Acceptance and Commitment Therapy (ACT)

ACT (pronounced ‘act’) is form of Cognitive Behavioural Therapy that is growing rapidly in its clinical use and evidence base. There are in excess of 600 randomised clinical trials (RCTs) reporting its effectiveness with helping anxiety, depression, pain and so on (Association for Contextual Behavioral Science, 2021). There are several RCTs of ACT with neurological conditions, including traumatic brain injury, stroke, multiple sclerosis and epilepsy (Asqari & Donyavi, 2017; Giovannetti et al., 2020; Lang et al., 2017; Lundgren et al., 2008; Majumdar & Morris, 2019; Motlagh et al., 2020; Pak et al., 2017; Proctor et al., 2018; Sander et al., 2020; Shakernegad et al., 2017; Whiting et al., 2020; Yazdanbakhsh et al., 2016).

ACT is a process-based therapy, that looks to alter the context/relationship with behaviours (which include thoughts, images, emotions, sensations, memories, urges, actions etc.) to help people move from a rigid, narrow repertoire of behaviour that is under aversive control, to engage in a broader, flexible range of behaviour, that leads to increased meaning, purpose and vitality in life.

The Psychological Flexibility Model or ‘Hexaflex’ was developed to help clinicians apply the underlying processes:

Figure 1 The Hexaflex model of ACT

Figure 1. The Hexaflex model of ACT. Copyright Steven C. Hayes. Used by permission

Defusion is the ability to see thoughts, images, emotions, sensations etc. as what they are, rather than being caught up in them without awareness and being pushed around by them, so that we can see if they are helpful to follow or not. 

Acceptance or willingness is the ability to open up and make room for difficult thoughts, images, emotions, sensations etc., rather than trying to avoid or get rid of them. 

Contact with the present moment is flexible attention: narrowing, expanding, or shifting the awareness in the current ‘now’ context. This might relate to the inner experience of thoughts, images, emotions, sensations etc., awareness of what is happening out in the world with sensory information (sight, sound, touch, smell, taste) and personal and interpersonal direct consequences.  This is noticing what actually happens, rather than what the Mind predicts or tells you happened.

Values are ongoing qualities of action (e.g., compassion, caring) that bring meaning to actions. They are what matters most to us about how we behave.  There is no end point to completing these (unlike goals) and they can be applied to an unlimited range of actions.

Committed action is engagement in action connected with values, where we aim to build a broad repertoire of behaviour, that leads to a rich, full, meaningful life. 

Self as context allows an observing position to witness the self as a container of experiences that change moment by moment, to hold the stories we have about ourselves lightly (e.g. the not good enough story), different perspectives (I/you, here/there, now/then) and provides a wholeness/stability to all the different aspects of self (caring, angry). 

Psychological flexibility sits at the centre. A definition for psychological flexibility that I find particularly helpful is “the capacity to respond adaptively to the challenges that life presents in ways that fit with our values” (LeJeune and Luoma, 2020).  This definition speaks to me of the challenge that clients with neurological conditions face and the intention of our therapeutic work with clients.