Acceptance and commitment therapy (ACT) - Giornale Italiano di ...

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A54 penses of the national health systems in western countries and are by far the leading cause of mortality in the world, representing 60% of all deaths. The long time span for those diseases to develop implicitly points to the fact that there might be opportunities for prevention of symptoms or disease worsening or bettering patient’s quality of life, while reducing the medical impact of drug therapies. Environmental conditions and individual characteristics, both in terms of lifestyles and psychological factors, can modulate the disease’s impact on the individual quality of life. Much research shows weak or no correlation between the nature and degree of physical impairment due to different medical conditions (e.g. ischemic heart diseases, head injuries, chronic pain, etc.), and the degree of the disability or the getting back to normal life (1-3). Data suggest that psychological adjustments are crucial in modulating the level of functioning in people facing injuries, trauma and pain, where in western societies patients with chronic conditions frequently are dealt with as if they were only affected by acute medical pathologies entailing shortterm symptom alleviation and not long-standing lifestyle changes. This bias not only leads to perpetuating chronic illness’ problems, both in terms of personal suffering and economic burden on society (4, 5), but also increases the risk of exacerbating, stabilizing or maintaining the problem by focusing only on symptoms alleviation drugs, sick leaves, or hospitalizations (5, 6). By addressing the care of chronic patients at the physical level with drugs, only a small part of the process is taken into account, whereas it is very important what over time the patient thinks and feels about his/her illness (covert behaviors) in order to predict and improve his/her adherence (overt behaviors) to any medical intervention (7). In pursuing this goal researchers showed that there are a number of personal factors in mediating patient’s adaptation to the chronic disease and adherence to the treatment that must be taken into account when working with physical impaired patients, some of which are: anxiety, depression, locus of control, self-efficacy, coping styles, real and perceived social support, etc. Cognitive-Behavior Therapy (CBT) has been demonstrated an effective psychological intervention to help both adults and children in dealing with many chronic diseases (8-10). More recently, third generation Cognitive-Behavior-Therapies (11), such as Dialectical Behavioral Therapy (DBT; 12), Mindfulness Based Cognitive Therapy (MBCT; 13), Functional Analytic Psychotherapy (FAP; 14) and Acceptance and Commitment Therapy (ACT; 15, 16) focused their attention and research efforts on developing intervention models aimed in helping those patients too. This paper has three aims. First, to briefly introduce ACT epistemological (Functional Contextualism) and theoretical (Relational Frame Theory) foundations as a stand point for understanding the peculiarity of ACT as a modern form of Clinical Behavior Analysis. The second aim is to introduce ACT clinical model and its six core processes (acceptance, defusion, present moment, self as a context, values and committed action) as both accountable, in their continuum, for psychological flexibility and inflexibility. Third, to perform a brief overview of studies G Ital Med Lav Erg 2011; 33:1, Suppl A, Psicol http://gimle.fsm.it and outcomes of ACT intervention protocols and assessment tools that have been investigated in patients with chronic physical diseases, and namely: diabetes, obesity, epilepsy, and chronic pain. Acceptance and Commitment Therapy (ACT) philosophical and theoretical roots: Functional Contextualism and Relational Frame Theory Even if it is not possible to exhaustively tackle all the issues entailed in the philosophical and theoretical basis of Acceptance and Commitment Therapy (ACT), the authors believe it is crucial to be aware of some of their stances and implications to the construction and purpose of the clinical model (ACT itself), as a stand point for understanding the peculiarity of ACT as a modern form of Clinical Behavior Analysis. One of the endeavors of ACT Scholars has always been to take into account basic and applied behavioral principles and frame them in a coherent epistemological picture to avoid the risk of this therapy being misinterpreted as a mere new set of more or less older psychotherapeutic techniques. Hayes, Strosahl and Wilson (15), clearly underline the importance of making all levels of analysis explicit. They suggest that this can help an ACT therapist analyzing patient’s problems, choosing a specific intervention, and understanding what are the ACT elements of continuity and discontinuity with other psychological theories and models. According to Hayes (11), ACT is grounded in Functional Contextualism, a pragmatic philosophy of science, which identifies the ongoing interactions of the whole organism with the historical and actual contexts as the unit of analysis of behavior (16, 17). From this perspective: • behavior is everything that an organism can do, including overt behaviors (thoughts are not discrete structures, nor the cause of behavior, but they are behaviors themselves) and it is what the analysis should explain (18); • context is everything, beside behavior itself, that can be analyzed and that influences the development, the expression, the modification, and the maintenance of that behavior, both in the present moment and in the past history. It is what we can manipulate in the analysis (18); • the former two statements clarify the aim of the explicatory categories as pragmatic, namely the prediction and influence of the behavior of interest, so that “truth” is relative (e.g. patient’s values are not arguable), and it is true what is workable. Truth is tied to practical consequences (committed actions), not to ontological assumptions (being sick, having a chronic disease, having a depressed disorder, etc.); • as a consequence, the emphasis of the analysis is on the function of behaviors rather than on their topography, shape and frequency, so that it is considered much more useful to try to change the variables of the context that are causally (either as actual or historic antecedents or consequences) linked to the “negative”
G Ital Med Lav Erg 2011; 33:1, Suppl A, Psicol http://gimle.fsm.it behaviors that an ACT therapist wishes to decrease or the “positive” behaviors he/she wishes to increase; moreover, the therapist should look at the function of behavior because events similar in topography may be dissimilar in function and vice versa. From a theoretical point of view ACT is based on Relational Frame Theory (RFT; 19), a comprehensive theory of language and cognition rooted in basic research, which states that human language is based on the learned ability to arbitrarily relate events. Research demonstrated that human beings can learn things through relational frames, the core functions of language and cognition, without necessarily directly having experienced those events (20). By relational framing humans can bring behavior under the control of verbal rules (social, cultural, familiar and similar conventions) and subtract it from the direct control of contingencies (what works in the present moment in the service of what someone values). RFT entails that the normal verbal processes that allow fragile creatures like human beings to dominate over the entire world are the same processes that can make their behavior very narrow, rigid, maintained and governed by socially constructed verbal rules, rather than by its direct consequences (17). Therefore, psychological pain inhabits in the normal function of humans’ language processes (e.g. problem solving), when those are applied to solve private experiences (e.g. problematic thoughts, feelings, memories, body sensations, etc.), rather than to the solution of external world’s problematic events or situations, leading to experiential avoidance (15, 21). Experiential Avoidance is any human behavioral pattern related to the unwillingness to stay in contact with particular painful private experiences (e.g. unpleasant sensorial and emotional reactions, thoughts and memories associated to this pain, etc.) that has the function to alter the content and frequency of these internal events and to avoid the contexts in which they occur. Human beings tend to experience language in a very literal way even when it is used to describe not objective characteristics of the world, so that the thought or the word of something (e.g. Because of my chronic disease, if I go out I will feel pain and be a burden to my friends and family) takes the place of the actual thing (e.g. I = burden for friends and family), allowing the literal content of a thought to dominate on the individual behavior (e.g. the person doesn’t go out because he/she feels to be a burden for others instead of going out AND verifying if there is or is not something he/she can do and appreciate with the family and friends). It is for those reasons that ACT never attempts to directly modify the content of cognitions, because by doing this there’s a chance even to increase their literal function (are they true/false, rational/irrational, real/distorted?). Rather, ACT seeks to foster actions in the person’s valued directions, changing the context (from literality to non-literality) of those cognitions, so that they are no longer barriers to these actions, regardless if they are “true” or not. Hayes et al (17) stated the following as the main implications of RFT to clinical practice and ACT interventions: 1) the problem solving process and reasoning constantly going on in humans’ minds involves the same cog- A55 nitive processes accountable for psychopathology so that it is not workable to either change or extinguish it, 2) because thoughts and cognitions reflect the person’s learning history, they can not be permanently modified or extinguished, 3) the effort to directly and topographically change their form or frequency can set a context in which their literal relevance and function can eventually increase, and, 4) it is possible to change internal events’ function (i.e. thoughts, feelings, and body sensations, etc.) as barriers or obstacle changing the context of literality in which they normally operate, even if they consistently occur in the same form or frequency. Clinical and Applied Behavior Analysis: the Hexaflex model of ACT The main aim of ACT is to increase the ability of an individual to persistently pursue goals in his/her valued directions, using experiential strategies such as metaphors, paradoxes and exercises to undermine the literal function of language and highlight its inadequacy in precisely describing the actual direct experience. In this way, the therapist helps the patient experientially to be aware that private and covert part of behaviors (i.e. thoughts, feelings, body sensations, etc.) are simply words, images and physical reactions that have a specific evolutionary functions, but are not real and binding facts. According to ACT researchers, experiential avoidance and consequent psychological suffering occurs when long term values and meaningful life domains are systematically deserted in the service of the immediate relief from private negative experiences while defending one’s conceptualized self. Driven by these short term purposes the behavioral patterns narrow and drive away the client from the goals he/she might value. The therapeutic work with ACT takes into account six processes to help the client reaching a more general goal: psychological flexibility, conceptualized as the ability of being in contact with the present moment, with consciousness and intention, persisting in actions or changing them when this is in the service of what the person values. The six core processes of the Hexaflex model (fig. 1) are interconnected and partially overlap. As stated above, they don’t represent real psychological construct, but processes extended on a continuum, which are accountable both for psychological flexibility and psychopathology. Processes of mindfulness and acceptance (i.e. acceptance, defusion, contact with the present moment and self as a context) lay on the left part of the Hexaflex, while processes of behavior change and commitment (i.e. values, committed action, contact with the present moment and self as a context) are on the right side (17). An exhaustive and thorough description of the six Hexaflex processes and supportive data from basic research goes beyond the intent of this paper and can be found elsewhere (15, 19, 21, 22). Briefly summarized the six ACT core processes deal with: • Acceptance (Experiential avoidance): it is the willingness to make room for and embrace the inner unwanted experiences, leaving the fight against them
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