On Psychotherapy

Acceptance and Commitment Therapy (ACT): Not Just CBT Light!

To begin with a little self-disclosure: I have been highly skeptical of ACT.  First, the clinicians who first explained ACT to me probably were not the best ambassadors for the model. Their descriptions and explanations made ACT sound as if the focus was simply on telling people it is okay to think and feel what you think and feel (not exactly a novel intervention for psychotherapists)  and some vague talk about remembering one’s values. Second, being an “experienced” clinician I have witnessed the arrival of many new models during the course of my career.  Many of the models have lacked coherent theoretical basis, not to mention reasonable empirical evidence to support them. Third, (and most importantly) there is a very solid body of literature that strongly suggests that the benefits of psychotherapy primarily result from the common or non-specific factors that are part of each therapy (e.g., the therapeutic alliance).  Research by a variety of well respected professional has demonstrated that  the client’s relationship with the therapist, therapist empathy, and sensitivity to the client’s goals  are the active ingredient in therapy (the factors which help clients change/feel better/relieve symptoms). (see below for source). Fourth, the overlap between ACT and CBT appears significant. Many CBT therapists, particularly more sophisticated clinicians, clearly focus on helping clients develop more realistic expectations of themselves, and work on helping clients be more accepting of themselves. Thus, in some respects ACT appeared to be a softer version of CBT.

In all fairness, the first two factors clearly reflect a combination of personal bias and chance. However, the third and fourth factors merit more serious consideration. Clearly, CBT is derived from CBT; it is often referred to as part of the “third wave” of cognitive behavioral approaches.  The question remains: is it that distinct from CBT or is it really reflecting a more sophisticated and nuanced use of CBT.  In addition, while there is empirical evidence support the benefits of ACT there is no reason to expect that the common or non-specific or core elements of therapy are what account for much of the benefit clients’ derive from ACT.

Thus, the question remains: Is ACT really a unique model that can offer therapists a new approach to helping clients (or at least a subset of clients)?

I would argue that ACT does have something to offer clinicians above and beyond (or distinct from) CBT.  It is important to note that this line of argument is based on the belief that the specific model of therapy also has a contribution to therapeutic outcome, above and beyond the benefit of the common or core factors.  More specifically, I would hypothesize that  for certain problems/clients certain models of therapy may be more effective. There is some evidence to support this line of thinking (see research from psychotherapy networker) and clearly there are many advocates of this concept.

What are ACT’s potentially unique contributions and benefits?

First, ACT’s focus on helping clients accept their thoughts and feelings (their inner experiences) and developing the understanding  that they do not have to be consumed/organized/overwhelmed by these thoughts/feelings stands in contrast to many therapeutic models focus on helping people change their thoughts and feelings.  However, it is important to note that these concepts are derived from a variety of sources (ranging from Buddhism to Salvatore Minuchin’s notion of “partial selves”,  to name only two). However, the way in which ACT integrates and understands these concepts brings a different focus to the therapeutic process.

Second, the concept of being present, in contact with the present moment, offers clients and therapists an increasingly important pathway to being more aware of our inner experiences.  While most ACT practitioners would argue that ACT and Mindfulness are not the same, ACT’s emphasis on being present in the moment overlaps significantly with Mindfulness. While it is a cliché to talk about how hectic and distracted modern life can be, there is much truth to this assertion. Thus, the emphasis on being more present , more in touch with one’s self, is increasingly important.

Third, ACT’s emphasis on values is also worth highlighting. As many social critics have noted we live in an increasingly materialistic world in which worth is often derived from wealth, fame, and appearance. A therapeutic model which helps our clients become more aware of their values (see below for definition) and use their values to strengthen their self-image, sense of worth, and guide their actions, is clearly important. While some advocates of ACT appear to struggle to explain values, the simplest explanation that values are akin to character traits: honesty, kindness, and the like, rather than aspects of specific belief systems.  By focusing clients on their values (and how to better live their values) ACT can help people live less frenetic and more congruent lives.

Proponents of ACT might take umbrage with this summary of ACT.  Clearly a blog piece cannot capture the richness of any therapeutic model. Moreover, different proponents of any model are likely to stress one or more aspects of the model over others.  However, for this write, these are the features of ACT that make this model stand out in a crowded field.

In other respects ACT is more the same old wine in new bottles. The focus on committed action really seems to be very similar to the effective use of homework, or the concept of “baby steps” so well explicated by Richard Dreyfuss’ character, in the movie “What about Bob?”.

Overall, I would argue that ACT is a model worth considering. I suspect that it may be more applicable for certain types of disorders and/or clients.  For example, clients with anxiety disorders ACT  may be an exceptionally good fit.  Similarly, those clients who struggle with negative thinking and who are prone to ruminating on their difficulties might also be excellent candidates for ACT.  However, ACT may be less applicable to more impulsive individuals, and to those persons we might consider less psychologically minded.

An additional concern regarding ACT is that it is one more model which focuses on the individual’s inner experience (thoughts and feelings) and appear to neglect the power and impact of the client’s social context and current relationships. While many have argued that the behavioral therapies represented a major break from psychodynamic and analytic models, it is also true that all of these models (later iterations of behavioral therapy from CBT to DBT to ACT) continue the focus on the individual and his or her inner experience (even when applied to work with couples or families these models frequently focus on the individuals thoughts and experiences, rather than taking a more systemic focus). The real revolution in therapy is much more likely to be the inclusion of others (spouses, partners, parents and children) into therapy and a shift off focus from the individual to systemic. Thus, ACT practitioner may be at neglecting the importance of day to interactions/relationships and overemphasizing inner experience of the client (which ironically is often a by-product of the client’s day to day life/ongoing relationships).

In sum, I am now far more accepting of ACT, than I previously was, and consider a therapy learning more about and integrating into my work with clients, particularly for those struggling with anxiety and depressive disorders.


Note: as this is a blog I tend to be less formal than a paper. However, I still believe that it is important to cite source material for my thinking:

First, for my new and improved and vastly expanded understanding of ACT:

Roger Thomson, PhD  and Kaimy Oehlberg, PhD, “Acceptance and Commitment Therapy,”  June 27, 2014, Illinois Psychological Association.

David Carbonell, Ph.D, “Acceptance Based Treatment of GAD,” June 3, 2014, Northern Illinois Employee Assistance Professionals Association 36th Annual Conference.

These excellent presentation on ACT helped further my understanding significantly.

Second, for more info on the research and arguments that the “common factors” model best explains the effects or benefits of psychotherapy I would recommend the work of John Norcross, Michael Lambert,  Bruce Wampold, Scott Miller and Barry Duncan, to name just a few.