First published 2011 by Routledge 27 Church Road, Hove, East Sussex BN3 2FA Simultaneously published in the USA and Canada by Routledge 270 Madison Avenue, New York NY 10016 Routledge is an imprint of the Taylor & Francis Group, an Informa business Ø 2011 Paul E. Flaxman, J. T. Blackledge and Frank W. Bond Typeset in Times by Gar eld Morgan, Swansea, West Glamorgan Printed and bound in Great Britain by TJ International Ltd, Padstow, Cornwall Cover design by Sandra Heath All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. This publication has been produced with paper manufactured to strict environmental standards and with pulp derived from sustainable forests. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Flaxman, Paul Edward. Acceptance and commitment therapy : distinctive features / Paul E. Flaxman, J. T. Blackledge, and Frank W. Bond. p. cm. ISBN 978-0-415-45065-2 (hardback) Ð ISBN 978-0-415-45066-9 (pbk.) 1. Acceptance and commitment therapy. I. Blackledge, J. T. (John T.) II. Bond, Frank W. III. Title. RC489.A32F55 2011 616.89 1425Ðdc22 ISBN: 978±0±415±45065±2 (hbk) ISBN: 978±0±415±45066±9 (pbk)
Contents Preface Dedications and acknowledgements vii xi Part 1 THE DISTINCTIVE THEORETICAL FEATURES OF ACT 1 1 ACT, human suffering, and experiential avoidance 3 2 Developments within CBT: ACT and the Third Wave of behaviour therapy 7 3 Functional contextualism 11 4 Relational frame theory 15 5 Acceptance 21 6 Cognitive defusion 25 7 Self-as-context 29 8 Contact with the present moment 33 9 Values 37 10 Commitment 41 11 Mindfulness and behaviour change: Toward psychological exibility 45 12 ACT and CBT: Assumptive differences 53 v
CONTENTS 13 ACT and CBT: Strategic and technical differences 57 14 Empirical matters 61 Part 2 THE DISTINCTIVE PRACTICAL FEATURES OF ACT 65 15 Overview of ACT's therapeutic strategies 67 16 ACT-based case conceptualization 71 17 Examining the workability of the control/avoidance agenda 75 18 Creative hopelessness 79 19 Control is the problem, not the solution 85 20 Introducing willingness as the alternative to control 89 21 Promoting active acceptance 95 22 Cognitive defusion I: Altering language conventions 103 23 Cognitive defusion II: Objectifying psychological content 111 24 Cultivating mindfulness to promote contact with the present moment 115 25 Contacting the self-as-context 121 26 Clarifying values 127 27 Values-based goal and action planning 135 28 Building larger patterns of committed action 139 29 ACT in groups and non-clinical contexts 145 30 Therapeutic stance 151 References 159 Index 168 vi
DISTINCTIVE THEORETICAL FEATURES OF ACT 12 ACT and CBT: Assumptive differences Though there are many speci c differences in the techniques and strategies used in ACT and conventional CBT, perhaps the most profound differences can be seen in the assumptions each treatment model holds regarding the nature of thoughts and emotions, the purpose of psychotherapy, and the therapeutic stance one should take toward a client. Assumption 1: Thoughts and/or feelings must change for overt behaviour to change Deeply embedded in cognitive or cognitive-behavioural models of psychotherapy is the notion that maladaptive thoughts (or in some cases, thoughts or distressing emotions, depending on the speci c model) typically must change before overt problematic behaviours can be expected to change (e.g. Beck, 1991). This assumption is clear at virtually every phase of CBT. Therapeutic goals are set at the beginning of treatment. In cases where these goals involve things other than simply feeling better or thinking differently (e.g. when an anxious client sets goals of following through with a public-speaking commitment or regularly attending his or her daughter's public recitals), a variety of cognitive restructuring techniques are used to correct relevant maladaptive thoughts, and relevant exposure opportunities are arranged to reduce levels of anxiety. ACT embodies a different assumption, one where thoughts and feelings do not need to change in order for overt behaviour to change. Of course, it is not assumed that nothing need be done to instantiate such a state of affairs. In a state of cognitive fusion, evaluative and prescriptive thoughts will most likely 53
ACCEPTANCE AND COMMITMENT THERAPY lead to concordant action, and relatively high levels of emotional distress will likely lead to experiential avoidance. Thus, ACT employs mindfulness-based processes to help clients view thoughts and feelings as experiences to be noticed and willingly carried, rather than as concrete barriers to effective action. 54 Assumption 2: When thought change can expedite other forms of behavioural change, logical/ rational change strategies are the best choice Conventional cognitively-oriented models of psychotherapy are also based on the assumption that strategies designed to help a client think more logically and rationally about her or his experience will most effectively change these thoughts and arrive at meaningful emotional and overt behavioural change. Unfortunately, process evidence has yet to convincingly support the assumption that cognitive restructuring techniques successfully mediate positive clinical outcomes (Longmore & Worrell, 2007). It could plausibly be the case that the kinds of long-standing, emotion-laden thinking common in clients distressed enough to report for psychotherapy are resistant to the kinds of logical/rational change strategies employed in cognitive restructuring. Aspects of the ACT model appear to initiate thought change, though the strategies used do not involve rational/logical change strategies. Metaphors are used in ACT to help the client consider an alternative view of his or her experience. Such metaphors involve a relatively loose, non-literal comparison between the client's experience and a previously unrelated set of actions designed to help the client think about and approach his or her experience in a more ACT-consistent way. Other ACT strategies that may bene t, at least in part, from thought change include values clari cation, where a client is shaped to think more speci cally and expansively about what ways of living and acting bring increased meaning and vitality to her or him, and self-as-context strategies that shape a client to adopt a
DISTINCTIVE THEORETICAL FEATURES OF ACT sense of self that is distinct from the content of his or her thoughts and feelings. In both cases, the client's direct experience is repeatedly highlighted before and alongside potential changes in thinking that are occurring, as will become apparent in the applied points of this book. Assumption 3: The primary goal of psychotherapy is symptom reduction Reductions in the frequency and intensity of unwanted feelings and thoughts are a major goal in CBT. An ACT therapist, by contrast, would place a priority on getting the client off an agenda of feeling better and thinking differently. The agenda of ACT's entire creative hopelessness phase is geared toward this end (see Point 18), and the message is typically revisited many times throughout treatment. Within an ACT model, the desired outcome is for the client to more effectively, constructively, and consistently live a life in line with her or his values, even when any potential degree of psychological distress is present. Ironically, distress levels typically do go down once clients drop a control agenda and more successfully pursue their values. The difference in process (feeling better by trying to feel better vs. feeling better and living a more vital and meaningful life by letting go of trying to feel better) remains a critical distinction between ACT and CBT, however. Assumption 4: Preferred temporal focus in session The primary temporal focus within most CBT sessions (those, for example, that do not include in vivo exposure) is on the review or planning of activities or experiences occurring outside of session (see, for example, Wright, Basco, & Thase, 2006, pp. 78±79). The ACT model prompts a different temporal focus. A typical ACT session would more often than not exhibit a ``here and now'' focus on thoughts, feelings, and other aspects of 55
ACCEPTANCE AND COMMITMENT THERAPY experience. To be sure, an in vivo focus on such experiences would often be prompted by discussion of events occurring outside of session (``there and then''), but the focus typically would move to thoughts and feelings arising now as the client re ects on the out-of-session event. Then, any number of techniques instantiating defusion, acceptance, or other core ACT processes would be used with these thoughts and feelings. From an ACT perspective, since the client must learn to use these strategies in the moment as new thoughts and feelings arise, the best way to teach them is in the present moment, as applied to thoughts and feelings arising now (even when they are a response to what happened ``then''). 56