Acceptance and Commitment Therapy (ACT)
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Mindfulness & Neurobiological
Tools for Healing - A Training Resource
By Jim Messina, Ph.D., CCMHC, NCC, DCMHS-T
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Introduction to Acceptance and Commitment Therapy (ACT)
Offered by COPING.US Training Programs (CE Provider # 50-21474)
With Troy University’s Tampa Bay Site
Zoom Interactive Online Training Program
(CE Broker # 20-787200) 3 CEU’s
This Program is approved by Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling for: LMHC's, LMFT's, LCSW's & CMSW's
and Florida Board of Nursing for: RN's, ARNP's, LPN's & Clinical Nurse Specialists
Resources for Course on Coping.us:
Acceptance and Commitment Therapy (ACT) at: http://www.coping.us/mindfulnessneurobiology/act.html
Pain Management: A Neurobiological Approach at: http://www.coping.us/mindfulnessneurobiology/painmanagement.html
Program Description:
This program is geared to train mental health professionals about Acceptance and Commitment Therapy (ACT). It is important for therapists who work with clients who suffer from pain, depression, anxiety or other emotional stressors. These therapists have to have a thorough understanding of how ACT fits into the mindfulness approach of both Mindfulness-Based Stress Reduction (MBSR) and Mindful Self-Compassion (MSC) so that they can use these three models to effectively help their clients. It is also important that therapists are able to comfortably explain the six steps used in ACT to help them resolve their anxiety and depression as they confront the physical and emotional stressors in their lives.
Learning Objectives
After participating in this program, the participants will be able to
1. Demonstrate their understanding of the methodology, philosophy and intentionality of ACT by reviewing all relevant literature and research available in this training program.2. Demonstrate their understanding of the six components of the ACT Model (Cognitive Defusion; Acceptance; Contact with the Present Moment; Self as Context (Observing self); Values and Committed Actions) and how to facilitate their impact on their clients’ physical and emotional wellbeing.3. Demonstrate their understanding of the five basic processes of ACT - Examining Avoidant Behavior; Examining Strategies that have not worked; Identifying Self-as-Context distinguished from self-in-content; Determine Values and Choose Goals and Focus on Commitment.4. Demonstrate their understanding about the various ACT tools utilized in this model including metaphors, mindful meditations, language exercise to physicalize negative thoughts or feelings, and use of journal writing and written assignments.
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Intro to ACT Training Workshop Scheduled Wednesday November 4, 2020 via Zoom 5:30-8:30 pm
Evaluation of Nov 4th ACT Training Workshop: Click Here
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What is Acceptance and Commitment Therapy (ACT)?
Acceptance and Commitment Therapy or ACT (pronounce as a word not as separate initials)
Developed in late 1980’s by: Steven Hayes, Kelly Wilson & Kirk Strosahl
Part of a “Third Wave” of behavioral therapies along with Dialectical Behavior Therapy (DBT). Mindfulness-Based Cognitive Therapy (MBCT) and Mindfulness-Based Stress Reduction (MBSR).All four place a major emphasis on the development of mindfulness skills
ACT is an empirically based therapy using acceptance and mindfulness strategies along with commitment and behavior-change strategies to increase psychological flexibility
ACT is based on relational frame theory (RFT), a comprehensive theory of language and cognition that is an offshoot of behavior analysis
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What is RFT?
There is a strong empirical and conceptual relationship between language and derived stimulus relations. An empirical relationship does not indicate that derived stimulus relations depend upon language or that such relations are mediated by language. When two dependent variables are correlated, one conservative strategy is to determine whether both variables are reflective of the same basic underlying psychological process. If the two areas do overlap at the level of behavioral process, then questions about human language may also be questions about derived stimulus relations, and vice versa.
This is the basic theoretical and empirical research strategy of RFT. The overarching aim of this behavioral research has been to integrate a range of apparently diverse psychological phenomena including, for example, stimulus equivalence, naming, understanding, analogy, metaphor, and rule-following. Here is a sample list that gives a sense of the complexity that emerges from the small set of core concepts in Relational Frame Theory:
● Simple examples of verbal understanding
● Simple examples of genuinely verbal governance of behavior by others
● More complex examples of verbal understanding
● Regulation of the behavior of the listener through the establishment of relational networks in the listener
● Development of perspective-taking and sense of self
● Regulation of the behavior of the listener by orienting the listener to abstracted features of the environment
● Increasing dominance of the verbal functions of the environment
So you can see that ACT puts into action the principles of RFT and why it is considered a branching off model from RFT.
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How does ACT differ from CBT?
ACT differs from traditional cognitive behavioral therapy (CBT) in that rather than trying to teach people to better control their thoughts, feelings, sensations, memories, and other private events,
ACT teaches them to notice and accept them - even previously unwanted ones
ACT helps the individual get in contact with a transcendent sense of self - known as “self-as-context”
Self-as-context is the self that is always there observing and experiencing but is separate from one’s thoughts, feelings, sensations and memories.
ACT aims to help people clarify their personal values and take action on them, bringing more vitality and meaning to life and increasing psychological flexibility
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Assumptions of ACT
ACT assumes that psychological processes of a normal human mind are often destructive, which differs from Western psychology which operates under the “Healthy Normality” assumption which states that by their nature, humans are psychologically healthy.
The core conception of ACT is that psychological suffering is usually caused by experiential avoidance, cognitive entanglement and resulting in psychological rigidity.
This process leads to a failure to take needed behavioral steps in accord with core values.
ACT views the core of many problems to be due to the concepts represented in the acronym FEAR
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FEAR
Fusion with your thoughts
Evaluation (often negative) of experience
Avoidance of your experience
Reason-giving for your behavior and the healthy alternative is to ACT
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ACT
Accept your reactions to be present
Choose a valued direction
Take action
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Root Goal of ACT
Change one’s internal self-talk and one’s external behavior
ACT teaches clients to observe themselves having feelings and then accept those feelings, as fighting or avoiding emotions worsens their effect
ACT then focuses on a shift from the content of an experience to the context of the experience
ACT distinguishes between acceptance of things that cannot be changed-like our history- and those that can, such as leaving an abusive relationship
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Six Core Processes of ACT
1.Cognitive Defusion: Learning to not be so controlled by one’s own thoughts, but rather to recognize thoughts without getting caught up in the content
2.Acceptance: Allowing one’s thought and feelings to come and go without struggle and accepting the reality of one’s circumstances
3.Contact with the present moment: Mindful awareness of the present on a moment-to-moment basis
4.Self as Context (Observing Self): Learning to access a continuity of consciousness that is unchanging-the ”observing mind” or “observing self”
5.Values: Defining what is most important to a person
6.Committed actions: Setting goals based on values and committing to them, despite contrary thoughts or emotions that may arise
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Basic Processes of ACT
1. Examine avoidant behavior
2. Examine strategies that have not worked
3. Identify self-as context, distinguished from self-in-content
4. Determine values and choose goals
5. Focus on commitment
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1. Examine avoidant behaviors
Clients have often struggled at great length with their problems and frequently enter treatment with a goal of eliminating painful thoughts or emotions
Avoidant behaviors are usually examined first. For example, what does the client do currently to avoid negative thoughts or feelings, or to escape them when they arise?
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2. Examine strategies that have not worked
In struggling with and focusing on the presenting problem, clients often make the problem appear even worse
ACT helps clients differentiate between unpleasant inner experiences (feelings, thoughts, sensations) and psychological problems
Clients often confuse the two and assume that being healthy means eliminating these negative experiences
The ACT therapist works to challenge this belief by asserting that healthy, normal brains churn out negative feelings and thoughts all throughout the day. In other words, it's just what the brain does.
One's job, then, is not to eliminate these feelings and thoughts-which is impossible-but to establish a healthier relationship with them, so they do not control or govern one's actions. (Cognitive Defusion, Acceptance)
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3. Identify self-as context, distinguished from self-in-content
Similar to many mindfulness practices, clients are taught to get in touch with an observant self that watches, and experiences yet is distinct from one's inner experiences.
This is done using a number of experiential mindfulness exercises, both in session and out. (Contact with the Present Moment, Self-as-Context)
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4. Determine values and choose goals
Clients are taught the difference between deeper values (family, health, etc.) and the goals that might help them work towards those values (spend an hour a night exercising with the kids, etc.).
Therapists help clients establish the willingness to regain control of life, rather than simply trying to control thoughts and feelings.
A great deal of emphasis is placed on defining willingness and helping the client establish it.
Clients are taught to take action towards their values, even when they "don't feel like it." For example, one may not feel willing to go to the dentist, but one might willingly go anyway. (Values)
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5. Focus on Commitment
Clients commit to ending the war with their own emotional states.
Clients integrate the practices of defusion, mindfulness, and acceptance into their daily lives.
Clients continue to move forward on goals that are in line with their values and learn to take action on these goals in spite of sometimes having negative (and normal!) thoughts or feelings.
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Techniques used in ACT
ACT therapists are active and engaged in sessions. ACT frequently includes experiential work with the client in the therapy room, as well as "homework" between sessions.
ACT therapists have generated a tremendous number of metaphors for use with clients in explaining the various tenets of ACT
ACT also uses mindfulness strategies derived and adapted from a number of meditative traditions used solely to help clients make contact with their "observing self" and practice mindfulness in various moments throughout the day.
ACT draws on experiential work guided by therapists in session, including techniques that "physicalize" negative thoughts or feelings, language exercises to help clients disconnect from the content of thoughts, and imaginative experiences led by the therapist to help clients internalize parts of the model and/or define values and goals more clearly.
ACT therapists sometimes use worksheets and written assignments to help clients clarify their deeper values and set goals based on these values. As with CBT, clients might also use worksheets to track their progress and better understand any resistance or setbacks, so the therapist might help them identify problem areas and solutions.
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Research Support for ACT
ACT is considered an empirically validated treatment by the American Psychological Association
Modest Research Support in Depression
Strong Research Support in chronic pain
ACT has been found effective in randomized trials for a variety of problems: including addictions, smoking cessation, anxiety, psychosis, workplace stress, diabetes management, weight management, epilepsy control, self-harm, body dissatisfaction, eating disorders, burn out and other areas of concer
ACT has recently been applied to children and adolescents and couples with good results
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Review of Meta-Analyses of the Research in Which ACT was included
Use of ACT to Treat Pain
Twenty-five random controlled treatment studies totaling 1285 patients with chronic pain were analyzed for their outcome measures of pain intensity, depression, anxiety, pain interference, disability and quality of life. Treatments compared were acceptance- and mindfulness-based interventions to the waitlist, (medical) treatment-as-usual, and education or support control groups. Effect sizes ranged from small (on all outcome measures except anxiety and pain interference) to moderate (on anxiety and pain interference) at post-treatment and from small (on pain intensity and disability) to large (on pain interference) at follow-up. ACT showed significantly higher effects on depression and anxiety than MBSR and MBCT. This study concluded that current acceptance- and mindfulness-based interventions, while not superior to traditional cognitive behavioral treatments, can be good alternatives (Veehof et al., 2016).
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Use of ACT to provide psychological intervention for chronic headache in adults
Of the 938 identified studies, 28 papers were selected, whose quality largely varied. Interventions included CBT (42.85%), multi-disciplinary treatments (22.43%), relaxation training (17.86%), biofeedback (7.14%), or other interventions (10.72%). Treatments duration (1 day-9 months) and intensity varied, with a prevalence of individual-basis implementation. The majority of the studies focused on all primary headaches; 4 studies focused on medication-overuse headache. Most of the studies suggest interventions as effective, with the reduction in frequency of attacks as the most reported outcome (46.43%). ACT is characterized by willingness to experience rather than control of pain and the pursuit of broader life values. Such interventions appeared to be feasible, well-tolerated (medium-high percentage of adherence to treatments) and able to effectively
impact at least one headache outcome, which is in line with previous reviews. These researchers reported that they encourage the use of ACT and mindfulness because of their efficacy in the reduction of headache intensity and in chronic pain treatment in general (Perlini et al., 2020).
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ACT interventions for Patients with Fibromyalgia
This study set out to analyze health effects on patients with fibromyalgia with mindfulness- and acceptance-based interventions, including mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT) and acceptance and commitment therapy (ACT). Additionally, the study aimed to explore content and delivery components in terms of procedure, instructors, mode, length, fidelity and adherence in the included interventions. The study included randomized and quasi-randomized controlled trials analyzing health effects of mindfulness and acceptance-based interventions for patients with fibromyalgia compared to no intervention, wait-list control, treatment as usual, or active interventions. MBSR combined with other treatments were included. Predefined outcomes were pain, fatigue, sleep quality, psychological distress, depression, anxiety, mindfulness, health-related quality of life and work ability. The search identified 4430 records, of which nine original trials were included. The vast majority of the participants were women. The analyses showed small to moderate effects in favor of mindfulness- and acceptance-based interventions compared to controls in pain, depression, anxiety, mindfulness, sleep quality, and health-related quality of life (Haugmark et al., 2019)
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ACT as Treatment for Depression and Anxiety
Acceptance and commitment therapy (ACT) is a modern form of cognitive behavioral therapy based on a distinct philosophy (functional contextualism) and basic science of cognition (relational frame theory). In a systematic review of randomized controlled trials (RCTs) evaluating ACT for depression and anxiety disorders across a total of 36 RCTs, ACT appears to be more efficacious than waitlist conditions and treatment-as-usual, with largely equivalent effects relative to traditional cognitive behavioral therapy. Evidence from several trials also indicates that ACT treatment outcomes are mediated through increases in psychological flexibility, its theorized process of change (Twohig & Levin, 2017).
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Effects of ACT in Psychosis Treatment
A study identified, evaluated, and synthesized existing randomized controlled trials
(RCTs) that examined the effect of acceptance and commitment therapy (ACT) in the
treatment of psychotic disorders and worked to integrate this knowledge and experience into the nursing literature. This study was completed with 11 RCTs meeting the research criteria. It was determined that the vast majority (82%) of the assessed studies were published after 2010. There is evidence that ACT is effective on depression, anxiety, and hallucinations seen in psychotic disorders. This meta-analysis study concluded that ACT is a reasonable approach to be used and tested by nurses and other clinicians because it provides an explanatory and pragmatic approach to psychotic disorders (Yildiz, 2019).
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Test of Processes for Psychological Flexibility in ACT
Mediation studies test the mechanisms by which interventions produce clinical outcomes. Consistent positive mediation results had been previously evidenced for the putative processes that compromise the psychological flexibility model of acceptance and commitment therapy (ACT). This study aimed to update and extend the ACT mediation evidence base by reviewing mediation studies published between 2006 and 2015 which were systematically collated, synthesized and quality assessed. Twelve studies met inclusion criteria and findings were synthesized by (a) the putative processes under investigation, and (b) the outcomes on which processes were tested for mediation. Mediation results were found to be generally consistent with the psychological flexibility model of ACT (Stockton et al., 2018).
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Comparison of Effectiveness of ACT with Traditional CBT
A meta-analysis using 39 randomized controlled trials, compared ACT to established treatments (CBT) and its findings indicated that ACT was more effective than treatment as usual (CBT)l or placebo and that ACT may be as effective in treating anxiety disorders, depression, addiction, and somatic health problems as established psychological interventions (A-Tiak et al, 2015)
Another meta-analysis of sixteen studies comparing differential outcomes (N= 954) of ACT versus CBT in diverse problems were identified following several search strategies. The metanalysis, which applied random and mixed effects models, showed that mean effect sizes on primary outcomes significantly favored ACT. Mean effect sizes were not significant with anxiety symptoms whereas a positive trend for ACT was obtained in depression and quality of life at post-treatment. Likewise, ACT showed a greater impact on its putative processes of change and no differences were found regarding CBT proposed processes. Nine of the sixteen studies conducted formal mediation analyses. Overall, ACT seemed to work through its proposed processes of change, but CBT did not (Ruiz et al., 2012).
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ACT with Patients with Long-Term Neurological Conditions
A systematic review sought to summarize and appraise the quality of published empirical studies using third-wave therapies such as Compassion Focused Therapy; Acceptance and Commitment Therapy; and Mindfulness-Based Cognitive Therapy or Mindfulness-Based Stress Reduction. This study review and screened 437 abstracts; retrieved 24 full-text articles and 19 studies were found to meet inclusion criteria. Six out of seven randomized studies had unclear or high risk of bias, while the majority of non-randomized studies were considered moderate quality. Overall, studies reported a statistically significant reduction in emotional distress. Of the 13 studies that used model-specific process measures, 10 found statistically significant improvements in transdiagnostic factors. ACT is theoretically rooted in Relational Frame Theory a contextual behavioral approach to human language and cognition. Psychological flexibility is the applied model that underlies an ACT approach and refers to the ability to more fully contact the present moment, and the thoughts and feelings it contains, to change or persist with behaviors that serve personal values. The findings indicated that ACT as one of the third-wave therapies which shows promise in addressing transdiagnostic difficulties within neurological conditions.
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ACT Works with Adolescents and Juvenile Delinquents
A systematic review critically examined the extent to which mindfulness therapies (ACT, DBT & MBSR) may be useful in the treatment of adolescents and juvenile delinquents. Clinically speaking, the more applicable approaches appear to be ACT and MBSR. This is particularly true because they pertain to the treatment of juvenile delinquents, especially because they are likely to be more transportable (Montgomery et al., 2013)
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Dropout Rates in ACT
Many psychotherapies, including cognitive behavioral therapy and acceptance and commitment therapy (ACT), have been found to be effective interventions for a range of psychological and behavioral health concerns. Another aspect of treatment utility to consider is dropout, as interventions only work if clients are engaged in them. To date, no research has used meta-analytic methods to examine dropout in ACT. Thus, the objectives of this meta-analysis were to (1) determine the aggregate dropout rate for ACT in randomized controlled trials, (2) compare dropout rates in ACT to those in other psychotherapies, and (3) identify potential moderators of dropout in ACT. This meta-analysis worked with 68 studies, representing 4,729 participants. The weighted mean dropout rates in ACT exclusive conditions (15.8%) and ACT inclusive conditions (i.e., those that included an ACT intervention) (16.0%). ACT dropout rates were not significantly different from those of established psychological treatments. In addition, dropout rates did not vary by client characteristics or study methodological quality (Ong et al, 2018).
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Cultural adaptation
The ACT model may be amenable to adaptation and delivery in a variety of contexts and formats, and in the treatment of various groups. This is because the process-oriented nature of the ACT model suggests that it may be particularly amenable to adaptation for use with a variety of diversity related issues (Woidneck et al., 2012)
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ACT Interventions as a Means of Preventing Frontline Worker Burnout
A meta-analysis of research in 4 studies on work-related stress among staff working in direct care roles in mental health and intellectual disability settings researched the use of acceptance and commitment therapy (ACT)-based interventions in these staff populations. Results of the meta-analysis were most convincing for the effectiveness of ACT-interventions to reduce psychological distress within a subgroup of those with higher distress at baseline. There was no statistically significant effect for the amelioration of burnout, nor for an increase in psychological flexibility (a key ACT construct) (Reeve et al, 2018).
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References for the Research Articles on ACT
A-Tjak, J.G.L., Davis, M.L., Morina, N., Powers, M.B., Smits, J.A.J. & Emmelkamp, P.M.G. (2015). A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems. Psychotherapy and Psychosomatics, 84, 30-36. DOI: 10.1159/000365764
Haugmark, T., Hagen, K.B., Smedslund, G. & Zang, H.A. (2019). Mindfulness-and acceptance based interventions for patients with fibromyalgia-A systemic review and meta-analyses. PLoS ONE, 14(9): e0221897. https://doi.org/10.1371/journal.
pone.0221897
Lin, J., Scott, W., Carpenter, L., Norton, S., Domhardt, M., Baumeister, H. & McCracken, L.M. (2019). Acceptance and commitment therapy for chronic pain: Protocol of a systematic review and individual participant data meta-analysis. Systematic Reviews, 8. https://doi.org/10.1186/s13643-019-1044-2
Montgomery, K.L., Kim, J.S., Springer, D.W. & Learman, J.A. (2013). A systematic and empirical review of mindfulness interventions with adolescents: A potential fit for delinquency intervention. Chapter 1 in: Best Practices in Mental Health, 9(1), 1-19.
Ong, C.W., Lee, E.B. & Twohig, M.P. (2018). A meta-analysis of dropout rates in acceptance and commitment therapy. Behaviour Research and Therapy, (104), 14-33. https://doi.org/10.1016/j.brat.2018.02.004
Perlini, C., Donisi, V. & Del Piccolo, L. (2020). From research to clinical practice: A systematic review of implementation of psychological interventions for chronic headaches in adults. BMC Health Services Research, 20, 459. https://doi.org/10.1186/s12913-020-05172-y
Reeve, A., Tickle, A. & Moghaddam, N. (2018). Are acceptance and commitment therapy-based interventions effective for reducing burnout in direct care staff? A systemic review and meta-analysis. Mental Health Review Journal (23)3, 131-155. DOI 10.1108/MHRJ-11-2017-0052
Robinson, P.L., Russell, A. & Dysch, L. (2019). Third-wave therapies for long-term neurological conditions: A systematic review to evaluate the status and quality of evidence. Brain Impairment (20)1, 58-80. doi:10.1017/BrImp.2019.2
Ruiz, F.J. (2012). Acceptance and commitment therapy versus traditional cognitive behavioral therapy: A systemic review and meta-analysis of current empirical evidence. International Journal of Psychology & Psychological Therapy 12(2)m 333-357,
Stockton, D., Kellett, S., Berrios, R., Sirosis, F., Wilkinson, N. & Miles, G. (2018). Identifying the underlying mechanisms of change during acceptance and commitment therapy (ACT): A systematic review of contemporary mediation studies. Behavioral and Cognitive Psychotherapy, 47, 332-362. doi:10.1017/S1352465818000553
Twohig, M.P. & Levin, M.E. (2017). Acceptance and commitment therapy as a treatment for anxiety and depression: A review. Psychiatric Clinics of North America (40)4, 751-770. https://doi.org/10.1016/j.psc.2017.08.009
Veehof, M.M., Trompetter, H.R., Bohlmeijer & Schreurs, K.M.G. (2016). Acceptance- and mindfulness-based interventions for the treatment of chronic pain: A meta-analytic review. Cognitive Behaviour Therapy, (45)1, 5-31. http://dx.doi.org/10.1080/16506073.2015.1098724
Woidneck, M.R., Pratt, K.M., Gundy, J.M., Nelson, C.R. & Twohig, M.P. (2012). Exploring cultural competence in acceptance and commitment therapy outcomes. Professional Psychology: Research and Practice, 43(3), 227-233. DOI:10.1037/a0026235
Yildiz, E. (2019). The effects of acceptance and commitment therapy in psychosis treatment: A systematic review of randomized controlled trials. Perspectives in Psychiatric Care, 56,149-167. DOI: 10.1111/ppc.12396
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Steven Hayes ACT Training Sessions
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ACT the Home of Metaphors
Metaphors are a chosen model in ACT to help clients to get in touch with the present moment, defuse negative thoughts and to grow in acceptance that negatives will come their way but that they not let them over take their state of centeredness and to help them commit to not give these negative power over their lives.
The metaphors include: the chess board, the passengers on the bus,unwelcomed guest, demons on the boat and quick sand (see the videos below of these metaphors).On all all websites focused on ACT there are samples of metaphors given. However one of the most exhaustive list of ACT Metaphors is on the Association for Contextual Behavioral Science (ACBS) on their Metaphor resource list at: https://contextualscience.org/metaphors
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Helpful Resources for working with ACT Metaphors
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Mindfulness and ACT Related Videos
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4 videos from D.J. Moran, Ph.D. with Transcripts
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Books on Acceptance and Commitment Therapy (ACT)
ACT Made Simple: An Easy-to-Read Primer on Acceptance and Commitment Therapy (2019) By Russ Harris and Steven Hayes. Oakland, CA: New Harbinger Publications, Inc.
Committed Action in Practice - A Clinician's Guide to Assessing, Planning & Supporting Change in Your Clients (2018). By: Daniel Moran, Patricia Bach & Sonja Batten. Oakland, CA: New Harbinger Publications, Inc.
Acceptance and Commitment Therapy - The Process and Practice of Mindful Change (Second Edition) (2012). By Steven Hayes, Kirk Strosahl & Kelly Wilson. New York, NY: Guilford Press
ACT in Practice - Case Conceptualization in Acceptance & Committment Therapy. (2008). By Patricia Bach & Daniel Moran. Oakland, CA: New Harbinger Publications, Inc.
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