Acceptance And Commitment Therapy For Depression In

IntroductionACT-D OverviewThe experience of depression can profoundly affect a Veteran’s life. The personal cost and emotional suffering related todepression can significantly impact interpersonal and daily life functioning, leading to further difficulties and a potential long-termdecrease in functioning. Indeed, depression is one of the leading mental health diagnoses among Veterans seeking care in VHA(Karlin & Zeiss, 2010). Depression has a significant impact on life functioning, including problems ranging from loss of interestin pleasurable activities to isolation to failure in social and work situations (Fava & Cassano, 2008). Providing effective treatmentfor those suffering with depression can lead to personal re-vitalization and return to functioning. Acceptance and CommitmentTherapy (ACT, said as one word; Hayes, Strosahl, & Wilson, 2012) is one such intervention that not only focuses on decreasingsuffering, but also focuses on personal values in the service of bringing vitality and meaningful functioning to the Veteran’s life.Dr. Steven Hayes and colleagues developed ACT. It is considered a “third-wave” behavioral intervention and it is one of anumber of “acceptance-based psychotherapies” developed in recent decades that focuses on promoting acceptance of internalexperiences and taking committed actions consistent with personally chosen values. Other acceptance-based psychotherapiesinclude Dialectical Behavior Therapy (Linehan, 1993) and Mindfulness Based Cognitive Therapy for Depression (Segal, Williams& Teasdale, 2012).The clinical goals of ACT are exemplified in its very name. When using ACT, the therapist works to help the patient acceptinternal events (thoughts, emotions, sensations, images and memories) while also helping them make and keep behavioralcommitments that reflect personal values. ACT-D includes a number of acceptance and mindfulness strategies and commitmentand behavior change strategies to reduce depression and help patients move forward in their lives. Within the treatment, patientsare explicitly guided to come into contact with two different ways of knowing the world and themselves. In addition to knowingthings with the mind, an experiential sense of knowing is re-created. The latter provides a place where the patient can learn torelate to internal experience in a non-judgmental and open way. This work supports the patient in finding the freedom to be guidedby values rather than the literal content of emotions and thoughts.Part of the work done in ACT-D is about drawing the distinction between knowing with the mind and knowing withexperience. There are two ways of knowing the world – through verbal knowledge and through experiential knowledge. Verbalknowledge is all that goes on “in the mind” – describing, planning, problem solving, imagining, creating, predicting, talking,reading, writing, communicating, and etc. It is all that we learn with the mind – it is language. Experiential knowledge is whatwe have learned through direct experience and practice. It is distinct from verbal knowledge. For example, learning to walk isexperiential in nature – we were not instructed on how to walk, we moved around, crawled, wobbled, and fell down as we learned– it was by experience and practice that we came to walk. In fact, most of us learned to walk before we were verbal, before wewere talking. This kind of experiential knowledge continues to grow throughout our life. However, once we become fully verbal,we tend to lose contact with much of this other kind of knowledge. We begin to live “in our heads.” We become so involvedwith the world from a verbal perspective that we lose contact with what else we know – life experienced. For instance, a sociallyanxious patient might complain that he will “die of embarrassment” (verbal knowledge), however, experiential knowledge tellshim that this is not so. The experience of embarrassment contains a certain set of physiological sensations that might look likeblushing or sweating or feel like an increasing or rapid heart rate, however, these experiences pass and other experiences comealong – actual death does not occur. We all may have had the thought that we “can’t stand it another moment” – but even as wethink these words, experiential knowledge tells us that we can. ACT-D actively works to help patients get back in touch withexperiential knowledge, to observe and notice the ongoing and changing flow of their internal and bodily experience apart fromwhat their mind is saying about the same. ACT-D patients are taught to see themselves as a context for ongoing experientialevents that include all things occurring inside the skin – emotion, thinking, memories, images, and bodily sensations – withoutexcessive involvement of the mind and misapplied or excessive control of these experiences. Simultaneously, patients work toclarify and define personal values and goals and are supported in taking specific behavioral actions that bring these values to life.These two processes are brought together in a flexible and interactive way to assist the patient in accepting and committing tovalues-based living.Philosophical origins. ACT’s philosophical origins rise out of functional contextualism and a solid theory of human languagecalled Relational Frame Theory (RFT; Hayes, Barnes-Holmes, & Roche, 2001). RFT has been well-researched and continues togrow as a viable explanation for understanding language and cognition or the “mind.” The research in RFT informs the role thatTherapist Manual13342 VA ACT D manual v5.indd 998/7/15 9:06 AM

language plays in human suffering. For an extensive description and understanding of the theory supporting RFT, see Torneke,2010 and Hayes, Strosahl, & Wilson, 2012. The reader may also access additional information at: www.contextualscience.orgthe main website for ACT, RFT, and a broader community of scientists who are interested in contextual influences on behavior,mindfulness, and compassion interventions. Included on this website are links to an RFT tutorial and a review of functionalcontextualism, as well as information on the theory of language. This tutorial is highly recommended for those that plan toimplement ACT-D.Clinical Definition: Functional Contextualism (FC) as it is used in radical behaviorism is a philosophical worldview in which any behavior is interpreted as inseparable from its current setting or context. Additionally, thefunction of the behavior is the target of understanding and influence. FC defines truth and meaning in terms ofpragmatism (i.e., what works) rather than absolute truth (i.e., what is).In brief, RFT is a behaviorally based theory of language. It essentially holds that language is established through operantlearning and that with a history of reinforcement children learn that a certain sound (e.g., “apple”) refers to a particular object(e.g., a physical apple); children are reinforced for saying “apple” in the presence of an apple. This is directly trained, say “apple”when you see an apple. Additionally, a phenomenon that is fundamental to human learning of language and assists with explainingits complexity is derived relational responding. Here, human beings learn not only that a word is related to an object, but also thatthe object is related to the word. The relationship is bi-directional. This may seem overly simplistic, but this bi-directionality doesnot need to be directly trained. It is derived. Being able to derive relationships among words and events/objects sets the stage fora vast network of relational responding known as verbal behavior, or thinking itself. This kind of symbolic relating allows us togenerate and expand knowledge across our lifetimes. It gives us the amazing capacity to create and develop, but also the gravecapacity to compare and evaluate in negative and harmful ways. Indeed, all of the possibilities in derived verbal relations canmove us to loftier places as well as lead us to sorrows.Tenets of ACT. ACT is a principle-based intervention and is broadly applicable to all behavior including ineffective ormaladaptive behavior. It is rooted in behaviorism and is interested in the function of behavior as well as the consequences thatare shaping and maintaining behavior. For purposes of clarity, the type of behaviorism referred to in this manual holds true tothe model that what human beings are doing is the focus of study and intervention. This is not simply the outwardly observableactions of a person, but also the behavior that occurs “inside the skin.” Stated otherwise, thoughts, feelings, remembering, etc. arealso considered behavior and are part of what human beings are doing and therefore are also the focus of study and intervention.Two examples of relational frames and how they can serve or harm us:1. Temporal or Causal Frames: “if/then” or “before/after”:Serve: “If I save my money, then I will be able to go on that trip of a lifetime.”Harm: “If I don’t get over my childhood, then I will never be able to live a good life.”2. Comparative and Evaluative Frames: “better than,” “bigger than,” “faster than,” etc.:Serve: “This apple is better than that candy bar. I will eat the apple.”Harm: “Everyone is better than me. I must be worthless.”Based on this focus, ACT specifically targets psychological problems that emerge from behavioral rigidity or inflexibility(Hayes, et al., 2012). This is defined in ACT as the inability to persist or change behavior in the service of chosen values, usuallydue to the dominance of verbal processes. Examples of this kind of inflexibility might include a person “thinking” he is unable totake healthy action until his symptoms are eliminated (e.g., until he feels better); or it might include an individual “seeing” onlyone way to solve a problem (e.g., escape from pain via suicide); or “buying” a specific belief about himself (e.g., “I am a failure”)and then basing his abilities on that belief. Rigidity and inflexibility are linked to other areas where problematic behavior canarise including excessive or inappropriate rule following (e.g., “There is only one right way to do things”), loss of contact withthe present moment (e.g., spending excessive time thinking about the past), or over-identifying with only one aspect of the self(e.g., I am a victim, I am “broken,” etc.). Inflexibility is often also found in an excessive effort to be in control, in an overly rigid1013342 VA ACT D manual v5.indd 10Acceptance and Commitment Therapy For Depression in Veterans8/7/15 9:06 AM

focus on being right, or in an inability to forgive or let go. Finally, rigidity and inflexibility may occur when an individual persistsin a type of problem solving that doesn’t actually lead to desired outcomes, or said otherwise, that doesn’t work. One of the maingoals of ACT, then, is to decrease rigidity and increase flexibility in the service of workability.Empirical grounding of ACT. A growing body of research hasshown ACT to be effective for depression, anxiety, and other mental andbehavioral health conditions (Hayes, Luoma, Bond, Masuda, & Lillis,2006; Lappalainen, Lehtonen, Skarp, Taubert, Ojanen, & Hayes, 2007;Powers, Zum Vörde Sive Vörding, & Emmelkamp, 2009; SubstanceAbuse and Mental Health Services Administration, 2010; Ruiz, 2010;Zettle & Rains, 1989). Beyond decreasing symptoms of depression,ACT has been found to reduce negative behaviors related to undesirablethoughts and feelings, and to reduce the strength of depressive thoughts(Zettle & Hayes, 1986; Zettle & Rains, 1989).IN ACT, WORKABILITYIS ALWAYS TIED TO ANINDIVIDUAL’S PERSONALVALUESThe processes of ACT have also been studied as mediators and moderators of change in outcome. Changes in ACT processeshave been linked to changes in outcome (Hayes, et. al. 2006) and provide empirically based feedback that the mechanisms ofchange targeted in ACT are producing positive and predicted effects.ACT processes. ACT maintains that a large part of psychological suffering is due to attempts to avoid internal negativeexperience or experiential avoidance (EA). EA is the process of being unwilling to contact, or remain in the presence of, certainnegatively evaluated private experiences such as difficult thoughts, painful feelings and memories, and/or unpleasant bodilysensations. Moreover, the individual unwilling to feel is often cognitively “entangled” – fused with his or her mind (e.g., thethought and the individual are one and the same; “I am worthless;” see Clinical Definition below) – and fails both to noticethe thought as a passing experience and to take the behavioral steps that are necessary for values-consistent living. The personengaged in this behavior is often suffering as their focus is on solving “the problem” of a difficult private experience. The Veteranis in a “battle” with their thoughts and emotions. Solving the problem of negative internal experience often involves efforts toseek positive feelings in order to replace or control negative ones – believing the former need to be in place before a “good” lifecan be lived. A life that is guided by values in the here and now is often sacrificed to this problem solving activity.Clinical Definition: Cognitive fusion refers to the human tendency to get caught up in thought content in sucha way that it comes to dominate over other, potentially more useful, sources of behavioral regulation. We tendto merge thought content with an automatic attribution of meaning, thus losing awareness of the ongoing (andimperfect) process of thinking itself (Luoma, et. al., 2007).ACT is designed to target and reduce harmful experiential avoidance and non-acceptance while also encouraging patients toclarify values and engage life by making powerful life-enhancing choices. Given these treatment targets, ACT works by assistingpatients to shift from viewing negatively evaluated internal experience as a problem to be solved to an “event” to be experienced(i.e., emotions and thoughts are not like math problems; they are more like sunsets; Wilson & Dufrene, 2009). ACT employsmultiple core processes that are designed to decrease maladaptive behaviors and unhealthy attempts to avoid internal experienceby focusing on increasing behavioral and psychological flexibility. Included among these processes are strategies that help thepatient to identify and abandon problematic control and to accept negatively evaluated emotions and thoughts, treating them muchlike other emotions and thoughts, while also taking specific behavioral actions that produce meaningful life outcomes based onpersonal values.There are six core processes in ACT. Acceptance is the process of fostering acceptance and willingness while underminingthe dominance of emotional control and avoidance in the patient’s response hierarchy. Undermining the language-based processesthat promote fusion with “mind,” needless reason-giving, and unhelpful evaluation that cause private experiences to function aspsychological barriers to life enhancing activities is the process referred to as Cognitive Defusion. The third process, Getting inContact with the Present Moment, is actively working to live in the present moment, contacting more fully the ongoing flow ofexperience as it occurs. Self as Context is the process whereby the individual makes contact with a deeper sense of self that canserve as the context for experiencing ongoing thoughts and feelings. It is distinct from the self that may be defined by the contentTherapist Manual13342 VA ACT D manual v5.indd 11118/7/15 9:06 AM

of those thoughts and feelings (conceptualized self), and thus helps to establish a position from which acceptance of private eventsis less threatening. The final two core processes are Values and Committed Action. These processes involve first identifying valuedoutcomes in living that help patients choose purposive life directions while confronting verbal processes that serve as barriers(e.g., avoidance, fusion) and second, taking committed action which involves building larger and larger patterns of behavior thatreflect the patient’s stated values. Each of the six core processes is designed to create and support psychological and behavioralflexibilit

Acceptance and Commitment Therapy (ACT) is an effective intervention for many who struggle with depression. ACT is a behaviorally-oriented psychotherapy that addresses a person’s relationship with cognitions, feelings, sensations, memories, and images and seeks