Using Acceptance and Commitment Therapy to Improve Mental Health

Clients in the psychiatric residential and day treatment programs at Skyland Trail benefit from a powerful mix of evidence-based therapeutic approaches.  Acceptance and Commitment Therapy, or ACT, is an important component of treatment for many clients.

Who Benefits from ACT?

Some modalities like Cognitive Behavioral Therapy (CBT) or Dialectical Behavior Therapy (DBT) work best for clients with specific diagnoses and symptoms: CBT is most appropriate for depression and anxiety, and DBT is more appropriate for borderline personality disorder or emotional dysregulation. Acceptance and Commitment Therapy, or ACT, on the other hand, is a useful tool for a broad spectrum of individuals struggling with mood, thought, anxiety, or personality disorders.

Its broad appeal and effectiveness comes from the fact that it meets you where you are. Wherever you are right now.  If you are really ill with acute symptoms, ACT can help you take the first steps toward defining your values. As your symptoms and skills improve, ACT can help you make decisions about the best next steps toward specific recovery goals.

What is ACT? How is ACT different from other approaches?

ACT encompasses both CBT and DBT, challenging thoughts and distortions while practicing mindfulness, distress tolerance, and emotion regulation. It sits at the nexus of CBT and DBT approaches. ACT is more process-based than CBT and DBT which are both skills-based, and it is more client-driven where some approaches tend to be more clinician-driven.

The goal of ACT is to develop “psychological flexibility.”  Every time you begin an ACT exercise you are examining four core questions:

1. What do I value?
2. What is pulling or pushing me away from my values?
3. What action do I need to take now to push myself closer to my values?
4. How do I continue to move toward my values in the future?

ACT is a self-directed process. You define your values. You describe your challenges. You identify and describe negative coping strategies. You determine the actions you will take to resolve those challenges by using your values as a compass and guide.

Dr. Steven Hayes, creator of ACT, sums the importance of ACT in a 2005 interview:

“ACT… grew out of my own experience with panic disorder and treating other clients with anxiety problems. I’d been trained as a cognitive behavioral therapist. But when I realized that cognitive behavioral therapy (CBT) wasn’t helping me deal with my own problems with anxiety, I returned to some of the more Eastern ideas that had appealed to me earlier in my life. If you either avoid something or fight and argue with it, you give it power. Instead, I began to see how to apply meditative and mindfulness practices to my anxious thoughts and feelings about myself. I added the idea of examining a person’s deepest values as a guide to determining the direction of change. It’s not enough to focus on what you don’t want to experience. If I don’t focus on my symptoms, what do I want to be doing with my life? That’s where the role of commitment came into ACT.”

How do you use the ACT process?

Clients use a 13-step process, and a matrix helps them visualize each step. Each time you use the matrix, you are examining your values and committing to your values as the touchstone to guide behavior change or decision making.

As you repeat the ACT process over time, you solidify your sense of self. You become more skilled at identifying when you are straying from center and understanding what you need to do to realign with your values and feel balanced.

Imagine your goals and values on the other side of a field of tall grass. As you navigate toward your goals over and over using the ACT matrix, you begin to create a path through the field. It becomes more obvious and easier to follow every time to retrace your steps. Even if you start in a slightly different place each time, you spend less effort fighting through the tall grass because you reach a familiar path more quickly.

In addition to using the matrix, ACT helps us be present in the moment and learn to accept painful or stressful thoughts and emotions. This is another area where ACT differs from CBT.

In CBT, we challenge distressing thoughts by looking for evidence and coming up with a more rational response. In ACT, the thought is accepted as a thought and then defused using a variety of techniques, which may include mindfulness, metaphors and language contextualism.

For individuals who struggle with mood, anxiety, or psychotic symptoms, ACT trains us to notice the uncomfortable emotion or thought and acknowledge it, but to let it flow by without holding on to it or letting it drive our actions in that moment.  We can use ACT to keep our self-defined values and goals in the driver’s seat.

Back in our field of grass, we can notice the heat, the bugs, our thirst, our tiredness, or the heavy load we’re carrying, but we don’t allow those things to take us off the path. We don’t struggle through the field indefinitely, fighting or pursuing each distraction. We reach our destination – a life worth living.

How do you use ACT at Skyland Trail?

Several Skyland Trail clinicians have received training in ACT and we offer weekly ACT groups where trained clinicians guide clients through the process. If the treatment team determines a client may benefit from ACT, clients attend the weekly ACT group.  Counselors may also use ACT as a tool in one-on-one therapy sessions.

We encourage clients to use ACT to evaluate decisions they are facing. For example, “Do I return to my job? I think I value my job. It feels like a big part of who I am. But it is really stressful and tends to take me away from my family.” Examining your options through the ACT process matrix may help clarify your thinking.

If documented over time, the ACT process matrix can be a useful tool for therapists and their clients to see and acknowledge progress toward goals long-term. And because clients can continue to use the ACT matrix after they leave Skyland Trail, it can serve as a good starting place for work with a therapist in the community or as a continued self-directed strategy for maintaining health.

ACT has become an important part of the treatment program at Skyland Trail. While in treatment, clients are learning and utilizing CBT and DBT to develop and maintain skills to manage symptoms. ACT facilities a unique, process-based experience that includes modules of both CBT and DBT. Clients who are more familiar with CBT are able to develop skill-based techniques to manage symptoms, while DBT clients are able to develop processing skills. Many clients have accredited ACT to getting them “unstuck” by allowing them to achieve psychological flexibility.