Motivation and emotion/Book/2013/Acceptance and Commitment Therapy and emotion

Overview
This chapter is committed in educating you on the intricacies of how acceptance and commitment therapy (ACT) works, what the philosophical basis of ACT is and how you can approach emotional experience using some of these strategies. The chapter will also attempt to provide information surrounding emotions so as to educate you on what is occurring in your body when you’re feeling. The chapter includes specific strategies to combat certain psychopathology such as anxiety and depression in everyday life. Acceptance and commitment therapy (ACT) was not constructed for a specific treatment plan thus is can be used in everyday life to resolve dysfunctional behaviour. That said, one should keep in mind that the present research should be taken as a tool for learning rather than a means of treatment.

Functional contextualism

 * Through research I’ve come to understand that clinical definitions of Acceptance and Commitment therapy are extremely complex and have many facets. ACT has philosophical underpinnings which are based on functional contextualism and theoretical roots in Rational Frame Theory (Hayes, 2004; Hayes, Levin, Plumb-Vilardaga, Villatte & Pistorello, 2013; Rector, 2012; Twohig, 2012 ;). I know you’re thinking, what does this mean? I will attempt to provide an understandable description: Functional contextualism perceives psychological events as a set of interactions between whole entities which are ongoing throughout all aspects of life, emphasising both historically and situationally defined contexts (Hayes, 2004). This perspective highlights the goal of predicting and influencing events based on empirical concepts and rules (Ruiz, 2010). Furthermore, according to functional contextualism, thoughts and feeling do not directly cause action it is the context in which these events occur that activate certain behaviour (Ruiz, 2010). Functional contextualism is reflected in ACT, as ACT emphasises effective action as a truth criterion, the truth criterion is based on finding out what works for that individual through setting analytic goals (Hayes, 2004). These analytic goals are based on the premise that thoughts are neither correct nor incorrect rather useful tools in acquiring a more valued life (Ruiz, 2010).

Relational Frame theory (RFT)

 * We will not go into too much details in reference to RFT as it will help you better understand ACT but it will not assist in a therapeutic manor. RFT is concerned with how humans learn a language and suggest that cognitions and language are abilities under contextual control and a consequence of randomly related events both reciprocally and in combination (Hayes et al 2006). Languages and cognitions have the ability to change functionality of events, specifically based on their relation to other events (Hayes et al 2006). An example proposed by Hayes et al (2006): a child will have the understanding that a 50cent coin is bigger than a 1dollar coin in physical size, but that child does not understand that the smaller coin is of larger value until society advices him as such. From an ACT perspective a key cause of psychopathology is formed via a problematic interaction between language and cognition, which results in failure to continue or modify behaviour connected to self-valued goals (Hayes et al., 2006). According to ACT such inflexible behaviour arises from fragile and obstructive contextual control over processes of language (Hayes et al., 2006).

Description of ACT processes and strategies

 * Acceptance and commitment therapy (ACT) perceives thoughts, feelings and bodily situations as inner experiences that are not inherently problematic or positive;
 * it is rather how these events function for the individual that determine outcome (Twohig, 2012).


 * The fundamental concept of ACT is the facilitation of therapeutic change through modifying the environment within which private events function, rather than methods of reducing, eliminating or exchanging unwanted thoughts and feelings (Zettle, 2012). ACT perceives human language as a problematic concept, as private events such as anxiety or depression are socially depicted as “bad”, thus giving reason for an individual to escape or avoid these events rather than following ones goals and values, ultimately leading to dysfunctional behaviour (Zettle, 2012). ACT is said to be part of a “third wave” of behavioural therapies, incorporating both cognitive and behavioural perspectives, creating a more holistic approach to psychopathology (Twohig, 2012;). Although ACT is a transformation of early forms of therapy integrating acceptance and mindfulness strategies and behaviour, commitment and change process, it is nevertheless part of a large group of cognitive and behavioural therapies (Hayes et al., 2013; Rector, 2013;). For more or more information regarding mindfulness refer to


 * ACT is built on the premise that language impacts emotion, cognition, and behaviour (Hayes, et al. 2013). ACT proposes that mental distress; also termed psychopathology is caused by cognitive entanglement or cognitive fusion, which is the act of over literalising thoughts and forcing oneself to remain in a state of “problem solving” even when it is obstructive (Hayes at al. 2013; Rector, 2013;). According to ACT these thoughts become pervasive and in an attempt to reduce this over-analysis private events such as emotions, thoughts, memories and bodily sensations are avoided (Hayes at al. 2013; Rector, 2013;). Such an occurrence leads to the focus on past events and failure to stay within the present (Hayes at al. 2013; Rector, 2013;). The inability to perceive the existent self will eventually lead to behavioural inaction, impulsivity, avoidance and over conformism to social norms rather than chosen values (Hayes et al., 2013; Rector, 2013;). These events are termed destructive experiential avoidance which several articles propose results in a mutual state of “psychological inflexibility” (Hayes et al., 2013; Rector, 2013; Ruiz, 2010).

How does ACT suggest we improve cognitive inflexibility?
''knowingly avoiding feelings of sadness or anxiety and continually looking at everything that’s gone wrong, just falling deeper and deeper into your own thoughts and constructions until you felt like you may explode?… Sound familiar? Well you’re not alone in your actions; we have all felt like that at some point but the question is how do we get out of this pit of despair? ACT suggests ways you can help yourself.''

Research suggest six core treatment process of ACT,which include: (Powers, Zum Vörde Sive Vörding, & Emmelkamp, 2009). These processes are applied through specific exercises, which are described bellow (Powers et al., 2009).
 * 1) Acceptance
 * 2) Defusion
 * 3) Contact with the present moment
 * 4) Self as context
 * 5) Values
 * 6) Commitment action




 * The process of acceptance is used as an alternative to experiential avoidance, rather than escaping the private event the individual is encouraged to take life from moment – to moment by adopting an open, receptive and flexible attitude towards experiences (Hayes et al., 2013). Hayes (2004) suggests that deliberate attempts at avoiding thoughts and feelings, have an adverse effect of an increased occurrence of the dysfunctional behaviour. The choice of acceptance is an important aspect as one is not simply tolerating these experiences but welcoming them and moving into defusing dysfunctional cognitions (Twohig 2012). For example: when faced with anxiety, acceptance comprises being actively involved in situations which cause anxiety and confronting the anxious feeling in a welcoming manor (Twohig, 2012). In a therapeutic situation the patient may be asked “how open are you to your anxiety” unlike “how much anxiety are you feeling” (Twohig, 2012, p. 503).


 * The act of noticing thinking as it occurs; through applying a reduced literal meaning to inner experiences thus throughs, feelings and bodily sensations are no more than the words themselves (Twohig, 2012). Haye et al., (2013) suggests Clinical techniques of defusion are as follows: “thanking one's mind for a thought, watching thoughts goes by as if they were written on leaves floating down a stream, repeating words out loud until only the sound remains or giving thoughts a shape, size, and texture” (p. 183).As the goal is improved behavioural flexibility, Hayes et al., (2013) suggests classifying the method of thinking e.g., “I am having the thought that I cannot go to work as its all too much” and behaving contrary to the through: e.g., “ saying I cannot go to work whilst taking the steps to get to work”. This change will not be immediate and the frequency of incapacitating thoughts will not diminish right away (Hayes et al., 2013; Rector 2012). Twohig (2012) maintains that experiencing debilitating thoughts such as “I will never be good enough” as only words and prohibiting these thoughts to influence action are sound techniques of defusion.


 * Fusion and experiential avoidance often force an individual out of the present; their attention is on being somewhere else where the problematic events are not happening (Hayes et al., 2013). Thus being present is attending to our inner experiences and environment in the here and now rather than focusing on past events (Twohig, 2012). Being present in both your internal and external environment reduces the impact and likelihood of being trapped in your cognitively constructed world thus facilitating feelings surrounding the present moment.Twohig (2012) suggest that being present requires skills such as: “the ability to regulate attention to the now; openly and fully experiencing what is occurring; and labelling and describing these events in a nonjudgmental manner” (p. 503). Disconnection with the present has much to do with worrying and contemplating past or future experiences (Twohig, 2012). A clinical technique to reduce this disconnection is teaching the individual to be consciously aware of when they regress into the past and shifting their attention into the present moment, allowing the individual to refocus attention into current events, environment and the their inner experiences (Twohig, 2012).


 * The goal of ACT is to challenge the conceptualised self- the “you” that is assembled through categorising and evaluating oneself (Hayes et al., 2013; Twohig, 2012). We are unaware of this creation as we believed it to be us, thus the clinical issue is that we will strive to protect and retain this conceptualised self even when is has disabling properties (Hayes et al., 2013; Twohig, 2012). Individuals will behaviour in ways that maintain their self-categorisation for example: if an individual labels themselves as “anxious” they will behaviour in a manner that reflects this evaluation (Hayes et al., 2013; Twohig, 2012). ACT seeks to encourage contact with the here and now also termed “self as context”, allowing patients the choice to behave according to their values rather than defining inner experiences by private events (Twohig, 2012; Ruiz, 2010). As is evident in other ACT process cognitive flexibility is the desired outcome of “self as context”, which is attained through “mindfulness exercises, metaphors, and experiential processes” (Hayes et al., 2013. p. 185). Hayes et al., (2013) provides some interesting therapeutic examples such as “clients may be asked to imagine that they are older and to write a letter of advice back to the person struggling now, or they may engage in eyes-closed mindfulness activities where they are asked to look at difficult experiences and then to notice who is noticing” (p. 185).


 * A dominate goal of ACT is to increase ones capability of behavioural change in favour of your chosen values, thus afore mentioned processes intend on assisting you in living a values-consistent life (Hayes et al., 2013). ACT defines values as personal constructs which motivate us to engage in certain actions within our lives (Hayes et al., 2013; Twohig, 2012). ACT describes these values to be verbal constructs that are ever changing and evolve to become intrinsic in defining our behaviour (Hayes et al., 2013; Twohig, 2012). Values can be seen as on-going actions, providing life direction, guidance and meanings, the problem occurs when values lack precision, are based on social approval rather than personal choice, and are dominated by avoidance in fear of shame (Hayes et al., 2013; Twohig, 2012). Behavioural choices biased on said values have disabling outcomes such as inflexible characteristics leading to negative consequences. Therapeutic methods of improvement include: looking for meaning and purpose in life (existential strategies) and moving away from social conformism’s and avoidance (Hayes et al., 2013). These methods are implemented through exercises such as: client’s journaling their choices and directions in various areas of life and tracking the consequences of behaving in a value-directed manor (Hayes et al., 2013).




 * This part of ACT is dedicated to the continuation of skills in areas of acceptance, defusion, being present and viewing self in context, these skills are value directed and practiced in accordance to valued goals (Twohig, 2012; Hayes, 2004). Committed action seeks to construct a growing pattern of flexible and effective behavioural responses, through the removal of psychological inflexibility and the promotion of considered actions in accordance to preferred values (Hayes, 2004; Twohig, 2012).  An assortment of techniques are utilised which focus on traditional behavioural change such as, learning generalizable strategies emphasising movement toward valued goals and disbanding  psychological and situational obstacles through defusion, acceptance and directive action (Hayes, 2004; Twohig, 2012). Examples of committed action comprise: the establishment of specific goals which are worked toward progressively and making commitments concrete through publication (Hayes, 2004). It should be noted that ACT can incorporate behavioural intervention methods such as: exposure exercise or skills training activities if aligned with the six processes (Twohig, 2012)..

Emotional experiences
How can we define an emotion? Emotions work in mysterious ways, strong emotions can make you do things you normally wouldn’t such as, avoiding situations that are generally enjoyable, we understand how to stop such pervasive reactions through ACT but it would help to understand the cause (Gross & Munoz, 1995). Gross and Muñoz (1995) define emotions as: “biological based reactions that coordinate adaptive responding to important opportunities and challenges; each emotion appears to address a somewhat different adaptive problem” (p.152). As our emotions physically and mentally respond to situations in our lives, contextual reasoning for feelings can have a major impact on how we react (Gross & Munoz, 1995). This explanation is likened to that of B.F Skinner (1938) who posed that “all of behaviour reflects reaction to rewards and punishments (reinforcers) provided by the environment” (as cited in Rolls, 1999. p. 605). Viewing emotions and behaviour from this perspective gives the impression that environments with continual negative reinforcements will have obstructive outcomes on emotions for example: if an individual consistently thinks their life is not worth living and everything just doesn’t go their way, their emotions and behaviour will reflect this attitude, which is the core issue that ACT strategies intend on resolving.
 * The next section of the chapter will focus on applying ACT strategies in everyday emotional experiences such as depression, anxiety and stress.

Depression


Difficulties regulating your emotions have been suggested to be a foremost cause in depression and anxiety (Aldao, Nolen-Hoeksema, & Schweizer, 2010; Joormann, & Gotlib, 2010; Ehring, Tuschen-Caffier, Schnülle, Fischer & Gross, 2010).Emotional regulation can be defined as: an individual’s ability to consciously and unconsciously control their emotions in response to environmental stressors (Aldao et al., 2010; Bargh, &Williams, 2007). Individuals adopt regulatory strategies in order to adjust their emotional experiences to fit the emotion provoking event (Aldao et al., 2010). Research suggests that Acceptance and mindfulness strategies such as those previously mentioned in the chapter can minimize an individual’s distress (Aldao et al., 2010).

Take depression for example, it is not how an individual initially responds to a negative event, rather the ability to which an individual can revive their mood after feeling a negative emotion such as sadness (Joormann, 2010). Therefore, frequent negative thoughts, selective attention to negative stimuli and easily assessable negative memories are all interrelated and consequences of negative moods (Joormann, 2010). The issue is in the in congruency between research and practicality, as it is theorised that an individual should be able to quickly change cognition to regulate mood states (Joormann, 2010). However, people with depression have an inability to do so and rather fall into a self-defeating cycle of negativity (Joormann, 2010).

The ACT perspective sheds some light on the current problem, and views this self-defeating cycle as made up of psychological inflexibility and suggests strategies such as acceptance of the negativity, keeping in contact with the present (which reduce the reliance of past memories of negativity) self as context (removing yourself from these negative evaluations), values (to increase ones capability of behavioural change in accordance with own values) and committed action (Hayes et al., 2013). If you’d like a further explanation of the ACT processes refer to section of the book chapter. This exercise can be initiated and sustained through activities such as: carrying a self-monitoring index card to refer to when you encounter a difficult situation (Powers et al., 2009). The index card is suggested to have two sides; one side: The fear algorithm which is a reminder for patients to review whether they’re avoiding inner-experiences, fusing thoughts, evaluating experiences and giving reason for behaviour (Powers et al., 2009). On the other side is the ACT algorithm: a positive reminder of acceptance of inner-experiences, living in the present moment with self as context, choosing a valued direction and taking action (Powers et al., 2013). We can conceptualise the sides as depicting the ease to which we move from the barriers that stop us from achieving our goals, to the realistic removal of those barriers and visualising a value directed life (Powers et al., 2013).

 For more information regarding emotional regulation refer to 

Stress
/Acceptance and Commitment therapy (ACT) and Stress/

Anxiety
''Everyone has been guilty of avoiding a situation because of fear or embarrassment, and at times it feels unbearable. You may not want to leave your house in fear of coming into the contact with the problematic situation so you don’t, or maybe you've “chucked a sickie” at school or work due to fearing embarrassment. An example of how we can make it easier to face our fears is through engaging in ACT processes.''
 * The main issues within anxiety disorders are the aspects of avoiding the problematic situation, prediction of the outcome and control of the situation (Arch & Craske, 2008). Thus working through acceptance strategies may be beneficial in reducing the distress caused by social anxiety disorders (Arch & Craske, 2008; Dalrymple & Herbert, 2007). Social anxiety disorder (SAD) is marked by extreme fear of social situations in anticipant of embarrassment, thus individuals tend to avoid such situations (Dalrymple & Herbert, 2007).


 * The aim of the present study by Dalrymple and Herbert (2007) was to examine the satisfactory value of creating a treatment plan for adults diagnosed with SAD. The treatment was based on ACT process with the inclusion of exposure exercise contextually based on ACT (Dalrymple & Herbert, 2007). The treatment was delivered weekly through 12, 1 hour sessions, the first stage of treatment facilitated clients to understand why their past attempts of controlling the anxiety were ineffective, also termed creative hopelessness (Dalrymple & Herbert, 2007).


 * The second stage included the introduction of acceptance as a substitute to avoiding private events. Exercises consisted of; allowing oneself to engaging in thinking and feeling the unwelcome events, whilst taking part in self-valued behaviour e.g., going outside or initiating a conversation (Dalrymple & Herbert, 2007). The incorporation of exposure exercises were initiated at stage three and continued into stage 12, these exercises included being exposure to the problematic event and accepting the experience of anxiety rather than focusing on eliminating thoughts (Dalrymple & Herbert, 2007). The next stage included the introduction of mindfulness and cognitive defusion strategies to promote observing private events in a non-judgmental manor and accepting the experiences without trying to stay in control (Dalrymple & Herbert, 2007). Towards the final stages, participants reviewed their values and goals in great detail not taking into account perceivable complications. Ideas were explained through metaphors and experiential exercises, session further included out of hours homework and role play exercises (Dalrymple & Herbert, 2007).

ACT vs.Cognitive Behavioral Therapy(CBT)
/Acceptance and commitment therapy (ACT) vs. Cognitive Behavioral Therapy(CBT)/

Does acceptance and commitment therapy actually work?
The evidence surrounding the effectiveness of ACT is large; all articles reviewed suggested that ACT does work (Hayes et al., 2013; Zettle, 2012; Twohig, 2012). Many of studies conducted found positive results for the six ACT processes (Twohig, 2012). A major area of success is found in anxiety disordered patients (Twohig, 2012). A meta-analytic review was conducted by Powers et al., (2009) which concluded that ACT had better follow up results then other treatments, it should be noted that the present study found little difference between ACT results and other established treatments. Thus suggesting that although evidence is in favour of ACT it works better than other therapies in limited areas (Powers et al., 2009;Forman, Herbert, Moitra, Yeomans, & Geller, 2007). Another consideration is the difficulty in measuring the effectiveness of ACT on specific disorders, as ACT is not made for one disorder but rather a range of board problems (Powers et al., 2009; Hayes et al., 2013). As ACT is a relatively new therapy and still in the growth stages further research needs to be conducted (Powers et al., 2009).

Conclusion

 * I hope you've come to understand the six process of ACT and how you can implement ACT in problematic situations. As in every therapy there are limitations and ACT will not work for everyone however, I would encourage you to have a look at the external links for further information and strategies regarding ACT.

Quiz
{What is the philosophical basis for ACT? - Relational Frame theory + Functional contextualism - Stress management and training - Cognitive behavioural therapy
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{Which of these in not an one of the six ACT strategies?? - Acceptance - Defusion + Psychological flexibility - Self as context - Values - Contact with the present moment
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{What is the main contributing factor in reducing anxiety? - Reducing experiential avoidance - Increasing acceptance of experiences - Regulating emotions + Both 1 & 2
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{Define cognitive fusion: + Act of over literalising thoughts and forcing oneself to remain in a state of “problem solving” - The definition of entangled thoughts and feelings - Escaping the presentment moment to remove problematic experiences - Verbal constructs that define our behaviour
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