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005256

Introduction to acceptance ARTICLE

and commitment therapy

Mark Webster

cognitive change and outcomes has not been Mark Webster is a psychotherapist
Summary registered with the UK Council for
established. This set the scene for the emergence
Acceptance and commitment therapy (ACT) is a Psychotherapy. Following a first
of new treatment models that focus on the function career in the computer industry, he
descendant of cognitive–behavioural therapy (CBT).
of problematic cognitions rather than the content. qualified in cognitive–analytical
The model draws techniques from a wide variety
The third wave differs from the first wave in that therapy and worked for 10 years at a
of sources and unites them within a philosophical specialist personality disorder clinic
and scientific framework to create a principle- it has a considerable focus on private events, and
in the NHS. His involvement in third-
driven therapy. Psychopathology is understood as a it differs from the second in that it does not try wave CBT began with dialectical
narrowing behavioural repertoire that develops over to change the form or frequency of these private behaviour therapy in 1997, which led
time through maladaptive strategies to cope with events. Over the past 15 years, these new treatments to an early interest in acceptance
and commitment therapy (ACT). He
unwanted private events. The six core components have developed an expanding evidence base. Based
started to offer training in ACT from
of the therapy remain consistent across a wide on acceptance and mindfulness procedures, this 2003 and eventually developed a
range of clinical conditions. The approach combines third wave of CBT includes dialectical behaviour business of his own, specialising
processes of acceptance and mindfulness with therapy (DBT)† and mindfulness-based cognitive in third-wave CBT. He is founder
those of commitment and behavioural change therapy (MBCT) as well as ACT.
and current Chair of the ACT
to produce increased psychological flexibility Special Interest Branch within the
British Association for Behavioural
and an expanded behavioural repertoire. Since
its introduction in 1999 an increasing number of
Relational frame theory and Cognitive Psychotherapies.
Correspondence Mark Webster,
trials show promising results for a wide range of Relational frame theory (RFT) has been developed Acceptance & Mindfulness Centre,
conditions. over the past 25 years as a post-Skinnerian model International House, George Curl
providing an empirically based account of language Way, Southampton SO18 2RZ,
Declaration of interest UK. Email: [Link]@
and cognition (Hayes 2001) that underpins ACT.
M.W. is a director of a private practice developing [Link]
This theory emerges from earlier work on rule
ACT-based programmes and ACT training.
governance and derived stimulus relations in the
behaviour analytic tradition. Relational frame For a discussion in Advances,
†

see Palmer RL (2002) Dialectical

Acceptance and commitment therapy (ACT) theory extends these ideas to regard thinking itself behaviour therapy for borderline
has been described as part of the third wave of as a special form of learned behaviour in its own personality disorder. 8: 10–16. Ed.
cognitive–behavioural therapy (CBT) (Hayes particular class.
2004a). The first wave was traditional behavioural From the RFT perspective, language is seen as
therapy, which focuses on observable behaviour the main difference between humans and non-
and direct interaction with the environment. humans and relational framing as the core process
Pavlov, Watson, Thorndike and Skinner are among in developing language. In a developmental
the well-known figures from that era. Exposure continuum, more complex language abilities
work and skills training are the main interventions develop over time, and relational frames continue
within a clearly defined empirical framework. to expand throughout the lifespan.
Such interventions worked but were unable
to account for the problems of thinking and Transformation of functions
the influence of private events on behaviour. In Try the following exercise. Imagine that there is
response to this weakness, cognitive theories a screw stuck in the wall and you want to remove
began to emerge and over the past 30 years it. The only tool that you have is a toothbrush.
cognitive methods have taken centre stage. In this With just this tool, a reasonable solution may not
second wave, Beck and Ellis have been the key easily present itself. However, if we add another
figures, and illogical thinking or thinking error tool, a cigarette lighter, then a solution may be
is seen as the primary cause of any problem. The more apparent.
evidence base for standard CBT is extensive, with Relational frame theory attempts to offer an
an emphasis on outcome research in randomised explanation of how human beings can solve
control trials across a wide range of disorders. problems like this in the absence of actual objects.
The second wave was a tremendous advance The theory is interested in the process of thinking
but the scientific link between the processes of – how is it possible to imagine that the lighter

309
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completely unaware of the underlying process of

Box 1 Pathological transformation of language. In the world of thought, the event and
functions
the person thinking about the event are usually
Imagine that when an accident took place, Bob Dylan experienced as one, so it appears real. Words alone
was playing on the radio. It might then happen later that can elicit pain. Consequently, in ACT clinical work,
the same person was enjoying a meal out in an Italian undermining the functions contained in language
restaurant when Bob Dylan was played as background plays a central role, as opposed to changing the
music and they felt anxious as if for no reason. Over content of thoughts themselves.
time, the anxiety provoked by the Dylan music could be
transformed into the context of restaurants in general The ACT model of psychopathology
(irrespective of music) or Italian food. Perhaps buying a
pizza in a supermarket could provoke anxiety, and then Figure 1 shows the cognitive and behavioural
supermarkets and shops could elicit fear. It is easy to see processes that underlie many forms of psycho­
how anxiety could become irrational quite quickly through pathology: cognitive fusion and experiential
transformation of functions. avoidance.

Cognitive fusion
The tendency to act in the world on the basis
could melt the plastic so that the toothbrush can
of verbally ascribed functions is referred to as
be formed into a lever?
cognitive fusion. The thought and the person
Another exercise: Ning4 is Cantonese for lemon.
thinking the thought become as one, or fused,
If you tried to imagine a Ning4 in front of you,
hiding the nature of the language process. Fusion
what colour would it be and what would it look
can lead to a loss of contact with actual events, or
like? What would it smell like? What would it taste
real experience, so that thoughts start to become
like if you took a bite?
self-confirming (Box 2).
In this example, knowledge of lemons is assumed.
The human mind will then automatically make
Experiential avoidance
the relation between the lemon and the Ning4,
and some or all of the properties of the lemon will From an ACT point of view, the increasing
transfer to the Ning4 – yellow, citrus, bitter. From dominance of cognitive fusion is one aspect of
an RFT perspective, it is the process by which the way in which psychopathology develops and
the properties of the lemon are transferred to the produces a restricted repertoire. The other is
Ning4 that is of particular interest. more behavioural and emanates from the process
This language ability is called ‘transformation by which verbally ascribed functions easily lead
of functions’ and it appears to have played a to negative emotions. For instance, worry can
significant role in allowing the human race to develop when thinking about the imagined future,
become successful problem solvers and attain a and sadness or guilt can result from remembering
position of dominance on the planet. However, the past. Mainly these are normal experiences and
there is a darker side to the process that can most people develop strategies to cope.
underpin many mental health disorders (Box 1). The situation becomes problematic when indi­
From a clinical perspective, RFT shows how viduals try to suppress or avoid the pain that is
humans are able to interact with events purely on evoked through thinking. This tendency is known
the basis of verbally ascribed functions, while being as experiential avoidance, and has been defined as
‘the attempt to escape or avoid the form, frequency
or situational sensitivity of private events, even
COGNITIVE
when the attempt to do so causes psychological
Reduced contact
with actual, external
Dominance harm’ (Hayes 1996).
of cognitive fusion
experience

Box 2 An example of cognitive fusion

Verbally ascribed functions Narrowing repertoire
If someone with depression is fused with the thought
‘I don’t have enough confidence’, it is likely that they
Increased contact will do less. Doing less sets up a cycle in which there
Experiential
with painful, internal avoidance
is a reduced contact with actual events and a further
experience (natural) loss of confidence. Fusion with the thought is
BEHAVIOURAL strengthened and a pattern is established that could
develop into a mental disorder over time.
fig 1 The process of formation of mental disorders.

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 Acceptance and commitment therapy

Contact with the

Box 3 How experiential avoidance can lead present moment
to mental health problems

Social anxiety
Thinking of a forthcoming social event may evoke Acceptance Values
concerns about possible rejection or inability to make
conversation. Choosing to avoid the event produces
immediate relief but can lead to longer-term problems Psychological
with social situations. flexibility

Psychosis
Committed
Hallucinations are an extreme form of verbal event. Defusion
action
A person experiencing them may try many strategies,
such as arguing them away, denying their occurrence or
avoiding situations in which they might occur. Over time,
this could cause hallucinations to dominate further and Self-as-context
behaviour to become more extreme.
fig 2 The acceptance and commitment therapy model.

The same paradox tends to emerge in most Acceptance

mental health disorders: trying to get rid of This means taking a position of non-judgemental
unwanted private events leads to increased awareness towards thoughts, feelings and bodily
domination by those events. The behavioural sensations as they arise. The process begins with
impact is an increasingly restricted repertoire the client learning to notice behaviours that are
which, over time, develops into a mental health not moving towards values, known in ACT as
disorder (Box 3). unworkable. After that, the client moves on to
noticing how attempts to control unwanted private
Therapeutic aims experience leads to a struggle. Acceptance involves
Cognitive fusion and experiential avoidance tend letting go of this struggle, while still working on
to create behavioural repertoires that are insen­ external issues that can be changed.
si­t ive to the events of the moment and inflexible
in changing circumstances. The fundamental Defusion
objectives of ACT are to undermine these processes Cognitive defusion addresses the problem of
and to help clients move forward in valued cognitive fusion described above. It is about
directions by developing behaviour that is sensitive trying to dilute the impact of harmful functions
to the current context (Box 4). Collectively, this contained in language. It involves trying to shift
is known as psychological flexibility, and an focus from the content of thoughts to the process
increased ability to adapt is the main aim of ACT. of thinking itself, thus weakening the verbally
ascribed functions. Defusion creates distance from
Therapy model the thoughts, as if the individual were standing
In their first presentation of ACT, Hayes et al de­fined back from their mind, like an observer.
six core components: acceptance; defusion; contact
with the present moment; self-as-context; values Contact with the present moment
(valued directions or actions); and committed Clients are taught to notice their external and inter­
action (Hayes 1999). These are not sequential, but nal experience in the present moment. The practice
are interlinked to create a fluid model in which of mindfulness‡ provides the foundation. Later, this ‡Mindfulness is discussed in
therapist flexibility is also important (Fig. 2). can be extended into operant exposure routines Advances in Mace C (2007)
Mindfulness in psychotherapy: an
in which clients learn to develop new behaviour, introduction. 13: 147–154. Ed.
based on values that they choose (see below), in the
Box 4 Setting valued directions presence of previously avoided experience.
A valued direction for many might be to improve health
and fitness. In this context, going for exercise after work Self-as-context
could be seen as workable (see text), whereas going Cognitive fusion with thoughts such as ‘I’m
home and sitting in front of the TV all night might be seen worthless’ is referred to as self-as-content: the
as unworkable. person’s identity is caught up in the content of the
particular thought. Acceptance and commitment

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Webster

therapy assumes that, in order to fully experience Experiential exercises conducted in the therapy
painful feelings or really stand back from difficult setting allow clients to contact thoughts and
thoughts without trying to change them, a wider experiences that are usually feared or avoided.
perspective is necessary. This transcendent sense The safer context can allow private events to be
of self is referred to as self-as-context, and can observed with more distance and detachment,
be developed through defusion and mindfulness. allowing for behaviour to emerge that is more in
From this perspective, the ‘observer’ self is not line with values. Language processes can be seen,
threatened by the content of experience, but is studied and more easily defused in this format.
instead the context in which all experience unfolds. Metaphorically, the therapist style in ACT is
more like helping someone learn to swim than
Values teaching them maths. The therapist may be seen
Clients are encouraged to clarify their valued more as a coach, trying to help the client get a feel
directions or actions. These ‘values’ are neither for what is happening rather than explaining how
feelings nor goals, but connect to a deeper sense it works.
of purpose and meaning as an ongoing process
of behaviour. This component closely resembles Overview of interventions
modern existential ideas (Frankl 2006), where The interventions of ACT are fully detailed in
choice and freedom of action are the main focus. publications on the practical applications of the
Consequently, in ACT the individual focuses on the therapy (Hayes 2004b) and on therapist training
future, as opposed to exploring the past, and their (Luoma 2007). In addition, there are specific
chosen values underpin all aspects of therapy. manuals for different diagnoses (Box 5). The
strategies, metaphors and exercises below are
Committed action summarised from the original reference book on
Committed action is about learning to move ACT (Hayes 1999).
in valued directions while in the presence of
unwanted or painful thoughts and feelings. The Acceptance
choice between an easy life and a rich, full life is The therapist identifies examples of unworkable
presented, and clients are encouraged to find the behaviour (behaviour that is not moving towards
willingness to have painful thoughts and feelings the individual’s values) and develops suitable
in the service of moving in a valued direction. metaphors for them (Box 6). Once a suitable
Vitality develops as the client’s behaviour becomes metaphor is found, the therapist refers to it each
more oriented to their underlying values. time the client mentions an unworkable behaviour.

Clinical style
Above all, the ACT therapist is aware of the Box 5 Further resources
traps in ‘literal’ language and will try to sidestep
The main body of resources for ACT can be found online
these through the use of metaphor, paradox and
at the website of the US Association for Contextual
experiential exercises. Behavioral Science ([Link] The
Metaphors have many advantages, being site includes information on:
much more like pictures than the usual form of
• reference books
language. Well-chosen metaphors allow directly
• self-help books
experienced contingencies to be more easily
examined. Metaphors are often easier to remember • published research
and to transfer between situations, which helps in • DVDs
developing broader patterns of behavioural change. • training workshops
Paradox is of particular importance to ACT In addition, there is a great deal of material that can be
because it plays such a significant role in breaking downloaded:
down language processes. It can help by high­ • resources for clinicians
lighting the contradictions of language itself,
• discussions
for instance in instructions such as ‘try to be
spontaneous’ or ‘just relax’. The ACT view of • treatment protocols
psychopathology is itself inherently paradoxical – (access to some resources require ACBS membership).
the harder you try, the worse it gets – and the use of In the UK, the British Association for Behavioural and
Zen-like stories (koans such as ‘What is the sound Cognitive Psychotherapies (BABCP) has an ACT special
of one hand clapping?’) typifies the approach of the interest group (actsig@[Link]).
ACT therapist.

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 Acceptance and commitment therapy

slowly or in a silly voice. Imaginal work can be

Box 6 The tug-of-war metaphor done to find voices or characters that render the
Imagine that you are standing on one side of a deep thought less believable, or more comical.
ravine. Between you and the other side is a chasm with Such exercises are used to increase interaction
a long drop to a certain death on the rocks below. You with the fused thought in a new context.
are in a tug of war with a monster that you cannot see,
on the other side of the ravine. Each time you pull, you Contact with the present moment
make one step back, but in response the monster pulls
The therapist is alert for experiential avoidance
even harder and you take two steps forward towards the
during sessions and gently brings the client
ravine. Slowly you are inching closer to the edge, feeling
back into contact using questions that reorient
increasingly anxious.
attention. It is common to hear interventions such
(Adapted from Hayes 1999)
as ‘What are you noticing right now?’ or ‘What
are you aware of in this moment?’ throughout all
phases of therapy.
In this phase the therapist sets homework and Formal mindfulness practices can be used to
conducts exercises that amplify the cost of help the client develop this ability. These exercises
unworkable solutions from the perspective of combine with operant exposure as the therapist
valued living. tries to amplify experiencing and develop new
Once the client has started to notice the futility behaviours in the presence of previously avoided
of the struggle to control unwanted feelings or experience.
thoughts, the therapist will introduce the idea
that all of these are forms of ‘control’ that operate Self-as-context
paradoxically – ‘The harder you try, the worse it In the chessboard metaphor, the client is encouraged
gets’. The idea of letting go is allowed to surface, to recognise the distinction between the chess
and experiential exercises are used to undermine pieces and the chess board. Thoughts and feelings
avoidance further and dichotomise the choice are the chess pieces, which are constantly moving,
between control and willingness. opposing each other in a never-ending struggle.
The client is encouraged to adopt the metaphorical
Defusion role of the board, which just holds the pieces.
The mind is introduced as a functional organ that Therapists ask clients to notice experience on
just does a job. In response to an example of the a regular basis in sessions. The self-as-context
client’s cognitive fusion, the therapist may well question is then to ask ‘Who is noticing that?’.
ask ‘Is that what your mind is telling you?’ or say In this component, longer exercises are used to
‘Thank your mind for that thought’. help the client find experiential contact with the
‘Leaves on the stream’ (Box 7) is one of several ‘observing self’.
mindfulness exercises that can be used to help the
client develop an experiential sense of distance Values
from their mind/thoughts. The client’s values (valued directions or actions)
Examples of more structured defusion exercises are thought of metaphorically as directions on a
include inviting the client to write thoughts on compass. The individual is taught to distinguish
cards and to sing them out loud, or say them very values from feelings and directions from goals.
Ogden Lindsley’s ‘dead man’s test’ can be used
effectively to counteract the normal tendency to
Box 7 Leaves on the stream: a mindfulness think in terms of symptom removal: if a dead
exercise
person can achieve something, then it is not usually
In this exercise, the client is first brought to a mindful considered a good direction for a living person. For
state and then, with eyes closed (if the client agrees), instance, dead people aren’t depressed, don’t have
invited to imagine sitting beside a stream that has large anxiety or OCD and don’t take drugs. This is an
leaves floating down it. As the client sits there, they are effective device to focus back on the behavioural
invited to notice their thoughts. The therapist suggests nature of values as living action.
that, as each thought occurs, the client place it out on a Homework and assignments are used in this
leaf and watch as the stream takes it along. The idea is phase to clarify values and identify any discrepancy
to experience, to feel, the difference between the thought
between how important a compass point is and the
in the mind and the thought on a leaf.
amount of actual movement towards it. Imaginal
(Adapted from Hayes 1999) work is used to establish even greater contact with
values and to strengthen motivation.

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Webster

Session 1
Box 8 Passengers on the bus
•• The therapist explores the unworkable strategies
Imagine that your life is a bus. On the front of the bus the client has been using, and suggests that these
is the route, which is your value. As you try to drive the solutions may actually be part of the problem.
bus in a valued direction, passengers jump on board and •• The nature of hallucinations is discussed and put
start to give you a hard time. These are the thoughts
on a ‘thoughts continuum’ with other difficult
and feelings that you struggle with. The passengers can
content, such as paranoid or self-harming
become very threatening and so you start to argue with
them, or placate them or even try to get them off the bus.
thoughts.
What happens to the bus when its driver is struggling •• The therapist points out that the difference
with the passengers? between hallucinations and normal content is
(Adapted from Hayes 1999) not actually that wide, but it is how content is
responded to that differs greatly and distinguishes
between who is in hospital and who is not.
•• Believability of hallucinations is introduced and
Committed action defusion explained through the metaphor of a
Helping clients break tasks down into small steps computer screen, where thoughts can be treated
is very similar to standard practice in behavioural as no more than just words on a screen.
therapy. If the client is struggling with feelings or is •• The idea of noticing hallucinations instead of
fused, the passengers-on-the-bus metaphor (Box 8) believing them is further developed through the
can be used as a way of examining the relationship leaves-on-the-stream exercise (Box 7).
with unwanted content or of creating a sense of •• Finally, the strategy of doing what works is
distance. The therapist may even turn the metaphor presented, linked to treatment adherence and
into an experiential exercise using props or index the client’s values.
cards. Various experiential exercises will be used
to build new patterns of action using small steps. Session 2
Throughout, the emphasis is on generating new This is held 3 days after the first session.
behaviour towards values while in the presence
•• Clients are asked to describe their symptoms in
of previously avoided feelings. The ‘pick up your
detail, including content, frequency and severity
keys’ exercise (Box 9) illustrates this approach and
of distress.
shows how willingness is worked on. Such new
•• A detailed discussion is held to see how the client
behaviour is the overall goal of ACT.
responds to thought content, and especially to
establish whether their main strategy is to get
Example of the therapy protocol
rid of the unwanted symptoms.
Acceptance and commitment therapy has been •• The responses are examined to establish whether
used successfully as a four-session intervention it is this strategy that actually led to hospital
for psychosis in an in-patient setting (Bach 2002; admission. Other negative consequences are
Gaudiano 2006), showing an approximate 50% considered, such as legal, housing and relationship
reduction in the readmission rate at 3 months difficulties.
compared with treatment as usual. Below we •• The futility of the struggle is amplified, and the
illustrate ACT in such a setting. The sessions are alternative of letting go is brought in through the
one to one and each lasts 1 hour. tug-of-war metaphor (Box 6).
•• Letting go of the rope is linked with acceptance
and described as an action with the choice
Box 9 Pick up your keys between doing what you want and doing what
For the purposes of this example, let’s say that the client works.
is struggling with anxiety. The therapist would ask the •• These two polarised options are then put into the
client to get out their keys and hold them. The therapist context of hospital admissions, and acceptance of
would then ask the client to nominate one of the keys treatment is linked to improved choice in valued
to represent anxiety. Once selected, the therapist would living.
explore the valued direction involved. Once that has been
established, the therapist would encourage the client to Session 3
pick up this key and hold it while moving in that direction.
The third session is held 3–5 days later and focuses
Imaginal exposure work can often be conducted during
sessions and the exercise can be generalised quite easily on developing acceptance.
as most people take their keys out with them. •• The distinction between the process of having an
hallucination and being fused with the content of

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 Acceptance and commitment therapy

that hallucination is learnt by practising defusion therapy shows promise in treating conditions that
statements such as ‘I am having the thought that have not responded well to CBT. The debate will
the Prime Minister is Satan’, contrasted with continue.
saying ‘The Prime Minister is Satan’. In possibly the most balanced review of the ACT
•• The client is asked to think about the consequences outcome data, Pull (2008) offers this summary:
of acceptance compared with past attempts to ‘The available evidence suggests that ACT works
change content. through different processes than active treatment
•• Valued directions are explored again, and the comparisons, including traditional CBT. Although
client is asked to compare the consequences of currently available data are promising there is,
however, a need for more well controlled studies to
trying to control symptoms v . acceptance in verify whether ACT is generally as or more effective
relation to these values. than other active treatments across the range of
•• A detailed discussion follows, comparing whether problems examined.’
it is better to believe the content of thoughts or Beyond outcome data, the ACT community is
to choose valued directions, looking at what is working to identify mediational effects of the six
workable. components of the model. The 7-item Acceptance
•• Workability is then brought into the context of and Action Questionnaire II (AAQ-II) (Bond 2011)
hospital admissions and the client is helped to uses the construct of ‘psychological flexibility’ to
generate new, alternative strategies that will work summarise the effects of the six components, with
for them. experiential avoidance at the lower end of the scale.
In the future it is hoped that mediational effects
Session 4 will be established for each of the six components.
This is held within 3 days of the client’s discharge The start of this seems to be happening with the
from hospital. This is mainly a review of the acceptance component in the area of chronic pain
previous sessions. (Mason 2008), with acceptance correlated to the
World Health Organization quality of life measure.
Research
Since the publication of the first ACT reference References
book (Hayes 1999), evidence on the efficacy Bach P, Hayes SC (2002) The use of Acceptance and Commitment Therapy
of the intervention has been accumulating at to prevent the rehospitalization of psychotic patients: a randomized
controlled trial. Journal of Consulting and Clinical Psychology 70:
an increasing rate and for a widening range of 1129–39.
conditions. There are currently over 50 published
Bond FW, Hayes SC, Baer RA, et al (2011) Preliminary psychometric
randomised controlled trials (RCTs). During recent properties of the Acceptance and Action Questionnaire - II: a revised
years there have been three independent reviews measure of psychological flexibility and experiential avoidance. Behavior
Therapy , in press.
of these data (Öst 2008; Pull 2008; Powers 2009)
comparing ACT with standard CBT. Frankl VE (2006) Man’s Search for Meaning. Boston Beacon Press.
The reviews of the RCT outcome data contain Gaudiano B (2010) Evaluating acceptance and commitment therapy:
areas of agreement and of difference. The an analysis of a recent critique. International Journal of Behavioral
Consultation and Therapy 5: 311–29.
reviewers all point to methodological flaws in
Gaudiano BA, Herbert JD (2006) Acute treatment of inpatients with
the ACT studies, and the ACT community is psychotic symptoms using Acceptance and Commitment Therapy: pilot
in agreement with this. There is also general results. Behaviour Research and Therapy 44: 415–37.
agreement that the ACT data show promising Hayes SC, Wilson KG, Gifford EV, et al (1996) Experiential avoidance
outcomes that are in line with CBT outcomes and behavioral disorders: a functional dimensional approach to diagnosis
but no better. A reply from the ACT perspective and treatment. Journal of Consulting and Clinical Psychology 64: 1152–
68.
(Gaudiano 2010) points out differences in the life
Hayes SC, Strosahl K, Wilson KG (1999) Acceptance and Commitment
cycle of the two therapies: standard CBT has been
Therapy: An Experiential Approach to Behavior Change. Guilford Press.
generating RCTs for over 35 years, so trials are
Hayes SC, Barnes-Holmes D, Roche B (eds) (2001) Relational Frame
now more focused on controlling the methodology, Theory: A Post-Skinnerian Account of Human Language and Cognition.
whereas research into ACT is only around 10 years Plenum Press.
old and is still focusing more on outcomes and Hayes SC (2004a) Acceptance and Commitment Therapy and the
conditions. Gaudiano also notes ACT studies have new behavior therapies: mindfulness, acceptance and relationship.
focused more on complex conditions and less on In Mindfulness and Acceptance: Expanding the Cognitive Behavioral
Tradition (eds SC Hayes, VM Follette, M Linehan): 1–29. Guilford Press.
the standard mood disorders such as depression
Hayes SC, Strosahl KD (2004b) A Practical Guide to Acceptance and
and anxiety that are the focus of much of the CBT Commitment Therapy. Springer-Verlag.
literature. The two therapies do not differ much in
Luoma JB, Hayes SC, Walser RD (2007) Learning ACT: An Acceptance MCQ answers
effectiveness in mood disorders, but show different and Commitment Therapy Skills-Training Manual for Therapists. New 1b 2d 3c 4b 5e
processes of change. Acceptance and commitment Harbinger.

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Mason VL, Mathias B, Skevington SM (2008) Accepting low back pain: Powers MB, Zum Vorde Sive Vording MB, Emmelkamp PM (2009)
is it related to a good quality of life? Clinical Journal of Pain 24: 22–9. Acceptance and commitment therapy: a meta-analytic review.
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MCQs d experiential avoidance c contact with the present moment

Select the single best option for each question stem e inadequate values. d acceptance
e values.
1 Within ACT, values can best be described
as: 3 Which one of the following is an example
a beliefs about what is right of defusion? 5 Which of the following would you
b important behavioural directions a ‘I can’t go out and visit my friends’ most associate with the acceptance
c goals that have a high priority b ‘People should always tell the truth’ component?
d achieving good feelings c ‘I’m having the thought that this is bad’ a the chessboard metaphor
e a moral code. d ‘I get things wrong most of the time’ b mindfulness practice
e ‘Nothing ever works out for me’. c dead man’s test
2 Psychopathology in ACT can be d the leaves-on-the-stream exercise
understood as: 4 Which of these is not one of the six core e the tug-of-war metaphor.
a the result of past experience components of ACT?
b faulty thinking a committed action
c lack of skills b self-as-content

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