Acceptance and Commitment
Therapy (ACT) with College
and University Students
Gregory T. Eells, Ph.D.
Director, Counseling & Psychological
Services
Cornell University
Outline
I. Introduction
II. Philosophical and Theoretical
Foundation
III. Model of Psychopathology
IV. Processes and Course of Therapy
V. Application to College and University
Students
Outline
VI. Applications as a Director
VII. Efficacy Research
VIII. Conclusion
Introduction
Founded by Steven Hayes and
colleagues
University of Nevada, Reno
former president of Association of
Behavioral and Cognitive Therapies
So-called "third wave" therapy
first wave: behavioral therapy
second wave: cognitive behavioral therapy
third wave: acceptance based behavioral
therapy
Introduction
Third wave vs. CBT
Emphasis on acceptance-willingness to
have
Approach to cognition
Not disputing “negative thoughts”
Not trying to change thoughts (though
change sometimes happens)
Introduction
Similarities with:
Dialectical Behavior Therapy (DBT), Linehan
Mindfulness-Based Stress Reduction (MBSR),
Kabat-Zin
Mindfulness-Based Cognitive Therapy
(MBCT), Segal, Williams, Teasdale
Gestalt Therapy
Existential Therapy
Introduction
very experiential
use of metaphor
perception of both therapist and client as
people struggling with what life offers
Very relevant to our work with college
students
Philosophical and Theoretical
Foundations
The Dilemma of Human Suffering
Humans as a species are suffering creatures.
The assumption of destructive normality is
basic to many of our cultural traditions
(religious), but is much less dominant in
psychology.
All mystical traditions have practices that are
oriented toward reducing or transforming the
domination of analytical language over
experience
Philosophical and Theoretical
Foundations
Positive and negative of human
language.
Human misery can be understood in the
context of human achievement,
because the most important source of
each is the same: human symbolic
activity.
Language is both the reason for our
ascendance as a species and a primary
cause of our suffering.
Philosophical and Theoretical
Foundations
Why language creates suffering
if your paint is peeling
scrape it off and repaint
if there is dirt on the floor
sweep it up
if you are sad or angry or fearful
?
Terms we use to deal with the physical world
can be used inappropriately to the internal
world
Relational Frame Theory
An account of language that is the theoretical
underpinning of ACT
Everything we say (or think) has multiple
relations
We can globalize one experience to similar
(according to our language) experiences
Example: panic disorder
Establishing behavior by direct rules can
induce rigidity and should not be done lightly.
Rules are useful but can often trick and be
dangerous.
Relational Frame Theory
Suicide-
Suicide is purposive, has not been
experienced directly and does have a
verbal purpose.
People can formulate the consequences
of their own death and verbally place it
in a class with termination of suffering.
“If death then no suffering”
Philosophical and Theoretical
Foundations
Functional Contextualism
1) The whole event -ask “ And that is in the
service of..?”
2) The role of context- “And in what context
does that occur?”
3) Pragmatic Truth Criterion-Analyses are
true only in terms of the accomplishment of
particular goals. Clients often think “ It exists
out there and thus I have to respond to it
even though it does not work to do so.”
Philosophical and Theoretical
Foundations
no "symptom" is a problem in and of itself
symptoms become problems when they
get in the way of living a life worth living
example: social phobia
why confront your fears if you don't value
relationships or feeling connected?
Philosophical and Theoretical
Foundations
psychological pain is normal
cannot get rid of it
can avoid increasing it artificially
pain is different from suffering
accepting your pain reduces suffering
(Hayes and Smith, 2005)
Philosophical and Theoretical
Foundations :
Psychopathology in ACT
ACT Model of
Dominance of the conceptualized past and future;
Psychopathology limited self-knowledge
Experiential avoidance
Lack of values
clarity/contact
Psychological
Inflexibility
Cognitive fusion
Inaction, impulsivity,
or avoidant persistence
Attachment to the Conceptualized Self
What Traps Us
Problems, it seems, have to be here for a
reason and the context of literality and
reason giving dominate.
We all have poor access to actual motivations
and verbal explanations have little chance of
being fully accurate.
Mistakenly think that thoughts and feelings
are good reasons and causes.
Mistakenly assume that to control the
outcome we must control the cause.
What Traps Us
Our minds don‟t really know what is
good for us.
Our language did not evolve for fun or
to accurately describe our internal
experience.
What Traps Us
Culture sanctifies language and tells us:
Psychological problems can be defined
as the presence of unpleasant feelings,
thoughts, memories, bodily sensations,
etc.
Undesirable experiences are signals that
something is wrong and has to change.
Healthy living cannot occur until
negative experiences are eliminated.
What Traps Us
Client needs to get rid of negative
experiences by correcting the deficits
that are causing them.
This is best achieved by understanding
or modifying the adverse factors
causing the difficulty.
ACT reduces down to “control of private
experience =successful living” then asks
“will you believe your mind or
experience?”
Experiential Avoidance
also "experiential control"
the attempt to control or alter the form,
frequency, or situational sensitivity of
internal experiences -- thoughts,
feelings, sensations, or memories --
even when doing so causes harm
Don‟t think of pink elephants!
Examples of Avoidance (and
Control) Leading to Suffering
Panic disorder
Obsessive-compulsive disorder
Substance abuse
Eating disorders
Depression
Etc.
Cognitive Fusion
We conflate the meaning of thoughts
with the literal events we are thinking
about
We don't notice the process of thinking
We look "from" our thoughts, not "at"
them
Dominance of the Conceptualized
Past and Future; Limited Self-
knowledge
Or, “We are so focused on the past and future
we don‟t pay any attention to the present ”
Because of avoidance and fusion:
we are ruled by our stories about the past and
our thoughts/worries about the future
Little knowledge of what‟s going on right now
Our behavior becomes programmed by our
histories and we continue to repeat the same
stuff
Attachment to the Conceptualized
Self
Or, “We are fused to who we think „I‟
is”
We develop stories about ourselves that
can trap us
Sometimes real solutions don't exist
within our stories
The story feels so true that possible
ways out of it would be experienced as
invalidating
Lack of Values Clarity/Contact
Values are about living in a chosen and
meaningful way
Values = our compass
doing important things sometimes
HURTS
Inaction, Impulsivity, or Avoidant
Persistence
Inability to behave in accordance with
our values
So focused on feeling good, being right,
managing anxiety, handling depression,
etc., that we lose focus on what's
important.
So what do we do?
Six Core Therapeutic
Processes
Psychological
Flexibility
Acceptance
Alternative to avoidance
Active and aware embrace of what's
going on inside
Without trying to change things,
especially if attempting to change
causes psychological harm
“Creative Hopelessness”- engendering a
posture of giving up strategies when
giving up is what is called for in the
service of larger goals.
Man In The Hole Metaphor
In a field with a blindfold and a bag of tools.
You are told your job is to run around the
field blindfolded but you don‟ know there are
widely spaced deep holes.
You fall in and find only a shovel in your tool
bag and start digging.
You come to therapy thinking you can find a
“gold plated steam shovel.”
Man In The Hole Metaphor
You can think “Maybe I should put up with it?”
“I need to understand my past?”
“Am I responsible for these problems?”
”Should I blame myself?”
“What is the way out?”
The need to give up first. Take a leap of faith.
The opportunity presented by suffering.
The ultimate yardstick for any new strategy is the
workability in the clients life.
Tug of War with a Monster
Metaphor
You are in a tug of war with a big ugly very
strong monster.
In between you and the monster is a
bottomless pit.
So you pull and pull but the monster pulls
harder.
The hard thing to see is that our job in
therapy is not to win the tug of war but to
learn how to drop the rope.
Control is the Problem, Not the
Solution
Deliberate control works for me in the
external world.
I was taught it should work with personal
experiences (Don‟t be afraid)
It seems to work for others around me (Dad
never seemed scared)
It appears to work with certain experiences
I‟ve struggled with (relaxation techniques)
Polygraph Metaphor
Hooked up to the world‟s best
polygraph machine. Can pick up any
anxiety.
All you have to do is stay relaxed.
You also have a gun to your head that
will go off if you get anxious and the
machine registers it.
So just stay relaxed.
The Alternative to Control is
Willingness
Willingness diaries
Two scales metaphor-The scale on the left is anxiety
(guilt, shame, etc) that goes from 0-10.
You have come to get help to pull this lever down but
can‟t
My job is to get you to look at the scale on the right.
The willingness scale also 0-10.
When willingness is low anxiety is always ratcheted
up high.
When willingness is high anxiety will float. Usually
lower.
Let‟s talk about milk!
Deliteralizing Language
Milk, milk, milk exercise
What comes to mind when I say milk?”
Usually white, cold, creamy, experience of
drinking.
All of this brought up with a simple silly
sound.
Together we are going to say “milk” over and
over again for 1-2 minutes.
Where did the image of milk go? Other things
we say to ourselves are the same. Nothing
solid.
Deliteralizing Language
And/Be Out Convention.
We use the word “but” to enhance our
internal conflict.
“And” is almost always more honest “ I
love my partner and he/she drives me
crazy sometimes”
Can use the root of but “be out”
Cognitive Diffusion
de-fusion
learn to notice thoughts as just
thoughts
not change their content
rather, change their context and
function
Being Present
contact with present moment, which
undermines fusion, avoidance, and
reason giving
Self as Context
or, "If I'm not my thoughts, then who
am I?"
a continuous and secure "I" from which
events are experienced, but that is also
distinct from those events.
Helps to disentangle us from words,
memories, thoughts, our histories
Observer Exercise
You are not Your programming. No one
Can Fail. Whatever comes up is just
right.
Notice surroundings and current
feelings-introduce the “Observer You”
Remember something that happened
last summer ..sights…sounds…feelings
Observer Exercise
Remember something that happened
when you were a teenager
..sights…sounds…feelings
Remember something that happened
when you were a young child (6 or 7
years old)..sights…sounds…feelings
Everywhere you have been you have
been noticing
Observer Exercise
Observe roles student, son/daughter,
wife/husband, etc
Observe constantly changing emotions
Observe thoughts constantly changing.
Going to school to learn new thoughts.
As a matter of experience you are not
just your body, your memories, your
roles, your emotions or your thoughts
Defining Valued Directions
Values are chosen actions that can
never be obtained as an object, but can
be instantiated moment by moment.
Distinguishing between valuing as
feeling versus valuing as action.
Differentiate between judgments and
choices
Path up the Mountain Metaphor
Trails with switchbacks. Sometimes the path
goes below previous heights.
If asked in a switchback or a drop how you
were doing you may say not very well.
At the top of the mountain looking through
binoculars back on other hikers and asked
how they were doing would report positive
progress every time.
See the overall direction not at any given
point
Bubble In The Road Metaphor
You are a soap bubble moving along a path
you have chosen.
Another bubble blocks you and says stop and
you can‟t get around it.
You have two choices: You can stop moving
in a valued direction or you can touch the
other bubble and continue with it inside you.
The other bubble is your thoughts, feelings
and memories. Are you willing to have them
by choice or not.
Committed Action
“IF you always do what you always did,
you‟ll always get what you always got.”
–”Moms” Mably
goals and behavior in the service of
values
like traditional behavior therapy
Eye Contact Exercise
We will put two chairs close together and
look into each others eyes for about 3
minutes.
It may seem longer. Goal is to be present and
maintain eye contact.
Mind will tell you all sorts of reasons you can‟t
do it.
Just notice another human being looking at
you and that you can persist on a course of
action when it feels uncomfortable.
Swamp Metaphor
Journey to a beautiful mountain you can see
in the distance.
Come up on a smelly muddy swamp.
Choice is to abandon the journey or enter the
swamp.
Therapy and life like that. We don‟t go into
the swamp because we want to get muddy
but because the swamp stands between us
and where we are going.
Given the distinction between your self and
the stuff you are struggling with and trying to
change (self as context), are you willing to
have that stuff -- fully and without defense
(willingness/acceptance), as it is, not as what
it says it is (defusion) -- and does it takes you
(committed action) in the direction of your
chosen values (values), in this time and this
situation (being present)?
Cue-Response Relations in ACT
Functions for you: In ACT terms
Were you within yourself accepting, present,
conscious, defused, values-based, active, and
flexible?
Process of therapy: In ACT terms
Was the therapeutic response and its relation to
client cues accepting, present, conscious, defused,
values-based, active, and flexible?
Application to College and
University Students
Our students live very symbolic lives
They are reinforced for existing in their head and
within language
Technology only adds to the symbolic living and
conveys messages that reinforce failed control
strategies.
Technology fills the space that previously was filled
with experiences that facilitated willingness.
Competition and achievement focus benefits our
culture but harms individuals.
Applications as a Director
How willing am I to feel like I am failing.
How willing am I to accept colleagues anger
and frustration.
Can I learn to focus on valued directions even
(especially) when it leads into the swamp.
Cultivating psychological flexibility is essential
to my success as a director.
Efficacy Research
Many different problems
Still not EST‟s
Small sample sizes
Many different problems, not all DSM
Many studies focused on components, not
whole package
Less research funding
Efficacy Research
“Overall ACT seems to be producing
consistently positive gains, sometimes
quickly, across an unusually broad
range of problems including notably
severe ones, and at times better than
existing empirically supported
procedures”
-S. Hayes-
Efficacy Research
“It seems to work through at least some
of it‟s theoretically specified processes
and components, not just through
general processes of change”
"State of ACT Evidence" 2005
PowerPoint
Efficacy Research
Chronic pain patients at risk for disability
Reduced sick day usage by 91% over six months
compared to TAU
Chronic pain patients with long treatment
histories
Changes in acceptance predicted positive changes
in depression, pain related anxiety, physical
disability, psychosocial disability
Significant outcomes also in decreased medical
visits, pain intensity, and decreased medication
use
Efficacy Research
Poly-substance abusing opiate addicted clients
N = 114
Methadone maintenance, methadone plus ACT,
methadone plus “Intensive 12-Step Facilitation”
No differences immediately post treatment
Six-month follow-up: ACT = greater decrease in
opiate use
Efficacy Research
Epilepsy- ACT compared to yoga and
“attention control therapy” in India and
South Africa.
ACT reduced seizures compared to both
treatments
Efficacy Research
Smoking -ACT compared to nicotine
replacement (NRT)
Quit rates no different at post
One-year follow-up:
NRT < 10%
ACT = 35%
Efficacy Research
Stigmatizing Attitudes- Amongst
substance abuse counselors
Compared to multicultural training
workshop and control group
ACT = greater decreases in
stigmatization and therapist burnout
Efficacy Research
Depression- 2 small, early studies
ACT compares favorably to CBT
Efficacy Research
Psychoses- 2 studies
Short interventions
First study: reduced hospitalization by
50% over four months
Second study: reduced believability in
hallucinations decrease in overtly
psychotic behavior
Conclusion
“When suffering knocks at your door and you
say there is no seat for him, he tells you not
to worry because he has brought his own
stool.” –Chinua Achebe
We cannot reverse the suffering caused by
language but we can cultivate our skill at
putting on and taking off aspects of human
language to decrease our suffering.
Resources
www.acceptanceandcommitmenttherapy.com
www.contextualpsychology.org
Acceptance and Commitment Therapy: an
Experiential Approach to Behavior Change.
Hayes, Strosahl & Wilson (1999)
Get Out Of Your Mind and into Your Life.
Hayes & Smith (2005)
Learning Act. Luoma, Hayes & Walser (2007)
Acceptance and Commitment Therapy for
Anxiety Disorders. Eifert & Forsyth (2005)