Acceptance and

Commitment Therapy (ACT)

Hailemariam Hailesilassie (Assistant professor of clinical psychology)
Psychiatry Department
Jimma University

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 Definition: ACT

• Teaches patients to accept, rather than control or eliminate, private

experiences that are not amenable to first order change.

– Patients see private experiences as conditioned verbal

responses, rather than literal truth.

• ACT sessions ranges from 4 to14

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• ACT assumes that psychological processes of the normal mind

naturally lead to suffering/distress

• Encourage patients approach valued life goals, even though pursuing

such goals may stimulate “uncomfortable” private experiences

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Theoretical bases of act

• ACT is developed from relational frame theory (RFT)

– A psychological theory of human language

– Developed by Steven C. Hayes (1980s) of University Nevada,

Reno and Dermot Barnes-Holmes of National University of Ireland,
Maynooth

– RFT argues that the building block of higher cognition (reasoning)

is ‘relating’, i.e. the human ability to create links between things:
human language and
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behavior
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• ACT:
– applies mindfulness and acceptance processes, and commitment
and behavior change processes, to the creation of psychological
flexibility

– Patients engage in values-based behaviors even while

experiencing difficult or unwanted thoughts, feelings, and
sensations

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 Destructive Normality
• ACT assumes that the psychological processes of a normal human mind are
often destructive, and create psychological suffering for us all, sooner or
later.

• ACT postulates that the root of this suffering is human language itself.

• Memories/perceptions/schemas are created through analyzing, comparing,

evaluating, planning, remembering, visualizing- and all of these processes
rely on human language.

• I am stupid vs. I have the thought that I am stupid

• I cannot go on vs. I am feeling like I cannot go on

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 Psychological flexibility

• Is the ability to contact the present moment fully as

a conscious historical human being and, based on

what the situation affords, changing or persisting in

behavior in the service of chosen values (-Hayes)

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 Assumptions of ACT

• Pain in life is inevitable

• Normal verbal processes contribute to psychopathology

• Control is best applied where it works-to overt behavior rather

than to thoughts, feelings, and sensations

• “The aim of ACT is to create a rich, full, meaningful life while

accepting the pain that inevitably goes with it (Haris, 2009)

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 ACT model

Contact with the

present moment

Acceptance Components of
ACT = Psychological Values
flexibility

Committed
Diffusion action
Self-as-
perspective

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 The Goal of ACT
• To create a rich and meaningful life, while accepting the pain that inevitably goes with it.

• Who is important?
• What is important to me? (values, things, experiences)

• To take effective action guided by patient’s deepest values

• To increase psychological flexibility:

1. ability to be psychologically present – i.e. aware, attentive, open to, and

engaged in your experience;
2. ability to control your behavior to serve valued ends
• In ACT, there is no goal of symptom reduction. Symptom reduction frequently happens,
but it is simply a fortuitous byproduct, not a goal

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 Experiential avoidance

• Deliberate attempts to avoid,

control, suppress, escape, or

get rid of negatively evaluated

or unwanted thoughts, feelings

and body sensations

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 Experiential avoidance

• The more time and energy we spend trying to avoid

or get rid of unwanted private experiences, the more

we are likely to suffer “quicksand”

– Addiction

– Anxiety

– Depression

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 Higher avoidance scores are associated with:

– Higher anxiety – High risk sexual behavior

– More depression – BPD symptomatology and
– More overall pathology depression
– Poorer work performance – Thought suppression
– Inability to learn – Anxiety sensitivity
– Substance abuse
– Long term disability
– Lower quality of life
– Greater severity of PTSD

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 Experiential avoidance..

• The ACT interventions focus around two main processes:

• Developing acceptance of unwanted private experiences

which are out of personal control

• Commitment and action toward living a valued life

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struggle switch/ clean & dirty discomfort
With the struggle switch ON With the struggle switch OFF

• Our emotions are stuck. • Our emotions are free to move.

• We waste a huge amount of • We don’t waste time and

time and energy struggling with energy fighting or avoiding
them. them.
• We create a lot of painful and • We don’t generate all that
unhelpful “dirty discomfort.” “dirty discomfort.”

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 Six Core process/ Principle of ACT

• Apply six core process of ACT to help clients develop

psychological flexibility:
1. Defusion
2. Acceptance
3. Contact with the present moment
4. The observing self
5. Values
6. Committed action
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(Willingness = Defusion, Acceptance, Contact with the Present Moment)

1. Cognitive Defusion

– Overall purpose: to catch psychological activities processes in flight, and

bring them under contextual control, so that they can be looked AT rather
than looked from.

– (More simply: Looking at thoughts, rather than from thoughts

– Noticing thoughts, rather than being entangled in thoughts

– Seeing thoughts as what they are – just pictures, words, and sounds)

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Defusion Techniques:

• Repetition – eg Khat, Khat, or • See thoughts on a

• Pop-up thoughts (children should computer/TV screen –
be seen and ….)
change font, case, colour
• I’m having the thought that …
(+/- bouncing Karaoke ball)
• I notice that I’m having the
thought that …… • Radio doom & gloom
• Hear thoughts sung to Happy • Thank your mind
Birthday – or other tunes
• Naming the story
• Hear thoughts in silly voices

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In Cognitive Fusion:
• Thoughts are Reality; it’s as if what we’re thinking is actually
present, here and now!
• Thoughts are The Truth; we literally believe them!
• Thoughts are Important; we take them seriously, and give
them our full attention!
• Thoughts are Orders; we automatically obey them!
• Thoughts are Wise; we assume they know best and we follow
their advice!
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In Cognitive Defusion:
• Thoughts are merely sounds, words, stories, bits of language,
passing through our heads.
• Thoughts may or may not be true. We don’t automatically believe
them.
• Thoughts may or may not be important. We pay attention only if
they’re helpful.
• Thoughts are not orders. We don’t have to obey them.

• Thoughts may or may not be wise. We don’t automatically follow

their advice.
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Helpful questions for unhelpful thoughts

– Is this thought in any way useful or helpful?

– Is this an old story? Have I heard this one before?

– What would I get for buying into this story?

– Could this be helpful, or is my mind just babbling on?

– Does this thought help me take effective action?

– Am I going to trust my mind or my experience?

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Observing Thoughts
– Find a comfortable position.
– Close your eyes.

– Imagine a stream, with leaves floating down (or a moving black strip)
– As thoughts appear, place them on the leaves and let them float past
(or place them on the moving black strip and let it carry them past)
– Whenever you get hooked by thoughts, gently unhook yourself and
carry on.
– Do this once or twice a day for 3 to 5 minutes.

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2. Acceptance
– Acceptance = willingness = mindfulness
– Two countries at war metaphor
– Cultivate willingness to feel unpleasant emotions
in order to do something of value
– Discriminate willingness from tolerating/
resignation
– You don’t have to like it, want it, approve of it, in
order to accept it.
– Acceptance = making peace, letting go of the
struggle
– Demons on the Boat
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Acceptance of Difficult Content
– Mindfulness of physical sensations
– Observe; Breathe; Expand; Allow

– Pick the strongest sensation; observe it like a scientist – non-

judgmentally, without trying to interfere; accept it; repeat with next
sensation etc
– Visualise feelings as objects: shape, colour, weight, temperature,
texture etc.
– I’m having a feeling of …

– This is a feeling of __ and I’m evaluating it as__

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 Emotional acceptance
• 4 Quick Steps To Emotional Acceptance
– 1. OBSERVE. Bring awareness to the feelings in
your body.
– 2. BREATHE. Take a few deep breaths. Breathe into
and around them.
– 3. EXPAND. Make room for these feelings. Create
some space for them.
– 4. ALLOW. Allow them to be there. Make peace
with them

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3. Contact With The Present Moment
– Any mindfulness exercise, eg breath, stretching, sounds,
food
– Notice your feet on the floor; your body; your breathing
etc.
– 5-5-5 technique: Notice 5 things you can: hear, see, feel
- right now

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 What is Mindfulness?
• “consciously bringing awareness to you’re here-and-now
experience with openness, interest and receptiveness
• Facets to mindfulness
• Living in the present moment

• Engaging fully in what you are doing rather than “getting lost” in
your thoughts
• Allowing your feelings to be as they are, rather than trying to control
them
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 4. Observing self : Self-as-context
• Spirituality and transcendence as human experiences
• Observer exercise: notice who is noticing; notice what doesn’t
change
• From this perspective, it is possible to experience directly that you
are not your thoughts, feeling, memories, urges, sensations,
images, roles, or physical body
– These phenomena change constantly and are peripheral
aspects of you, but they are not the essence of who you are

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5. Values
– What do you really want?
– What do you want your life to stand for?
– What sort of person do you want to be?
– What sort of relationships do you want to build?
– How do you want to act/behave in the world/ towards others/ towards yourself?
– What do you want to do with your life?
– Values first - then goals/actions

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• Stages of values work
1. Defining life values
2. Defining life activities
3. Dealing with barriers to valued living

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 Example

• If she does not attend

• A woman diagnosed with Panic Disorder
the graduation to avoid
with Agoraphobia
a
• Important value is parenting panic attack, she is not

• Woman’s daughter will graduate from high living in accordance

with her parenting
school soon, and she would very much like
value
to attend graduation...but
• She is afraid of having a panic attack in the
large auditorium where commencement is
held

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• Instead of making therapy about how to get rid of panic attacks,

therapy is about how to be at her daughters graduation, in spite of

panic attacks (exposure ? psychological flexibility)

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6. Committed Action
– Is Not a promise.
– is Not a prediction.
– Is Not an attempt to be perfect.
– It means: commitment to a valued direction.
– Take it for granted that you will go “off-course”, and “stuff
up” again and again and again.
– Commit to getting back on track again, as soon as you
realize what has happened.
– Clarify: values / goals / actions / barriers
– DAVE cycles (defusion/acceptance/ values/engagement) -
build ever larger patterns of behaviour
• Committed action = mindful, valued, effective action
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 who can benefit from ACT?

• Substance abusers

• People suffering from chronic pain and medical illness

• Patients with:

– obsessive thoughts

– anxiety

– depression

– Psychosis
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 ACT: Summary
• The goal of ACT is to increase a rich and meaningful life, while accepting the
pain that inevitably goes with it
• Being aware and present in the moment
• Destructive Normality the psychological processes of normal human mind
are often destructive, and create psychological suffering. “this is depressing.
I am helpless.”
• Therapeutic interventions focus around two main processes:
– Developing acceptance of unwanted private experiences which out of
personal control.
– Commitment and action toward living a valued life.
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 ACT: Summary

• Six core processes of ACT

1. Diffusion-separate self from feelings/experience

2. Acceptance-accept what it is

3. Contact with the present moment-mindfulness

4. The Observing Self-fly on the wall

5. Value identification

6. Committed action
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