Acceptance and commitment therapy (ACT, typically pronounced as the word "act") is a form of cognitive behavioral psychotherapy that uses mindfulness to recognize one's psychological responses and be open to one's experiences and accept them, and commitment to one's core values to create a meaningful life.

ACT was developed in the 1980s by Steven C. Hayes, taking a contextualistic and holistic approach to human behaviour, arguing that human suffering is created by human language (cognition), that is, the way we create and are entangled in our subjective world, and avoid certain unpleasant feelings.

Theoretically, ACT is rooted in B. F. Skinner's philosophy of radical behaviorism and in Hayes' post-Skinnerian functional contextualism. As a therapeutic practice, ACT takes a holistic approach borrowing aspects from "the human potential movement, Eastern traditions, behavior therapy, mystical traditions, and the like".

Origins and development Steven C. Hayes developed ACT around 1982, elaborating on the cognitive therapy technique of cognitive distancing, the ability to take an objective stance towards thoughts and to investigate them as hypotheses rather than as confirmed truths. After analyzing the functionality of this concept, Hayes concluded that "thoughts alone cannot directly cause psychological distress or ineffective behavior," but that their impact depends on their context. According to Hayes, "distancing techniques establish a less literal context that can weaken the behavior regulatory impact of language," that is, cognition (pre-existing assumptions that regulate and shape the way we perceive and give meaning to the world). Hayes observed that this fit in with the restrictive "excessive regulation" which "verbal rules" can cause, and tried to find ways to reduce this impact, and create more room for "long-time contingencies" (unexpected events), by putting more emphasis on distancing and "confronting unworkable rules that we thought artificially sustained the behavior regulatory impact of private experiences by encouraging experiential avoidance." Hayes developed a treatment to test this model, first calling it comprehensive distancing.

The foundational concepts of ACT were formally introduced in Steven C. Hayes's 1987 article "A contextual approach to therapeutic change: Toward a functional analysis of human language," published in Behavior Therapy. He did not yet name the approach "Acceptance and Commitment Therapy." The term ACT began to appear in print in the early 1990s, as the model became more developed. The first major use in a formal publication was in the 1999 book: Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change.

Theoretical background Theoretically, ACT is rooted in behavior analysis the pragmatic philosophy of Hayes' functional contextualism, and is guided by Hayes' relational frame theory, a comprehensive theory of language (cognition) that is derived by Hayes from behavior analysis and B. F. Skinner's philosophy of radical behaviorism. As a therapeutic practice, ACT takes a holistic approach borrowing aspects from "the human potential movement, Eastern traditions, behavior therapy, mystical traditions, and the like".

Guiding theory

Functional contextualism Functional contextualism, like social constructionism and similar contextualist approaches, approaches behaviour as determined by the context in which one acts, with "context" including the "environment, behavior, history, and outcome of the behavior." It sees language (that is, cognition, the way our experience is structured by thought patterns, memories, and expectations) as "the primary root of human suffering," especially because of experiential avoidance and cognitive fusion. Experiential avoidance is the avoidance of unpleasant or frightening events and emotions; cognitive fusion is the immersion in thoughts and feelings, being unable to distance oneself from them.Jennifer Delgado (2021), Cognitive fusion, when thoughts are the enemy, Psychology Spot

Relational frame theory Relational frame theory (RFT) is a behavior analytic theory of human language, cognition, and behaviour developed by Hayes as an extension of his functional contextualism. RFT argues that the building block of human language and higher cognition is relating, i.e. the human ability to create bidirectional links between things. RFT has been extended in research notably by Dermot Barnes-Holmes and colleagues of Ghent University.

Third wave of cognitive behavior therapy

ACT, dialectical behavior therapy (DBT), functional analytic psychotherapy (FAP), mindfulness-based cognitive therapy (MBCT) and other acceptance- and mindfulness-based approaches have been grouped by Steven Hayes under the name "the third wave of cognitive behavior therapy".

According to Hayes' classification, the first wave, behaviour therapy, commenced in the 1920s based on Pavlov's classical (respondent) conditioning and operant conditioning that was correlated to reinforcing consequences. The second wave emerged in the 1970s and included cognition in the form of irrational beliefs, dysfunctional attitudes or depressogenic attributions.

In the late 1980s empirical limitations and philosophical misgivings regarding the second wave gave rise to Steven Hayes' ACT theory which shifted the focus of abnormal behaviour away from the content or form towards the context in which it occurs. People's rigid ideas about themselves, their lack of focus on what is important in their life, and their struggle to change sensations, feelings or thoughts that are troublesome only serve to create greater distress. According to Steven Hayes, "the third wave of behavioral and cognitive therapy is particularly sensitive to the context and functions of psychological phenomena, not just their form, and thus tends to emphasize contextual and experiential change strategies in addition to more direct and didactic ones."

However, this classification of like-minded third wave CBT-approaches has been questioned. For example, David Dozois and Aaron T. Beck argued that there is no "new wave" and that there are a variety of extensions of cognitive therapy; for example, Jeffrey Young's schema therapy came after Beck's cognitive therapy but Young did not name his innovations "the third wave" or "the third generation" of cognitive behavior therapy.

Similarities with humanistic approaches The textbook Systems of Psychotherapy: A Transtheoretical Analysis includes various criticisms of third-wave behaviour therapy, including ACT, from the perspectives of other systems of psychotherapy, including the complaint that third-wave therapies "display an annoying tendency to gather effective methods from other traditions and label them as their own".

The emphasis of ACT on ongoing present moment awareness, valued directions and committed action is similar to other psychotherapeutic approaches that, unlike ACT, are not as focused on outcome research or consciously linked to a basic behavioral science program, including approaches such as Gestalt therapy, Morita therapy, and others. Hayes and colleagues themselves stated in their book that introduced ACT that "many or even most of the techniques in ACT have been borrowed from elsewhere—from the human potential movement, Eastern traditions, behavior therapy, mystical traditions, and the like".

Technique

Aims The goal of ACT is not to eliminate difficult feelings but to be present with what life brings and to "move toward valued behavior".

Questioning "healthy normality" While Western psychology has typically operated under the "healthy normality" assumption, which states that humans naturally are psychologically healthy, ACT assumes that the psychological processes of a normal human mind are often destructive. The core conception of ACT is that psychological suffering is usually caused by experiential avoidance, cognitive entanglement, and resulting psychological rigidity that leads to a failure to take needed behavioral steps in accord with core values.

ACT questions the assumption that happiness is "the true state of normal health" and the aim of psychotherapy, and employs "creative hopelessness" as a therapeutic strategy, "to help the patient realize the futility of avoiding [...] depressed mood, anxiety, or pain."

Cognitive distancing ACT differs from some kinds of cognitive behavioral therapy (CBT) in that, rather than trying to teach people to control their thoughts, feelings, sensations, memories, and other private events, ACT teaches them to "just notice", accept, and embrace their private events, especially previously unwanted ones. ACT helps the individual get in contact with a transcendent sense of self, "self-as-context" or Observing Self, a consistent perspective from which to observe and experience, and yet distinct from one's thoughts, feelings, sensations, and memories. ACT tries to help the individual clarify values and then use them as the basis for action, bringing more vitality and meaning to life in the process, while increasing psychological flexibility.

Basic causes of psychological problems ACT views the core of many problems to be due to the concepts represented in the acronym, FEAR: Fusion with your thoughts Evaluation of experience Avoidance of your experience Reason-giving for your behavior

And the healthy alternative is to ACT: Accept your thoughts and emotions Choose a valued direction Take action

Developing psychological flexibility ACT commonly employs six core principles to help clients develop psychological flexibility: Cognitive defusion: Learning methods to reduce the tendency to reify thoughts, images, emotions, and memories. Acceptance: Allowing unwanted private experiences (thoughts, feelings and urges) to come and go without struggling with them. Contact with the present moment: Awareness of the here and now, experienced with openness, interest, and receptiveness. (e.g., mindfulness) The observing self: Accessing a transcendent sense of self, a continuity of consciousness which is unchanging. Values: Discovering what is most important to oneself. Committed action: Setting goals according to values and carrying them out responsibly, in the service of a meaningful life.

Creative hopelessness is a technique used to give up ineffective approaches and facilitate acceptance, by exploring what a person has done to alleviate their suffering, and if those strategies worked.Steve Rose, What is Creative Hopelessness?

Adaptations and compatibility ACT has also been adapted to create a non-therapy version of the same processes called acceptance and commitment training. This training process, oriented towards the development of mindfulness, acceptance, and valued skills in non-clinical settings such as businesses or schools, has also been investigated in a handful of research studies with good preliminary results.

In 2020–2021, after three RCTs of ACT by the World Health Organization (WHO), WHO released an ACT-based self-help course Self-Help Plus (SH+) for "groups of up to 30 people who have lived through or are living through adversity". See also the course materials: As of July 2023, there are six RCTs of Self-Help Plus.

In behavioral health, a brief version of ACT is focused acceptance and commitment therapy (FACT).