1. No category

Giornale Italiano di Medicina del Lavoro ed Ergonomia
© PI-ME, Pavia 2011
http://gimle.fsm.it
Supplemento A, Psicologia
2011; Vol. 33, N. 1: A53-A63
ISSN 1592-7830
Anna Bianca Prevedini, Giovambattista Presti, Elisa Rabitti, Giovanni Miselli, Paolo Moderato
Acceptance and Commitment Therapy (ACT): the foundation
of the therapeutic model and an overview of its contribution
to the treatment of patients with chronic physical diseases
IULM University-Milan-Italy, IESCUM, ACT-Italia
ABSTRACT. Nowadays, treatment of chronic illnesses, such as
stroke, cancer, chronic heart and respiratory diseases,
osteoarthritis, diabetes, and so forth, account for the largest part
of expenses in western countries national health systems.
Moreover, these diseases are by far the leading causes
of mortality in the world, representing 60% of all deaths.
Any treatment aimed at targeting them might engage an
individual for a large portion of his/her life so that personal
and environmental factors can play a crucial role in modulating
the person’s quality of life and functioning, on top of any
medical cure. Anxiety, depression, and distress for examples
are not rare in patients with chronic diseases. Therefore,
Cognitive and Behavior Therapy research has largely
contributed in the last decades in identifying and programming
interventions on such aspects as real and perceived social
and family support, coping abilities, locus of control,
self-efficacy that might help patients living with their chronic
disease.
More recently, third generation Cognitive-Behavior-Therapies,
such as Dialectical Behavioral Therapy (DBT), Mindfulness
Based Cognitive Therapy (MBCT), Functional Analytic
Psychotherapy (FAP) and Acceptance, and Commitment
Therapy (ACT) focused their attention and research efforts
on developing intervention models targeting the needs of
patients with a chronic disease.
This paper has three aims. First is to briefly introduce ACT
epistemological (Functional Contextualism) and theoretical
(Relational Frame Theory) foundations as a stand point for
understanding the peculiarity of ACT as a modern form of
Clinical Behavior Analysis. The second aim is to introduce ACT
clinical model and its six core processes (acceptance, defusion,
present moment, self as a context, values and committed action)
as both accountable, in their continuum, for psychological
flexibility and inflexibility. Third, to present a brief overview
of studies and outcomes of ACT intervention protocols
and assessment tools that have been investigated in patients
with chronic physical diseases, and namely: diabetes, obesity,
epilepsy, and chronic pain.
Key words: Cognitive-Behavior Therapy, Acceptance
and Commitment Therapy, chronic diseases, Functional
Contextualism, Relational Frame Theory, Chronic pain.
RIASSUNTO. ACCEPTANCE AND COMMITMENT THERAPY
(ACT): LE BASI DEL MODELLO TERAPEUTICO E UNA PANORAMICA
queste malattie costituiscono la principale causa di morte,
rappresentando il 60% dei decessi nel mondo. Ogni intervento
mirato al trattamento delle malattie croniche coinvolge
la persona per gran parte della sua vita, così che i fattori
personali e ambientali rivestono un ruolo cruciale nel
modulare la qualità di vita e il funzionamento della persona,
al di là di qualsiasi cura medica. Ansia, depressione e stress,
per esempio, sono piuttosto frequenti in questo tipo
di pazienti. Perciò, negli ultimi decenni la ricerca di stampo
cognitivo-comportamentale ha contribuito ampiamente
a identificare e programmare interventi mirati a quegli
aspetti, quali il supporto sociale e familiare reale e percepito,
le abilità di coping, il locus of control, l’autoefficacia,
che possano aiutare i pazienti a convivere con la propria
condizione di salute cronica.
Più di recente, le terapie cognitivo-comportamentali di terza
generazione, come la Dialectical Behavioral Therapy (DBT),
la Mindfulness Based Cognitive Therapy (MBCT),
la Functional Analytic Psychotherapy (FAP) e l’Acceptance,
and Commitment Therapy (ACT) hanno focalizzato
attenzione e intenti di ricerca al fine di sviluppare modelli
di intervento mirati ai bisogni di pazienti con malattia cronica.
Il presente articolo ha tre obiettivi principali. Il primo è quello
di introdurre le basi epistemologiche (Contestualismo
Funzionale) e teoriche (Relational Frame Theory) dell’ACT,
come punto di partenza per la comprensione della peculiarità
dell’ACT come moderna forma di Analisi Clinica
del Comportamento. Il secondo obiettivo è di introdurre
il modello clinico dell’ACT e i suoi sei processi chiave
(accettazione, defusione, momento presente, sé come contesto,
valori e impegno all’azione) come aspetti centrali, lungo
il proprio continuum, sia della flessibilità sia dell’inflessibilità
psicologica. Il terzo, è quello di presentare una breve rassegna
degli studi e dei risultati relativi ai protocolli di intervento
basati sull’ACT e agli strumenti di valutazione che sono stati
applicati a pazienti con malattie fisiche croniche e in
particolare: diabete, obesità, epilessia e dolore cronico
Parole chiave: Terapia Cognitivo-Comportamentale, Acceptance
and Commitment Therapy, malattie croniche, Contestualismo
Funzionale, Relational Frame Theory, dolore cronico.
Introduction
DEL SUO CONTRIBUTO AL TRATTAMENTO DEI PAZIENTI CON
MALATTIA FISICA CRONICA. Al momento attuale, l’intervento
terapeutico rivolto a malattie croniche quali stroke, cancro,
malattie cardiache e respiratorie croniche, artrosi, diabete
e così via, rappresenta la spesa più grande che i sistemi sanitari
nazionali dei paesi occidentali devono affrontare. Inoltre,
Any chronic illness, such as stroke, cancer, chronic
heart and respiratory diseases, osteoarthritis, diabetes, and
so forth, can take decades to be fully established, and often
its origin can be traced back in younger ages. Nowadays
chronic diseases account for the largest part of the ex-
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penses of the national health systems in western countries
and are by far the leading cause of mortality in the world,
representing 60% of all deaths. The long time span for
those diseases to develop implicitly points to the fact that
there might be opportunities for prevention of symptoms
or disease worsening or bettering patient’s quality of life,
while reducing the medical impact of drug therapies. Environmental conditions and individual characteristics,
both in terms of lifestyles and psychological factors, can
modulate the disease’s impact on the individual quality of
life. Much research shows weak or no correlation between
the nature and degree of physical impairment due to different medical conditions (e.g. ischemic heart diseases,
head injuries, chronic pain, etc.), and the degree of the disability or the getting back to normal life (1-3). Data suggest that psychological adjustments are crucial in modulating the level of functioning in people facing injuries,
trauma and pain, where in western societies patients with
chronic conditions frequently are dealt with as if they were
only affected by acute medical pathologies entailing shortterm symptom alleviation and not long-standing lifestyle
changes. This bias not only leads to perpetuating chronic
illness’ problems, both in terms of personal suffering and
economic burden on society (4, 5), but also increases the
risk of exacerbating, stabilizing or maintaining the
problem by focusing only on symptoms alleviation drugs,
sick leaves, or hospitalizations (5, 6). By addressing the
care of chronic patients at the physical level with drugs,
only a small part of the process is taken into account,
whereas it is very important what over time the patient
thinks and feels about his/her illness (covert behaviors) in
order to predict and improve his/her adherence (overt behaviors) to any medical intervention (7). In pursuing this
goal researchers showed that there are a number of personal factors in mediating patient’s adaptation to the
chronic disease and adherence to the treatment that must
be taken into account when working with physical impaired patients, some of which are: anxiety, depression,
locus of control, self-efficacy, coping styles, real and perceived social support, etc.
Cognitive-Behavior Therapy (CBT) has been demonstrated an effective psychological intervention to help both
adults and children in dealing with many chronic diseases
(8-10). More recently, third generation Cognitive-Behavior-Therapies (11), such as Dialectical Behavioral
Therapy (DBT; 12), Mindfulness Based Cognitive Therapy
(MBCT; 13), Functional Analytic Psychotherapy (FAP; 14)
and Acceptance and Commitment Therapy (ACT; 15, 16)
focused their attention and research efforts on developing
intervention models aimed in helping those patients too.
This paper has three aims. First, to briefly introduce
ACT epistemological (Functional Contextualism) and theoretical (Relational Frame Theory) foundations as a stand
point for understanding the peculiarity of ACT as a
modern form of Clinical Behavior Analysis. The second
aim is to introduce ACT clinical model and its six core
processes (acceptance, defusion, present moment, self as a
context, values and committed action) as both accountable, in their continuum, for psychological flexibility and
inflexibility. Third, to perform a brief overview of studies
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and outcomes of ACT intervention protocols and assessment tools that have been investigated in patients with
chronic physical diseases, and namely: diabetes, obesity,
epilepsy, and chronic pain.
Acceptance and Commitment Therapy (ACT) philosophical and
theoretical roots: Functional Contextualism and Relational Frame
Theory
Even if it is not possible to exhaustively tackle all the
issues entailed in the philosophical and theoretical basis of
Acceptance and Commitment Therapy (ACT), the authors
believe it is crucial to be aware of some of their stances
and implications to the construction and purpose of the
clinical model (ACT itself), as a stand point for understanding the peculiarity of ACT as a modern form of Clinical Behavior Analysis.
One of the endeavors of ACT Scholars has always
been to take into account basic and applied behavioral
principles and frame them in a coherent epistemological
picture to avoid the risk of this therapy being misinterpreted as a mere new set of more or less older psychotherapeutic techniques. Hayes, Strosahl and Wilson (15),
clearly underline the importance of making all levels of
analysis explicit. They suggest that this can help an ACT
therapist analyzing patient’s problems, choosing a specific
intervention, and understanding what are the ACT elements of continuity and discontinuity with other psychological theories and models. According to Hayes (11),
ACT is grounded in Functional Contextualism, a pragmatic philosophy of science, which identifies the ongoing
interactions of the whole organism with the historical and
actual contexts as the unit of analysis of behavior (16, 17).
From this perspective:
• behavior is everything that an organism can do, including overt behaviors (thoughts are not discrete
structures, nor the cause of behavior, but they are behaviors themselves) and it is what the analysis should
explain (18);
• context is everything, beside behavior itself, that can
be analyzed and that influences the development, the
expression, the modification, and the maintenance of
that behavior, both in the present moment and in the
past history. It is what we can manipulate in the
analysis (18);
• the former two statements clarify the aim of the explicatory categories as pragmatic, namely the prediction
and influence of the behavior of interest, so that “truth”
is relative (e.g. patient’s values are not arguable), and
it is true what is workable. Truth is tied to practical
consequences (committed actions), not to ontological
assumptions (being sick, having a chronic disease,
having a depressed disorder, etc.);
• as a consequence, the emphasis of the analysis is on
the function of behaviors rather than on their topography, shape and frequency, so that it is considered
much more useful to try to change the variables of the
context that are causally (either as actual or historic antecedents or consequences) linked to the “negative”
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behaviors that an ACT therapist wishes to decrease or
the “positive” behaviors he/she wishes to increase;
moreover, the therapist should look at the function of
behavior because events similar in topography may be
dissimilar in function and vice versa.
From a theoretical point of view ACT is based on Relational Frame Theory (RFT; 19), a comprehensive theory
of language and cognition rooted in basic research, which
states that human language is based on the learned ability
to arbitrarily relate events. Research demonstrated that
human beings can learn things through relational frames,
the core functions of language and cognition, without necessarily directly having experienced those events (20). By
relational framing humans can bring behavior under the
control of verbal rules (social, cultural, familiar and similar conventions) and subtract it from the direct control of
contingencies (what works in the present moment in the
service of what someone values). RFT entails that the
normal verbal processes that allow fragile creatures like
human beings to dominate over the entire world are the
same processes that can make their behavior very narrow,
rigid, maintained and governed by socially constructed
verbal rules, rather than by its direct consequences (17).
Therefore, psychological pain inhabits in the normal function of humans’ language processes (e.g. problem
solving), when those are applied to solve private experiences (e.g. problematic thoughts, feelings, memories,
body sensations, etc.), rather than to the solution of external world’s problematic events or situations, leading to
experiential avoidance (15, 21).
Experiential Avoidance is any human behavioral pattern related to the unwillingness to stay in contact with
particular painful private experiences (e.g. unpleasant sensorial and emotional reactions, thoughts and memories associated to this pain, etc.) that has the function to alter the
content and frequency of these internal events and to avoid
the contexts in which they occur. Human beings tend to
experience language in a very literal way even when it is
used to describe not objective characteristics of the world,
so that the thought or the word of something (e.g. Because
of my chronic disease, if I go out I will feel pain and be a
burden to my friends and family) takes the place of the actual thing (e.g. I = burden for friends and family), allowing the literal content of a thought to dominate on the
individual behavior (e.g. the person doesn’t go out because he/she feels to be a burden for others instead of
going out AND verifying if there is or is not something
he/she can do and appreciate with the family and friends).
It is for those reasons that ACT never attempts to directly
modify the content of cognitions, because by doing this
there’s a chance even to increase their literal function (are
they true/false, rational/irrational, real/distorted?). Rather,
ACT seeks to foster actions in the person’s valued directions, changing the context (from literality to non-literality) of those cognitions, so that they are no longer barriers to these actions, regardless if they are “true” or not.
Hayes et al (17) stated the following as the main implications of RFT to clinical practice and ACT interventions: 1) the problem solving process and reasoning constantly going on in humans’ minds involves the same cog-
A55
nitive processes accountable for psychopathology so that
it is not workable to either change or extinguish it, 2) because thoughts and cognitions reflect the person’s learning
history, they can not be permanently modified or extinguished, 3) the effort to directly and topographically
change their form or frequency can set a context in which
their literal relevance and function can eventually increase, and, 4) it is possible to change internal events’
function (i.e. thoughts, feelings, and body sensations, etc.)
as barriers or obstacle changing the context of literality in
which they normally operate, even if they consistently
occur in the same form or frequency.
Clinical and Applied Behavior Analysis: the Hexaflex model of ACT
The main aim of ACT is to increase the ability of an
individual to persistently pursue goals in his/her valued directions, using experiential strategies such as metaphors,
paradoxes and exercises to undermine the literal function
of language and highlight its inadequacy in precisely describing the actual direct experience. In this way, the therapist helps the patient experientially to be aware that private and covert part of behaviors (i.e. thoughts, feelings,
body sensations, etc.) are simply words, images and physical reactions that have a specific evolutionary functions,
but are not real and binding facts.
According to ACT researchers, experiential avoidance
and consequent psychological suffering occurs when long
term values and meaningful life domains are systematically deserted in the service of the immediate relief from
private negative experiences while defending one’s conceptualized self. Driven by these short term purposes the
behavioral patterns narrow and drive away the client from
the goals he/she might value. The therapeutic work with
ACT takes into account six processes to help the client
reaching a more general goal: psychological flexibility,
conceptualized as the ability of being in contact with the
present moment, with consciousness and intention, persisting in actions or changing them when this is in the service of what the person values. The six core processes of
the Hexaflex model (fig. 1) are interconnected and partially overlap. As stated above, they don’t represent real
psychological construct, but processes extended on a continuum, which are accountable both for psychological
flexibility and psychopathology. Processes of mindfulness
and acceptance (i.e. acceptance, defusion, contact with
the present moment and self as a context) lay on the left
part of the Hexaflex, while processes of behavior change
and commitment (i.e. values, committed action, contact
with the present moment and self as a context) are on the
right side (17).
An exhaustive and thorough description of the six
Hexaflex processes and supportive data from basic research goes beyond the intent of this paper and can be
found elsewhere (15, 19, 21, 22). Briefly summarized the
six ACT core processes deal with:
• Acceptance (Experiential avoidance): it is the willingness to make room for and embrace the inner unwanted experiences, leaving the fight against them
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Figure 1. The Hexaflex model of ACT for psychological flexibility and inflexibility
Legend: between brackets are the processes responsible for psychopathology
•
•
without attempting to change nor eliminate them; it is
the opposite of Experiential avoidance represented by
those behaviors aimed at flying away form difficult
thoughts, emotions and physical sensations.
Defusion (Fusion): it is the process of distancing from
the literal products of language and cognitions
(thoughts, beliefs, memories, words, judgments, etc.),
learned through defusion techniques (metaphors, paradoxes and experiential exercises), to see them for what
they are and not as unquestionable truths and reasons
for action or inaction; the aim is to bring the person’s
behavior back to the control of direct contingencies
(the five senses) rather than of language.
Contact with the present moment (conceptualized past
and feared future): it refers to be psychologically present to what is happening in the here and now, being
aware of and committing to what one is doing and
living, instead of lingering in a conceptualized past or
being afraid of the future; the aim is to bring the person
in contact non-judgmentally with the environmental
events for what they are.
•
•
•
Self as context (Attachment to a conceptualized self): it is
the process of stepping back from all the definitions and
the stories about one’s self, without disputing them but
learning to observe them; the propose is to undermine
the definition of the self as a few and very narrowing labels and verbal rules that everybody has because of one’s
own past experiences and social environment and that
can become the only reasons for action or inaction.
Values (Lack of values clarity): they are what one believes it is important in his/her different life’s domains,
beyond ethical and moral dictates; the aim is to bring
the person in contact with personal meaningful directions that give the person a dignified context for the
therapeutic and life difficult experiences.
Committed action (Inaction, impulsivity, avoidance): it
is the ability of pursuing, or interrupting, behaviors
when this is in the service of the person’s meaningful
directions; many behavioral interventions (e.g. behavioral activation, skills training, etc.) are used to help
the person in defining and planning realistic and effective plans of actions in line with his/her own values.
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This model is useful in conceptualizing patients with
chronic diseases and working with them to build psychological flexibility. One of the crucial aspects is that ACT
challenges the patient’s avoidance and control agenda on
private experiences, confronting the person with his or
her past experience (e.g. Did your control attempts work
in the past and brought you towards the things you
value?), helping the patient experiencing how to accept
and embrace private experiences in the service of chosen
values. Learning mindfulness and defusion behaviors
might offer a realistic alternative to experiential avoidance. Those might offer these patients different contexts
in which these stressful and painful internal experiences
related to their illness is looked at, rather than looked
from (e.g. past and narrow definitions of the self the patient is very attached to and that now are at risk because
of the limitations due to the disease). Those “now” contexts may foster the capability to see thinking and feeling
as ongoing processes, both useful and fallible tools, rather
than unquestionable representations of reality. This is
done without any attempt of reducing or changing the
form and the content of those inner events but by undermining their role as reasons for action or inaction. This is
particularly important for these patients, who have to deal
with chronic and physical symptoms. By using experiential exercises and metaphors, informed by the six core
processes of psychological flexibility, the therapist works
to help the client to clarify personally chosen values (e.g.
social interactions, family, work, etc.) that have been neglected for a long time because of illness-related problems and are re-discovered as dignified context for commitment actions (e.g. exposure to physically and psychologically painful activities, such as physiotherapy, life
styles modification, etc.).
ACT with physical chronic diseases: an overview of the current
empirical evidence and assessment tools
ACT-based protocols, interventions, and assessment
tools have been investigated with different chronic diseases. We summarize below the main outcomes and assessment tools. In table I a summary of the controlled
comparison trials with ACT in patients affected by physical chronic diseases is reported.
ACT oriented assessment tools for chronic diseases
The Acceptance and Action Questionnaire - II (AAQII) (23), is a 10-item self-report measure of psychological
flexibility, conceptualized as a continuum from acceptance to experiential avoidance, with questions assessing
the ability to stay in contact with emotions without behaving in order to get rid of them; there is also an AAQ-II
Italian version (24). The AAQ (nine-item version) (25) has
been used also in medical rehabilitation settings with patients with spinal cord dysfunction, stroke, amputation, or
orthopedic surgery, and data support that it is a reliable
and valid measure also in medical populations and that
avoidance plays an important role in rehabilitation outcomes (26). So far, different versions of this questionnaire
A57
are available for assessing psychological flexibility and
acceptance-experiential avoidance process related to
many different health conditions, specifically:
• Acceptance and Actions Diabetes Questionnaire
(AADQ) (27), an 11-item Likert-type self-report scale
(Cronbach’s α = .94), which measures acceptance of
diabetes-related thoughts and feelings and the degree
to which they interfere with valued action.
• Diabetes Acceptance and Action Scale (DAAS) (28), a
42-item Likert-type self-report scale that is used to indicate levels of psychological flexibility in youth with
type 1 diabetes. The authors are still in the process of
collecting psychometric data.
• Acceptance and Action Epilepsy Questionnaire
(AAEpQ) (29), an 8-item Likert-type self-report scale
for epilepsy related problems (Cronbach’s α = .65-.76;
these alpha values are considered acceptable for a
scale in early use, particularly one with few items).
• Chronic Pain Acceptance Questionnaire (CPAQ) (30),
a 20-item Likert-type self-report scale, which has two
subscales that assess activity engagement (11items) and
pain willingness (9 reversed-key items). The subscales
and total scale are internally consistent (Cronbach’s α
= .78-.82) and reliably predict patient functioning. The
questionnaire is also validated in Italian language (31).
• Acceptance and Action Questionnaire for Weight-Related Difficulties (AAQW) (32), a 22 items Likert-type
self-report scale, designed to measure acceptance of
weight-related feelings, defusion from weight related
thoughts, and the degree to which thoughts and feelings interfere with valued action. The mean score for
the sample was 88.9 (sd = 19.8, range 49 to 124) and
the internal consistency is good (Cronbach’s α = .88).
• Psychological Inflexibility in Pain Scale (PIPS) (33): a
12-item Likert-type self-report instrument to assess psychological inflexibility in people with chronic pain.
Analyses support the reliability and validity of a two factors solution: the avoidance subscale (8 items) measuring
the tendency to engage in behaviors that lead to avoid
pain and related distress, and the cognitive fusion subscale (4 items) assessing the experience of thoughts as if
they were true. The questionnaire demonstrates good internal consistencies (Cronbach’s α = .87 for the total
scale, .89 and .66 for the two subscales respectively).
ACT and diabetes
Diabetes is a chronic illness entailing a high risk of
disability and death, when life styles are not adjusted and
the adherence to medical treatments is low or not regular.
Interventions aimed to manage diabetes-related distress
may help people in dealing with its emotional challenges
and to improve self-management skills.
Gregg et al (27) randomly assigned 81 type-II diabetes
patients to a 7 hours education group (n = 38, following a
patient education manual; 34) and to a group where education (same as above but in an abbreviated 4 hours form)
was associated with a mindfulness and acceptance training
on difficult thoughts and feelings about diabetes, an exploration of personal values related to diabetes, and a
focus on the ability to act in a valued direction while con-
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Table I. Summary of empirical studies on ACT-based treatments with Chronic diseases
where a control group was included in the design
Study
Chronic health
condition - ACT (n)
Primary or
relevant measure
Comparison
condition (n)
Dahl et al, 2004
Chronic pain (11)
Mean of sick leave
days
Medical treatment
as usual (8)
Gregg et al, 2007
Diabetes type II (43)
Glycated Hemoglobin
(HbA1C)
Diabetes education
(7hrs) (38)
Laundgren et al, 2006
Epilepsy (14)
Laundgren et al, 2008
Post treatment
differences between
ACT = 1
MATAU = 11.5,
t = -2.34, p<.025
F-up differences
between
F-up weeks
ACT = .5
MATAU = 56.1
t = -1.99, p<.043
24
–
Mann–Whitney U = 621,
z = - 2.61, p<.009
12
Seizures Index
Supportive therapy
(frequency x duration) (13)
–
Chi Sq = 13.5,
p<.0003
52
Epilepsy (10)
Seizures index
Yoga (8)
(frequency x duration)
–
t = 2.4,
p<.05
Lillis et al, 2009
Obesity (40)
Weight-related stigma Waiting list (44)
(WSQ)
–
F(1,83) = 24.34,
p<.001
McCracken et al, 2005
Chronic pain (108)
Sit to stand
(freq./1 min)
Same group during
waiting list
M(SD) pre = 11.2(7.6) M(SD) pre = 11.2(19.5)
post = 16.6(9.8)
post = 16.8(10.2)
p<.01
p<.01
12
Tapper et al, 2009
Obesity/
overweight (62)
Physical Activity
(BPAT)
Continuing diet (31)
–
t = 2.46,
p = .018
24
Wicksell et al, 2008
Chronic pain and
whiplash-associated
disorders (11)
Pain disability (PDI)
Waiting list (9)
F(1,16) = 12.6,
p = .003
F(3,30) = 4.0,
p = .017
28
Wicksell et al, 2009
Longstanding pediatric Perceived functional
pain (32)
ability in relation
to pain (PAIR, 0-90)
Multi-disciplinary
treatment (16)
F(1,29) = 11.79,
p = .002
F(1,29) = 8.46,
p = .007
26
12
Legend: ACT = any treatment based on Acceptance and Commitment Therapy
tacting difficult experiences (n = 43) (35). At three months
follow up, in the group where 3 of the 7 hours diabetes
workshop were focused on ACT processes, patients reported diabetes self-management improved significantly
more (Mann-Whitney U = 331.5, z = -2.40, p<.043) and
were more likely to show glycated hemoglobin (HbA1C)
levels in the target range than in the control group (MannWhitney U = 621, z = -2.61, p<.009). Moreover, mediational analysis shows that changes in HbA1C were mediated both by changes in self-management and diabetes-related acceptance (measured by the AADQ). These outcomes are encouraging, since they were assessed on an independent measure for diabetes control (HbA1C), but further investigations are needed with larger samples.
ACT and epilepsy
Two RCTs have been published where ACT was used
with drug resistant epileptic patients. In the first one (36),
individuals randomly assigned to 9 hours of ACT training
(n = 27) were compared to a group that underwent supportive therapy. Data showed that seizures were dramatically reduced in the ACT group. In the first month following exposure to the ACT protocol, 57% were seizure
free compared to none in the control group. Twelve
months later, 86% were seizure free, compared to 8% in
the control group (Yates Chi Sq = 13.5, p<.0003, d =
1.99). Over a one-year follow-up period, quality of life,
personal well-being, and life satisfaction measures continued to improve. The evaluation of mediators of change
in the treatment of epilepsy with ACT showed that both
values and acceptance, alone or in combination, worked as
mediators for most outcomes (29).
In the second trial (37), 18 participants were randomized to ACT (12 hours of both individual and group sessions) aiming at increasing psychological flexibility
around seizures, fear of seizures and improve activity in
personally chosen valued directions or to Yoga (same
length treatment) and were followed up for 1 year. ACT
reduced seizures more than yoga (t = 2.4, p<.05) and both
improved quality of life.
These studies are relatively small in subject size, but
results are encouraging, especially if we look at data of
mediational analysis. Moreover, measures of the hypothesized effect (seizures frequency and length) strengthen the
reliability of results.
ACT and weight loss
Obesity is an increasing and complex health problem
and WHO estimated that by 2015 over 1.5 billion people
worldwide will be at least overweight. Moreover, overweight and obesity are now also a growing problem in so
called third world countries and they represent one of the
major risk factor for other chronic illnesses such as stroke,
heart and chronic respiratory diseases and diabetes (38).
Efficacy of ACT with obese patients has been investigated
in three comparative studies.
Forman et al (39) combined traditional behavioral
strategies with acceptance and mindfulness components in
a 12 sessions (once a week) training for 29 obese women.
Participants lost an average of 6.6% (range = 2.4% gain to
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17.2% loss, SD = 4.49) between baseline and post-treatment and an average of 9.6% (range = 4.5% gain to 25.9%
loss, SD = 7.34) after six months. Further, participants’
ratings of the extent to which their weight was having a
negative impact on their quality of life (measured by the
Impact of Weight on Quality of Life-Lite; IWQOL-Lit)
(40) decreased significantly from baseline (M = 61.13) to
both post-treatment (M = 47.56, t = 5.83, p<.001) and to
follow-up (M = 51.54, t = 4.54, p<.001). Acceptance and
mindfulness processes targeted by intervention, changed
to a statistically significant extent in the expected directions and related to weight loss.
Tapper et al (41) randomly assigned 62 dieting obese
or overweight women (BMI of 31.57, SD = 6.06) either to
a four 2-hour ACT sessions mainly focusing on values, enhancing motivation, cognitive defusion (to help breaking
links between food and exercise-related thoughts and behavior), and acceptance (to help the individual tolerate
negative feelings or to continue dieting) or to simply carry
on with dieting. Independent t tests revealed that, compared to controls, intervention participants showed a significantly greater increase in physical activity (Brief Physical Assessment Tool; BPAT) (42) (t = 2.46, p = .018), but
no differences in BMI change or change in mental health
difficulties. When intervention participants who reported
‘never’ applying the workshop principles at 6 months (n =
7) were excluded, those in the intervention group showed
significantly greater reductions in BMI (t = 2.24, p = .031)
and significantly greater increases in physical activity (t=
2.36, p = .023). There were no group differences in mental
health difficulties.
Researchers in the third study attempted to target experiential avoidance in order to reduce stigma and distress,
and improve quality of life. Lillis et al (43) randomly assigned 84 patients who had completed at least 6 months of
a weight loss program to a 1-day (6 hours) mindfulness
and acceptance-based workshop, targeting obesity-related
stigma and psychological distress, or to a waiting list. At a
3-month follow-up, ACT workshop participants showed
greater improvements in obesity-related stigma (WSQ)
(44) (F(1, 83) = 24.34, p<.001), quality of life (ORWELL)
(45) (F(1, 83) = 27.42, p<.001), psychological distress
(GHQ) (46) (F(1, 83) = 17.88, p<.001), and Body Mass
Index (F(1, 83) = 9.80, p<.01), as well as improvements in
distress tolerance (objective measure of breath holding
time) (F(1, 83) = 16.70, p<.001), and both general (measured by AAQ) (F(1, 83) = 10.46, p<.01) and weight-specific (measured by AAQ-W) (F(1, 83) = 40.69, p<.001)
acceptance, defusion and action in the face of barriers.
Mediational analyses indicated that changes in weightspecific acceptance and psychological flexibility mediated
changes in outcomes. The treatment participants also lost
more weight compared to the control group, even if that
was not the target of the intervention. Moreover, the
weight loss per se didn’t account for the outcomes.
Weight control and weight loss maintenance over time
is a critical health problem and these studies give a preliminary evidence that acceptance, mindfulness and
values-based actions components can improve lives of
obese people in terms of reduced stigma, stress, impact of
A59
weight on quality of life and loss of weight. In addition,
outcomes and processes effects are consistent with the underlying model.
Longer and more extensive acceptance and mindfulness protocols have to be evaluated with larger and more
representative samples of obese population and, moreover,
longer follow-up intervals are needed to evaluate the intervention effect over time.
Act and chronic pain
Chronic pain is a complex and controversial health
condition, which involves physical, psychological and environmental factors (47). A unique definition for this
health problem is still lacking, since pain may or may not
be associated with existing or potential tissue damage.
Pain is considered chronic when it persists beyond the
usual course of an acute disease or healing of an injury, or
causes continuous or intermittent aching over months or
years even when it is not associated with an acute or
chronic pathologic process. Many different illnesses can
result in chronic pain such as back pain, low back pain,
whiplash-associated disorders, fibromyalgia, etc. It can
cause considerable impairment in functioning and it is a
costly social problem too.
Quite a number of trials (at least 10) have studied the
impact of ACT interventions with chronic pain patients
targeting different processes: experiential avoidance (negative thoughts, feeling and interoceptive sensations associated with pain became the target for exposure, with no
attempts of disputing their irrational or distorted nature),
fusion with inflexible stories about pain (metaphors and
experiential exercises to focus the person on the real world
of direct experience) and valued life directions neglected
for long time due to the painful symptoms (metaphors and
experiential exercises to explore patient’s life directions if
he/she was living in a world where pain did not make such
choices impossible). Main outcomes are outlined in table
I and discussed in more details below.
Dahl et al (48) randomly selected 24 individuals (5 declined to carry on in the study after the baseline) among
220 chronic pain patients working in public agencies, who
missed work repeatedly due to pain over the last year. The
participants were randomly assigned either to a medical
treatment as usual (MTAU: multidisciplinary variety of resources; n = 8) or to MTAU plus four ACT sessions
weekly delivered (n = 11). The ACT intervention consisted in four 1-hour individual sessions, during which
working on valued actions clarification with mindfulness
and experiential exercises helped undermining cognitive
fusion and literal language related to problematic behavioral barriers to acceptance and commitment. Following
intervention ACT participants used a mean of 1 day (SD =
2.3) of sick leave versus a mean of 11.5 days (SD = 12.5)
for the MTAU condition, indicating significantly less days
of sick leave for the ACT condition (t = -2.34, p = .025).
These differences widened at 6-months follow-up (t = 1.99, p = .043): ACT participants showed a mean of .5 sick
days (SD = 1.8) versus MTAU that showed 56.1 sick days
(SD = 78.9). The ACT participants also asked significantly
fewer medical visits at 6-months follow-up (t = -1.98, p =
A60
.043). The study, though conducted with a small sample of
patients and for a short period of observation, nevertheless
provides preliminary evidence of the efficacy of a short (4
hours) ACT intervention in preventing sick-leave and
medical access in people with chronic pain. Moreover,
further studies are needed to clarify the putative change
processes, also analyzing the separate contribution of the
different therapeutic components.
McCracken et al (49) followed 108 chronic pain patients with a long history of treatment (average 10 years)
through an ACT-based 3-4 weeks residential treatment
program. In this multi-disciplinary and intensive protocol
physiotherapists, occupational therapists, nurses, physicians, and psychologists all worked together on an ACTbased program delivered approximately 6 hours a day,
with daily individual psychological sessions. The program
included exposures and explicitly targeted the role of feelings and thoughts as reasons for action (or inaction),
without attempting to change the form or reduce the frequency of the feared internal experiences. In the run-in period measures improved from initial assessment to pretreatment on average only by 3% (average of 3.9 month
wait), but improved on average by 34% following treatment. 81% of these gains were maintained at 3 months
follow up. Further, positive changes in acceptance of pain
measured by the CPAQ co-varied with improvement in
depression, pain related anxiety, physical disability, psychosocial disability, and the ability to stand. Positive outcomes were also seen in a timed walk, decreased medical
visits, daily rest due to pain, pain intensity, and decreased
pain medication use. Although there was no randomization to treatment, the waiting period of each subject before
treatment worked as his/her own comparison condition.
McCracken et al (50) also compared the impact of an
intensive and multi-disciplinary three-week treatment
(total time 80h, including principles of exposure, acceptance, cognitive defusion, mindfulness, and values based
approaches) with two groups of highly disabled (n = 53)
and standard patients (n = 234) with chronic pain. The
highly disabled patients showed significant changes (t-test
p<.005) in a healthy direction as evaluated by physical and
psychosocial disability, depression, pain-related anxiety,
acceptance of pain, daily rest related to pain, and sit to
stand performance, although the reduction during treatment was not statistically significant. Moreover, there
were large-effect sizes for the selected variables in both
groups and in some cases the highly disabled group
achieved larger effect sizes than the standard group,
showing that also the most difficult and chronic pain patients benefit significantly following this interdisciplinary
pain management treatment. Further study are needed to
assess the repeatability, long-term stability, and generality
of these effects.
In another study, Wicksell et al (51) evaluated the impact of an exposure and acceptance-based intervention (529 weekly individual sessions and 0-10 sessions with their
parents) with 14 adolescents with idiopathic chronic pain.
Substantial and stable decreases in functional disability,
pain intensity, pain interference, school absence and internalizing/catastrophizing, with statistically significant dif-
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ferences (p<.01) in pre-post data including follow-up,
were observed. The intervention goal was to improve the
patients’ ability to carry on in the direction of personal
values also in the presence of disturbing private experiences (e.g. pain and distress), with no emphasis on symptoms alleviation. A significant number of patients reported
clinically relevant changes in both intensity and interference of pain following treatment despite an important increase in functioning, suggesting that exposure can reduce
this type of pain.
Further, Wicksell et al (52) evaluate the effectiveness
of the same exposure and acceptance intervention (7-20
individual and parental psychotherapy sessions) compared
to a multi-disciplinary treatment (pain experienced physician, physiotherapist, and psychiatrist/psychologist for an
average of 10.6 sessions) with 32 pediatric patients with
longstanding idiopathic pain (between 6 and 96 months
length) randomly assigned to either of the two groups.
Comparisons at follow-up assessments were complicated
due to more sessions for control treatment. When followup assessments were included, ACT performed significantly better than multi-disciplinary treatment on perceived functional ability in relation to pain (Pain and Impairment Relationship Scale - PAIR) (53) (F(1,29) = 8.46,
p = .007), pain intensity (0-10) (F(1,29) = 4.25, p = .048)
and pain related discomfort (0-10) (F(1,29) = 5.12, p =
.031). At post-treatment, before the extent of treatment
and control interventions started to diverge, significant
differences in favor of the ACT condition were also seen
in kinesiophobia (Tampa Scale of Kinesiophobia -TSK)
(54) (F(1,29) = 7.66, p = .010), pain interference (F(1,29)
= 5.70, p = .024) and in quality of life (SF-36, Mental
index) (55) (F(1,29) = 4.99, p = .010).
Wicksell and al (56) also compared to a waiting list a
valued-based exposure and acceptance protocol (10 individual sessions), delivered to 21 patients with WhiplashAssociated Disorders (WAD) randomized to treatment or
control group. To improve the management of pain in
WAD, in fact, cognitive and behavioral components should
be taken in to account (57). Both groups continued treatment as usual (TAU). Significant differences in favor of
ACT-based intervention emerged in pain disability (Pain
Disability Index; PDI) (58) (F(1,16) = 12.6, p = .003), life
satisfaction (The Satisfaction With Life Scale; SWLS) (59)
(F(1,16) = 10.1, p = .006), fear of movements (TSK) (53)
(F(1,16) = 10.8, p = .005), depression (Hospital and Anxiety Scale; HADS) (60) (F(1,16) = 22.8, p = .001), and psychological flexibility measured with PIPS (33) (F(1,16) =
8.2, p = .011). Improvements in the treatment group were
maintained at 7 months follow up. The study shows the
utility of ACT-based interventions in helping whiplash patients in engaging in physical exercises perceived as potentially harmful, though crucial to increase strength and functioning. Further investigations are needed with a larger
sample of patients, randomly selected evaluating them also
on behavioral measures of change.
Finally, Volwes and McCracken (61) evaluated the effectiveness of an ACT interdisciplinary treatment, as described in McCracken et al (49), with 171 chronic pain
patients. Statistically significant improvements were
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found at post-intervention (F(1,170) = 50.16, p<.001) and
at 3-months follow up when compared to pre-treatment
(F(1, 113) = 5.57, p<.02) across all measures of outcome
such as: pain, depression, pain-related anxiety, disability,
medical visits, work status, and physical performance. Effect size outcomes were uniformly medium or large. Further, the improvements in pain acceptance and valuesbased action processes in relation to changes in outcomes
were evaluated to test the treatment model’s theory of
psychological functioning. The results showed that increases in these processes were associated with improvements in the primary outcome domains, especially in the
pretreatment to follow-up measures.
As to our knowledge, a few more studies examined the
contribute of ACT to the treatment of patients with chronic
pain, by investigating the impact of a self-help intervention ACT-based (62), comparing control and acceptance
strategies for pain tolerance with analogous studies (e.g.
63), and targeting an ACT-based intervention with an outpatient group-based intervention (64).
Conclusion
ACT is a clinical behavior-analytic model that is part
of the larger umbrella of cognitive-behavior therapies
movement. However, specific issues at different levels of
analysis characterize it. For these reasons, Hayes (11)
claimed for the emergence of a new generation of behavioral and cognitive therapies. In fact, ACT is explicitly
grounded in the basic principles of Behavior Analysis and
Relational Frame Theory and framed in a contextualistic
and pragmatic philosophy of science, both of which inform the clinical work that itself empirically enhances the
growth of the theory of science. It is worth noticing the effort it has been doing in building a comprehensive psychological approach, where the clinical procedures of the
applied model (ACT) are empirically tested and also
grounded in the basic theory (RFT), and where missing
and existing principles are developed and tested in a laboratory setting and then verified in the clinical work (17).
For the ACT underlying theoretical model, avoidance
or control of unpleasant covert and overt experiences is
one of the core processes responsible for the functional relationship between symptoms and existential limitations.
In particular, this can be crucial for symptoms regarding
physical chronic illnesses. In fact, people with those diseases may experience persistent and aversive sensations
(pain, distress, etc.) that are difficult to control or avoid
and that may become the only reasons for action of inaction. The unwillingness to experience pain and symptoms
prevents the pursuing of personally chosen valued directions and set the stage for the increasing disability and progressive decreasing of functioning.
The studies mentioned in this article emphasize the impact of different ACT-based protocols in helping patients
in identifying meaningful life directions and in pursuing
them. In fact, most of those protocols, even if different in
extension and length and applied to different kinds of populations, particularly emphasize the role of values, accep-
A61
tance and exposure work in helping patient with chronic
physical illnesses. The data are so far encouraging especially with chronic pain patients, the group with the largest
number of trials dedicated to, with different ages, diseases,
contexts, and protocols.
In general, the empirical support for ACT-based interventions with chronic illnesses is rapidly growing in the
last years for a relatively recent and new approach as ACT
is. Further studies are needed, with larger groups of patients, that may also allow to evaluate the processes responsible for change in behavior patterns (e.g. 29). In fact,
it is not only important to measure the treatment efficacy
but also the consistency of the model on which the treatment is based on (e.g. 61), allowing to build protocols
more and more suited on those patients’ needs. This is true
both inside a specific model (e.g. which are the ACT
model components accountable for the results?) and between different models (e.g. is more effective an intervention targeting the function of internal experiences or their
form/content?). More extended follow-ups are also needed
to assess the ideal length of intervention, for acquiring a
good stability of the results during time.
Finally, it could be of great interest to explore the usefulness of ACT-based interventions with other chronic
physical illnesses than those mentioned above, and particularly with those where psychological components and
life styles play a crucial role either in their onset or in the
adjustment to them, as for example heart diseases (e.g. 65)
and neurological diseases (e.g. 66).
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1/2, 21143 Milano, Italy - Cell.: +39 347 9305235, E-mail: [email protected]