Recommended Therapies: 2) ACT and Other Therapies
Acceptance and Commitment Therapy (ACT)
As a third-wave CBT, Acceptance and Commitment Therapy (ACT) is an empirically based psychotherapy which uses a fusion of the concepts of acceptance (flexibility, openness, compassion and forgiveness) and commitment (taking action based on our deepest values and accepting responsibility) as well as the strategies of mindfulness meditation to increase psychological flexibility and to facilitate positive behavioural changes.
Steven Hayes (American clinical psychologist, University of Nevada, 1982) developed ACT, which was initially called “comprehensive distancing.” He combined ideas from cognitive and behavioural therapy to create this therapeutic approach. ACT is developed within a pragmatic philosophy called “Functional Contextualism,” which is based on Relational Frame Theory (RFT), a theory of language and cognition, a branch of behavioural analysis. Both ACT and RFT are based on B. F. Skinner’s “Radical Behavioural Philosophy.”
We can’t always change the circumstances that cause stress. There are always difficult people we must deal with and some pressures we must manage. Therefore, we need to find strategies that help us deal with unavoidable stressors in a way that minimises their adverse effects. ACT has proved to be an effective stress management tool. In the ACT, instead of questioning the validity of negative thoughts (as discussed in CBT), people learn to notice, accept and embrace their thoughts and feelings (especially those they don’t like). This acceptance helps people get in touch with a transcendent sense of self, known as “self-as-context”, the observing and experiencing self, which is different from “self-as-content”, which is the expression of the content of one’s thoughts, feelings, and sensations.
In other words, we are not our fears or our pains; we are the experiencers, the recipients or the observers of them. This idea allows a sense of distancing (dissociating) from the difficult feelings rather than being in unison (associating) with them. The ACT aims to help people increase their psychological flexibility, clarify their values, and commit to appropriate actions to bring openness, vitality and meaning to their lives.
ACT’s objective is not to eliminate difficult feelings but to become at ease with them as we move closer to our core values. ACT encourages people to open up/expose themselves to unpleasant feelings and stop overreacting to them either by avoiding the situations that bring them up or making a big deal of them. The therapeutic effect of ACT is achieved through a positive spiral, where feeling calmer leads to a better understanding of the situation, which in turn makes us feel better, and the process spirals to positive outcomes.
ACT employs mindfulness to help individuals become more aware of their automatic reactions. However, instead of challenging distressing thoughts (as in CBT) by examining the evidence and developing a more rational response, people learn to accept and defuse them. This acceptance helps them end the struggle that things should be any other way. ACT helps them accept what is out of their control and commit to improving and enriching their lives.
Assumptions and Principles of ACT
ACT believes that the root of many of our problems is the absence of psychological flexibility in the form of a) closely associating with our thoughts and feelings (taking them as inevitable facts), b) overly analysing and trying to justify them, and c) avoiding the difficult or distressing situation. Instead, ACT suggests that it’s healthier to 1) accept our unwanted thoughts and behaviours (allowing them without struggling with them), 2) be mindful of the present (awareness of the here and now, with openness and interest), 3) choose a valued direction (most important goal), and take appropriate action to fulfil that value.
When we work within ACT therapy, we learn to listen to our self-talk and how we talk about a specific distressing event, such as a complicated relationship or situation. We can then change any “being” sentences, such as “I am x” (expressing self as content), to an experiencing or observing sentence: “I have the thought that….” This new phrase (expressing self as context) puts a “distance” between us and our thoughts, emphasising that we are not “x”, which is fixed, but we are experiencing it, which is transient and changeable. In this format, “x” has much less impact. Notice there has been no effort to eliminate the thought; only the relationship with it has changed. Such a change shows the power of language, as portrayed in the Relational Frame Theory (RFT).
A word, sentence or symbol (e.g., stimulus) can have a different meaning (function) depending on the context. In RFT, a stimulus can have various functions depending on contextual cues. Take these examples: a) Driving that car was a piece of cake. b) You baked a delicious cake. In the above sentences, the stimulus “cake” has two different “functions” (meaning) in the presence of various contextual cues.
Once you have faced and accepted your current issues (dissociatively), you stop fighting your past, thoughts and emotions; instead, you commit to practising more confident and hopeful behaviour based on your values and goals. The core of ACT is a change in both internal (self-talk) and external (action) behaviour. ACT is reminiscent of the Serenity Prayer (by American theologian Reinhold Niebuhr, 1892–1971); hence, it’s essential that you initially identify the areas that can and cannot be changed. For example, physical disability and past trauma are examples of things that cannot be changed and are best accepted.
God, grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.
ACT has a non-therapy version called “Acceptance and Commitment Training,” which develops mindfulness, acceptance, and valued skills in non-clinical settings such as businesses or schools. Despite some criticisms (both in methodology and theory), ACT remains popular, and there is more evidence about its effectiveness than its shortcomings.
Resources and Further Reading
Zettle, R. D. (2011). The evolution of a contextual approach to therapy: From comprehensive distancing to ACT. International Journal of Behavioural Consultation and Therapy, 7(1), 76-82.
Hayes, Steven. “Acceptance & Commitment Therapy (ACT)”. ContextualPsychology.org
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2009). Acceptance and commitment therapy. Washington, DC: American Psychological Association.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2011). Acceptance and commitment therapy: The process and practice of mindful change. Guilford Press.
Forman, E. M., Herbert, J. D., Moitra, E., Yeomans, P. D., & Geller, P. A. (2007). A randomised controlled effectiveness trial of acceptance and commitment therapy and cognitive therapy for anxiety and depression. Behaviour modification, 31(6), 772-799.
Hayes, S. C. (2004). Acceptance and commitment therapy, relational frame theory, and the third wave of behavioural and cognitive therapies. Behaviour therapy, 35(4), 639-665.
Barnes-Holmes, S. C. H. D., & Roche, B. (2001). Relational frame theory: A post-Skinnerian account of human language and cognition. Springer Science & Business Media.
Well-Being Therapy
Dr Giovanni Fava has developed Well-Being Therapy (WBT), a specific short-term therapeutic strategy based on Jahoda-Ryff’s psychological model of well-being (http://www.well-being-therapy.com/therapy). WBT was validated through randomised controlled trials. It emphasises self-observation, the use of a structured diary, interaction between patients and therapists, and some homework. Patients are encouraged to identify incidents of well-being in a diary and place them into a situational context. Once the instances of well-being are correctly recognised, the patient is encouraged to identify thoughts and beliefs leading to disturbances to their well-being (e.g., automatic negative thoughts).
The drive for self-observation is based on well-being instead of distress, where cognitive restructuring may take place along the six dimensions of psychological well-being (autonomy, environmental mastery, personal growth, positive relationships, purpose in life and self-acceptance - Carol Ryff, 1995). Hence, activities that are likely to prompt well-being are encouraged. The findings from controlled studies indicate that WBT can promote flourishing and resilience. These interventions lead to a positive evaluation of self, a sense of continued growth, the belief that life is purposeful, the quality of relationships with others, the capacity to manage one’s life and a sense of self-determination. A decreased vulnerability to depression and anxiety has also been demonstrated after well-being therapy in high-risk populations.
Note: Marie Jahoda (1958) and Carol Ryff (1989) are influential figures in the study of psychological well-being, but their contributions differ. Jahoda focused on defining positive mental health, while Ryff developed a model of psychological well-being with six core dimensions.
Resources and Further Reading
Fava, G. A. (1999). Well-being therapy: Conceptual and technical issues. Psychotherapy and psychosomatics, 68(4), 171-179.
Fava, G. A., Rafanelli, C., Cazzaro, M., Conti, S., & Grandi, S. (1998). Well-being therapy. A novel psychotherapeutic approach for residual symptoms of affective disorders. Psychological medicine, 28(2), 475-480.
Ryff, C.D., & Singer, B. (1998). The contours of positive human health. Psychological Inquiry, 9, 1-28.
Ryff, C.D. (1995). Psychological well-being in adult life. Current Directions in Psychological Science, 4, 99-104.
Dr Frankl’s Logotherapy
In 1942, Dr Viktor Frankl (1905-1997) and his family were taken to a Nazi concentration camp. He was the only family member to survive the Holocaust (Shoah). In 1945, he returned to Vienna and published a book on his theories based on his observations during his time in the concentration camps. Before his death, his book, “Man’s Search for Meaning”, had been published in 24 languages.
Dr Frankl believed that humans are motivated by a “will to meaning”, which equates to a desire to find meaning in life. He argued that life can have “meaning” even in the most miserable circumstances and that the motivation for living comes from recognising that meaning. Taking it a step further, Dr Frankl wrote: “Everything can be taken from a man but one thing: the last of the human freedoms (freedom of will), to choose one’s attitude in any given set of circumstances.” This opinion was based on his suffering experiences and his attitude toward finding meaning through suffering. In this way, he believed that when we can no longer change a situation, we are forced to change ourselves.
Healing Through Meaning
Dr Frankl’s therapeutic approach, logotherapy, was based on three philosophical and psychological concepts, i.e., freedom of will, will to meaning, and meaning in life. Logotherapy was recognised as the third school of Viennese therapy after Freud’s psychoanalysis and Alfred Adler’s individual psychology.
Logos is the Greek word for meaning, and logotherapy involves helping patients find “their meaning in life”. Dr Frankl believed in three core properties on which his theory and therapy were based: First, people have a healthy core. Second, life offers purpose and meaning but does not promise fulfilment or happiness. Third, the therapist’s primary focus should be on educating and guiding the clients to use their internal resources and providing them with tools to use their inner strengths.
Logotherapy proposes that meaning in life can be discovered in three distinct ways: first, by creating a work or doing a deed; second, by experiencing something or encountering someone; and third, by the attitude we develop toward unavoidable suffering. An example that explains the basic tenets of logotherapy is the story of Dr Frankl meeting with an elderly general practitioner who was struggling to overcome depression after the death of his wife. Dr Frankl helped the elderly man see that his purpose had been to spare his wife the pain of seeing him die first.
Logotherapy consists of six basic assumptions that overlap with its fundamental constructs and ways of seeking meaning:
Body, Mind, and Spirit: Humans are entities consisting of a body (soma), mind (psyche), and spirit (nous). Dr. Frankl argued that we have a body and mind, but the spirit is what we are, or our essence. Note that Frankl’s theory was not based on religion or theology but often had parallels with religious beliefs.
Life Has Meaning in All Circumstances: Dr. Frankl believed life has meaning in all circumstances, even the most miserable ones. This means that even when situations seem objectively terrible, there is a higher level of value that involves meaning.
Humans Have a Will to Meaning: Logotherapy proposes that humans have a will to meaning, i.e., meaning is our primary motivation for living and acting and allows us to endure pain and suffering. This idea is viewed as different from the will to power and pleasure. Logotherapy is based on an existential analysis focusing on Kierkegaard’s will to meaning instead of Adler’s Nietzschean doctrine of will to power or Freud’s will to pleasure.
Freedom to Find Meaning: Dr Frankl argued that individuals have the freedom to (can) access their will to meaning (can find meaning) in all circumstances. This doctrine is based on his experience of pain and suffering and choosing his attitude in a situation that he could not change.
Meaning of the Moment: This assumption argues that for decisions to be meaningful, individuals must respond to the demands of daily life in ways that match their values and conscience.
Individuals are Unique: Dr Frankl believed every individual is unique and irreplaceable.
Dr Frankl believed that turning suffering into achievement and accomplishment was possible. He viewed guilt as an opportunity to change ourselves for the better and the transient nature of life as a chance to take responsible action. In this way, logotherapy was aimed at helping people to make better use of their spiritual resources to withstand adversity.
Logotherapy Techniques
De-reflection: This logotherapy technique aims to help people focus away from themselves and toward other people so that they can become whole and spend less time being self-absorbed by their problems or how to reach a goal.
Paradoxical Intention: This technique has the patients wish for what they feared most and was designed for application in anxiety or phobias, where humour and ridicule can be employed when fear is paralysing. For example, a person who fears looking foolish might be encouraged to try to look foolish on purpose. Paradoxically, the fear would be removed when the intention is involved in what we fear most.
Socratic Dialogue: Socratic dialogue could be used in logotherapy to help patients self-discovery through their own words. The therapist would highlight some words and help the client understand their meaning. This process allows the client to realise an answer waiting to be discovered (see Columbo’s approach).
It’s easy to see how some logotherapy techniques overlap with newer forms of treatment, such as cognitive-behavioural therapy (CBT) or acceptance and commitment therapy (ACT). Thus, logotherapy may be a complementary approach to cognitive and behaviour-based treatments. Some aspects of logotherapy are routinely used in tandem with other techniques.
Criticisms of Logotherapy
Other therapists have criticised logotherapy for diminishing the patient’s role in solving their problems (authoritarianism). This concern was based on the argument that logotherapy claims that there is always a clear solution to a problem and that the therapist is responsible for finding it for the client. This assertion seems to undermine the complexity of humans and their lives (Rollo May 1969).
However, Dr Frankl maintained that logotherapy only guides and educates patients to take responsibility. The patient/client must always be an active participant rather than a passive recipient. Nonetheless, there is ample evidence that meaning in life correlates with better mental health. Logotherapy is applied in depression, anxiety, phobias, pain, guilt, grief, substance abuse and post-traumatic disorder. Dr Frankl believed that many mental health issues are disguised as existential angst and that many patients struggle with a lack of meaning, which he referred to as the “existential vacuum.”
Positive Psychotherapy
Positive Psychotherapy (PPT) should not be confused with positive psychology. PPT is a psychotherapeutic method developed by Nossrat Peseschkian and colleagues in Germany in 1968. It is a humanistic psychodynamic psychotherapy based on the premise that human nature is intrinsically good. PPT is an integrative method that consists of humanistic, systemic, psychodynamic, and cognitive behaviour therapy (CBT) elements.
The founder of positive psychotherapy, Nossrat Peseschkian (1933–2010), was an Iranian-born German psychiatrist, neurologist and psychotherapist. In the late 1960s and early 1970s, he was inspired by different sources, which helped him develop his ideas about PPT. These include humanistic psychology, the humanistic teachings and virtues of the Bahai faith, problems between psychoanalysts and behaviour therapists at the time, and his encounters with prominent psychotherapists, such as Viktor Frankl, Jacob Moreno, Heinrich Meng and others.
PPT was initially called “differentiation analysis”, but in 1977, Peseschkian published his work in English, titled “Positive Psychotherapy”. For him, the term “positive” was a derivative of its Latin origin, positum, which means actual, real or concrete. One distinct feature of positive psychotherapy is the introduction of imagination and intuition into the healing process. This technique uses multicultural stories and metaphors to encourage people in therapy to view their mental health in unique and positive ways. The person in therapy is incorporated into the story to allow them to play an active role in the healing process. This interdisciplinary approach incorporates various forms of psychotherapy to help individuals become actively engaged in the therapy process.
Positive psychotherapists aim to help patients see their abilities, strengths, potentials and resources. There are three main principles or pillars of positive psychotherapy:
The principle of hope reflects the therapist’s effort to assist the patient in understanding and seeing their disorder from a new perspective so that it can be reinterpreted in a “positive” way.
The principle of balance: Despite social and cultural differences and the uniqueness of every human being, it can be observed that during the management of their problems, people often refer to typical ways of coping in four different areas: a) body (health – psychosomatic); b) achievement (work – stress factors); c) contact (relationships – depression); and d) future (meaning of life – fears and phobia). Although these four areas are inherent in all humans, the emphasis is often more on body and achievement in the West, whereas in the East, the focus is more on contact and the future (the cross-cultural aspect of positive psychotherapy).
The principle of consultation reflects the fact that therapy and self-help are closely interrelated and consist of five stages: observation (understanding the situation), taking inventory (exploratory interviewing), situational encouragement (focusing on positive aspects), verbalisation (discussing relationships), and expansion of goals (setting achievable positive goals).
Positive psychotherapy assumes all individuals, regardless of gender, ethnicity, age, social class, financial standing or mental health, possess two basic unconscious capabilities: the capability of perception and the capacity of love. According to Peseschkian, these capacities give rise to an individual’s general abilities.
The capability of perception drives a person to try to perceive the connections between different aspects of life, the reasons behind daily phenomena, and the meaning of existence.
The capability of love is inborn and relates to a person’s emotional sphere and interpersonal relationships.
Resources and Further Reading
Positive Psychotherapy: Theory and Practice of a New Method, by Peseschkian, Nossrat (Walker, Robert R, Dr. Translator), Publisher: Springer-Verlag, Berlin, 1987, ISBN 978-0-387-15794-8 (first German edition 1977 by Fischer Verlag)
Positive Family Therapy, by Peseschkian, Nossrat, Publisher: Springer ISBN 978-0-387-15768-9, republished Sterling Publishers Pvt. Ltd, India ISBN 978-81-207-1839-5 (first German edition 1980 by Fischer Verlag)
Psychotherapy of Everyday Life: Training in Partnership and Self Help With 250 Case Histories, by Peseschkian, Nossrat, Publisher: Springer ISBN 978-0-387-15767-2 (first German edition 1974 by Fischer Verlag).
