. It is only our fusion

with a specific desired or predicted outcome that feels inconsistent
with what is actually present in the room.
The model can help us here, as can Steven C. Hayes’s (n.d., c) four-
point plan for learning ACT (discussed in detail in Chapter 40). When
the unexpected happens, we can utilise our skills of noticing and
tracking processes, remind ourselves of the underlying foundations
of the model, identify the processes in action for the client, and utilise
our ACT toolkit to further explore what is helpful.
A technique ‘not working’ in sessions provides helpful data. Behav-
iour change intervention consists of an ongoing cycle of a­ ssessment –
formulation – intervention – reformulation – intervention etc. We
never stop assessing the data we are gifted with in sessions, and we
never stop formulating how all of that data fits together for the client.
When holding this in mind, we can then see that a technique not going
to plan can help us to reflect on our formulation, and what might re-
ally be going on for the client. That is sometimes different to what we
think is going on for the client. A good practitioner is humble enough
to be flexible in their work, to change their intervention based on the
newly acquired data that they are presented with. This is where the
underlying science and philosophy of the model are required, so you
can, with precision, alter your work accordingly. Some helpful ques-
tions could include:

• What new data does their response provide?

• Based on this new information, am I working on the most helpful
Hexaflex component in order to effect behaviour change?
• A key question to ask from a functional contextualist perspective
is, “Whether or not the client gave the anticipated response, was
the technique helpful to them in effecting behaviour change in
line with their values and goals?”

When reflecting on our work, especially the parts that do not go quite
as we may expect, it can be helpful to check on the function of utilising
any specific technique at any particular time. It is always possible that
the procedure we selected was not the most precise tool for the job
we wanted it to perform. The middle-level nature of ACT’s terms can
sometimes confuse our approach to the work, and more clarity can
come from carefully considering the process/procedure/outcome dis-
crimination. For example, if clients are fused with the literal meaning
172 Critical questions about ACT

of a word like ‘worthless’ it would make sense to address that with

procedures that target the process of fusion. However, as identified in
Chapter 30, there are different classifications of ‘defusion techniques’
that each function in slightly different ways. In this instance, selecting
a technique to specifically target the de-literalisation of words might
be indicated. Such a technique might help ‘worthless’ be experienced
more as an arbitrary sound that carries fewer aversive functions,
thereby changing the relationship that the client has with the word. In
this instance, you could introduce the client to a word repetition pro-
cedure. They would be asked to repeat “lemon, lemon, lemon” over
and over as fast as they can. Once they begin to experience the reduced
effect of the word ‘lemon’ on their salivary glands, they could practise
the same thing with ‘worthless’. This carefully selected procedure may
then lead to the intended outcome of the client being less hooked by
the impact of the word in their thoughts, which would then lead to an
increased opportunity for them to engage in value-driven behaviours.
In every aspect of ACT practice, it feels important for practitioners
to try and let go of the idea that there is an absolute right and wrong
way to do things. We can learn just as much from things that might be
perceived as going wrong, as from things that seem to run smoothly.
As the above example hopefully illustrates, the flexibility to revisit and
adapt the techniques that we use is a helpful quality for any practi-
tioner to possess, and, as always, the focus should be on the function
of any procedure, rather than its form.
Index
Note: Bold page numbers refer to tables; italic page numbers refer to
figures.
Acceptance and Commitment
Therapy (ACT): assumptions of
10–12; in contemporary context
1; describing ACT to a client 4–6;
introducing ACT to a client 79–81,
84–86; issues for which ACT is
recommended 7–9, 9; number of
sessions 118–120; philosophy and
theory of 3, 135–136; in practice
69, 115–117; relationship to other
therapies 32–35, 34; when to
choose ACT 73–75
acceptance part of ACT:
co-ordinating values 58; explaining
to a client 87–88; Hexaflex 113;
misconceptions 53–55, 167;
working with a client
100–102, 167
ACT for Life 116
ACT Matrix 11, 84–86
action see committed action
active listening 31
antisocial values 163–165
Association for Contextual
Behavioural Science (ACBS) 8, 77,
123, 132–133, 154
Australia, national guidelines 9
avoidance: discussing with a client
166–167; experiential avoidance
behaviour 28, 54, 161; toward and
away moves 62–64
awareness, tuning in to the present
moment 94–96
away see toward and away moves
Beck, J. S. 13, 109–111, 147
behaviourism 11
behaviours: as acts-in-context
11–12; client’s presentation 92–93;
functional contextualism 12,
17–18; as purposeful 12; toward
and away 22–24, 62–64; tuning
in to the present moment 95–96;
values, goals and rules 59–61
bias in psychology 145
cognition 33
Cognitive Behaviour Therapy (CBT):
Acceptance and Commitment
Therapy (ACT) as part of 1, 3;
differences with ACT 81; evidence
base 147–149; first wave 11, 33;
relationship to other therapies
32–35, 34; second wave 11, 33, 56,
147; third wave 11, 33–34, 81, 147,
153; traditional forms of 148–150,
149
cognitive function, in ACT client 75
174 Index
cognitive restructuring 33, 56
cognitive therapy 109
committed action: Hexaflex 114; and
values 58; working with a client 90,
166–167
compassion 65–67
Compassion Focused Therapy
(CFT) 65
competencies see skills as an ACT
practitioner
component studies 73–75
contextualism 16; see also functional
contextualism
creative hopelessness 37, 42–45,
92–93
critical questions about ACT 143;
discomfort and pain 160–162;
‘emperor’s new clothes’ criticism
151–153; evidence base 144–146;
harmful or antisocial values
163–165; and the medical model
157–159; need for ACT 147–150;
tools and techniques 154–156;
when ACT is not working 166–172
cultural context: disagreement
between the fields of medicine and
ACT 157–159; diverse populations
76–78; WEIRD nations 76–77, 146
cultural diversity 78
defusion: explaining to a client 88;
Hexaflex 114; relational frame
theory 71–72; and self-as-context
49, 50–51, 51–52; which procedure
to use 103–105; working with a
client 58, 167–168
de-literalisation 171–172
Dialectical Behaviour Therapy 33
didactic learning 128–130
discomfort experienced by ACT
clients 58, 160–162, 166
diverse populations 76–78
education see learning as an ACT
practitioner
ethics see moral relativism; values of
the client
evidence base for ACT 144–146; see
also research in ACT
evidence base for CBT 147–149
evoking behaviour 95, 101–102
evolutionary theory 13–15, 22
experiential avoidance 28, 54, 161
experiential learning 128–130, 135,
136
experiential methods in ACT
140–141, 154–156
flexibility see psychological flexibility
Focused ACT (FACT) 119
functional contextualism 16–18;
behaviours 11, 12; “it depends”
19–21; moral relativism 163–164;
toward and away 23–24; working
with a client 170–172
goals of the client 59–61; see also
values of the client
Hayes, Steven C. 126, 135, 171
Hexaflex: ACT as synonymous with
10; compassion 66; explaining each
component of 87–90; focussing
on key processes of 91–92;
introducing clients to 82–83;
mapping to the ACT Matrix 85,
86; mindfulness 46–47; working
with all processes 112–114,
119–120
historical context 11
hopelessness, creative 37, 42–45
human evolution 13–15, 22
human language 25
hurt experienced by ACT clients
160–162, 166
Inflexahex 82–83, 83
“it depends” 19–21
language 11; defusion procedures
104; de-literalisation 171–172;
functional contextualism 17; in
human decision-making 23; in
human evolution 14; metaphors in

ACT 28–31, 44; relational frame
theory 25, 26, 27; self-as-context
98–99; value-driven behaviour 110
learning as an ACT practitioner:
experiential vs. didactic 128–130;
lack of formal qualification 131–
133; ongoing supervision 138–141;
shaping your learning as an ACT
practitioner 134–137
the medical model 157–159
metaphors in ACT 28–31, 29, 44
mindfulness 46–48, 47; see also
present moment, tuning in to
Mindfulness-Based Cognitive
Therapy (MBCT) 33, 46
Mindfulness-Based Stress Reduction
(MBSR) 46
modelling behaviour 95, 100–101
moral relativism 12, 163–164
national guidelines on ACT 9, 9
National Institute for Health and
Care Excellence (NICE) 119
natural selection 14–15
the Netherlands, national guidelines 9
operant conditioning 56
pain experienced by ACT clients 58,
160–162, 166
peer consultation 136
perspective-taking skills 140
philosophy behind ACT 3, 11, 12,
16–18
practical skills 136–137
practitioners see skills as an ACT
practitioner
present moment, tuning in to
88–89, 94–96, 114, 168; see also
mindfulness
professional qualifications, lack of
formal ACT qualification 131–133
psychological distress 42–43
psychological flexibility 10, 38–41;
ACT in practice 115–117, 162;
building skills in 96; component
Index 175
studies 74–75; components of the
psychological flexibility model
91–93; creative hopelessness 45;
evidence base 144–145; experiential
learning 135; should ACT
practitioners practise ACT for
themselves? 125–127; tuning in to
the present moment 94–96, 95–96;
using the Hexaflex 112–113
psychotherapy applications 7–9
qualifications, lack of formal ACT
qualification 131–133
radical behaviourism 11
randomised controlled trials
(RCTs) 8
REBT 152
reinforcing behaviour 96, 102
relational frame theory (RFT) 25–27;
do I need to know RFT in order
to practise ACT? 70–72; link with
ACT 11, 145–146, 153; self-as-
context 98–99
replication crisis 145
research in ACT 8–9; component
studies 73–75; evidence base
144–146; experiential learning vs.
didactic learning 128–130; need
for ACT 147–150; should ACT
practitioners practise ACT for
themselves? 126–127; see also
critical questions
about ACT
respondent conditioning 56
rule-governed behaviour 60–61
self in ACT literature 97
self-as-context: and defusion 49–52,
51–52; explaining to a client 89;
Hexaflex 114; present moment
awareness 48; psychological
flexibility 162; working with a
client 97–99, 168–169
self-as-process 97
self-esteem 49–50
self-help approach 7
176 Index
Self-Practice/Self-Reflection (SP/SR)
126–127
self-report measures 144–145
sessions, number of 118–120
sexual behaviour 26–27
SHAPE model 141
skills as an ACT practitioner 121;
experiential learning vs. didactic
learning 128–130; lack of formal
qualification 131–133; ongoing
supervision 138–141; shaping your
learning 134–137; should ACT
practitioners practise ACT for
themselves? 125–127; tools and
techniques 154–156; what do I
need in place? 122–124
Skinner’s verbal behaviour theory
11, 25
SMART goals 59–61
stimulus functions 56–58
supervision, as an ACT practitioner
138–141
survival tactics 22, 62
symbolic learning 27, 56
theoretical foundations of ACT 3,
135–136
time limitations 118–120
toward and away moves 22–24,
62–64, 109–111
training see learning as an ACT
practitioner
transformation of stimulus functions
56–58
United Kingdom, national
guidelines 9
United States, national guidelines 9
values of the client: committed action
58; conflicts around 106–108;
discussing with a client 89–90, 166–
167; distinction from goals or rules
59–61; harmful or antisocial values
163–165; moral relativism 12,
163–164; should ACT encourage
value-driven behaviour? 109–111;
supervision 139
WEIRD (Western, educated,
industrialised, rich, and
democratic) nations 76–77, 146
World Health Organization (WHO)
7, 119