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Acceptance and commitment therapy (ACT) is one of the "third wave" of psychotherapies to treat mental disorders. It is similar to CBT but has a different ethos and techniques employed but is equally useful in the treatment of anxiety disorders.

What is acceptance and commitment therapy?

Acceptance and commitment therapy (ACT) is one of a “third -wave” of therapies that include behavioral, cognitive-behavioral and other acceptance and mindfulness-based approaches. The first wave was the behavioral models which utilized classical and operant conditional theories and which focused upon learning and consequences in its understanding of distress and approaches to resolve it. The second wave included more cognitive approaches, which focused more on irrational and dysfunctional beliefs and attitudes and challenging those faulty assumptions. The rigidity of this approach paved the way for the third wave which considers the context in which dysfunctional behavior occurs.

The theory asserts that the way in which people try to solve their problems (often through emotional defenses) typically produce further distress. Rigid self-beliefs, unhelpful priorities in life and the drive to avoid discomfort (be that physical, emotional, psychological) is in fact what causes the distress. These ideas borrow heavily from Buddhist teachings around suffering and seeing it as an opportunity rather than something to be avoided.

ACT posits that the meaning and significance we give to thoughts, reinforces emotional distress. It is very similar to cognitive-behavioral therapy (CBT) as it draws heavily on its basis, but it is different in that it accepts and embraces thoughts that CBT would hold as dysfunctional and in need of repair. So rather than the focus being identifying, challenging and correcting thoughts that may be causing or reinforcing anxiety, ACT encourages people to view them without emotion and in a “matter of fact” way. This essentially encourages the person to put the thought into perspective and afford it less power – the only meaning that thoughts have are the ones we ascribe to them. Rather than fighting distress, people are encouraged to accept it and learn to follow a life based on values that are important to them rather than allowing their symptoms to dictate their life. Meditation and mindfulness are therefore a key part of this approach as the person moves towards acknowledging their thoughts without judgment or avoidance.

Coincidentally, when thinking about ACT as a treatment for anxiety, it is interesting to know that the approach views the root of many problems to arise from the following conditions, as illustrated in the acronym FEAR

  • Fusion - this refers to how your thoughts direct your actions and get in the way of your goals
  • Evaluation/excessive goals – this concerns setting realistic goals
  • Avoidance – this refers to avoidance of discomfort which in turn prevents growth and change.
  • Remoteness – this concerns being detached from your values and how this impacts upon motivation and becomes a barrier to action.

The way to resolve this is to DARE

  • Defusion – identifying the thoughts and detaching from them
  • Acceptance of discomfort – this entails allowing yourself to acknowledge painful thoughts and feelings rather than dismissing them.
  • Realistic goals – this is about accepting your limitations and applying expectations accordingly
  • Embracing values. The requires you to stop and think about why you are doing something and what is important or meaningful about it to you.

Evidence base

Despite the dominance of CBT in the treatment of mental disorders, in general, CBT, psychodynamic psychotherapy and other approaches such as ACT generally produce similar results in terms of treatment outcomes. CBT can sometimes prove more successful when treating anxiety as people can find its structural and directive approach easy to follow; and it can also feel reassuringly unambiguous. However, the person carrying out the therapy and their qualities in interacting with clients, have been found to be five to ten times more significant than the specific techniques in the therapeutic model in terms of treatment outcomes. Those who communicate acceptance, understanding and a genuine interest in the person they are trying to help, typically achieve greater success.

Application to anxiety

To overcome anxiety, sufferers essentially need to confront fears that they have long been avoiding or have only been able to manage by engaging in safety-seeking behaviors (actions the person conducts to make themselves feel less anxious or as a way to stop feared catastrophes happening). Although avoidance of situations or objects associated with fears (or safety-seeking behaviors such as rituals) helps reduce the feelings in the short-term, this only serves to reinforce the fear long-term. This is because the relief that is immediately felt by removing yourself from a situation or avoiding a stimulus reiterates that the stimulus is bad as it triggers uncomfortable feelings. The avoidance (or ritual) is therefore deemed “good” as it makes you feel better by reducing the anxiety.

How can ACT help?

The general goal of ACT is to increase someone's psychological flexibility through the following six processes:

  1. Accepting rather than avoiding
  2. Defusing cognitions – that is, altering the way you relate to your thoughts by providing a different context, thus changing their significance. This achieves the extent to which someone allows them to affect them rather than making them go away.
  3. Focusing on being present with the ultimate goal of being more congruent – if we allow ourselves to directly experience the world then we can be more flexible and act in accordance with our values.
  4. Self as the context – this enables you to be aware of experiences without attaching yourself to them to them or investing in them.
  5. Values – ACT encourages people to identify their values and making sure their choices honor those, rather than being determined by expectations, either from themselves or others.
  6. Committed action – this is where ACT looks like other therapies in terms of defining goals, and carrying out tasks etc.

One of the things that ACT refers to is known as “the control paradox”. Human beings are driven to control and we have an innate instinct to do so, which is generally a successful strategy. However, when we are unable to for some reason (often our emotions), this causes anxiety. ACT argues that paradoxically when we try to control our thoughts or feelings, it often has the opposite effect of what we desire and can cause the exact response we are seeking to avoid. A good example of this is telling yourself not to feel anxious or not to think about a particular thing: the end result is likely to be more anxiety or more focusing on the undesirable thought.

Accepting that your emotions do not define you, defusing your cognitions (not experiencing them as you would real-life events), mindfulness, and being in the present moment (not ruminating on the past or focusing on the future) are all processes that are likely to prove beneficial to those suffering from anxiety disorders. Being focused on the present and living a life determined by values and not avoidance of anxiety can only be a desired outcome for those plagued by anxiety.

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