Acceptance and Commitment Therapy (ACT)

Acceptance and Commitment Therapy (ACT; pronounced like the word “act”) is a cognitive-behavioral approach used in the treatment of substance use disorders that is based on the concepts of acceptance, mindfulness, and personal values.

The primary ACT goal is to help patients develop the psychological flexibility to cope with challenges without using substances. Part of this process involves developing strategies to tolerate emotionally difficult or painful experiences (e.g., cravings, avoidance of negative emotions, thoughts, feelings, bodily sensations).

WHAT HAPPENS IN ACCEPTANCE AND COMMITMENT THERAPY?

Acceptance and Commitment Therapy helps patients to distinguish between thoughts and behaviors. Specifically, patients become aware of their inner experiences, and engage with exercises that help them simply be mindful of and accept those experiences. One example includes “singing and silly voices.” Here, a patient takes a distressing negative thought (e.g., “I’m no good”) and sings it within an easy popular tune (e.g., “Twinkle Twinkle Little Star”). The patient may also repeat the thought continuously using humorous cartoon-like voices. The goal of this exercise is to help individuals separate the meaning they are placing on the thought from the content itself; that is, to transition from points of psychological inflexibility toward more flexible ones (see “Six Core Principles of Acceptance and Commitment Therapy” below).

Acceptance and Commitment Therapy helps patients to reinterpret past painful events, identify avoidant behaviors, and address emotional difficulties that often co-occur with substance use (e.g., depression, anxiety, and shame). Broader ACT goals that provide direction to these tasks include identification of values and commitment to actions that are in line with those values. Of note, substance use per se is not the target in ACT. Rather, the treatment is intended to decrease the influence of painful emotional experiences that may lead to substance use, thereby influencing it indirectly.

WHAT IS THE THEORY BEHIND ACCEPTANCE AND COMMITMENT THERAPY?

The overarching goal of Acceptance and Commitment Therapy is to consistently act in effective ways (i.e., to become empowered by values and personal goals) even when facing difficult or disruptive inner experiences.

Central Assumptions of Acceptance and Commitment Therapy:

It is human nature, and thus understandable, that people tend to avoid negative inner experiences.
Clarity of personal values and commitment are keys to behavior change.
Rather than fighting the feeling attached to a behavior, a person can observe having the feeling but still act in a way not directly influenced by the feeling.

Six Core Principles of Acceptance and Commitment Therapy:

Cognitive de-fusion: Detaching from inner experiences by interacting or relating to them differently.
Acceptance: Allowing thoughts and feelings to arise without trying to change their form or frequency.
Mindfulness: Retain contact with the present moment.
Self understanding: Letting go of concrete and inflexible thoughts or ideas about oneself, and moving to understanding oneself within the context of situations.
Values: Learning what is most important to oneself (family, service, etc.).
Committed action: Efforts to empower behavioral change.

WHAT ARE THE ORIGINS OF ACCEPTANCE AND COMMITMENT THERAPY?

Conceptualized by Steven C. Hayes in 1982, and first tested by Robert Zettle in the late 1980s, ACT is a behavioral approach based on Relational Frame Theory. This theory, while complex, suggests that when attempting to change a behavior (substance use in this case), it is important to understand how individuals form relationships between their inner experience (e.g., thoughts) and this behavior in order to help alter those relationships. Some consider ACT part of the Third Wave of behavioral therapy (also see: Mindfulness-Based Relapse Prevention), after the first wave (traditional Behaviorism) and the second wave (Cognitive Behavioral Therapy). Hayes and colleagues began testing ACT as a treatment specifically for individuals with substance use disorder in the 2000s. As mentioned in the “What Happens in Acceptance and Commitment Therapy?” section above, much of this work focuses on reducing painful feelings thought to lead to substance use, such as shame (see: work by Jason Luoma), rather than the substance use itself.

EVIDENCE FOR ACCEPTANCE AND COMMITMENT THERAPY

Initial studies testing whether ACT helps people are promising, including randomized trials of the treatment as an addition to standard psychosocial treatment, or as a stand-alone treatment in comparison to other treatments. More research is needed comparing ACT to other empirically-supported approaches (such as 12-step facilitation and standard relapse prevention). Studies are also needed that investigate exactly how ACT is helpful or how it works (i.e., studies that examine its mechanisms of behavior change). Overall, at present, the evidence for ACT in the treatment of substance use disorder is encouraging yet limited.

CITATIONS

Lee, E. B., An, W., Levin, M. E., & Twohig, M. P. (2015). An initial meta-analysis of acceptance and commitment therapy for treating substance use disorders. Drug and alcohol dependence, 155, 1-7. doi: 10.1016/j.drugalcdep.2015.08.004

Luoma, J. B., Kohlenberg, B. S., Hayes, S. C., & Fletcher, L. (2012). Slow and steady wins the race: A randomized clinical trial of acceptance and commitment therapy targeting shame in substance use disorders. Journal of Consulting and Clinical Psychology, 80(1), 43-53. doi: 10.1037/a0026070