19

Acceptance and Commitment

Therapy
Eric B. Lee, Benjamin G. Pierce, Michael P. Twohig, and Michael E. Levin
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T his chapter provides a basic overview of acceptance and commitment

therapy (ACT; Hayes, Strosahl, & Wilson, 2011), with the aim of allowing
professionals to learn the basics of ACT and providing guidance on how to
more fully “dig in” to learn more. We first discus the historical context in
which ACT was developed and its theoretical foundations. We then introduce
ACT concepts and familiarize the reader with some of ACT’s vernacular. A
case example is used to illustrate the practical use of these concepts in a treat-
ment setting.1 Finally, we provide a brief review of the literature, describing
areas and populations in which ACT might be best utilized and where mental
health professionals can find further information.

BRIEF HISTORY

ACT is a modern cognitive behavioral therapy (CBT), sometimes referred to as

contextual CBT, to recognize its emphasis on the context in which behavior
occurs for conceptualizing and treating psychological problems (Hayes, Villatte,
et al., 2011), or as a “third-wave CBT” to recognize its differences from more
traditional CBT (Hayes, 2004). Before presenting the key features of ACT and
its clinical application, we briefly review the history of ACT’s development to
contextualize its defining features and points of departure from traditional CBT
(see Zettle, 2005, for a more in-depth review).

1
Clinical examples are disguised to protect patient confidentiality.

https://doi.org/10.1037/0000218-019
Handbook of Cognitive Behavioral Therapy: Vol. 1. Overview and Approaches, A. Wenzel (Editor)
Copyright © 2021 by the American Psychological Association. All rights reserved.

Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A. Wenzel 567
Copyright © 2021 American Psychological Association. All rights reserved.
 568 Lee et al.

Early development of ACT began in the 1970s–1980s with research by Dr.

Steven C. Hayes and his colleagues on rule-governed behavior and verbal
behavior (e.g., Hayes et al., 1986; Zettle & Hayes, 1983). This research was con-
sistent with the growing interest in cognitive phenomena in understanding and
treating psychological concerns but sought to pursue this aim from a behavior
analytic framework emphasizing the context and contingencies that govern the
impact of thoughts on behavior. Examples included a behavioral interpretation
and empirical analysis of coping self-statements (Zettle & Hayes, 1983) and the
impact of verbal rules on behavior (Hayes et al., 1986). This early body of litera-
ture led to research evaluating whether the cognitive distancing component of
cognitive therapy, reducing the literal functions of cognition by noticing
thoughts as just thoughts, was effective relative to full cognitive therapy in
treating depression (Zettle & Hayes, 1986). Referred to as comprehensive distanc-
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ing, this was the precursor of ACT, representing a behavior analytic interpreta-
tion of the way in which cognition affects behavior and a proposed explanation
for the way in which cognitive therapy improves mental health. This line of
scholarship resulted in a refined intervention focused on targeting the func-
tions of thoughts by altering the context in which they occur. In other words,
ACT shared the interests of other so-called second-wave CBTs in understanding
the role of cognitive processes, but it sought to do so using the “first-wave”
paradigm of behavior therapy and behavior analysis (Hayes, 2004).
Although early development and evaluation of ACT occurred in the 1980s,
subsequent randomized controlled trials (RCTs) and broader implementation
efforts did not start until the mid to late 1990s. During this second period of
ACT development between the mid-1980s and 1999 (Zettle, 2005), a heavy
emphasis was placed on developing a more adequate behavioral account of
language and cognition to provide a stronger theoretical and basic scientific
foundation for ACT. The most notable development during this period was rela-
tional frame theory (RFT; see Hayes et al., 2001, for the first book-length publica-
tion), which provided a modern behavioral account of these verbal processes.
This work was essential for clarifying the way in which verbal processes influ-
ence behavior and alter the effects of direct learning histories, providing the
basic principles upon which to develop contemporary ACT theory and inter-
vention strategies. This emphasis on such connections to basic behavioral
research is a defining feature of ACT and some other third-wave CBTs that seek
to include complex human behavior and phenomena such as cognition and
affect in their models, but using the contextual framework developed in earlier
behavioral approaches.
Following this period of basic research and theoretical refinement, the first
book-length description of ACT was published in 1999 (Hayes et al., 1999),
which has led into a subsequent period of rapid development, research, and
dissemination of ACT that continues today. For example, the third RCT on ACT
was published in 2000 (Bond & Bunce, 2000), and the number of RCTs has
increased exponentially, with over 200 RCTs published to date and approxi-
mately 28 published in 2017 alone. ACT is now recognized on various empiri-
cally supported/evidence-based treatment lists, such as the American
 Acceptance and Commitment Therapy 569

Psychological Association’s Division 12, the Society of Clinical Psychology. The

Association for Contextual Behavioral Science (ACBS) was founded in 2005,
providing an organization for ACT, RFT, and other modern behavioral
approaches, and has a current membership of over 7,000 members internation-
ally. This rapid growth in research and dissemination of ACT is due in part to
the early, careful theoretical and basic research done before 2000, which pro-
vided a strong philosophical, basic science, and theoretical basis for subsequent
development and evaluation of ACT (Hayes et al., 2013).
The next section of this chapter considers the philosophy of science and
basic behavioral principles that inform the ACT model of psychopathology and
intervention. ACT is defined more by a set of theoretical pathological processes
and processes of change rather than by specific techniques. Thus, understand-
ing the basic philosophy and principles underlying the ACT model can help one
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understand how they are then flexibly applied in practice.

THEORETICAL FOUNDATIONS
Functional Contextualism

ACT is founded in the philosophy of functional contextualism (Hayes et al.

2013). Functional contextualism advances the idea that the truth criterion for anal-
ysis should be defined by what is effective in predicting and influencing behav-
ior. In other words, an account is true insofar as it is successful in identifying the
conditions under which a behavior occurs and can be changed. This pragmatic
approach provides the foundation for the scientific strategy and approach to
theory used in ACT (Hayes et al., 2013) and echoes into clinical practice.
One result of adopting a functional contextualist viewpoint is a heavy
emphasis on what works for clients being defined by their own experiences and
goals. Although this is common across many therapies, ACT places a particu-
larly strong focus on identifying clients’ values and evaluating what works in
relation to moving toward these values (including case conceptualization,
treatment plan, current coping strategies, and therapeutic methods). In other
words, what is true is what works for clients in living the life they want to live.
Another result is the stance that behavior is only understood in context.
ACT emphasizes the contexts that govern the relations between thoughts, feel-
ings, and behavior because these contexts are where a therapist would inter-
vene. For example, understanding that a depressed thought leads to withdrawal
does not directly identify how to change this pattern, whereas understanding
the external conditions that lead to this depressed thought or the impact of the
thought on behavior would (i.e., what could be changed to make the thought
less likely or what would make the thought not lead to this behavior).

Behavior Analysis and RFT

Behavior analysis and RFT offer the analytical lenses for functional contextual-
ism through which the interactions between behavior (including cognition)
 570 Lee et al.

and context can be understood for prediction and influence. ACT can be under-
stood as part of behavior analysis, with behavior analysis sharing the same
functional contextual roots as ACT. Behavior analysis provides the foundation
and basic research for understanding the way in which context influences
behavior to either increase or decrease the probability of that behavior recur-
ring in the future. As noted in the previous section on history, however, tradi-
tional behavior analytic accounts of human behavior did not adequately
address complex human behaviors relevant to cognition that are of critical
importance for some applied domains, including psychotherapy (Zettle, 2005).
RFT, as a modern behavior analytic account of cognition (Hayes et al., 2001),
thus provides a second analytic lens to explain the way in which cognition
might influence behavior and the impact of context on behavior in ways that
go beyond direct learning histories accounted for by traditional behavior ana-
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lytic principles. In other words, RFT offers a framework for applying behavior
analytic principles to more complex human behavior and phenomena. Let us
take a brief example of how RFT expands the ability to account for complex
behaviors, difficult to understand just with reference to direct learning experi-
ences. Suppose an individual receives the message that people who cry are
“weak” and relates the behavior of crying to feeling sad. In turn, the individual
may attempt to avoid or suppress feelings of sadness to also avoid the notion of
being a “weak person.” In the absence of any direct learning history (i.e., being
punished by others for crying), crying has become something important to
avoid through these verbal relations.
Behavior analysis and RFT provide the foundation for ACT’s theoretical
model. For example, practitioners of ACT posit that a key process that contrib-
utes to psychopathology is experiential avoidance, in which individuals engage
in rigid patterns of behavior to avoid, escape, or otherwise change internal
experiences (e.g., thoughts, feelings). RFT provides the basic principles for
understanding why individuals might experience an expanded set of stimuli as
aversive experiences to be avoided at all costs. From an RFT perspective, a core
aspect of cognition is the ability to arbitrarily relate any stimulus to any other
stimulus and to derive further relations beyond those directly learned (Hayes et
al., 2001). For example, someone could learn that the symbols “C-A-T” are the
same as the audible utterance “cat” and that the utterance “cat” is the same as
an actual live cat in the room. A unique aspect of this relational behavior is that
the person can automatically derive that the actual live cat is the same as the
symbols “C-A-T” despite this not being directly learned. Furthermore, if that
person then gets scratched by the actual live cat, they might avoid going to a
house they are told “has a cat” despite a lack of any direct history. This process
of arbitrarily applying and deriving relations and the transformation of func-
tions due to these relations could quickly lead to avoiding a whole host of situ-
ations that are now associated with potential cats. As another example with
more complex/abstract phenomena, a person might learn to relate social rejec-
tion to ugliness and sadness to social rejection, and they may derive a relation
between sadness and “ugliness” and may also relate sadness to rejection and
 Acceptance and Commitment Therapy 571

ugliness to rejection in the absence of direct training of these relations (Fig-

ure 19.1). They may, in turn, avoid expressing feelings of sadness in their rela-
tionship to avoid being perceived as “ugly” and being rejected, as the function
of sadness has been transformed. In turn, this may impede their ability to con-
nect authentically in their relationships in the presence of sad emotions. Thus,
RFT provides a framework for understanding how humans can come to contact
an expanded array of aversive experiences and engage in broad patterns of
avoidance despite the negative consequences of doing so.
Another pathological process identified in the ACT model that is closely con-
nected to RFT is cognitive fusion, in which people’s behavior is rigidly controlled
by verbal rules and cognitions rather than direct contingencies or personal val-
ues (Tórneke et al., 2008). For instance, say the person above derives a rule that
“crying results in being rejected.” This person may later have problems effec-
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tively expressing negative affect, even when it may be appropriate to do so

(e.g., at a funeral, upon hearing another person’s loss). This rule unnecessarily
restricts the person’s actions by reducing their sensitivity to immediate cues,
such as others crying or displaying sadness, and it may interfere with other
potentially adaptive behaviors, such as expressing empathy. In turn, following
this rule detracts from the person’s ability to engage effectively in their relation-
ships with others, which may have negative consequences. RFT provides a
framework for understanding how someone’s behavior can be more strongly
affected by a verbal rule (e.g., how things should work and what one should
do) than direct learning history (e.g., what actually happens when one follows
this rule).
In summary, RFT allows for the application of behavior analytic principles to
a functional contextual understanding of psychopathology within ACT. Due to
the ability to arbitrarily relate internal events via relational framing, internal
experiences (e.g., thoughts, emotions, memories) can acquire the function of
promoting avoidant behavior in the absence of an immediate threat or previous
learning history. This avoidant behavior can inappropriately generalize to a

FIGURE 19.1. Direct and Derived Relational Associations

Rejection Sadness

“Ugly”

Direct Relation
Derived Relation
 572 Lee et al.

wide range of situations, including contexts in which sensitivity to external or

social cues would support more effective responses. This rigidity ultimately
impedes the individual’s ability to choose behavior that would support living a
vital life, resulting in further distress and diminished life quality.
Within ACT, this behavioral rigidity is often described as psychological inflexi-
bility, referring to behavior that is rigidly under the control of internal experi-
ences, or efforts to avoid such experiences, at the expense of living consistently
with one’s personal values. ACT attempts to build psychological flexibility as a way
to help clients engage in values-consistent behavior while being mindful of the
present and accepting whatever internal experiences arise. ACT aims to alter
the context in which internal experiences occur, changing how an individual
relates to these experiences (i.e., their function) to increase their capacity to
engage in effective, valued actions. With the previous example of someone for
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whom sadness impinges on relationship values, ACT would help clients respond
more flexibly to sadness and rules about vulnerability, such that they could be
vulnerable with their partner when it is effective or meaningful to do so. In
other words, ACT would involve helping clients choose behaviors based on
what would be effective or meaningful in the moment, rather than based on
inflexible verbal rules or avoiding unwanted thoughts and feelings.

The ACT Model

The ACT theoretical model consists of six relational and behavioral processes
thought to support psychological flexibility (Hayes, Strosahl, & Wilson, 2011;
see Figure 19.2). Each process is defined functionally, meaning that it describes
how people respond to their experiences instead of the specific contents of
those experiences. Each process is described in terms of the pathological process
that contributes to psychological inflexibility and the opposing therapeutic pro-
cess that increases flexibility. These processes are further explored through a
case example.
Cognitive fusion refers to responding to one’s thoughts as if they are literally
true, such that they dominate one’s experiences and actions. This process
reduces an individual’s flexibility by restricting their available choices of behav-
ior in the presence of specific thoughts. For example, someone fused with the
thought “I’m too shy for public speaking” may avoid public speaking whenever
they feel shy; hence, they are limited by this thought. Conversely, defusion
refers to the process of responding to thoughts in a nonliteral way and choosing
one’s behavior despite the thoughts that arise. Defusion is practiced by relating
to cognitions in ways that do not support their literal meaning, such as by
repeating a thought over and over until it loses its meaning, or acknowledging
one’s thoughts with the preface “I’m having the thought that . . .”
Experiential avoidance refers to excessive efforts to avoid or control unwanted
thoughts, feelings, or other internal experiences. As noted previously, this is
defined functionally such that just about any action could be done in the ser-
vice of moving away from unwanted inner experiences (e.g., thought suppres-
 Acceptance and Commitment Therapy 573

FIGURE 19.2. The Acceptance and Commitment Therapy Process of Change

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sion, mindfulness, substance use, exercise, seeking reassurance, procrastinating,

working). In contrast, acceptance refers to the process of choosing to respond to
unwanted feelings by openly experiencing them instead of trying to control,
avoid, or otherwise react to them. The practice of acceptance involves the active
choice to have an internal experience to its full extent, without changing one’s
behavior to suppress or change it. This includes valued actions typically avoided
due to unwanted thoughts and feelings, while allowing whatever internal
experiences arise to naturally come and go. In this way, acceptance is often
framed in the context of being in the service of moving toward one’s values
(i.e., doing it because it works to help you do what matters) rather than for its
own sake.
Loss of contact with the present refers to when an individual’s experience is
dominated largely by thoughts about the past and future. This reduces a per-
son’s ability to respond flexibly to what is happening in the present and to
choose to move toward values based on the immediate situation. Contact with
the present moment refers to the process of choosing to actively attend to the pres-
ent moment. This skill is practiced by making the conscious choice to notice
and participate in what one is doing while redirecting one’s mind from thoughts
about the past or future. The practice of being in the present moment increases
the ability to respond flexibly and adaptively to one’s changing experiences,
such that it supports valued living.
Self-as-content describes an experience of self that is dominated by conceptual
evaluations and labels based on the contents of one’s experiences. This experience
 574 Lee et al.

can reduce flexibility by unnecessarily restricting a person’s contact with expe-

riences and choices that do not fit the contents associated with one’s “self.” As
an example, a person may apply the label of “failed student” when feeling
frustrated with their academic performance and may later behave in ways that
confirm this label (e.g., by dropping out of classes or school altogether). On the
other hand, self-as-context involves connecting with an experience of the self as
the observer of one’s changing internal and external experiences. The practice
of self-as-context involves, first, acknowledging the presence of an observing
perspective and, second, looking through this perspective at the contents of
one’s experience. An important component of self-as-context is the awareness
that although the contents of one’s experience change and are included by the
“self,” the observer point of view is content free. This component of ACT
increases people’s flexibility to respond in values-consistent ways to their
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changing experience, without attachment to the changing thoughts, emotions,

and memories that comprise this experience or the need to adhere to self-
evaluations or labels derived from one’s history.
A lack of values clarity can contribute to excesses in avoidant behavior and
limited contact with rewarding experiences. Specifically, in the absence of guid-
ing principles for living a vital life, changing internal experiences or rigid rules
come to dominate one’s behavioral choices. On the other hand, values are ver-
bally derived qualities of behavior that serve to increase one’s engagement in
that behavior and one’s sense of meaning. Values focus on what is deeply
meaningful about how one does things and what one wants one’s actions stand
for, rather than the specific outcomes and goals one achieves. In this way, val-
ues are focused more on the day-to-day process of doing what matters, provid-
ing an ongoing motivator and guide for behavior. The practice of values involves
identifying what qualities of action are important and noticing whether one’s
behavior moves toward the qualities about which one cares. Returning to the
functional contextual roots of ACT, values provide the criterion against which
clients can determine what works for them.
Inaction refers to problems choosing or persisting in behavior that is aligned
with one’s values. Deficient valued action will restrict a person’s opportunities
to connect with rewarding aspects of pursuing a values-consistent behavior and
may diminish flexibility and persistence in the presence of barriers to valued
pursuits. Committed action refers to ongoing engagement in behavior that is val-
ued. The practice of committed action involves choosing overt behavior that
reflects one’s values, such as through setting goals and monitoring one’s prog-
ress in aspects of life that are important. Committed action helps the client
sustain contact with rewarding contingencies on a regular basis and replaces
behavior that is mostly about unwanted thoughts, feelings, and other internal
experiences.
Each of these processes is targeted through a variety of ACT interventions,
in a way that matches the client’s unique presentation and needs. This model
allows clinicians to flexibly engage with ACT, in a way that matches the kind of
flexibility that is encouraged for clients engaged in the intervention. Consistent
with the ACT’s emphasis on flexibility, implementation of ACT can vary consid-
 Acceptance and Commitment Therapy 575

erably depending on the needs of the situation. It can, and often does, take the
form of traditional eight to twelve 1-hour sessions of therapy protocols, but
treatment can be lengthened or shortened depending on client and logistical
needs. Additionally, although ACT traditionally employs many metaphors to
help illustrate concepts to clients, a more straightforward and didactic approach
can also be successful, again depending on the needs of the client. Finally, the
order in which ACT concepts are presented might vary a great deal based on
client needs. For example, imagine a client who is psychologically minded, is
not overly fused with internal content, and has some ability to be open to this
content but is still struggling to find meaning in their life. In this case, the thera-
pist might emphasize processes like values and committed action over others at
the beginning of treatment. Ultimately, practitioners of ACT meet clients where
they are and promote psychological flexibility in the service of living more rich
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and meaningful lives. Doing so requires clinicians to practice and exemplify

psychological behavior in session with clients as well as in their treatment plan-
ning. In the next section, we provide a case example of a more typical session-by-
session ACT structure that would meet the needs of the client; however,
alterations should be considered on a case-by-case basis.

CASE EXAMPLE

We present a case example in order to illustrate a common structure for ACT

over multiple sessions. It should be noted, however, that although the exam-
ples provided clearly target a specific process, in practice, ACT should be
employed in a flexible manner. Often, this involves dynamically targeting mul-
tiple processes within session in an attempt to foster psychological flexibility
and ultimately valued action. As depicted in the diagram of what has become
known as the hexaflex (see Figure 19.2), each of the six processes targeted in
ACT is interconnected. Thus, affecting one is likely to have an impact on the
others as well. For example, increasing one’s ability to make space for difficult
thoughts and emotions (acceptance) might also assist in not overidentifying
with them (self-as-context), not believing them to be necessarily important
(defusion), and increasing willingness to make and keep behavioral commit-
ments (committed action). We present snippets of treatment over multiple ses-
sions using the following case example.
Jamie is a 40-year-old single woman seeking help for anxiety. She was
recently promoted to an upper managerial position at her job. Although she
was happy for the promotion, Jamie reports that she feels overwhelmed with
her new duties and is not performing well at her job. She experiences what she
calls “anxiety attacks” in which her anxiety becomes “unbearable” and causes
her to “shut down.” She states that her mind is constantly racing and planning
how to perform her job well, although she spends little time engaged in mean-
ingful activities that would accomplish her work goals. Jamie says that she
would experience “extreme anxiety” if she did not constantly review and make
plans about her work because she may not be fully prepared and then make
 576 Lee et al.

mistakes. Since her job promotion, her racing thoughts and planning behaviors
have increased in intensity and frequency. She says that her anxiety has nega-
tively impacted her relationships with her coworkers whom she cares about,
largely because she avoids contact except when absolutely necessary. Addition-
ally, Jamie indicates that she spends so much time on work that she does not
have time to do other activities she wants to do.

Creative Hopelessness: Challenging the Change Agenda

We will assume that a general assessment and introduction to therapy have

been conducted. Because ACT emphasizes increasing valued living and de-
emphasizes the reduction of symptoms (e.g., anxiety, depression, pain) it is
important to get the client on board with this agenda and make sure they
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understand what the priorities of the treatment are going to be. Thus, ACT usu-
ally begins with some form of a procedure called creative hopelessness. This pro-
cedure sets the stage for the rest of treatment. In a nutshell, creative hopelessness
is a process of helping clients recognize that their attempts to control inner
experiences ultimately fall short and often get in the way of engaging in valued
behaviors. No matter how hard they have worked and no matter how many
strategies they have tried, here they are, still stuck with the same thoughts,
emotions, memories, and urges as before. Often a metaphor is used to illustrate
this situation, such as in the following example.

THERAPIST : What else have you tried to control your anxiety?

JAMIE : Well, I make plans in my head of all the things I need to accom-
plish at work and how I can get them done in the best way.

THERAPIST : And how does that work for you?

JAMIE : It helps me get organized . . . to make sure things are done

properly.

THERAPIST : And the anxiety?

JAMIE : I mean, I feel better for a bit, but then my mind is off again, rac-
ing, worried about different plans.

THERAPIST : So, it sounds like in the long run you are right back where you
started?

JAMIE : Yes! And you know the real irony of it all is that all of this plan-
ning and worry just make me feel worse at the end of the day
when I realize that I didn’t actually get anything done.

This conversation continues and covers other ways that she tries to
control her anxiety.
 Acceptance and Commitment Therapy 577

THERAPIST : It sounds to me that you aren’t the type of person to just give up
on something difficult. You are a hard worker and have clearly
spent years working on this anxiety problem. Yet here you are.
Still with essentially the same problems.

JAMIE : I know. . . . If anything, they are worse. I still can’t get over this
worry and, on top of that, I feel like a failure. I am just so sick
and tired of doing this.

THERAPIST : So what now? Is there some strategy you haven’t tried that
would finally beat this thing?

JAMIE : I sure don’t have one. I was hoping you might. I guess that’s why
I’m here.
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THERAPIST : Absolutely. Because there has just got to be something that

would beat this anxiety for good, right? But at the same time,
you know your experience better than anyone and, from what I
understand, you’ve tried everything. What if this whole thing,
this whole strategy of beating this anxiety, is actually part of the
problem? It reminds me of a tug-of-war match. A rope is
stretched out over a vast pit, with you on one end and your
opponent on the other. You have become very familiar with this
opponent—it is a huge, strong, smelly, monster. A monster we
could perhaps name anxiety. And for years you have put great
effort into this match. You’ve developed new ways to pull on the
rope, maybe you’ve put gloves on to help you grip, you’ve even
invited friends to come help you pull for a while. But every time
you seem to make any progress the monster just grunts and
pulls back even harder than before. You tell me that you are
exhausted, but you fear that if you don’t keep fighting, that you
will be pulled into the pit and be done for. In the situation you
are in, the difficult thing to see is that perhaps your job is not to
win this fight. Perhaps your job is to simply drop the rope.

JAMIE : How do I drop the rope? What would that look like?

THERAPIST : These are excellent questions, but first it is important to just

understand that this tug-of-war match cannot be won and that
it doesn’t need to be.

Despite the name, the goal of this process is not to change the sense of
hopelessness in the client. The only thing hopeless about this process is the
client’s control strategy, not her prospects for a meaningful life. In fact, it can
be a liberating process of letting go of an often lifetime long struggle coupled
with a creative energy of trying something truly new. By letting go of a strat-
egy of control, space is made for an alternative way of engaging with inner
experiences.
 578 Lee et al.

Of note, the creative hopelessness process is key to getting clients on board

and willing to embrace a new paradigm with regard to how they interact with
their internal experiences. Therefore, it is not unusual for this process to take
multiple sessions. We provide only the briefest version of this process here.

Control as the Problem and Acceptance

Now that Jamie’s change agenda has been challenged, we will continue to rein-
force this by further exposing the paradoxical nature of attempting to control
her anxiety. Moreover, we will introduce an alternative paradigm—acceptance
or willingness. Many practitioners of ACT tend to favor the word “willingness,”
as it conveys the idea of being open to experiences without some of the verbal
baggage of the word “acceptance” that can invoke concepts such as tolerance
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and resignation that are counter to our goals.

During this phase of treatment, the client is introduced to what is referred to
as control as the problem before formally introducing the concept of willingness.
Control as the problem highlights the negative impact that constantly avoiding
or trying to reduce unwanted internal experiences has on one’s quality of life.
This runs counter to our experiences in the physical world where, when a
problem arises, the solution is to work, work, work at it until it is solved. Too
often, we use this same strategy on our unwanted internal experiences and
find ourselves caught in a struggle that cannot be won and that simply makes
the matter worse than it was before we started. There are many exercises that
can illustrate this process. The following is just one example.

THERAPIST : Imagine that I had a million dollars in a suitcase with your name
on it. I am prepared to give it to you if you do just one simple
thing for me. Now imagine the large sports arena near here. The
next time that there is an event, and all of the seats in the sta-
dium are full, I want you to walk out to the middle of the arena
and sing the national anthem to the tens of thousands of fans.
That’s it. Do that and you are an instant millionaire. What do
you think? Would you do it?

JAMIE : I hate to sing! I would get booed off the stage.

THERAPIST : Doesn’t matter. You just have to do it. Believe me for just a min-
ute. Imagine this is real.

JAMIE : Well, if it doesn’t matter how well I do, I guess I would. I mean,
that’s a lot of money.

THERAPIST : Exactly! You may even hate every moment of it, but it would be
worth it, right? Now, I want to do the same thing—same million
dollars, same arena, same song—but this time there is one other
small criterion. You aren’t allowed to feel anxious while you do
it. And I am going to attach a magical device to your wrist that
 Acceptance and Commitment Therapy 579

will detect if you get anxious. You can’t fake it; it will know if
you feel even a bit of anxiety. What about now? Could you do it?

JAMIE : Of course not! I’d be a wreck the whole time.

THERAPIST : Not even for a million dollars though? Isn’t there something you
could do?

JAMIE : If there is, I haven’t found it. I mean, I’d be anxious about trying
not to be anxious!

THERAPIST : Right. And how often do you find yourself in a similar situa-
tion—not for a million dollars, but for your own well-being—
where you tell yourself that you have to not feel a certain way
before you can accomplish things that are important to you? If I
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said I’d give you that same million dollars to complete a task at
work, I’d imagine you’d find a way. But if I said you couldn’t feel
anxiety while you did it, I’m pretty confident I’d be keeping
my money.

Once Jamie recognizes the problem with her control strategies, we introduce
acceptance or willingness as an alternative. Exercises are often useful to illustrate
the benefits of willingness over more traditional control strategies. As in the
tug-of-war metaphor, dropping the rope (i.e., practicing willingness) changes the
relationships one has with internal experiences. They are not defeated, however.
There is just no longer any struggle with one’s thoughts and feelings, which can
reduce their impact. Additionally, all the effort that was previously put into the
fight can be asserted elsewhere toward behaviors that are personally meaningful.
Another useful exercise is to have clients write their unwanted experience on a
card. In this case, Jamie would write “anxiety” or “worry.” The therapist would
then place the card in her hand and ask her to push the card away as it approaches
her. Much like the tug-of-war match, this requires a fair amount of focus and
effort and ultimately does not result in the card going away. Subsequently, Jamie
would be asked to simply lay the card on her lap and notice the experience of
letting the card sit with her without struggling with it, but also without changing
or removing it. This is acceptance. Perhaps Jamie’s experiences of anxiety do not
have to go away before she can accomplish work that is meaningful to her.

Defusion and Self as Context

We will cover these processes together, as they complement one another. Jamie
now better understands the concept of willingness and has had a chance to
practice it between sessions. She might say something like,
I like the idea of being more willing to just have my anxiety, but it is so hard to
make space for something so scary. I’m just such an anxious person that I don’t
know if I can do this. It feels like that if I truly “let go of the rope,” that anxiety
monster is going to come over here and throw me in the pit!
 580 Lee et al.

We can see that her feelings of anxiety are not only uncomfortable but also
intimidating and frightening. This is where the processes of defusion and
self-as-context might be useful.
As previously stated, defusion is responding to thoughts in a nonliteral way.
In more clinically appropriate words, it is the process of making space between
a person and their internal experiences and noticing those for what they are:
internal experiences, and nothing more. Similarly, self-as-context is a process
that describes defusing from internal experiences that we identify as part of
what makes up our “self” and noticing that we are not made up of these inter-
nal experiences. Rather, we are simply a vessel through which these experi-
ences pass (just as the sky is a vessel that contains passing clouds and weather).
So often we “buy into” the thoughts our mind gives us (e.g., “I’m not good
enough”) and the emotions we feel (e.g., “I am depressed”) and treat them as
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important and true, without any consideration. In session, ACT therapists often
use defused language to set an example for how we can engage with our inter-
nal experiences in a different manner. Thus, when a client says that he “is not
good enough,” the therapist may simply ask him to notice that thought and to
thank his mind for it. Or if a client states that she “is worthless,” the therapist
might rephrase it as “You are having the thought that you are worthless. And
what other thoughts, feelings, or experiences come with this thought?”
In the case of Jamie, her therapist would say that she is fused with her
thoughts and feelings that come with the experience that she calls anxiety. In
addition, she identifies as an “anxious person.” Thus, anxiety is not just some-
thing that she experiences; it is a part of who she is. In other words, she does
not recognize that she is the context in which these experiences occur; rather,
the experiences define her. Like before, exercises and metaphors can be power-
ful tools to illustrate these concepts. The following is an example of what one
could do in Jamie’s situation.

THERAPIST : Let’s imagine that you are the driver of a bus. And like any bus
driver, you make stops along the way when there are passengers
who need to get on or off the bus. Except in this scenario, these
passengers are your thoughts, emotions, urges, and memories—
the stuff inside your skin. Some of the passengers are quiet and
just sit in the back until it is time to for them to get off—you
hardly notice these ones. Some are talkative and friendly—you
don’t usually mind having them on board. And some are down-
right scary. They are disruptive, they yell, they make demands,
they may even carry weapons and threaten you. What might
you name some of these passengers on your bus?

JAMIE : Anxiety for sure. Worry. Fear of failure. And guilt.

THERAPIST : Right. And you’ve described them as scary before. And we’ve
talked about how they can push you around. And we’ve dis-
cussed all of the ways that you have tried to get them off your
 Acceptance and Commitment Therapy 581

bus. In this story, it is like you have pulled over and said, “That’s
enough! Get off my bus!” and tried pushing them out. And as
commendable as your hard work has been, how has that worked
out for you?

JAMIE : It’s like we talked about. The harder I fight, the more passengers
there seem to be. It’s like they are climbing through the win-
dows as I push them out the door.

THERAPIST : Hmm . . . and another thing to notice in this scenario. When you
pull your bus over to fight, notice that you aren’t driving any-
where. You aren’t getting to where you want to go.

JAMIE : Yeah. It really does stop me in my tracks sometimes.

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THERAPIST : And over time, I see another thing happen. You get sick and
tired of fighting, so you make a deal with these passengers. You
say, “Anxiety, I’ll do what you say if you will just sit in the back
of the bus where I don’t have to see you as much. You just tell
me when to turn and I will. I just don’t want to deal with you
anymore.” And off you go, back to driving your bus. But now
the anxiety passenger is in charge. It says where to go and when
to do it, and in exchange, you don’t have to look at it as much.
Does this sound familiar? Have you ever made a deal like this
before?

JAMIE : It’s weird to think of it that way, but yeah, I guess so. When I
shut down and skip work or avoid my coworkers, it feels a lot
like what you said. The anxiety is in charge. I feel a bit better for
the day and it hides in the back for a bit.

THERAPIST : Okay. Now the thing about this whole scenario is—it’s a trick.
The real threat that these thought, emotion, and urge passengers
offer is as simple as this: they say, “If you don’t do what we say,
we aren’t going to hide in the back and we will come up here
and make you look at us.” That’s it. They may claim that they
will hurt you if you don’t listen, but this has never actually hap-
pened. These passengers, our thoughts, our emotions, our inside
stuff, have no real power to control—except for that which you
give them.

Contact With the Present Moment

At this point, we would like for Jamie to be actively practicing making space for
her anxiety and noticing her anxiety thoughts and symptoms as “passengers on
her bus” and nothing more. Treatment would have also incorporated teaching
Jamie how to better contact the present moment. The ability to be present, and
 582 Lee et al.

to notice one’s experiences as they occur, can have a powerful impact on

behavior. Being present allows one to attend to and learn from direct contin-
gencies as they occur. Moreover, this skill can help facilitate the development of
other processes. Contacting the present moment in ACT allows for the simple
recognition of one’s current experiences and fosters an environment in which
to practice acceptance and defusion skills. In the case of Jamie, she reports hav-
ing near-constant racing thoughts about tasks that need to be completed. Thus,
she is rarely focused on the present and instead places much of her energy in a
future that she cannot actually engage with. It is as if she feels that she must
sort out her thoughts and worry before she can effectively engage in the pres-
ent moment. However, this quickly turns into another tug-of-war match where
she spends her life engaged with this struggle instead of living in the present
and disengaging with the monsters in her mind.
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Some exercises that foster present moment awareness may be familiar to

readers who integrate mindfulness practice into their treatment (e.g., placing
thoughts on leaves on a stream or noticing one’s breath). These formal exer-
cises can be a great way for clients to practice being present each day. However,
in addition to these types of exercises, the process of present moment aware-
ness should be demonstrated by the therapist throughout treatment. This can
be done by simply describing present moment experiences in an accepting and
defused way (e.g., “When you say that, I notice my mind tell me to rescue you
and say that everything will be alright”). More often, the therapist will ask the
client to practice being present to facilitate objective awareness of a sensation
(e.g., “How would you describe the physical qualities of that emotion? What is
its color, texture, weight, and form?”) or to better understand the function of
their current behavior (“You just said, ‘I don’t want to talk about that.’ What
passenger on your bus are you frightened will show up if you do?”). In the case
of Jamie, fostering the ability to be present will be of crucial importance as she
practices making space for anxiety symptoms and while she moves toward a
more meaningful quality of life.

Values and Committed Action

Because ACT’s primary aim is to increase meaningful, values-directed behavior,

it is crucial that clients understand what that means for them. Once clients have
fostered psychological flexibility through the aforementioned processes, they
should be freer to engage in any chosen behavior, regardless of what internal
experiences they might have. If clients are spending less time dealing with their
anxiety, urges, depression, and so on, they should be spending more time
engaged in behavior that improves their quality of life. Clients’ values serve as
a guide for which behaviors to engage in to meet this goal. Values are identified
by asking the question, “What do I want my life to be about?” Moreover, values
are self-chosen patterns of behaving that provide a sense of meaning to one’s
life. They are generally defined as broad domains (e.g., family, education, com-
munity, spirituality) that are not readily achieved, but rather give direction to
 Acceptance and Commitment Therapy 583

smaller, achievable goals along a valued path. There are many ways to explore
a client’s values. We present a brief version of a values exercise with Jamie next.

THERAPIST : Close your eyes and simply follow my voice as we engage in this
exercise. Now imagine that we have traveled far into the future,
to your 80th birthday. You have lived a long, meaningful life,
and you are having a party to celebrate. Imagine who you would
want to be at this party. It doesn’t matter if it makes sense, just
who you would want to be there. Family, friends, people you
care about. Now pick just one of these people, someone you care
a great deal about. Imagine that they stand up in front of every-
one and offer a toast to you, to your life, to the things you’ve
accomplished, to the type of person you are. Imagine for a min-
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ute what you would like for them to say about you and the life
you’ve lived. What has your life been about? Not what you
think your life will be, but what you want for it to be.

Time would be given to allow Jamie to imagine what would be said.

This would then be repeated with one or two other party guests; the
exercise would then conclude.

THERAPIST : What did people say about you that stood out to you?

JAMIE : They said so many nice things. That I was always kind and easy-
going, but at the same time, that I accomplished a lot in my life.
And that I was a dependable friend to everyone. That I wasn’t
worried all the time. That I was there for people—I was pres-
ent—I listened.

THERAPIST : You’ve spoken about wanting to excel in your career. Are these
qualities that you would like to see in your job performance?

JAMIE : Absolutely. I want to get out of my head and be a better boss, a

better coworker, a better friend. I want to be dependable.

THERAPIST : Those are great examples of ways to move closer to your value
of excelling at your career. It sounds to me like this would be a
great sign to hang on the front of your bus as you go to work
each day. Do you think that you could make space for all of the
passengers on your bus while driving toward this value?

In this example, we briefly considered one values domain. However, there

are likely other areas of Jamie’s life that she would like to pursue and that
would be examined. Once Jamie’s values have been clarified, goals can be set
along the path toward these values. Committed action is the process of setting
these goals, making a clear plan to achieving them, and taking action to do so
 584 Lee et al.

with full knowledge that it may be difficult or that failure is a possibility. Thus,
practitioners of ACT help their clients make commitments in which they are
willing to fully engage. This has been likened to committing to jump off some-
thing. No matter the height, whether it is something very high or something as
low as a piece of paper, the commitment is the same— “I will jump.” Not “I will
think about jumping,” not “I will try to jump,” but “I will jump.” In the case of
Jamie, this might be a commitment as large as completing a difficult task or
project over the next week or as small as practicing being present while eating
lunch with coworkers. Each week, the previous commitments should be fol-
lowed up on, and new commitments should be made. These commitments
provide opportunities to pull together all that the client has learned to build
increasingly large patterns of valued living, while practicing acceptance, defu-
sion, and mindfulness with barriers that arise. Thus, this last phase often serves
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to support solidifying and generalizing gains made in therapy as final steps for
ending treatment.
This case example and introduction to ACT processes is very brief. However,
we hope that it has provided a starting point to understanding this type of treat-
ment. For readers interested in learning more, there are many widely available
resources for learning more about ACT, with some key resources noted in the
dissemination section below.

EFFICACY AND EFFECTIVENESS

ACT has been applied across a wide range of populations and settings for a
variety of presenting concerns. ACT is intended as a transdiagnostic interven-
tion, meaning that the intervention model is applicable to a range of symptom
categories and is not designed for a specific disorder. The primary goal of treat-
ment across disorders is engagement in effective, valued patterns of activity
(e.g., quality of life, psychosocial functioning, valued action), rather than symp-
toms reduction. In other words, ACT seeks to increase valued living irrespective
of levels or types of internal distressing symptoms, rather than focus on reduc-
ing internal symptoms themselves. However, studies of ACT across various
populations nevertheless have found reductions in symptoms that are consis-
tent with those found using other evidence-based interventions, concurrent
with changes in psychological (in)flexibility.

Applications in Mental and Behavioral Health

Meta-analytic evidence supports the use of ACT as a transdiagnostic interven-

tion for a range of adult mental health problems. The broadest meta-analysis to
date was conducted by A-Tjak et al. (2015) and included trials of ACT for anxi-
ety disorders, depression, somatic health problems, and addiction. The meta-
analysis found medium to large effect sizes for ACT as compared with placebo
(Hedges’s g = 0.51), wait-list (g = 0.82), and active control (g = 0.64) conditions
 Acceptance and Commitment Therapy 585

for primary outcomes as well as for quality-of-life (g = 0.37) and process mea-
sures (g = 0.56).
Although meta-analyses lend support for a transdiagnostic application of
ACT, certain mental health problems seem especially well suited. ACT has
strong potential as an intervention for chronic pain and related conditions, as it
emphasizes valued living despite unwanted inner experiences (e.g., pain) and
reduces the need to control these experiences (McCracken & Vowles, 2014).
Similarly, ACT’s focus on building flexibility around inner experiences may be
well suited to obsessive-compulsive and anxiety disorders (Bluett et al., 2014).
A number of other problem-specific applications of ACT have or are gaining
increasing empirical support, including ACT for depression, smoking cessation
and other addictions, psychosis, weight management, eating disorders, and
coping with medical conditions (e.g., cancer, diabetes, tinnitus). Altogether,
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these studies point to the application of ACT for chronic conditions as well as
conditions associated with problematic efforts to control or avoid distress.
Several authors have attempted to compare ACT with established treat-
ments. A-Tjak et al. (2015) and Ruiz (2012) compared ACT with established
treatments for a variety of diverse mental health problems and found few over-
all differences among these treatments. The Ruiz analysis of mediation results
suggested that ACT was more efficacious at targeting its putative mechanisms
of change, as compared with CBT (ACT: g = 0.38; CBT: g = 0.05). However, in
another meta-analysis comparing ACT and traditional CBT for anxiety disor-
ders, results suggested that the approaches produce equivalent positive effects
on psychological flexibility (Bluett et al., 2014). Altogether, ACT appears to be
equivalent to best practices for a wide range of mental health and behavioral
health problems in adults.
ACT has received less attention as an intervention for childhood and adoles-
cent emotional and behavioral problems. For children, parents are trained to
respond flexibly to the child’s experience, such as by validating emotions
instead of instructing the child to control or suppress their feelings. This
approach has been successfully applied to anxiety disorders, chronic pain, and
pediatric health conditions; however, trials evaluating these conditions tend to
include small sample sizes (Coyne et al., 2011; Murrell & Scherbarth, 2006).
For adolescents, ACT has been applied both with and without parental involve-
ment to address stress, depression, eating disorders, and chronic pain (Coyne et
al., 2011; Wicksell et al., 2011). Altogether, ACT has support for applications
with a range of childhood problems, although this research is still in its infancy.
A common theme in extant studies is that parents can support the application
of ACT principles with children and that ACT principles can be applied with
children and adolescents if they are sufficiently adapted to the client’s develop-
mental levels. At least one study suggests that the mechanisms in ACT for chil-
dren and adolescents are comparable to those involved in ACT for adults
(Wicksell et al., 2011).
Summarily, ACT has received research support for a wide range of applica-
tions to problems among adult clients, with burgeoning support for pediatric
 586 Lee et al.

concerns. ACT may be especially well suited to working with problems that
consist of distressing internal experiences that are difficult to control (e.g.,
obsessions, chronic pain, psychosis, addictions). Research on the application of
ACT to new problem areas is ongoing, while extant findings suggest that the
ACT model can be flexibly applied to a variety of problems.

Broad Applications

ACT has been applied outside the context of treating psychological and behav-
ioral health problems as a preventive intervention with populations at risk for
poor mental health or to enhance positive functioning. Such applications have
focused on enhancing psychological flexibility in a group of people with com-
mon stressors or challenges. In these contexts, the acronym “ACT” refers to
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acceptance and commitment training, wherein the primary goal is to enhance life
quality or satisfaction instead of working with extant symptoms (Flaxman &
Bond, 2010). The most common, broad applications of ACT have been in work-
place and educational settings.
Workplace applications of ACT have spanned a range of populations, includ-
ing nursing staff (Frögéli et al., 2016), intellectual disability staff (Bethay et al.,
2013), drug and alcohol counselors (Varra et al., 2008), people in management
and leadership positions (Moran, 2011), employees of government organiza-
tions (Flaxman & Bond, 2010), social workers (Brinkborg et al., 2011), and
psychological practitioners (Luoma & Vilardaga, 2013). Outcome data from this
research suggest that moderate effects on workplace satisfaction, performance,
and stress can be obtained with a relatively brief ACT intervention (Bethay et
al., 2013; Brinkborg et al., 2011; Flaxman & Bond, 2010). ACT has also been
shown to increase adherence to best practices for mental health care and may
support clinicians in developing and sustaining proficiency in mental health
interventions (Luoma & Vilardaga, 2013; Varra et al., 2008). The outcomes of
ACT in workplace settings appear to be moderated by participants’ use of ACT
skills (Bethay et al., 2013); therefore, employees may benefit most if provided
with ongoing support to use the target skills.
ACT has been applied in educational settings with school-age and college
populations to manage stress (Pahnke et al., 2014), reduce procrastination
(Scent & Boes, 2014), and reduce prejudice (Lillis & Hayes, 2007). In addition,
ACT has been applied as an online preventive intervention for college students
to address a range of mental health outcomes (Levin, Pistorello, et al., 2014). In
educational settings, briefer workshop interventions (e.g., Lillis & Hayes, 2007)
have tended to produce small to moderate immediate effects, with some sus-
tained effects at follow-up. Longer interventions with regular contact (e.g.,
Pahnke et al., 2014) have demonstrated more sustained outcomes.
Altogether, ACT has preliminary support as a preventive intervention in
workplace and educational settings for students and employees at risk for poor
psychological and educational outcomes. Broad applications of ACT appear to
be most effective when participants are provided with additional contact or
support following the initial intervention. These findings are consistent with
 Acceptance and Commitment Therapy 587

the notion that ACT skills are broadly applicable, with benefits for people with
and without significant psychological distress.

Transdiagnostic Potential of ACT

The ACT model is intended as a transdiagnostic intervention on the basis of the

notion of psychological inflexibility as a pervasive process across mental health
problems. Psychological inflexibility is related to a broad range of mental health
symptoms (Levin, MacLane, et al., 2014) as well as to poor adaptive function-
ing (Hayes et al., 2013). ACT interventions have demonstrated medium to large
effects on psychological inflexibility in recent meta-analyses (A-Tjak et al.,
2015; Ruiz, 2012), and changes in psychological inflexibility appear to mediate
outcomes in ACT trials (Hayes et al., 2013). A large body of evidence thus sup-
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ports a central role of psychological inflexibility in psychological suffering.

Very few studies have examined fully transdiagnostic applications of ACT.
However, studies of ACT as applied across broad diagnostic categories lend sup-
port for the flexibility of the ACT model. Such studies have included outpatient
clients with heterogeneous anxiety disorders (e.g., Arch et al., 2012); psychiat-
ric hospital clients with mood, anxiety, personality, substance use, and pain-
related disorders (Pinto et al., 2017); and college students with diverse mental
health symptoms (Levin, Pistorello, et al., 2014; Räsänen et al., 2016). These
studies indicate that although ACT resulted in overall improvements in psycho-
logical inflexibility as well as symptoms across samples, the effectiveness of ACT
varied across clients (e.g., Pinto et al., 2017) and treatment modalities (e.g.,
Levin, Pistorello, et al., 2014). Further research on what conditions moderate
the effectiveness of ACT will be necessary for fully evaluating its transdiagnostic
effectiveness.
The notion of psychological inflexibility as a transdiagnostic process can
inform whether ACT is appropriate for a given client. Although there is insuf-
ficient evidence to suggest that psychological inflexibility is a central compo-
nent across all mental health problems, extant evidence supports that targeting
this process in a range of concerns can be effective. Thus, for many clients and
presenting problems, clinicians may benefit from assessing psychological inflex-
ibility as a constellation of problematic behavioral responses to symptoms.
Based on this assessment, and in relation to the client’s unique goals, the clini-
cian may then decide whether ACT is an appropriate treatment approach.
When working with children or adolescents, the clinician may determine
whether concurrent work with the child and their caregiver(s) on psychologi-
cal inflexibility is warranted.

MECHANISMS OF ACTION

Mediation studies also provide support for the use of psychological inflexibility
as a transdiagnostic intervention target. Mediation analysis is used to test
whether an intervention produces changes in a target mechanism or process
 588 Lee et al.

(e.g., psychological inflexibility) and whether changes in the target mechanism

or process result in changes in intervention outcomes (e.g., quality of life).
Changes in psychological inflexibility have been shown to mediate outcomes in
studies of ACT for depression (Zettle et al., 2011), mixed anxiety disorders
(Arch et al., 2012), chronic pain (Wicksell et al., 2011), and various other men-
tal health conditions (Hayes et al., 2013). This evidence suggests that reduc-
tions in psychologically inflexible behavior are associated with improvements
in a variety of psychological problems.

DISSEMINATION
Association for Contextual Behavioral Sciences
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ACT is disseminated in much the same way as other CBTs. There is a central
organization, the Association for Contextual and Behavioral Sciences (ACBS)
and ancillary ones such as the Association for Behavioral and Cognitive Thera-
pies and the Association for Behavior Analysis International. ACBS was offi-
cially formed in 2005 after a couple of years of smaller conferences on ACT. In
2005, interested individuals agreed that an organization should be formed for
the dissemination of contextual behavioral science ideas rooted in functional
contextualism and associated areas including behavior analysis, RFT, and ACT,
among many others. Many of the principles of ACBS focus on cooperation and
a linear (as opposed to hierarchical) structure of membership. The idea that the
group will succeed if as many people as possible have opportunities has always
been central to ACBS. When the organization started, dues were “values
based,” meaning that people gave what they thought they were getting out of
the organization. Eventually, the base rate was matched to what it costs the
organization to have a member, but that rate was still below 10 USD. Most pay
much more, as the values-based rate still exits. The ACBS website is a wiki site;
therefore, all pages (except the home page) may be edited by any member. This
has resulted in impressive sharing of materials by members. For example, there
are lengthy pages of manuals, measures, and client handouts available to any
member to download and use. By allowing all members to participate freely,
the wealth of knowledge quickly grows.
In 2012, ACBS started a journal, the Journal of Contextual Behavior Science
(JCBS). In 2021 this journal is on its 10th volume (i.e., 10th year), publishing
four issues per year. Although the majority of the work published in this jour-
nal is not on ACT, it all is related to contextual behavioral science in some way.
Thus, there are studies on ACT, studies on ACT processes of change, and trans-
lational research on contextual behavioral science topics. There is a yearly con-
ference organized by ACBS that attracts approximately 1,000 professionals. As
a means to increase dissemination, the conference alternates between North
America and elsewhere. In addition, there are many special interest groups and
chapters that hold their own conferences throughout the world. Some of the
larger chapter conferences occur in Australia, New Zealand, the United King-
dom, and Scandinavia.
 Acceptance and Commitment Therapy 589

Although there are many training workshops immediately before the ACBS
conferences, ACT is also trained in single- or multiday trainings. A calendar for
ACT trainings exists on the ACBS website (https://contextualscience.org). It
should also be noted that ACBS allows for individuals who deliver trainings in
ACT to be “peer reviewed.” This process is not accreditation, but rather, it
allows trainers to be assessed for quality by their peers. A listing of trainers who
have been evaluated as acceptable at training ACT by their peers is also avail-
able on the ACBS website.

Resources

Like most forms of well-developed psychotherapy, ACT has a large library of

books on theoretical and applied issues. Interestingly, because ACT is the appli-
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cation of behavioral principles, it is utilized in many ways other than psycho-

therapy, including in sports, business, industrial organizational safety,
curriculum design, and so on. There are also many books on the use of ACT
with most diagnosable conditions. Although a variety of publishers of ACT
research exist, New Harbinger is the leading publisher of ACT material.
A noteworthy line of work is the testing of self-help books to treat psycho-
logical issues. To our knowledge there are at least eight randomized trials of
bibliotherapy from a self-help book on ACT (including intervention with teach-
ers and staff, foreign college students, anxiety disorders, depression, chronic
pain, weight self-stigma, and problematic pornography use). The results of a
recent meta-analysis (French et al., 2017) suggest that bibliotherapy alone or
with the addition of support, either via phone or internet, demonstrates small,
statistically significant effects compared with active control conditions (depres-
sion: Hedges’s g = 0.34; anxiety: g = 0.35; psychological flexibility: g = 0.42). The
same meta-analysis shows supportive data on the use of ACT-based applica-
tions for smoking cessation with small to medium effects over control condi-
tions (g = 0.26–0.54; French et al., 2017). Work has also been done using
applications for depression and anxiety in clients in therapy, health behaviors,
and general mental health (e.g., Krafft et al., 2019; Levin et al., 2017). Similar
support exists for ACT websites (French et al., 2017; Levin, Pistorello, et al.,
2014). Finally, web-based technologies have also been used to disseminate ACT
to professionals.

APPLICATION TO DIVERSE POPULATIONS

There are many levels to consider when thinking about the application of a
therapy to diverse populations. Cross-cultural psychology focuses on human
actions as they are influenced by culture and society. How large or small one
wants to go in this study depends on one’s goals. As this book will largely be
utilized by individuals in North America, we might focus on the effects of cul-
tures within North America and how that might affect the practices of a thera-
pist in North America. Another view of culture as it pertains to psychology is
 590 Lee et al.

cross-national research, which focuses on behavior of a larger sampling of indi-

viduals within a country. While not all within a nation share the same culture,
there are elements that may be shared. Thus, whenever considering the role of
culture in behavior and the corresponding use of psychotherapy with an indi-
vidual, there are many cultural levels to which one should attend. Major cul-
tural variables such as gender, sexual orientation, race, country of origin or
residence, religion, and acculturation, though major variables, do not represent
all the variables that are important to consider when conceptualizing a case and
planning intervention.
Although much of the preliminary development of ACT has occurred within
North America by white cisgender men (who are mostly of high socioeconomic
status) there has also been regard for cultural and national adaptions of ACT, as
well as a notable amount of research on the applicability of ACT across cultural
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groups. The brief review in this chapter illustrates the positive steps forward
that have been made by contextual behavioral science researchers, and the
concluding paragraph of this section describes where greater advancements
need to occur.
The main measure of psychological inflexibility is the Acceptance and Action
Questionnaire (AAQ). The original version was published in English in 2004
(Hayes et al., 2004) and was updated in 2011 (AAQ-II; Bond et al., 2011).Over
time, the translation and validation of the AAQ has occurred in many lan-
guages. The ACBS website offers AAQs in 23 different languages as well as vali-
dation work in many of them. Countries where ACT is more established (e.g.,
Italy, Spain, Sweden) offer translated versions of many ACT measures. Rates
are similar for books on ACT that are either translated from English or authored
by native speakers of those languages. A review of ACBS membership as well
as publications suggests that there is ACT work occurring in most countries,
suggesting that experts in particular countries can adapt ACT to their cultures.
The ultimate validity and success have been demonstrated in some, but not all,
countries.
Still, a key issue is the multicultural or cross-cultural adaption of ACT within
North America. North America has a large amount of diversity, and this is
where most of the early ACT development occurred; however, it was devel-
oped by, and researched on, rather homogeneous samples. A somewhat dated
review showed that the majority of the research on ACT utilized White partici-
pants (Woidneck et al., 2012). A handful of studies had notable minority sam-
ples, and a couple of studies administered treatment through an interpreter.
Thus, much more emphasis needs to occur at the research end on the use of
ACT with particular diverse populations.
Theoretical work has occurred on the use of ACT with particular diverse
groups. An edited book focuses on cultural competency and the use of accep-
tance and mindfulness approaches (Masuda, 2014). There is writing on cultural
adaptions of ACT, but much of the writing focuses on the use of ACT to pro-
mote cultural competency and undermine prejudice, stigma, and self-stigma
(Krafft et al., 2017; Lillis & Hayes, 2007).
 Acceptance and Commitment Therapy 591

CONCLUSION

In summary, ACT is a modern contextual CBT with promising to strong empiri-

cal support for a wide range of psychological and behavioral health challenges.
Research indicates that focusing on psychological flexibility processes specified
in ACT with methods such as those covered in the case example can lead to
meaningful improvements in psychosocial functioning, valued action, and psy-
chological symptoms. ACT has become widely disseminated internationally
and with an increasing emphasis on how to successfully implement this treat-
ment in diverse populations and refine its procedures for specific problem
areas. The success of ACT may be attributable to its unique development his-
tory and strategy, focused on carefully progressing and connecting the philoso-
phy of functional contextualism, basic research in behavior analysis and RFT,
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and therapeutic processes of change specified in the psychological flexibil-

ity model.

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