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

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