As a child, growing up under the communist regime I struggled with the chasm in worldview provided by my social environment as compared to my parents. The communist rules and worldview needed to be obeyed to live a regular life without threat. A wrong word, a wrong idea could put the whole family into jeopardy. It could possibly mean jail for my parents. However, at night, my parents would watch the news from West Germany, the “enemy”. Two truths were in the room at once and suddenly these needed to be juggled in life. My words and my thoughts needed to be evaluated carefully. The reunification changed the context of life drastically, suddenly the “virtual truth” from the news was real. The new reality demanded a change of my beliefs, values, and behavior. What was appropriate previously and even life enhancing was suddenly dangerous, in some cases even termed pathological.
This was my first personal experience of major cultural shifts, but not the last. As a wife of an Korean-American husband and the mother of two girls of mixed cultural heritage, I am living in a multi-cultural and multi-contextual world. Culturerepresents the use of similar language, a common history, a set of traditional ideas and values, handed down from generation to generation, to organize behavior in a systematic way (Kagitcibasi, 2007). A shift in culture also impacts a person’s worldviews (Koltko-Rivera, 2004). Worldviewprovides the basis for meaning and value of the universe and of an individual’s life. A person’s or a groups worldview provides a guiding set of beliefs and assumptions about the physical and social reality. Moreover, those have powerful effects on cognition and behavior through believes and values (Koltko-Rivera, 2004).
The philosophical assumptions of functional contextualism captures my lived experience by incorporating the study of how things function given a specific context, herein including worldview and culture (Harris & Hayes, 2009). While common psychological models are based on a mechanistic worldview with dysfunctional, maladaptive, and pathological events, functional contextualism implies that every action has a meaningful purpose and is therefore adaptive (Harris et al., 2009). The function of a behavior is considered within a given historical and situational context involving the whole organism (Hayes, Levin, Plumb-Vilardaga, Villatte, & Pistorello, 2013). The unit of analysis is a purposefully taken action impacted by a specific context and evaluated by its workability (Hayes, Strosahl, & Wilson, 2012). A change in context may change the whole event and its meaning in action (Hayes et al. 2013). This approach also acknowledges the existence of many world and truths allowing for the inclusion of historically and situational influences and a person’s worldview.
Past and present experiences shape a persons’ thoughts, their influence on emotions, and subsequent actions. Functional behavior is therefore determined by a person’s goals, purpose, and the given context. A focus on solely internal functionality of behavior based on thoughts and emotions is seen as incomplete (Hayes, Levin, Plumb-Vilardaga, Villatte, & Pistorello, 2013). Functional contextualism grew out of B. F. Skinner’s radical behaviorism (Hayes et al., 2013). This school of behaviorism understands everything an organism does as behavior, including thinking, feeling, and remembering (Harris & Hayes, 2009).
Skinner founded radical behaviorism and behavior analysis (Baum, 2011). According to Harris and Hayes (2009), radical behaviorism is grounded in behaviorism in a way that it understands the science of behavior as a natural science, involving the use of animal research to learn about human behavior, that the environment influences behavior, and a focus on intervention that can modify behavior. However, radical behaviorism emphasizes the role of biology, genetics and experiential factors, such as past and present environment, and evolutionary factors, in determining an organism’s actions. Radical behaviorists distinguish between two forms of behavior, public and private. Public events are actions that can be directly observed by others, while private events are only observable by the person experiencing them. Private events include thinking, feeling, fantasizing, remembering, ruminating, and sensory perceptions. The rigorous scientific study of those two realms of behavior have led to many evidence-based methods in clinical psychology capable of shaping human behavior (Blackledge, Ciarrochi, & Deane, 2009). From radical behaviorism developed applied behavioral analysis the science that was mainly dedicated to developing interventions to produce observable changes in behavior (Schneider & Morris, 1987). Moreover, Skinner introduced the idea of verbal behavior, implicating that verbal behavior is operant behavior (Baum, 2011). The third major conceptual contribution involved his idea that behavior may be shaped by consequences (Baum, 2011).
Relational Frame Theory
A post-Skinnerian contextualistic theory of language and cognition attempting to provide basic principles for all forms of cognitive events is Relational Frame Theory (RFT) (Hayes, 2016). RFT stipulates that human language and cognition has the ability to learn to relate events. Humans appear to be the only species with the capability of relating two stimuli based on their physical properties, but also on established social contingencies and conventions (Hayes, Barnes-Holmes, & Roche, 2001). RFT proposes that relational learning has three main characteristics. One, it is bidirectional, meaning that learning about an event in relation to another event in a specific context will infer relationship between these two independent events. For example, teaching a young child a new animal by repeatedly saying the name of the animal. The child will automatically relate the picture to the newly learned sound or word. The ability to quickly establish those relations is the basis for learning and knowledge acquisition developed during early childhood (Harris & Hayes, 2009).
Two, these newly established relationships can be combinatorial. Introducing a relationship between A and B, and B and C, will automatically lead to the assumption that A and C must be mutually related as well, at least in this particular context. From a set of few introduced relations a person has the ability to create a relational network.
Third, established relations between stimuli can change the functions among related stimuli. An example given by Hayes demonstrates this principle: “If you need to buy candy and a dime is known to be valuable, it will be derived that a nickel will be less valuable, and a quarter will be more valuable, without necessarily directly purchasing candy with nickels or with quarters” (p. 875).
The process of all three components combined is called “relational frame”. RFT incorporates Skinner’s verbal events as psychological function in that they are involved in relational framing (Hayes, Strosahl, & Wilson, 2012). Verbal knowledge is the result of networks that have highly interconnected relationships between stimuli. The establishment of relational networks enhances language and cognition, enabling the human species to generate infinite numbers of thoughts and ideas (Harris & Hayes, 2009). These relational responses, if taken out of context, are understood as the root of human suffering. The clinical utility of relational framing lies in the capability of the one altered related event to change the function of another related event (Hayes, 2016). For example, a person may learn that snakes are dangerous, even deadly. They live in the forest and are hard to detect. This relation may lead to a person’s extended fear of forests, since snakes may be living in it. The person may now avoid the forest and other areas that may be related to forests, because these places all have been relationally framed around snakes. These seemingly unrelated instances are now considered verbal/cognitive related events (Hayes, 2016). RFT understands relational framing as a generalized operant, meaning that it happens automatically (Hooper & Larsson, 2015). This unique ability to establish and respond to derived relationships is seen as the foundation for emotional distress. The human ability to plan, predict, judge, verbally communicate, and relate events and stimuli are sustaining human survival while also creating problems (Stoddard & Afari, 2014). The ability to combine previously learned relations and derive into new relations (mutual entailment) can explain the occurrence of negative emotional reactions when thinking about a negative incident. This process is also part of creating self-rules. The identified principles of cognition and language inform ACT conceptualization and interventions.
Contextual Behavioral Science
The ultimate purpose for a practitioner grounded in functional contextualism is to impact the world positively and intentionally (Hayes, Barnes-Holmes, & Wilson, 2012). The role of advocacy was also present in Skinner’s work and informed the foundation of CBS. He asked psychologists to take social responsibility, including issues such as democracy, education, and social equality (Vilardaga, Hayes, Levin, & Muto, 2009). The Association of Contextual Behavioral Sciences (ACBS) states its vision as being “dedicated to the alleviation of human suffering and the advancement of human well-being through research and practice grounded in CBS (Association of Contextual Behavioral Sciences, 2005). Nested within functional contextualism is the philosophical worldview of contextualism, the theoretical and philosophical basis for CBS (Hayes, Strosahl, & Wilson, 2012). This scientific philosophical agreement creates the foundation on which analytical assumptions and methodologies are based on. Limitations, explanations, interpretation, and logical underpinnings of gathered data are tied to the adopted scientific philosophy (Vilardaga et al., 2009). CBS was established as a framework for research and collaboration of various disciplines that reflected contextualism, allowing it to direct and influence underlying research assumptions, future directions of research, development of models of pathology, measurement, and treatment development. This approach seeks to explain actions by emphasizing the role of contextually driven assumptions as the main influence of human behavior. It strives to integrate philosophical assumptions, basic science, basic and applied theory, the development of interventions, treatment testing, dissemination, and training. It incorporates multi-dimensional and multi-level evolutionary science as well as the interaction of human behavior with genetics, epigenetics, and cultural dimensions (Hayes et al., 2012). CBS challenges existing philosophical assumptions held in the social sciences, such as that “happiness” is a state of normality (Hayes, Levin, Plumb-Vilardaga, Villatte, & Pistorello, 2013). Instead, CBS termed the phrase “the ubiquity of human suffering” (Hayes et al., 2012). This assumption is supported by data from the World Health Organization (WHO) which summarizes the likelihood of mental health problems in 17 countries, including Belgium, Colombia, France, Germany, Israel, Italy, Japan, Lebanon, Mexico, the Netherlands, New Zealand, Nigeria, China, South Africa, Spain, Ukraine, and the USA (Kessler et al., 2009). Through the use of structured interviews that screened for diagnostic criteria they found that between 12% in Nigeria and 47.4% in the United States experience a mental health disorder in their lifetime. Moreover, suicide was found to be the second leading cause of death globally between the ages of 15 and 29 years. Over 800,000 people succeed committing suicide yearly (Hooper & Larsson, 2015).
The extended purpose of CBS is to create a science that is more aligned with the challenge of the human condition. This involves the empowerment of individuals to engage in transformational change, a process focused on prosocial change (Hayes, 2016). CBS is the underlying research paradigm for Acceptance and Commitment Therapy (ACT) and Relational Frame Theory (RFT).
Historical Background of Behavioral Therapy
In 1913, Watson described the role of psychology from a behavioral perspective as “a purely objective experimental branch of natural science. Its theoretical goal is the prediction and control of behavior” (Benjamin, 2007, p. 145). Behaviorists believed that for psychology to become a natural science it needed scientific objective measures. Within the last century there have been “three waves” of behavioral therapies employing the principles of behaviorism to treatment (Hayes, 2004). Each “wave” of behaviorism had a distinct set of assumptions, used methods, and goals. Behavior therapy was established as a countermovement to prevailing clinical conceptions. Behaviorists wanted to establish a science that was based on scientifically established basic principles providing a strong scientific link between theory and clinical interventions (Hayes, 2016). This was in stark contrast to earlier forms of therapy, such as the psychoanalytical model, which developed mainly on the basis of clinical interactions of Freud and his patients (Hooper & Larsson, 2015). Behavioral therapy (BT) was almost independently and simultaneously established in South Africa (Joseph Wolpe), in America (Ogden Lindsay), and in England (Hans Eysenck) in the 1950s (Öst, 2008). These researchers had a common focus on overt behaviors. They used operant and classical conditioning techniques to influence those overt behaviors, mainly overlooking feelings and thoughts (Harris & Hayes, 2009). John Watson’s role in behavioral psychotherapy started with his famous experiment with “Little Albert”. A nine-month old boy was conditioned to fear a white rat in an experimental setting. He combined his observation of children being startled by loud noises and the touching of a white rat. Each time the baby would touch the rat a loud noise appeared. This experiment had direct implications for the development of psychopathology in that it could be explained by the principles of classical conditioning. As in “Little Alberts” case, the unconditioned stimulus (noise) elicits an unconditioned response (fear). These occurrences happened in the presence of a neutral stimulus (the white rat), with the rate becoming the conditioned stimulus for the fear response, now being a conditioned response. Now the sole appearance of the white rat caused the child to become distressed and fearful (Hooper et al., 2015). Mary Cover Jones was the first to incorporate this knowledge into clinical efforts. She designed the first desensitization experiment, involving a three-year old boy who first was conditioned to fear a rabbit and then through gradual exposure experienced a reduction in fear (Hooper et al., 2015). Joseph Wolpe expanded on her research and developed the method of systematic desensitization, including a progressive relaxation technique to inhibit the fear response, a feared stimuli hierarchy, and relaxation practice in the presence of the anxiety provoking stimulus (Hooper et al., 2015). Skinner introduced the operant paradigm in psychology, stating that behavior changes are related to its consequences. The researchers Agras, Leitenberg, and Barlow (1968) used this principle of social reinforcement successfully in the treatment of agoraphobia. It is generally considered the first “wave” of a psychotherapeutically approach that was based on scientific inquiry (Öst, 2008).
The “second wave” of behaviorism became prevalent in the seventies. The neo-behaviorists incorporated cognitive strategies to influence behavior based on neuroscience, linguistics, computer science, anthropology, and psychology (Hooper & Larsson, 2015). The change occurred mainly due to the inability of behaviorism to explain and interpret language and cognition (Hooper et al., 2015). Aaron T. Beck developed cognitive therapy (CT) promoting that negative cognitions lead to negative emotions and actions (Hooper et al., 2015). The main interventions involved the challenge of irrational and dysfunctional thoughts and to exchange them with rational, and functional thoughts (cognitive restructuring) (Harris & Hayes, 2009). The focus of interventions was on content changes, also called first-order changes. The application of the cognitive model started to identify patterns of cognition that were thought to be tied to particular disorders (Hayes, 2016). Cognitive-behavioral therapy (CBT) emerged as the synergy of first “wave” principles and newer cognitive concepts (Hayes, 2016). The “second wave” was finally dominated by CBT and Rational Emotive Behavior Therapy (REBT) (Harris et al., 2009).
Presently, so called “third wave” behavioral therapies have all in common an emphasis on acceptance, mindfulness, and second-order change (Zettle, 2007). Second-order changes focus on the workability of behaviors within a certain context, in contrast to altering the form or content of behavior (Zettle, 2007). Therapy approaches such as Acceptance and Commitment Therapy (ACT), Dialectical Behavior Therapy (DBT), Mindfulness-Based Cognitive Therapy MBCT), Functional Analytic Psychotherapy, (FAP), and others belong in this category (Harris & Hayes, 2009). Mindfulness-Based Cognitive Therapy started the process of moving away from first-order cognitive changes to emphasizing the cognitive context in which thoughts occur. Evidence was accruing that the function of thoughts may be altered without changing their content. During the 1990, it became evident that “second wave” therapy techniques may not impact the person as predicted and may not even be necessary for therapeutic success (Gortner, Gollan, Dobson, & Jacobson, 1998; Zettle, 2007). Process and component analysis of cognitive approaches challenged established cognitive interventions. One new element to promote change was the experience of the present moment (Hayes, 2016). ACT utilizes components from first and second wave behavioral therapy approaches.
Acceptance and Commitment Therapy
The specific therapy approach I align with mainly is ACT. ACT is theoretically grounded on the experimental findings of RFT, which asserts that human language and its bidirectional and evaluative properties are the cause of human suffering (Hayes, Barnes-Holmes, & Roche, 2001). “Psychological suffering is a basic characteristic of human life” is the bold statement of the founders of the ACT approach (Hayes, Strosahl, & Wilson, 2012, p. 4). This declaration is especially controversial in our modern Western civilization in which happiness, health, and external success are held as the standard way of being. A reflection of the notion that freedom from physical and mental distress is a main goal of life. A deviation from this norm, as the experience of physical and mental struggles, is many times felt and understood as pathological (especially in the medical field), as it is labeled through a set of symptoms that infer pathology in the field of psychology (Hayes, Strosahl, & Wilson, 2012). However, Hayes, Strosahl, and Wilson (2012) argue that this point of view minimizes or even entirely overlooks the crucial impact of specific environments on behavior, disregarding functionality of behavior.
The clinical attention of ACT includes historical and situational context, cultural influences, and the relation between thoughts, emotions, and action based on a person’s individual context (Hayes, Levin, Plumb-Vilardaga, Villatte, & Pistorello, 2013). The traditional assumption of physical health being the absence of disease, and human happiness the absence of abnormal processes, is being challenged by contextual science. Hayes, Strosahl and Wilson, (2012) propose that human suffering is ubiquitous and impacted by social, cultural, and contextual influences. The response reaction of a person experiencing distress (negative thoughts and emotions) is seen as more critical to healthy functioning then the experienced distress itself. ACT holds that all human suffering is caused by the dysfunction of the following core processes: “awareness of the moment, openness to private experience, and engagements in valued activities” (Strosahl, Robinson, & Gustavsson, 2012, p. 3). From an ACT perspective, every problem human beings experience is based on or related to experiential avoidance (Hooper & Larsson, 2015). To change outcomes, ACT aims to increase psychological flexibility, which is described as the ability to continue with valued life activities in the face of distress and unwanted private events (Hayes et al., 2012). It centers on identifying thoughts and feelings that hinder valued living. ACT seeks to alter the relationship to those internal experiences, instead of focusing on changing the experience itself (Stoddard & Afari, 2014). Healthy variations of behavior and flexibility are believed to maximize present moment contact with the lived experience to purposefully and intentionally chose between behavioral choices (Hayes et al., 2012). ACT seeks to establish internal cooperation of the whole person including its uncomfortable and unwelcomed components. Through the therapeutically guided use of metaphors, paradox, mindfulness, and experiential exercises, clients learn to become comfortable to learn about and identify thoughts, feelings, and sensations that have been avoided and feared previously. Clients are encouraged to accept and acknowledge inner events, develop value-based goals, and commit to changing behaviors in service of identified values.
A theoretical model of psychological flexibility, which is linked to RFT and behavioral principles, was developed as a useful tool for practitioners to guide conceptualization and treatment (Hayes, Strosahl, & Wilson, 2012). Two main areas that will inform the ACT case formulation process are: “What kind of life does the client most deeply want to create and live? What are the psychological and/or environmental processes that have inhibited or interfered with pursuit of that kind of life?” (Hayes et al., 2012, p. 105). Additionally, the interview process includes the evaluation of the client’s level on the six core processes of ACT.
The “Hexaflex” is the underlying model of psychological flexibility and simultaneously the model of psychopathology in ACT (Hayes, Strosahl, & Wilson, 2012). The hexagon-shaped model visualizes aspects of psychopathology, psychological health, and psychological interventions. The “Hexaflex” is a representation of the six core processes that promote a person’s psychological flexibility. Psychological inflexibility involves the processes of experiential avoidance, cognitive fusion, or individualistic self-defeating practices (Hayes et al., 2012). Experiential avoidance is experienced when a person tries to escape so called “negative” feelings, such as sadness, or anxiety. This often creates a conflict with valued living and is therefore the definitional negative to psychological flexibility (Hooper & Larsson, 2015). Fusion can be described as an escape from the experience of ambiguity and confusion. The conceptualization of a specific self will not allow for content that may not fit the established narrative and the experience of contradiction is unwelcome. It leads to a temporarily reduction of unwanted feelings (Hayes et al., 2012). This process is often extended to a limited or narrow repertoire of verbal rules, behavioral options, and a loss of contact with behavioral consequences (Hayes et al., 2012). The ability to change the course of action, even if obviously unworkable, is compromised. Furthermore, these patterns lead to a person focus on why things are not working for them, becoming trapped in this cycle. Cognitive fusion refers to the state in which a person is literally fused with their cognitions, becoming entangled in one’s own self-stories. Self-as-context refers to the ability of perspective taking and self-awareness. Being present refers to a person’s ability to stay in the present moment. Valued directions are being established through value-based goals combined with specific committed action toward a life worth living (Hayes et al., 2012). To the contrary the following six processes contribute to psychological flexibility: “flexible attention to present moment, chosen values, committed action, self-as-context, defusion, and acceptance” (Hayes et al., 2012, p. 63).
Nested in the model is the basic assumption of ACT that pain is a natural occurring consequence of living, but that a decreased level of psychological flexibility limits a person’s ability to adapt to internal or external changes (Hayes, Strosahl, & Wilson, 2012). The over-identification with the literal meaning of language leads to psychological inflexibility, which leads to suffering. The ACT approach to promote psychological flexibility involves the so called six dialectical core therapeutical processes: acceptance and willingness, cognitive defusion, mindfulness, self-as-context, values, and committed action (Stoddard & Afari, 2014).
Acceptance and Willingness
Acceptance can be described as the “voluntary adoption of an intentionally open, receptive, flexible, and nonjudgmental posture with respect to moment-to-moment experience” (Hayes, Strosahl, & Wilson, 2012, p. 272). Furthermore, it involves a person’s willingness to actively engage with distressing private experiences, situations, events, or interactions. The main difference of this approach from other therapy approaches is the concept that the content of thoughts and feelings does not need to be focused on, rather the person’s relationship to them (Walser & Westrup, 2007). The goal of ACT is to help the client to accept thoughts, feelings, memories, and sensations, holding them like “a butterfly in the palm of their hand” (Walser et al., 2007, p. 19). This entails the ability to overcome the over-identification with the human mind’s chatter.
The process of defusion describes the ability to experience thoughts as simple thoughts, not carrying literal meaning that controls a person’s behavior (Hooper & Larsson, 2015). Thoughts are seen as unproblematic, however, when a person blindly reacts in response to thoughts they become problematic. Defusion from thought content means that a person is able to be aware of a thought without experiencing detrimental self-talk. Herein, a person changes its relationship to the content of the thought. Like acceptance, defusion allows for space to live based on valued choices (Stoddard & Afari, 2014).
Mindfulness, from a psychological perspective, is best described as focusing one’s attention on the experience occurring in the present moment in a nonjudgmental or accepting way, incorporating present-centered awareness (Nagy & Baer, 2017). This ancient Eastern tradition has been adapted for secular Western culture. Mindfulness-based skills have been adapted in various “third wave” treatment approaches mentioned earlier. These mindfulness-based interventions have been applied to a variety of disorders and diverse populations. The practice of mindfulness has been shown to decrease rumination, enhance emotion regulation and attention, and working memory through the cultivation of new relationships to one’s thoughts and feelings (Nagy et al., 2017).
In ACT, mindfulness is used to practice compassionate present-moment awareness to enable the person to experience openness. The practice incorporates openness to observing feelings, thoughts, sensations, even if these events are producing discomfort. The following four ACT processes are utilized to support the development of mindfulness: acceptance of experience, defusion from literal thought content, present moment practice, and self-as-context (Walser & Westrup, 2007). These processes enable the person to treat previously positively and negatively evaluated internal events from an observer standpoint, allowing for a nonjudgmental interaction with content. Shapiro and Carlson (2017) state that “from a mindfulness perspective, our suffering arises out of our reactions and judgements about what is present as opposed to what is actually present” (p. 11).
Human language abilities also entail the capability to conceptualize a past and future self, while building as sense of who we are as a person. Self-as-context infers that there is a “you” that has the ability to observe and experience the inner and outer world, but is separate from internal behaviors (thoughts, feelings, roles). It may be described as an observer self that “watches” the occurrence of thoughts and feelings. A person who experiences a self-as-content is rather driven by internal scripts that define how they think about themselves, about their life, and their history. This person tends to be defined by the content of their self-created story, minimizing flexible interactions outside of that narrative, often against a person’s own values (Stoddard & Afari, 2014). The principle of self-as-context seeks to sway a client from this perspective to an observer and active experiencer of his life, who has the ability to choose his actions based on his values.
Within the conceptualization of ACT, values have a vital function in affecting behavior and may be used as powerful vehicles for change. Ciarrochi, Fisher, and Lane (2011) describe values as “qualities of ideal behavior, providing structure and coherence to life and guiding purposeful action” (p. 1184). Values exist across varying contexts and times, building the basis for motivation to pursue what a person deeply cares about in life. One of the goals in ACT treatment is the increase in value orientation while concurrently reducing experiential avoidance in the context of valued living (Ciarrochi et al., 2011). Values are generally described in nine domains including family, friends, couples’ relationships, work, education, leisure, spirituality, community, and health. Each of these domains may motivate the client to committed action and help to create focus on specific value-based goals. The practice of acceptance, defusion, present-moment awareness, and self-as-context promote greater flexibility for the purpose of living in accordance with personal values (Stoddard & Afari, 2014).
While values provide the direction for behavior, committed action provides the basis for actual behavior change (Stoddard & Afari, 2014). Through the establishment of valued goals clients can identify committed action items. While a value is a direction or path that does not have an endpoint, committed action involves discrete goals that can be accomplished and achieved. The therapeutic work around committed action incorporates quite often traditional behavior therapy components, such as problem-solving strategies, exposure, skills training, etc. to help clients move toward their values. The processes of acceptance, defusion, mindfulness, and self-as-context are unified to overcome internal obstacles that may interfere with taking action (Stoddard et al., 2014). Psychological flexibility is increased when values are established and with it an almost indefinite number of related goals and specific behaviors (Zettle, 2007).
Another common ACT approach to conceptualize psychological flexibility is the matrix, developed by Polk and Schoendorff (2015). The matrix can be described as an interactive diagram of the processes of ACT. The horizontal line of the diagram divides external and internal experiences. The top level of the matrix represents the physical world, while the lower part represents the private events of the client. The vertical line is a functional separation between events that the client is trying to escape or avoid (struggles) and actions that are moving the client towards his/her values. The client’s daily experience is then described through the four quadrants, identifying functional and dysfunctional actions (Hooper & Larsson, 2015). This process can help conceptualize a client’s experience and be used as a tool to move the client toward increased psychological flexibility.
The Therapeutic Relationship
Shapiro and Carlson (2017) summarize evidence that common factors may account for a significant proportion of the therapeutic success. Several essential common factors have been described, including client–clinician relationship, expectancies, confronting problems, mastery, and the attribution of outcomes. The strongest predictor are relationship variables. Relationships based on empathy, unconditional positive regard, and client-therapist congruence are most beneficial. Mindfulness has been suggested as a common factor due to its facilitation of beneficial therapeutic relationship characteristics, including presence, warmth, trust, connection, and understanding. From an ACT perspective, a strong therapeutic relationship requires psychological flexibility form the clinician. The clinician aims to model psychological flexibility in the room with the client. The therapist provides an environment in which his/her reactions function as key sources of instigation and promote contingency shaped learning opportunities. The clinician should allow the flexibility model to enter the room and guide the therapeutic relationship, meaning that the therapist needs to be open, accepting, coherent, and consistent with ACT principles. ACT proposes to interact with the client not so much on an expert level, but rather as another human being who is similarly struggling. Soft reassurance, as Hayes, Strosahl, and Wilson (2012) state it, is an additional important component in ACT therapy. Soft reassurance describes a clinician’s support through the willingness to be open to the experience of the other person’s pain, the ability to validate and normalize the experience. The ability of a therapist to be empathetic and compassionate toward the client’s struggle is described as a necessary attribute for an effective ACT therapist. Moreover, the ACT clinician displays a willingness to selectively self-disclose to facilitate the development of powerful human relationships. Presenting as a struggling human being in the room with the client fosters camaraderie and opens the opportunity for the therapist to act as a model of acceptance and commitment.
As I align with all the above-mentioned aspects of the therapeutic relationship and seek to become a better ACT therapist, I value present-moment experiences in the therapy room. Geller, Greenberg, & Watson (2010) state that a “therapists’ presence is understood as the ultimate state of moment-by moment receptivity and deep relational contact. It involves a being with the client rather than a doing to the client. It is a state of being open and receiving the client’s experience in a gentle, nonjudgmental and compassionate way . . . being willing to be impacted and moved by the client’s experience, while still being grounded and responsive to the client’s needs and experience” (p. 85). My goal is to increase my capability of present-moment awareness as an emerging clinician, while improving skills to combine mindfulness with the tools and technique necessary to promote psychological flexibility.
As an ACT therapist, respect and nurturance of human diversity is implemented by responding to individual social contexts and individual differences in a sensitive manner. An individual’s social context impacts the client’s experience of the world.
Motivational Interviewing and mindfulness have been adapted to a variety of cultural backgrounds. I see it as my duty to be informed about existing cultural adaptations of therapeutic tools, but also to be open to adaptive processes that may happen in the room due to diversity. Within ACT, the use of metaphors, and experiential exercises can be personalized and adapted to the client’s individual experience to increase efficacy. Hayes, Strosahl and Wilson, (2012) argue that within the ACT approach a practitioner needs to care about sexism, racism, degradation, and injustices, because these problems also enter the treatment session. Issues of diversity and community are relevant in the therapeutic process. ACT provides a process-focused method of incorporating cultural adaptations (Masuda, 2014). The framework of functional contextualism allows and guides the ACT clinician to develop and organize cultural knowledge in pragmatic and contextually sensitive manner.
Efficacy of Acceptance and Commitment Therapy
While many times evidence-based practice is defined through outcome studies, some are lacking a well-grounded theoretical and scientific basis (Hooper & Larsson, 2015). Several authorities consider ACT evidence-based due to increased successful outcome studies, including numerous random controlled trial treatment studies (Hooper et al., 2015). Hooper and Larsson (2015) present a summary of 265 empirical investigations spanning depression, anxiety disorders, serious mental illness, substance abuse, smoking cessation, eating behaviors, and pain. About 25% of this research has been focused on the relationship between ACT processes and outcome. However, Öst, (2014) concluded in his meta-analysis that ACT did not fulfill criteria to be considered a well-established treatment of any disorder. He identified methodological problems and small effect sizes. An additional efficacy investigation conducted by A-tjak and colleagues (2015) included 1,821 patients with mental disorders or somatic health complaints. The authors, based on the findings of this study, concluded that ACT is more effective than treatment as usual or placebo. They also stated that ACT may be as effective as established psychological interventions in anxiety disorders, depression, addiction, and somatic health problems. Atkins and colleagues (2017) reviewed Öst’s original meta-analysis and argue that his analysis may have involved discrepancies. The authors emphasize APA Division 12 listings of ACT’s evidence-based efficacy in the area of chronic pain, depression, mixed anxiety, obsessive-compulsive disorder, and psychosis and additional numerous randomized trial publications.
Additional Techniques and Strategies
While I consider myself as an ACT practitioner grounded in functional contextualism and a member of CBS, I am also employing techniques and strategies to supplement the ACT approach to therapy. I am implementing aspects of Solution-focused therapy, Motivational Interviewing, Dialectical Behavior Therapy, behavioral activation, and skill-based techniques to promote committed valued action.
My life experiences, the exposure to cultural diversity, my travel adventures, and my curiosity about various worldviews in combination with a training focused on diversity and social justice aligns well with the ACT approach and contextualism. I am striving to include cultural considerations and seek to increase cultural competency and sensitivity. Through active cultivation of mindfulness in my personal life, I am also seeking the cultivation of mindful presence in my therapeutic work. I utilize evidence-based practices and empirically supported treatments to inform my therapeutic work. Besides ACT, I draw from Dialectical Behavioral Therapy, Motivational Interviewing, and several skill-based interventions. As an emerging mental health provider, I align with the ethical principles outlined by the American Psychological Association in practicing responsibly, with integrity, and with an awareness of existing cultural diversity.
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Atkins, P. W., Ciarrochi, J., Gaudiano, B. A., Bricker, J. B., Donald, J., Rovner, G., . . . Hayes, S. C. (2017). Departing from the essential features of a high quality systematic review of psychotherapy: A response to Öst and recommendations for improvement. Behaviour Research and Therapy, 97, 259. 10.1016/j.brat.2017.05.016
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