ACT
Basic principles
Acceptance of what you can't change
Commitment to change what you can change (willingness to move forward)
Transdiagnostic
Holistic
Experiential avoidance and cognitive fusion are heart of categories: results in psychological inflexibility
Cognitive fusion: by in to negative thoughts about self = experiential avoidance (should seeing them as just thoughts)
Symptom reduction not primary focus: attempts to build broad and flexible behavioural repertoires even when psychological discomfort is present
Build broad and flexible behavioural repertoires in the presence - promoting psychological flexibility
What is working and what is not working? Workability
Evidence
Effective across a wide range of disorders
Strong support: chronic pain
Modest support: OCD, depression, mixed anxiety, psychosis
Outcome variables: same symptoms but less functional disability
CBT and ACT
CBT focuses on symptoms (antecedent), ACT focuses more on responses
CNT focuses on changing on cognition, ACT operates changing function of cognition
CBT: critical rationalism (Popper, 1959); ACT: workability, functional contextualism
Functional contextualism: function of behaviour, context (not fixed sense of self), normalise not pathologise, tailored interventions - What is the function? What strategies? Is it working? What has it cost him?
6 core principles
Contact with the present moment
Why transdiagnostric? Dual diagnoses, comorbidity is more the norm than the exception, viewing the person as whole
Psychological discomfort and suffering is a normal part of life
Why does it matter what the function of behaviour is? Therapeutic alliance (understand clients experience and life), self-awareness/insight, fosters self-compassion, tailored interventions
The goal of ACT is promoting psychological flexibility
Values (values exercises - cars, bullseye)
Committed action
Self as context
Defusion
Acceptance
Summary
Understanding context - things that may have been functional, may now be dysfunctional (functional contextualism and compassion)
Seeing that you are not your thoughts and feelings but they often influence you (present moment awareness and defusion)
Understanding that we spend a lot of our time trying not to experience things because we're afraid (experiential avoidance vs. acceptance)
Helping to shift people's perspectives of themselves and how they relate to things (self-as-context and perspective taking)
The pursuit of values despite thoughts and fears (values and committed action)
ACT Made Simple (Harris)
ACT assumes that even in the midst of tremendous pain and suffering, there's an opportunity to find meaning, purpose and vitality: aiming to help people learn and grow as a result of their suffering
Two normal processes of the normal human mind: cognitive fusion and experiential avoidance
Cognitive fusion
In a state of cognitive fusion, person is inseparable from thoughts, thoughts dominate our behaviour, lose contact with the world of direct experience - defusion means separating from thoughts and taking a step back and seeing them for what they are, engage fully in our experience
Experiential avoidance
Means trying to avoid, get rid of or escape from unwanted private experiences (any experience you have that no one else knows about)
Workability: 'Is that you're doing working to make your life risk, full and meaningful?', does a thought help a client to move toward a richer, fuller, and more meaningful life - not change content, fusion with thought that create problem
Increases suffering: higher experiential avoidance is associated with anxiety disorders, excessive worrying, depression, poorer work performance, higher levels of substance abuse, lower quality of life, high-risk sexual behaviour, BPD
Why does ACT not focus on symptom reduction? To do so is likely to reinforce experiential avoidance, the very process that fuels most clinical issues, and attempts to reduce symptoms can increase them
ACT advocates acceptance under two circumstances: (1) when control of thoughts and feelings is limited or impossible, (2) when control of thoughts and feelings is possible, but the methods used reduce quality of life,
Six core pathological process
Fusion: entanglement in our thoughts so that they dominate our awareness and have a huge influence over our behaviour
Experiential avoidance: means trying to get rid of, avoid or escape from unwanted private experiences such as thoughts, feelings and memories (fusion and avoidance generally go hand in hand)
Dominance of the conceptualised past and future/limited self-knowledge: loss of contact with our here-and-now experience and get caught in a conceptualised past and future - if we lose contact with our inner psychological world, then we lack self-knowledge
Lack of values clarity/contact: behaviour driven by fusion with unhelpful thoughts or attempts to avoid unpleasant private experiences - if we're not clear about our values or not in psychological contact with them, then we can't use them as effective guide (behaviour under influence of values)
Unworkable action: patterns of behaviour that pulls us away from mindful, valued living; patterns of action that do not work to make our lives richer and fuller, but rather het us stuck
Attachment to the conceptualised self: if we fuse with the story (conceptualised self or self-as-content) of ourselves, it creates problems
Suitable for: anxiety, depression, OCD, social phobia, GAD, schizophrenia, BPD, workplace stress, chronic pain, drug use etc.
Hofmann & Asmundson (ACT vs. CBT)
CBT and ACT both encourage adaptive emotion regulation strategies but target different stages of generative emotion process: CBT promotes adaptive antecedent-focus emotion regulation strategies (reappraisal), whereas ACT counteract maladaptive response-focused emotion regulation strategies
CBT: establishing a good therapeutic relationship, problem focus (negative automatic thoughts occur in specific situations when individual feels threatened/dysfunctional beliefs are assumptions about the world), challenging irrational thoughts, testing validity of thoughts, substituting irrational thoughts with rational thoughts and eliciting feedback
ACT
Individuals who show high levels of experiential avoidance rely on suppression, avoidance, and other control tactics
Psychological flexibility: defines as 'the ability to contact the present moment more fully as a conscious human being, and to change or persist in behaviour when doing so serves valued end'
ACT's critique of CBT
CBT is based on mechanistic realism: CBT does not mean that the therapy is limited to cognitive modification
CBT is overly symptom-focused: not the symptom per se, but the cognitive distortion and misinterpretation that underlies
The link between cognitive therapy and basic cognitive science is weak
None of the techniques developed in CBT have emerged from basic science laboratories: not corroborated by available evidence
Component analysis studies have failed to find support for the importance of direct cognitive change strategies: real questions is do changes in cognitions mediate changes in symptoms?
The response to traditional cognitive therapy often occurs before cognitive change techniques have been implemented: sudden gains of cognitive changes before symptom changes occur are neither a sufficient nor a necessary criterion for treatment mediation
Support for the hypothesised mediators of change in CBT are weak
Difference between CBT and ACT
Role of cognitions
Role of emotions
Both problem-focused: ACT targets experiential avoidance (maladaptive response-focused); CBT focus on emotion-eliciting stimulus (antecedent-focused)
Philosophical foundation: ACT based on functional contextualism, CBT based on critical rationalism
Mindfulness-based cognitive therapy: seek to change function of events and relationships to them through mindfulness
Hayes
Contextual behavioural science (CBS): principle-focused, inductive strategy of psychological system building that emphasizes developing interventions based on theoretical models tightly linked to basic principles that are themselves constantly upgraded and evaluated
ACT - functional contextualism: by adopting a functional approach to truth and meaning linked to the prediction and influence, with precision, scope and depth, of whole organisms interacting in and with a context considered historically and situationally
While functional contextualists assume the one 'real' world, there may be many of successfully differentiating the world, depending on one's goals
Models that specific the relation of one psychological action to another are viewed inherently incomplete until they identify the contextual variables that would allow in principle for the goal of influence to be met
Manipulable contextual factor are specified by behavioural principles that apply in a specific way to a given event (precision), are broadly applicable (scope) and that maintain coherence across levels of analysis (depth) - CBS is asking clinicians to help develop the basic work needed to support application, and by organising principles into models and theories
RFT: relational frames (infancy) - regulated by two features: relational context (what you think) and functional context (psychological impact of what you think) - functional context determines impact of relational responding
Six key processes
Cognitive fusion (word repetition): verbal dominance over behavioural regulation to the exclusion of other sources of stimulus control - RFT argues that it is safer to create more flexible responding by diminshing excessive impact of cognitive events: Defusion involves creation of nonliteral contexts that diminish unnecessary regulatory functions
Experiential avoidance: attempt to alter form/frequency/intensity of private experiences such as thoughts, feelings etc., emotions or private events are evaluated negatively and avoided (avoidance learning) - acceptance (increasing persistence in distressing tasks), adoption af intentionally open, receptive and flexible posture
Loss of flexible contact with present: contexts take individual out of flexible contact with the present - ACT promotes attending to what is present in a focused and flexible fashion, linked to values and purposes, sense of 'self as process' is encouraged
Attachment to a conceptualised self: undermine this and promote contact with a sense of self based on 'I/here/nowness' of conscious experience - RFT, sense of locus derives from learning 'deitctic relational frames', limits of perspective cannot be consciously known (mindfulness)
Values problems: increasing the ability to persist or change in behaviour in the service of one's chosen values - values direction not destination - problems: lack of clarity, based on pliancy, avoidant tracking = finding a direction
Inaction, impulsivity, or avoidant persistence: development of larger patterns of effective action linked to chosen values, undermining inaction etc. - in ACT, exposure is organised contact with previously repertoire-narrowing stimuli in a context designed to produce flexibility
The goal of ACT: psychological flexibility (importance of flexible behaviour, cognition and emotion), being able to contact the moment as a conscious human being more fully; the six processes, mindfulness and commitment and behaviour change processes
From an ACT/RFT approach, psychopathology is caused by the tendency to become entangled in cognition
Mediation: if mediation fails - important to see if failure was due to failures of technology (not impact processes of change) or limitations of model
Critique of current contextual behavioural science approach: where is ACT in this and why does CBTs have so much power? Human suffering that exists because of scientific ignorance
Cognitions are thought processes in CBT; cognitions under behaviour in ACT - ACT focus primarily on changing the function of cognitions, instead of changing the cognitive content