Intervention Summary

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Acceptance and Commitment Therapy (ACT)

Acceptance and Commitment Therapy (ACT) is a contextually focused form of cognitive behavioral psychotherapy that uses mindfulness and behavioral activation to increase clients' psychological flexibility--their ability to engage in values-based, positive behaviors while experiencing difficult thoughts, emotions, or sensations. ACT has been shown to increase effective action; reduce dysfunctional thoughts, feelings, and behaviors; and alleviate psychological distress for individuals with a broad range of mental health issues (including DSM-IV diagnoses, coping with chronic illness, and workplace stress). ACT establishes psychological flexibility by focusing on six core processes:

Acceptance of private experiences (i.e., willingness to experience odd or uncomfortable thoughts, feelings, or physical sensations in the service of response flexibility)
Cognitive defusion or emotional separation/distancing (i.e., observing one's own uncomfortable thoughts without automatically taking them literally or attaching any particular value to them)
Being present (i.e., being able to direct attention flexibly and voluntarily to present external and internal events rather than automatically focusing on the past or future)
A perspective-taking sense of self (i.e., being in touch with a sense of ongoing awareness)
Identification of values that are personally important
Commitment to action for achieving the personal values identified

The first four processes define the ACT approach to mindfulness, and the last two define the ACT approach to behavioral activation.

ACT is delivered to clients in one-on-one sessions, in small groups or larger workshops, or in books or other media, through the presentation of information, dialogue, and the use of metaphors, visualization exercises, and behavioral homework. The number and length of sessions and the overall duration of the intervention can vary depending on the needs of the client or the practice of the treatment provider.

In studies reviewed for this summary, ACT was used to (1) reduce symptoms of depression and the severity of obsessions or repetitive behaviors/mental acts associated with obsessive-compulsive disorder (OCD), (2) relieve the distress associated with delusions and hallucinations in acutely psychotic inpatients, and (3) improve general mental health in study participants by increasing their ability to cope with workplace stress. ACT also has been used in other areas, including the treatment of phobias, depression, trichotillomania, and substance abuse; smoking cessation; coping with end-stage cancer, type 2 diabetes, and epilepsy; and the management of chronic pain. In nonclinical settings, such as worksites, the intervention is also known as Acceptance and Commitment Training to avoid any stigmatizing impact of the word "therapy."

Descriptive Information

Areas of Interest	Mental health promotion Mental health treatment
Outcomes	Review Date: July 2010 1: Obsessive-compulsive disorder symptom severity 2: Depression symptoms 3: Rehospitalization 4: General mental health
Outcome Categories	Mental health Treatment/recovery
Ages	18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)
Genders	Male Female
Races/Ethnicities	American Indian or Alaska Native Asian Black or African American Hispanic or Latino White Race/ethnicity unspecified Non-U.S. population
Settings	Inpatient Outpatient Workplace
Geographic Locations	Urban Suburban
Implementation History	ACT was first implemented in the mid-1980s and was fully systematized in 1999. Since then, tens of thousands of practitioners have received training in the intervention. ACT has been used by hundreds of programs and agencies, ranging from those that include ACT as part of their treatment to organizations that use ACT as the model for their entire treatment program. Over 40 studies have been conducted on specific components of ACT, as well as over 50 effectiveness or efficacy trials; combined, this research covers several thousand participants. Articles have been published on ACT studies conducted in Australia, Canada, Finland, India, Japan, the Netherlands, South Africa, Spain, Sweden, the United Kingdom, and the United States. More than 60 books on ACT have been published. ACT development is guided by the Association for Contextual Behavioral Science (ACBS), which can provide referrals to professionals in a specific area of interest. ACBS also has a worldwide system of recognized trainers (http://www.contextualpsychology.org/act_trainers) who are available to assist agencies interested in implementation.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: Yes
Adaptations	ACT materials have been translated into Danish, Dutch, French, German, Italian, Norwegian, Portuguese, Spanish, and Swedish.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories	Indicated

Quality of Research

Review Date: July 2010

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Supplementary Materials

Banks, M. H., Clegg, C. W., Jackson, P. R., Kemp, N. J., Stafford, E. M., & Wall, T. D. (1980). The use of the General Health Questionnaire as an indicator of mental health in occupational studies. Journal of Occupational Psychology, 53, 187-194.

Gaudiano, B. A., & Herbert, J. D. (2006). Acute treatment of inpatients with psychotic symptoms using Acceptance and Commitment Therapy: Pilot results. Behaviour Research and Therapy, 44(3), 415-437.

Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Delgado, P., Heninger, G. R., et al. (1989). The Yale-Brown Obsessive Compulsive Scale. II. Validity. Archives of General Psychiatry, 46(11), 1012-1016.

Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Fleischmann, R. L., Hill, C. L., et al. (1989). The Yale-Brown Obsessive Compulsive Scale. I. Development, use, and reliability. Archives of General Psychiatry, 46(11), 1006-1011.

Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and Commitment Therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44(1), 1-25.

Twohig, M. P., Hayes, S. C., & Masuda, A. (2006). Increasing willingness to experience obsessions: Acceptance and Commitment Therapy as a treatment for obsessive-compulsive disorder. Behavior Therapy, 37(1), 3-13.

Outcomes

Outcome 1: Obsessive-compulsive disorder symptom severity
Description of Measures	The severity of OCD symptoms was measured by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), a 10-item structured interview administered by a clinician. The Y-BOCS separately measures the severity of obsessions and compulsions on a 5-point scale that ranges from 0 (no symptoms) to 4 (extreme symptoms), generating a total score that ranges from 0 to 40. The Y-BOCS total score indicates whether symptoms are subclinical (0-7), mild (8-15), moderate (16-23), severe (24-31), or extreme (32-40). For the study, researchers defined a pre- to postintervention change of 6.39 points in the Y-BOCS total score as reliable and clinically significant. Assessments occurred 1 week before treatment (baseline) and 1 and 12 weeks after treatment (follow-ups).
Key Findings	In a randomized clinical trial, adults with a DSM-IV diagnosis of OCD were assigned to eight sessions of either ACT or Progressive Relaxation Training (PRT). Participants in each group had a reduction in OCD symptom severity from baseline to both posttreatment follow-up assessments (p < .001 and p < .001 for participants who received ACT and PRT, respectively). However, compared with PRT participants, ACT participants had larger and more rapid reductions in OCD symptom severity (p = .026); this group difference was associated with a large effect size (Cohen's d = 0.84). A higher percentage of ACT than PRT participants reported clinically significant reductions (≥6.39 points in the Y-BOCS total score) from baseline to 1 week after treatment (56% vs. 18%; p < .002) and from baseline to 12 weeks after treatment (66% vs. 16%; p < .001); the effect sizes for these differences were medium and large (Cohen's d = 0.77 and 1.10 for the 1- and 12-week follow-ups, respectively).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.7 (0.0-4.0 scale)

Outcome 2: Depression symptoms
Description of Measures	Depression symptoms were measured with the Beck Depression Inventory--II (BDI-II). The BDI-II is a 21-item self-report instrument that assesses the presence and severity of depression symptoms according to DSM-IV criteria. Like the DSM-IV, the BDI-II evaluates symptoms of depression during the 2 weeks prior to assessment. Participants respond to 19 items using a 4-point scale and 2 items using a 7-point scale. The BDI-II total score ranges from 0 to 63 and indicates whether symptoms of depression are minimal (0-13), mild (14-19), moderate (20-28), or severe (29-63). Assessments occurred 1 week before treatment (baseline) and 1 and 12 weeks after treatment (follow-ups).
Key Findings	In a randomized clinical trial, adults with a DSM-IV diagnosis of OCD were assigned to eight sessions of either ACT or PRT. An analysis of study participants with at least a mild baseline level of depression symptoms (BDI-II score of ≥13; 70% of the participants) showed that ACT participants had greater reductions in depression symptoms than PRT participants from baseline to 1- and 12-week posttreatment follow-up assessments (p = .002 and p < .05, respectively). The group differences at the 1- and 12-week follow-ups were associated with large and medium effect sizes (Cohen's d = 0.96 and 0.63, respectively).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.7 (0.0-4.0 scale)

Outcome 3: Rehospitalization
Description of Measures	Rehospitalization was measured through examination of participant hospitalizations over two periods. At baseline, rehospitalization was defined as the number of days (up to 120) from a participant's prestudy hospital discharge date to the hospital admission date coinciding with study participation. At follow-up, rehospitalization was defined as the number of days between the hospital discharge date coinciding with study participation and a participant's rehospitalization occurring during the next 4 months (120 days), as well as by the percentage of participants rehospitalized during this period. These data were obtained from hospital admission records, cross-checked with client medical charts, and verified with case managers and study staff.
Key Findings	In a randomized clinical trial, adults experiencing auditory hallucinations or delusions at the time of admission to a State psychiatric hospital were assigned to one of two conditions: treatment as usual (comparison group) or treatment as usual plus four individual sessions of ACT (intervention group). Treatment as usual consisted of medication, weekly or twice-weekly psychoeducational groups, and weekly individual psychotherapy sessions for participants who were hospitalized for more than a few days. Treatment as usual continued after hospital discharge with case management services, monthly medication management, and the opportunity to voluntarily participate in Assertive Community Treatment, a team-based treatment approach designed to provide comprehensive, community-based psychiatric treatment, psychosocial rehabilitation, and social support services to persons with serious and chronic mental disorders (e.g., schizophrenia). During the 4-month follow-up period, a smaller percentage of intervention group than comparison group participants were rehospitalized (20% vs. 40%; p < .05). Additionally, intervention group participants remained out of the hospital an average of 22 days longer than comparison group participants during the follow-up period; this difference was significant after controlling for prestudy baseline days to hospitalization and self-reported medication compliance across the follow-up period (p = .03).
Studies Measuring Outcome	Study 2
Study Designs	Experimental
Quality of Research Rating	2.6 (0.0-4.0 scale)

Outcome 4: General mental health
Description of Measures	General mental health was measured with the General Health Questionnaire-12 (GHQ-12), a brief self-report instrument containing 12 items from the original, 60-item version of the GHQ. Each item in the GHQ-12 addresses recent experiences of a symptom or behavior and begins with "have you recently" (e.g., "Have you recently lost much sleep over worry?" and "Have you recently been able to concentrate on whatever you're doing?"). Respondents answer each item with a 4-point Likert scale that ranges from 0 (not at all) to 3 (much more than usual). Low GHQ-12 scores indicate a high level of recent mental health. Assessments occurred before each of the three intervention sessions (i.e., at weeks 1, 2, and 14 of the study) and 13 weeks after the final session (i.e., at week 27 of the study).
Key Findings	In a randomized controlled trial in the United Kingdom, workers in a media organization were solicited for voluntary participation in a workplace-based stress management program during working hours. Study participants were assigned to one of three conditions: ACT, the Innovation Promotion Program (IPP), or a wait-list control. The IPP is a problem-focused and solution-based program that helps workers to identify and then address the causes of workplace stressors. Both ACT and the IPP were delivered in small groups as three, half-day sessions during weeks 1, 2, and 14. Findings from this study included the following: GHQ-12 scores were lower for ACT than for IPP participants before the third intervention session (10.42 vs. 13.18 at week 14; p < .0001) and at the postintervention follow-up (10.42 vs. 12.95 at week 27; p = .001). These intervention group differences were associated with large effect sizes (eta-squared = .33 and .17 at weeks 14 and 27, respectively). Additionally, GHQ-12 scores were lower for ACT than for wait-list control participants at weeks 14 (10.42 vs. 12.57; p < .0001) and 27 (10.42 vs. 12.65; p < .0001). These intervention group differences were associated with large effect sizes (eta-squared = .35 and .22 at weeks 14 and 27, respectively). Among participants in the three conditions, only ACT participants had a GHQ-12 score that was lower at the postintervention follow-up than at the preintervention assessment at week 1 (10.42 vs. 12.17; p < .0001). This pre- to postintervention mental health improvement for ACT participants was associated with a large effect size (eta-squared = .25).
Studies Measuring Outcome	Study 3
Study Designs	Experimental
Quality of Research Rating	3.3 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)	61% Female 39% Male	89% White 5% Hispanic or Latino 2.5% American Indian or Alaska Native 2.5% Asian 1% Black or African American
Study 2	26-55 (Adult)	63.8% Male 36.3% Female	75% White 11.3% Hispanic or Latino 6.3% Race/ethnicity unspecified 3.8% Black or African American 2.5% American Indian or Alaska Native 1.3% Asian
Study 3	18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)	50% Female 50% Male	100% Non-U.S. population

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

1. Reliability of measures	4. Missing data and attrition
2. Validity of measures	5. Potential confounding variables
3. Intervention fidelity	6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Obsessive-compulsive disorder symptom severity	4.0	4.0	3.5	4.0	2.5	4.0	3.7
2: Depression symptoms	4.0	4.0	3.5	4.0	2.5	4.0	3.7
3: Rehospitalization	2.5	2.5	1.5	2.0	3.0	4.0	2.6
4: General mental health	4.0	4.0	2.0	2.0	4.0	4.0	3.3

Study Strengths

The Y-BOCS and the BDI-II are gold standard instruments, and the GHQ-12 is a widely used instrument with strong psychometric properties. Rehospitalization data that have been extracted from hospital admission records, cross-referenced with client medical charts, and verified with case managers and study staff are an objective measure. All three studies included a manual-driven approach, and one study had formal fidelity adherence instruments. The follow-up rate exceeded 80% in two of the studies, and a power analysis in the other study suggested that the sample was adequate for detecting between-group differences and interaction effects that were associated with at least a medium effect size. In one study, missing data were handled with a sophisticated multiple imputation statistical approach. All three studies used random assignment to conditions, which controlled for many confounding variables. In two of the three studies, the analyses were sophisticated and state of the art.

Study Weaknesses

Rehospitalization is only one measure of the mental wellness of people diagnosed with a psychotic illness, and other convergent indicators, such as independent living skills and social integration, were not measured. In two of the three studies, there were no formal instruments to measure fidelity. One study measured only the reported symptoms of OCD and not the actual behaviors associated with the disorder, which may have inflated the intervention's impact on OCD. The same study also had a relatively short follow-up assessment period.

Readiness for Dissemination

Review Date: July 2010

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Eifert, G. H., & Forsyth, J. P. (2005). Acceptance & Commitment Therapy for anxiety disorders: A practitioner's treatment guide to using mindfulness, acceptance, and values-based behavior change strategies. Oakland, CA: New Harbinger Publications.

Hayes, S. C. (2007). ACT in action [6-DVD series]. Oakland, CA: New Harbinger Publications.

Hayes, S. C. (2008). Acceptance and Commitment Therapy [DVD]. In J. Carlson (Host), Series 1--Systems of psychotherapy. Washington, DC: American Psychological Association.

Hayes, S. C., & Strosahl, K. D. (Eds.). (2004). A practical guide to Acceptance and Commitment Therapy. New York: Springer-Verlag.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and Commitment Therapy: An experiential approach to behavior change. New York: Guilford.

Luoma, J., Hayes, S. C., & Walser, R. (2007). Learning ACT: An Acceptance & Commitment Therapy skills-training manual for therapists. Oakland, CA: New Harbinger Publications.

Program Web site, http://contextualpsychology.org/act

Related Web sites:

http://www.actmindfully.com.au
http://www.learningACT.com

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	Overall Rating
4.0	4.0	3.9	4.0

Dissemination Strengths

Several textbooks provide theoretical and empirical foundations for ACT, vignettes and case studies, and guidance for using ACT with individuals with specific disorders. The ACT in Action DVD series provides clinicians with a conceptual understanding of the approach and very specific techniques and interventions for various clinical contexts. Web sites offer extensive ACT materials. An electronic mailing list allows users to ask questions and obtain information on various topics, including implementation, from ACT therapists and researchers. An extensive calendar of ACT training events and a Web-based training tutorial are available. Consultation can be provided to new implementation sites by the developer. The developer emphasizes quality assurance and quality improvement, with numerous process, fidelity, and outcome measures available at no cost. Worksheets that guide interpretation of the data derived from these measures are also provided.

Dissemination Weaknesses

Although tools for ensuring quality and fidelity are available, it may be a challenge for some clinicians to apply them, given the likely variability of intervention delivery. It is unclear how to secure supervision from the community of ACT therapists.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
Membership to ACBS (includes free access to electronic materials, such as treatment manuals, client handouts, books, outcome and process measures, and training materials)	Value-based fee (members choose the amount, with a minimum contribution of $1)	Yes (one resource for implementation materials is required)
Implementation materials, including: Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change Acceptance & Commitment Therapy for Anxiety Disorders: A Practitioner's Treatment Guide to Using Mindfulness, Acceptance, and Values-Based Behavior Change Strategies (includes a CD-ROM with client handouts) Learning ACT: An Acceptance & Commitment Therapy Skills-Training Manual for Therapists (includes a DVD with sample client lessons)	$30-$60 per copy	Yes (one resource for implementation is required)
ACT in Action DVD series (six DVDs)	$59.95 per DVD	No
Up to 6 days of training at the ACBS annual meeting for clinicians, clinical supervisors, and/or program administrators	About $400 per participant	No
Weekend training workshops for clinicians, clinical supervisors, and/or program administrators (held during the ACBS annual meeting)	About $300 per person, per workshop	No
Other training opportunities worldwide through ACT trainers	Varies depending on location and trainer	No
Ongoing implementation and evaluation consultation by ACT trainers	Varies depending on trainer and site needs	No

Replications

Selected citations are presented below. An asterisk indicates that the document was reviewed for Quality of Research.

Dahl, J., Wilson, K. G., & Nilsson, A. (2004). Acceptance and Commitment Therapy and the treatment of persons at risk for long-term disability resulting from stress and pain syndromes: A preliminary randomized trial. Behavior Therapy, 35, 785-801.

Forman, E. M., Herbert, J. D., Moitra, E., Yeomans, P. D., & Geller, P. A. (2007). A randomized controlled effectiveness trial of Acceptance and Commitment Therapy and Cognitive Therapy for anxiety and depression. Behavior Modification, 31(6), 772-799.

Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and Commitment Therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44(1), 1-25.

Hayes, S. C., Wilson, K. G., Gifford, E., Bissett, R., Piasecki, M., Batten, S. V., et al. (2004). A preliminary trial of Twelve-Step Facilitation and Acceptance and Commitment Therapy with polysubstance-abusing methadone-maintained opiate addicts. Behavior Therapy, 35, 667-688.

Lappalainen, R., Lehtonen, T., Skarp, E., Taubert, E., Ojanen, M., & Hayes, S. C. (2007). The impact of CBT and ACT models using psychology trainee therapists: A preliminary controlled effectiveness trial. Behavior Modification, 31(4), 488-511.

Ruiz, F. J. (2010). A review of Acceptance and Commitment Therapy (ACT) empirical evidence: Correlational, experimental psychopathology, component and outcome studies. International Journal of Psychology and Psychological Therapy, 10, 125-162.

Strosahl, K. D., Hayes, S. C., Bergan, J., & Romano, P. (1998). Assessing the field effectiveness of Acceptance and Commitment Therapy: An example of the manipulated training research method. Behavior Therapy, 29, 35-64.

Twohig, M. P., Shoenberger, D., & Hayes, S. C. (2007). A preliminary investigation of Acceptance and Commitment Therapy as a treatment for marijuana dependence in adults. Journal of Applied Behavior Analysis, 40(4), 619-632.

Wicksell, R. K., Melin, L., Lekander, M., & Olsson, G. L. (2009). Evaluating the effectiveness of exposure and acceptance strategies to improve functioning and quality of life in longstanding pediatric pain--A randomized controlled trial. Pain, 141(3), 248-257.

Woods, D. W., Wetterneck, C. T., & Flessner, C. A. (2006). A controlled evaluation of Acceptance and Commitment Therapy plus Habit Reversal for trichotillomania. Behaviour Research and Therapy, 44(5), 639-656.

Contact Information

To learn more about implementation or research, contact:
Association for Contextual Behavioral Science
acbs@contextualpsychology.org

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

Web Site(s):

http://contextualpsychology.org/act