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Acceptance and Commitment Therapy
Abstract and Keywords
Clinical social work is a derivative profession, drawing its knowledge and practice base from several theoretical schools. The four primary theoretical schools contributing to social-work philosophy are psychodynamic, humanist, cognitive–behavioral, and postmodern. Acceptance and commitment therapy (ACT), although considered one of the third-wave behavioral approaches, draws from all four theoretical schools of clinical intervention. This entry gives an overview of ACT development, its essential features, empirical base, tenets and techniques, and relevance to the social-work profession.
Keywords: acceptance and commitment therapy, ACT and social work, behavior therapy, mindfulness therapy, third-wave behaviorism
Carl Jung is quoted as saying, "We cannot change anything unless we accept it. Condemnation does not liberate, it oppresses" (Jung, 1955, p. 234). Although Jung was a psychoanalyst, his words actually lay the groundwork for acceptance and commitment therapy (ACT), a decidedly behavioral approach.
Acceptance and commitment therapy, a practical approach designed to move a person toward a valued life, is considered one of the exposure-based behavioral therapies. Far from the early interpretations of behaviorism based on classical or operant conditioning, the aptly called ACT rightfully is housed in the third wave of behavioral therapies.
The first behavioral approaches were introduced by psychologists John Watson, B. F. Skinner, and Ivan Pavlov. These early behavioral theories were rooted in stimulus-response reactions and classical and operant conditioning. Clinical interventions were applied accordingly, such as exposure techniques based on classical conditioning and applied behavior analysis based on operant conditioning principles. This view of behavior is based on the belief that all behavior is controlled by its consequences (rewards and punishments) (Angell, 2008).
The second wave of behaviorism recognized the importance of cognition as a mediating influence on behavior triggered by external stimuli. More attention was paid to the internal event of thinking about an event. It was hypothesized and demonstrated that removing and replacing irrational thoughts would result in behavioral change. Thus, the cognitive–behavioral approach emerged.
The third wave of behaviorism includes the postmodern and existential thought promulgated by social constructionism. The focus is on changing "the context, rather than the content, of thoughts and feelings" (O'Brien, Larson, & Murrell, 2008, p. 16). Techniques involving mindfulness, acceptance, cognitive defusion, dialectics, and values are considered crucial to the process. Third-wave behavioral therapies, of which ACT is one, utilize basic behavioral techniques (functional analysis, skill building, baseline measurement, direct shaping) but emphasize the context rather than the content of thoughts and feelings (O'Brien et al., 2008).
As an exposure-based therapy, ACT goes beyond decreasing reactions to stimuli (desensitization based on classical conditioning) to increasing psychological flexibility to stimuli. As an example, the internal experience of fear is not necessarily removed, but the response to it can be varied. The reactions become "as they are" instead of what one says, or perceives, they will be.
Acceptance and commitment therapy is a unique, empirically based psychological intervention that uses acceptance and mindfulness processes and commitment and behavior change processes to produce psychological flexibility. At its simplest level ACT helps a person accept and make sense of a psychological wound, take control of one's pain, and move toward the life one values.
Theoretical Frameworks
Acceptance and commitment therapy is built on two foundations: functional contextualism and relational frame theory (RFT). Functional contextualism provides the philosophical framework, whereas RFT, a theory of language and cognition, provides a theoretical foundation. Both are reminiscent of social constructivism in that every behavior is explained in terms of context. Thoughts and feelings do not occur in a vacuum and thus do not directly cause behavior. Neither is behavior totally governed by consequences (first-wave behaviorism) or cognition (second-wave behaviorism).
At its core, ACT is contextual learning in an effort to deal with experiential avoidance. Functional contextualism calls for examining behaviors in terms of the function or purpose they serve in a particular context. In this perspective, behavior is not necessarily seen as abnormal, but perhaps a functional response to an abnormal context. Acceptance and commitment therapy particularly emphasizes the role of language and cognition as processes used to create psychological inflexibility.
This use of language as it pertains to context suggests postmodern social constructionist interpretations of context, where the assumption is "words make worlds." This lens suggests that "the realities we live in are outcomes of the conversations in which we are engaged" (Gergen, 2009, p. 4). Likewise, ACT uses those language processes to create more flexible psychological responses that direct behavior toward a value-driven goal (O'Brien et al., 2008).
Relational frame theory provides a framework for the analysis of behavior mediated by language. As explained by O'Brien et al. (2008), ACT specifically targets the behavior of experiential avoidance, a "by-product of language and cognition" (p. 25). O'Brien et al. posit, "Without language and cognition, we would not be able to say to ourselves, 'I am anxious all the time,' or 'My parents were horrible,' or 'I will never be happy'. Neither would we be able to remember our past nor worry about the future" (p. 25). Relational frame theory assumes that human beings relate stimuli under changing contexts. Contextual cues are the relational frame. Change in ACT focuses on the functions of private events (thoughts and emotion, which are influenced more by language and cognition) rather than change focused on the content of private events.
Relational frame theory provides a definition of private and public events (cognitive and behavioral) in terms of the reciprocal responses derived from interpersonal relationships and context. Variables (such as gender or character traits) relate to other variables, thus influencing the frame in which a person reacts. Again, context provides the frame in which people relate or avoid experience. Roche, Barnes-Holmes, Barnes-Holmes, Stewart, and O'Hora (2002) explain "that derived relational responding is generalized operant behavior . . . the act of relating is a contextually controlled overarching response class than can occur with an infinite variety of stimulus topographies" (p. 76).
As a post-Skinnerian behavioral approach, ACT acknowledges that not every behavior is observable or quantifiable. Yet the essence of mindfulness is observation. We cannot observe thoughts, yet we attach words to our experience, even our thoughts. We can observe the thought in terms of the words. Observing words, such as "depressed" or "understand," brings mindfulness and curiosity into the world of words and attaches a different context.
Both functional contextualism and RFT emphasize the power of words to influence context. For example, every time a story is told, it is in a different context, which in turn influences the context in which it is being told. It is a reciprocal relationship.
Consider the following example:
"I am noticing that I am having the thought that depression is insurmountable." (relational frame)
"Where were you when you noticed you were having that thought?" (functional contextualism)
Putting the thought in context can diminish the power of the thought because the thought becomes something that happens along with many other events. It distances and externalizes the experience that is being avoided.
Acceptance and commitment therapy is akin to postmodern schools of therapy, such as narrative and solution-focused approaches, which also emphasize externalizing the problem. Solution-focused approaches postulate that the problem is not the problem; rather, the solution is the problem. The focus is on the solution, not the problem. Narrative therapists would say, "the problem is the problem; the person is not the problem." Acceptance and commitment therapy goes beyond externalizing problems to acceptance, observation, and movement to achieve a peaceful coexistence with the problem.
The theoretical foundations of ACT, RFT, and functional contextualism can be reduced to the following:
Relational frame theory: Learning, and thus, behavior, is contextual. (If thinking of sucking on a lemon can provoke a perceived sour taste reaction, likewise thinking of a trauma can evoke associated physical reactions).
Functional contextualism: Is the behavior working (functional) in this context? (The context is seen as the bigger picture.)
This foundation allows for a multitude of interventions focusing on both private (psychological) and public (behavioral) experiences of clients, which will be discussed in a subsequent section.
Major Concepts
Steven C. Hayes, widely accepted as the father of ACT, and coauthor Jason Lillis (Hayes & Lillis, 2012) provide an overview of ACT's main influences and its basic principles. The authors demonstrate how ACT illuminates the ways in which language encourages avoidance in clients' psychic lives. Acceptance and commitment therapy is used to help clients accept private experiences (thoughts and emotions), become more mindful, develop greater clarity about personal values, and commit to needed behavior change. The acronym ACT stands for accept, choose, take action.
Acceptance and commitment therapy does not strive to take away pain, but acknowledges that pain is a natural part of living. Hayes, Strosahl, and Wilson (2012) refer to "the dilemma of human suffering" (p. 3). The authors posit that "psychiatric diseases are actually more myth than reality" (Hayes et al., 2012, p. 7).
Succinctly described by Thyer and Wodarski (1998), ACT concentrates on the verbal and rule-governed behavior of people. The rules and language that govern behavior are categorized into three major sets: (a) literality, (b) reason giving, and (c) control. Literality means using literal definitions (anxiety literally means an uncomfortable state to most people). Reason giving goes beyond literality to explain behavior, as if internal experiences (anxiety) explain why a person cannot perform an action (experiential avoidance). The context of control implies that certain events must happen for other events to occur (anxiety must be eliminated for a person to function).
Eschewing these rules, ACT strives to change these "contingencies of reinforcement by exploring the paradoxes of such contexts" (Thyer & Wodarski, 1998, p. 336). An elemental step in this process is to separate clients' words and actions from the clients themselves, distinguishing people from their behavior. Demonstrating that people can exist and function with uncomfortable internal states (anxiety) eliminates the "control exerted by the contexts of literality, reason giving, and control [and] is a major goal of therapy" (Thyer & Wodarski, 1998, p. 336).
Acceptance and commitment therapy is related to cognitive behavioral therapy (CBT); however, it is also distinctly different. Acceptance and commitment therapy does not depend on a client changing his or her thinking, but rather changing the behavioral functions of that thinking. Thus, a person may indeed continue to have the same thought, but develop a different or additional response to the thought. In CBT, it is preferable that a thought be challenged and modified, with changed behavior a result of the correction in thinking.
The goal of incorporating mindfulness, acceptance, and change also distinguishes ACT from traditional CBT. Acceptance and commitment therapy combines the process-oriented aspects of mindfulness and the action-oriented processes of behavior and change with the desired goal of increasing psychological flexibility (Boulanger, Hayes, & Lillis, 2009). The goal is not to change distorted thinking, but to accept irrational thoughts for what they are, internal experiences, "not literal truth" (O'Brien et al., 2008, p. 16), and for clients to change their relationship to their thoughts. The authors go on to explain, "When clients are able to balance acceptance and change, accepting their thoughts as thoughts and thereby changing their relationship to their thoughts, they gain the flexibility to move in valued directions" (p. 16).
Although elements of ACT cross over with elements of CBT, ACT addresses the existential aspect of finding meaning in experience and emphasizing values-consistent action. Even if no meaning can be found, ACT teaches one how to accept a void in purpose and still commit to change. The mindfulness aspect of ACT involves nonjudgmental acceptance of the present moment, especially body or emotional sensations coupled with nonconcern for the future.
The mindfulness, relatively spiritual, component of ACT constitutes a major distinction from other CBT approaches. As one of the third-wave approaches, it is in a class that includes dialectical behavior therapy and mindfulness cognitive behavioral therapy. This third-wave class of therapies broadens attention to the psychological, contextual, and experiential world of its constituents (Dewane, 2012).
Although some approaches might view emotional and behavioral symptoms as psychopathological, in ACT an individual's "symptomatology" is interpreted only as experiential avoidance. An elemental presupposition of ACT is that many adjustment problems in both children and adults are the result of "experiential avoidance," which is defined as the inclination of people to avoid contact with a particular experience, somatic, cognitive, behavioral, and emotional. Acceptance and commitment therapy "emphasizes the need to undermine the avoidance of unwanted private experiences" (O'Brien et al., 2008, p. 18). To achieve acceptance, the opposite of avoidance, mindfulness is necessary.
Mindfulness calls for transcending a trauma, an event, or an injury and deciding how not only to survive but also to thrive. The client is not responsible for a harmful event, but is always responsible for the healing of the injury. Mindfulness often involves making peace with the past and with the self. Mindfulness techniques produce a detachment from ongoing preoccupations (de-centering) and should activate the rational system in the prefrontal lobe and attenuate the reflexive system (Beck, 2012).
An existential bent of ACT lies in its belief that suffering is a basic characteristic of human life, a premise reminiscent of that espoused by Viktor Frankl's concept of logotherapy (Frankl, 1992), and represents a dramatic change from traditional behaviorism and CBT. Being present with both external and internal stimuli is similar to Eastern philosophies of contemplative healing. In addition, mindfulness extends into the present encounter between therapist and client. It sees the therapeutic relationship as a microcosm of the client's world, not unlike the relational dynamics concepts utilized in contemporary psychodynamic approaches.
Mindfulness implies observing and noticing, especially one's own experience, "a way of being with oneself" (Hill, 1986, p. 29). Using an experiential approach means that a new way of being with oneself and thus a way of being with the distress in one's life defines the mindfulness component of ACT. Hill (1986) describes feminist work with posttraumatic stress disorder (PTSD) in which an ultimate goal would be to stand outside of the pain and regard it in some way. Self-acceptance, which then goes beyond to establish a relationship with the distress in a new way, is what ACT would interpret as increasing psychological flexibility.
Acceptance involves letting go of a psychological struggle without denying the reality of it. Accepting thoughts and private experiences, somatic or emotional, as what they are means accepting the verdict of an event, but rejecting its sentence. Instead of fighting or avoiding the experience, a person develops a different relationship to the experience, perhaps noticing it and peacefully coexisting with it.
Acceptance in ACT does not imply resignation. Accepting and experiencing the problem in a different way is definitive. Hill (1986) colorfully describes one client's different relationships with emotional pain: first trying to wipe it out with substance abuse, then denying that it was even real with subsequent rage toward it for not disappearing, and seeking help through prescribed medication to numb and silence it. An experiential ACT therapist would attest to the failure of these relationships as testament to the psyche's insistence to heal. The pain is seeking to be heard, not denied, suppressed, or silenced.
There are six core processes in ACT:
1. Acceptance
2. Cognitive defusion
3. Self as context
4. Being present
5. Values
6. Committed action
Each of the processes contributes to behavior change. Techniques designed to implement these processes are described in the subsequent section.
In summation, "reducing the hold of language" (Batten, 2011, p. 28) and learning by doing and experiencing (behavior), rather than learning and acting by words (cognition), comprise the major concepts of ACT. The outcome of ACT actually becomes a process.
Interventions and Techniques
The goal of ACT to achieve valued living with less struggling is defined by doing, not talking about it. It goes beyond reducing symptoms (strict behaviorism) to helping people construct lives they value. The therapeutic process of ACT can be summed up in achieving acceptance and mindfulness through the use of specific client-driven exercises, metaphors, and behavioral homework.
Acceptance and commitment therapy is a cognitive and experiential therapy in that it involves "doing" and attaching contexts to cognition. It shares some techniques of other approaches, but, in a way that is focused on a contextual behavioral model, focusing on processes that may underlie all behavior (avoidance of painful experience) and cognitive fusion (being stuck by language). Problems are viewed as "stuck stories." Assessment in ACT is a determination of the levels of stuckness and discovering where one's life is not stuck. The therapist also avoids getting hooked into the stuckness by making nonevaluative statements such as "You are noticing that your mind labeled this experience as stuck." Multiple ACT-specific instruments have been developed to measure ACT processes (Hayes, 2009).
The overarching therapeutic goal is less struggling with suffering and more moving toward valued living. Clients are guided to ask themselves, "Am I moving toward the desired value or struggling with the suffering? Given what is important to me, what am I willing to do and experience to move me in that direction, in this moment?"
Problem stories told by the client are usually stories of being "stuck." Instead of focusing on negatives, the therapist uses "creative hopelessness" to put the stuckness in a bigger context by asking, "Where were you when you thought that? What wasn't working? Are you willing to consider another way that we don't know yet?" Creative hopelessness (facing the situation) techniques are often used as a precursor to acceptance work.
Techniques used in ACT are often clever and playful and reinforce the doing and experiential aspect of the model. ACT uses language processes, such as metaphors and paradox, and experiential exercises to create more flexible psychological responses that direct behavior toward a values-driven goal (O'Brien et al., 2008). A comprehensive list of techniques has been developed by Stroshal, Hayes, Wilson, and Gifford (2004), some of which are described in the remainder of this section.
Values Techniques.
Techniques are designed to clarify what the client values and what gives life meaning, which underlies most behavior. These techniques determine whether behavior is moving toward these valued outcomes and what a person is willing to do to move toward the values. Clients are guided between values-driven behavior and goal-oriented behavior. The Valued-Living Questionnaire (Wilson, Sandoz, Kitchens, & Roberts, 2010) is used in ACT as a part of values clarification techniques.
Other simple techniques, such as listing values in all major life areas or having a client write his or her eulogy or tombstone, are used in addition to more sophisticated techniques, such as "traumatic deflection," establishing what pain a client would have to endure to do what is valued.
Creating confusion may also be part of the values identification process. According to Hayes and Smith (2005), "Outcome is the process through which process becomes the outcome" (p. 161).
Other values techniques include the following:
Redefining inaction as choosing not to choose
Accepting that choice cannot be avoided. We are always making choices; even no choice is a choice.
What if no one could know?
Imagining no one could know of one's achievements, what would a person still do? The answer defines values-driven behavior.
Traumatic deflection
Identifying what lengths or pain one would endure to do what you value?
Note. Extrapolated from An ACT primer, in S. C. Hayes & K. D. Strosahl, (Eds.), A practical guide to acceptance and commitment therapy (pp. 31–51), by K. Stroshal, S. Hayes, K. Wilson, and E. Gifford, 2004, New York, NY: Springer-Verlag. Copyright 2004 Springer-Verlag. Adapted with permission.
Acceptance Techniques.
Acceptance techniques are designed to give permission to the client to endure whatever inner experiences occur, if doing so produces action. The Acceptance and Action Questionnaire, versions I and II (Bond et al., 2011), is an instrument designed to measure acceptance and behavioral effectiveness in ACT.
Sample acceptance techniques are as follows:
Separating a thought from an action: thoughts/feelings do not always result in action.
Exploring effects of avoidance
How has avoiding worked? How has it not?
Amplifying responses
Bring the experience (the monster or pink elephant) into the room.
In vivo exposure
In-session flooding and desensitization.
The Serenity Prayer
Change what is possible; accept what is not.
Note. Extrapolated from An ACT primer, in S. C. Hayes & K. D. Strosahl, (Eds.), A practical guide to acceptance and commitment therapy (pp. 31–51), by K. Stroshal, S. Hayes, K. Wilson, and E. Gifford, 2004, New York, NY: Springer-Verlag. Copyright 2004 Springer-Verlag. Adapted with permission.
Mindfulness Techniques.
Often homework given in ACT entails "noticing": noticing when the mind gets hooked or stuck, noticing where it is associated in the body, then noticing what one does as a consequence. This type of detachment is empowering and is the main component of mindfulness techniques. Mindfulness experiential awareness essentially is noticing and paying attention to internal experiences and how they are somaticized. Brown and Ryan (2003) offer a tool to assess a client's capacity for mindfulness. The Mindful Attention Awareness Scale is a 15-item measure assessing mindfulness of moment-to-moment experience.
Simple education techniques (unhooking a thought from an action) clarify that thoughts or emotions do not always result in action; the thought is an inner behavior that does not have to manifest in an outward behavior.
Mindfulness techniques also include exploring and observing the consequence of avoidance. "Leaning in" to fear instead of away from it is the opposite of experiential avoidance.
Some techniques offered by Stroshal et al. (2004) include the following:
Noticing the struggle/tug of war
The metaphor envisions a tug of war with a monster; the goal is to drop the rope, not win the war.
Rehearsing the opposite/practice the unfamiliar
Paying attention to what happens when not doing the automatic response.
Distinguish willing from wallowing (moving through a swamp)
The only reason to jump into a swamp is because it is in the way of getting to the other side of where one wants to go.
Chinese handcuffs
No matter how hard one pulls to get out of them, it is pushing that does the trick.
Driving with the rearview mirror
Control strategies (avoiding experience) do not work.
Note. Extrapolated from An ACT primer, in S. C. Hayes & K. D. Strosahl, (Eds.), A practical guide to acceptance and commitment therapy (pp. 31–51), by K. Stroshal, S. Hayes, K. Wilson, and E. Gifford, 2004, New York, NY: Springer-Verlag. Copyright 2004 Springer-Verlag. Adapted with permission.
The three therapeutic components of ACT, which are primarily client driven, are as follows:
1. Behavioral activation—do something different;
2. Noticing—self-awareness through mindfulness; and
3. Reverse cognition—defusing thoughts and separating from behavior.
In ACT, a therapist and client have a variety of experiential exercises and metaphorical and paradoxical techniques at their disposal to achieve the goal of valued living.
Empirical Evidence
Third-wave behavioral approaches have broad applicability. Studies have shown ACT's usefulness across a span of adult clinical syndromes. Boulanger et al. (2009) state that an array of psychological and behavioral problems including depression, self-harm, chronic pain, anxiety, psychosis, prejudice, worksite stress, employee burnout, diabetic self-management, adjustment to cancer, obsessive–compulsive disorder, trichotillomania, adjustment to epilepsy, and self-stigma can be ameliorated with ACT.
Researchers have explored the effectiveness of ACT with life skills such as parenting. O'Brien (2011) found compelling evidence to support the use of ACT as an intervention for parenting. The use of ACT as a new approach to improve athletic performance has been proposed (Gardner & Moore, 2004). The authors demonstrated that a mindfulness, acceptance, commitment approach to sports psychology appears to be more effective than traditional cognitive–behavioral approaches.
Acceptance and commitment therapy may be suitable for multiple comorbid disorders. Batten and Hayes (2005) provide a convincing case study in which an individual with comorbid PTSD and substance abuse is treated with ACT. Twohig (2009) describes a case of treatment-resistant PTSD and major depressive disorder successfully ameliorated with a course of ACT. Considering that many major diagnoses carry others with them (PTSD/substance abuse), the approach strives to target not symptoms of a particular disorder but the experiential avoidance that gives rise to the symptoms of all disorders (Batten, 2011). In this view, one model does fit all.
Acceptance and commitment therapy continues to be studied across targeted populations. Its relevance for work with substance-abusing populations has been studied (Hayes, Wilson, et al., 2004). ACT seems to be well suited to the spiritual "letting go" aspects of traditional Twelve-Step substance-abuse treatment. One randomized clinical trial (RCT) with 138 opiate abusers compared methadone maintenance alone with methadone maintenance combined with ACT or Intensive Twelve-Step Facilitation. Results were that methadone maintenance alone resulted in a higher relapse rate, but methadone maintenance combined with either ACT or Intensive Twelve-Step Facilitation saw reduced drug use posttreatment and at the 6-month follow-up.
Behavioral approaches have traditionally been used in smoking cessation. In an initial investigation (Gifford et al., 2004) ACT has been applied in a comparison with nicotine-replacement therapy (NRT), in which ACT concentrated on the process of smoking and NRT focused on the outcome. Negative reinforcement available through avoidance is an important component of nicotine dependence (Shiffman, 1993, as cited in Gifford et al., 2004) and is a potent predictor of failed smoking cessation. Smoking serves to reduce negative internal states. Most smokers want to avoid the uncomfortable physical sensations that accompany quitting and to maintain the positive calming and numbing effect smoking supplies for negative internal states. Because smoking is often used to medicate negative internal experiences (uncomfortable somatic sensations), the acceptance-related dominance of ACT seems well suited. The researchers suggest that treatment focused exclusively on eliminating the uncomfortable residuals of smoking cessation is not the only option.
Gifford (2002) developed a four-layer process model for smoking cessation. Generated from this model was an ACT approach toward smoking cessation. The ACT approach was compared with NRT in a pilot study involving 76 participants with long-standing nicotine dependence and multiple histories of failed quit attempts. Participants were randomly assigned to NRT or ACT for a seven week treatment. Measurements were taken posttreatment and at six month and one year follow-ups. Quit rates were virtually the same posttreatment. At the six month follow-up, ACT participants maintained higher quit rates; in the one year follow-up the quit rate among ACT participants equaled that of posttreatment rates, whereas the quit rate among NRT participants remained significantly lower. The quit rate for participants in the ACT treatment was 2.3 times higher compared with the control group. Because ACT seems to produce longer-term results, it is presumably safe to say that the treatment provided an additional way for participants to calm internal states while simultaneously accepting and dealing with negative physical states in a new way, other than NRT delivered in another form. The authors suggest confirmatory studies be undertaken to determine whether ACT was the significant factor or whether the additive effect of any treatment coupled with NRT contributes to a higher quit rate.
In an interesting study on providers rather than patients, the influence of ACT was compared with multicultural training with regard to mitigating stigma, prejudice, and professional burnout of substance-abuse counselors (Hayes, Bissett, et al., 2004). The ACT protocol used in the training was drawn from the psychotherapy ACT protocols but was considered training rather than treatment, provided in a day-long workshop. The multicultural training had an immediate effect on reducing stigmatizing processes. The ACT intervention had a longer-term effect on mitigating burnout.
Proponents claim ACT to be user-friendly by both client and therapist. Beyond traditional uses for behavioral approaches, such as smoking cessation, ACT studies indicate that its applicability ranges from treating psychotic behaviors (Bach & Hayes, 2002; Gaudiano & Herbert, 2006) to working with pediatric chronic illness (Montgomery, Kim, & Franklin, 2011.) Twohig and Woods (2004) found three of six patients successfully decreased trichotillomania behaviors.
The use of ACT with various experiences of trauma demonstrates its potential usefulness. Trauma exposure is viewed as an important risk factor for emotionally avoidant behavior (experiential avoidance). Acceptance and commitment therapy has been suggested for the treatment of survivors of childhood sexual abuse (Walser & Westrup, 2007; Orsillo & Batten, 2005; Wilson, Follette, Hayes, & Batten, 1996) as well as a cautious primary or adjunct therapy for veterans suffering from PTSD. Vujanovic, Niles, Pietrefesa, Potter, and Schmertz (2011) elucidate ways in which the mindfulness approaches, including ACT, can mitigate trauma reactions. Vujanovic, Niles, Pietrefesa, Potter, & Schmertz (2011), reports an ongoing study of mindfulness approaches and ACT with PTSD. Two trials are currently underway for ACT, one for combat-related distress and another for PTSD.
Studies suggest ACT as a useful intervention for those suffering from panic symptoms or panic disorder (Levitt, Brown, Orsillo, & Barlow, 2004; Karekla, Forsyth, & Kelly, 2004). Researchers have found ACT applicability in coping with pain (Luciano et al., 2010; Dahl, Wilson, & Nilsson, 2004; Gutierrez, Luciano, Rodriguez, & Fink, 2004).
A meta-analysis (Hayes, Luoma, Bond, Masuda, & Lillis, 2006) provides a comprehensive review of the efficacy literature. Ruiz (2010) provides a thorough review of ACT empirical evidence, concluding the studies strongly support ACT with a wide range of psychological disorders.
Acceptance and commitment therapy is now considered an empirically supported treatment on the American Psychological Association list of empirically based treatments with moderate support in depression and strong research support in pain control (Society of Clinical Psychology, n.d.), and it is listed as an evidence-based practice on the Substance Abuse and Mental Health Administration's National Registry of Evidence-Based Programs and Practices (Substance Abuse and Mental Health Administration, 2012).
Founders recommend ACT for problem areas where it has an evidence base, such as affective disorders and chronic pain. Sufficient evidence also exists to suggest its use with smoking cessation, substance abuse, some psychoses, and occupational stress. It is recommended on an experimental basis, as an adjunct therapy or primary approach when other empirically based treatments have failed, where the presenting problem appears to involve a lack of value clarification, cognitive fusion, experiential avoidance, and resulting psychological rigidity.
The Association for Contextual Behavioral Sciences reports that as of March 2012 there are just under 60 RCTs of ACT published or in press. The studies average over 75 participants each—which totals over 4,000 participants. Over half of this literature has appeared since 2009 and 40% of it originated outside of the United States, attesting to the international reach of ACT (Hayes, 2010).
The Association offers a compilation of published and current ongoing major studies, divided into randomized controlled trials and other types of studies (for example, pre–post designs or single-case designs). The following table of ACT data is current as of early 2011 (Hayes, 2012).
5 RCTs; 3 other. Some indication that ACT is superior to CBT in some settings. Evidence of a distinct process.
Anxiety/stress/obsessive–compulsive disorder
9 RCTs; 11 other. Data supporting the application of ACT with a number of different problems related to anxiety and stress. Some indication that it is superior to CBT in some settings, but data also indicate that it can be beaten by traditional behavioral therapy in minor anxiety problems. Evidence of changes in ACT processes mediating outcomes.
3 RCTs; 5 other. Not yet compared with other psychosocial methods beyond support but effects are good for amazingly small interventions. Used in addition to antipsychotic medication. Mediated by ACT processes.
Substance abuse
3 RCTs; 3 other. Some indication that ACT does better than existing pharmacotherapy methods or supplements their effects.
3 RCTs; 2 other. Indication that ACT does better than existing pharmacotherapy methods or supplements their effects.
Chronic pain
3 RCTs; 7 other, including 3 decent-size effectiveness trials. Good outcomes. No good head-to-head comparisons with empirically supported alternative methods yet. Works through ACT-relevant processes.
Prejudice and burnout
3 RCTs; 1 crossover. Beats multicultural counseling and education alone. Works through ACT-relevant processes. Helps in both stigma and burnout. Other good studies completed and forthcoming.
Marital problems
1 other. Very limited data.
Eating disorder or body dissatisfaction
2 RCTs; 1 other.
Sexual deviation
2 other. Very limited data.
Dually diagnosed
1 RCT (subanalysis); 1 other. Promising but limited data.
Self-harm/borderline personality disorder
2 RCTs, 1 that mixed ACT with dialectical behavior therapy. Good outcomes. Limited follow-up. Did move ACT-relevant processes.
3 RCTs. Good outcomes on both seizures and quality of life. 1-year follow-up. Mediated by ACT processes.
Diabetes management
1 RCT. Good outcomes at follow-up on self-management and glucose control. Mediated by ACT processes.
Weight maintenance
2 RCTs. Good outcomes that were mediated through ACT processes.
Augmenting training in other therapies
2 RCTs. Found ACT can increase the adoption of evidence-based psychotherapy methods by clinicians and is mediated through ACT processes.
Coping with cancer
3 RCT; 1 other. Preliminary data suggest ACT can improve coping with cancer. One RCT shows ACT is more helpful than traditional CBT elements in dealing with end-stage cancer and works through a different process.
Sports performance
3 other. Very limited data suggesting ACT can improve performance in various sports.
Note. Extrapolated from State of the ACT evidence. Association for Contextual Behavioral Science. 2012, by S. Hayes, 2012. Adapted with permission.
There is increasing evidence for using ACT with children and adolescents (Greco & Hayes, 2008). O'Brien et al. (2008) include ACT as a promising third-wave behavioral approach for children and adolescents. Using developmentally appropriate exercises, ACT can be adapted for individuals ages 8 and older. Empirical evidence exists for ACT's effectiveness with youth populations, such as girls with anorexia, pediatric pain, adolescent girls engaging in risky sexual behavior, and adolescents at risk for dropping out of school (O'Brien et al., 2008).
The mainstay of most behavioral approaches with children, functional analysis, is considered best practice for children's behavioral dysregulation. This analysis must include the family's role in providing positive reinforcement for negative behavior. In an ACT view, the family is seen as the context in which symptoms (behaviors) may be functional (functional contextualism).
Theoretically, ACT would be suitable for children in that the exercises and metaphors can be playful. Children may be more appreciative than adults, being in the moment and noticing, thus making them easily receptive to mindfulness exercises. The symbolic use of objects and metaphorical language can be easily adapted to work with children. Along with other mindfulness-based approaches, such as mindfulness cognitive behavioral therapy or dialectical behavior therapy, ACT has recently been used for at-risk children and adolescents. It has been studied as effective for pediatric chronic pain, primary care, borderline personality disorder, externalizing disorders, and body-image problems. The use of ACT with children literally is in its infancy. The challenge and apparent contradiction is to help children use language in a different way, yet children only know the world through rules imposed by language. However, used skillfully, "acceptance and mindfulness training should broaden children's repertoires without creating conflicts between different styles of interacting verbally with their world" (Hayes & Greco, 2008, p. 7).
The literature about ACT across a variety of populations and challenges in living is considerable and ongoing. Proponents of all behavioral approaches point to the ease in which quantifiable outcomes can be demonstrated with the behavior therapies, and ACT is no exception.
Relevance to Social Work
Where is the intersection of social-work ideology and ACT? Is ACT applicable across cultures? Does ACT recognize or address issues of social injustice that may be contributing to the client's distress?
Perhaps one of the main criticisms of ACT from a social-work perspective is its emphasis on the individual to the neglect of the individual's environment. Because ACT is a contextual psychology, is it assumed that an individual's context (environment) is taken into account? More likely, the immediate context in which psychological inflexibility occurs is the emphasis. Proponents of ACT do recognize that in ACT work with children, it is essential to include their social contexts, such as families, schools, neighborhoods, and communities (Hayes & Greco, 2008).
The relevance of behavioral and cognitive therapies to social issues is evolving. Hayes, Bissett, et al. (2004) report on the usefulness of ACT in a multicultural training developed to reduce stigmatizing attitudes and professional burnout. They suggest that ACT has potential in reducing stigma toward marginalized populations. The core principles of ACT are consonant with several core concepts of social work, however.
In ACT psychopathological symptoms are seen not as a deficit, but as a clue to a need for experiential avoidance, consistent with social work's core principle of the inherent worth and dignity of each individual. Acceptance and commitment therapy is a distinctly client-driven and collaborative approach. Because client self-determination is a foundational principle of the field of social work, ACT represents movement toward client-centered behavioral treatment.
Whereas the second-wave behavioral approaches, including CBT, tend to emphasize content more than relational process, the third-wave approaches are bringing the therapeutic relationship back to the forefront as essential to treatment. Acceptance and commitment therapy and other mindfulness-based approaches have placed increasing emphasis in the relational "moment to moment dynamic which results in therapeutic change" (Turner, 2009, p. 101). The relationship as the cornerstone of cure is paramount in social-work ideology. In ACT, the reliance on mindfulness, by both the client and the therapist, represents a unique expression of "use of self," another salient concept in social-work practice.
The Social Work Special Interest Group of the Association for Contextual Behavioral Sciences (Boone, 2011) is "committed to supporting the intersection of social-work theory and practice and contextual behavioral science" (Mission/Objectives). The group purports that ACT is well suited to the practice of social work in that both ACT and social work share a focus on context, strengths, and understanding human suffering in ways that avoid pathologizing individuals and communities.
In an interview as the first social worker to be designated as a peer-reviewed ACT trainer, Joanne Steinwachs stated,
I cannot think of a theory that is more in line with social work values than functional contextualism. We provide the bulk of mental health care in this country and it breaks my heart that more social workers don't know about contextual behavioral science. I feel really good coming home to social work after all these years of hanging out with psychologists. There's a deep sense of "these are my people" that I feel when I talk functional contextualism with social workers. (Long, 2012, para. 11)
Although the third wave of behavioral therapies is relatively new (emerging in the mid-1990s), ACT has demonstrated empirically driven, cost-effective, efficacious, culturally sensitive intervention across multiple populations. It is consistent with social-work empowerment philosophy as clients are guided to recognize their own capacities. It reflects person-in-environment in the sense that context is environment defined by the client. Labeling and pathology orientation are discouraged, consistent with a social-work strengths perspective.
At the very least, techniques from ACT can be integrated into other approaches. At the very best, ACT used exclusively represents the best of the four dominant schools of intervention in social work:
• The use of relational dynamics in ACT borrows from contemporary psychodynamic practice.
• The growth-oriented emphasis of ACT represents humanistic philosophy.
• The influence of the cognitive–behavioral school is evident by ACT identifying and using private experiences (thoughts); realizing the importance of cognitive control, but teaching new forms of thinking that are not exclusively replacing distorted thoughts.
• Finally, the postmodern influence is seen in ACT's perspective of the social construction of language and context, combined with the existential philosophy of accepting that suffering is a necessary part of the human condition but does not define the quality of human existence. "Mind over matter" becomes "mind over mind."
Despite persistent criticism that the approach has not been sufficiently empirically proven, there is a substantial body of literature demonstrating its effective use with varied areas of distress. There is no body of literature disproving its effectiveness. Certainly the absence of such study does not guarantee that ACT is effective, but the literature supporting its efficacy is considerable.
As with most specialized approaches, with proper training and supervision, ACT may be very appropriate for social workers to use, particularly with clients who have experienced trauma. Although ACT may not address the core social-justice issues of social-work practice, its potentially significant contribution to social-work intervention with individuals cannot be ignored.
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Bach, P., & Hayes, S. C. (2002). The use of acceptance and commitment therapy to prevent the rehospitalization of psychotic patients: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 70(5), 1129.Find this resource:
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Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. C., Guenole, N., Orcutt, H. K., et al. (2011). Preliminary psychometric properties of the Acceptance and Action Questionnaire—II: A revised measure of psychological flexibility and acceptance. Behavior Therapy, 42, 676–688.Find this resource:
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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 symptoms: A preliminary randomized trial. Behavior Therapy, 35(4), 785–801. doi:10.1016/S0005-7894(04)80020-0Find this resource:
Dewane, C. (2012). Acceptance and commitment therapy for veterans with PTSD. Social Work Today, 12(3), 14.Find this resource:
Frankl, V. E. (1992). Man's search for meaning: An introduction to logotherapy. Boston. MA: Beacon Press.Find this resource:
Gardner, F. L., & Moore, Z. E. (2004). A mindfulness–acceptance–commitment-based approach to athletic performance enhancement: Theoretical considerations. Behavior Therapy, 35(4), 707–723.Find this resource:
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. doi: 10.1016/j.brat.2005.02.007Find this resource:
Gergen, K. J. (2009). An invitation to social construction (2nd ed.). Los Angeles, CA: Sage.Find this resource:
Gifford, E. V., Kohlenberg, B. S., Hayes, S. C., Antonuccio, D. O., Piasecki, M. M., Rasmussen-Hall, M.L. et al. (2004). Acceptance-based treatment for smoking cessation. Behavior Therapy. 35(4), 689–705.Find this resource:
Gifford, E.V. (2002). Acceptance based treatment for nicotine dependent smokers: Altering the regulatory functions of smoking related affect, physiological symptoms, and cognition. (Doctoral dissertation), University of Nevada, Reno.Find this resource:
Greco, L.A. & Hayes, S.C. (Eds.) (2008). Acceptance & mindfulness treatments for children & adolescents: A practitioner's guide. Oakland, CA: New Harbinger.Find this resource:
Gutiérrez, O., Luciano, C., Rodríguez, M., & Fink, B. C. (2004). Comparison between an acceptance-based and a cognitive-control–based protocol for coping with pain. Behavior Therapy, 35(4), 767–783. doi:10.1016/S0005-7894(04)80019-4Find this resource:
Hayes, S. (2009, August 9). ACT-specific measures. Retrieved December 19, 2012, from http://www.contextualpsychology.org/act-specific_measures
Hayes, S. (2010). Outcome studies. Association for contextual behavioral sciences. Retrieved December 19, 2012, from http://contextualpsychology.org/randomized_controlled_trials
Hayes, S. (2012). State of the ACT evidence. Association for Contextual Behavioral Science. 2012. Retrieved December 19, 2012, from http://contextualpsychology.org/state_of_the_act_evidence
Hayes, S., & Greco, L. (2008). Acceptance and mindfulness for youth: It's time. In L. Greco & S. Hayes (Eds.), Acceptance & mindfulness treatments for children & adolescents (pp. 3–11). Oakland, CA: New Harbinger.Find this resource:
Hayes, S. C., Bissett, R., Roget, N., Padilla, M., Kohlenberg, B. S., Fisher, G., et al. (2004). The impact of acceptance and commitment training and multicultural training on the stigmatizing attitudes and professional burnout of substance abuse counselors. Behavior Therapy, 35(4), 821–835.Find this resource:
Hayes, S. C., & Lillis, J. (2012). Acceptance and commitment therapy. (Theories of Psychotherapy Series). Washington, DC: American Psychological Association.Find this resource:
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: 1–25. doi:10.1016/j.brat.2005.06.006Find this resource:
Hayes, S. C., & Smith, S. (2005). Get out of your mind and into your life: The new acceptance and commitment therapy. Oakland, CA: New Harbinger.Find this resource:
Hayes, S.C., Strosahl, K. D., & Wilson, K.G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed). New York, NY: Guilford Press.Find this resource:
Hayes, S. C., Wilson, K. G., Gifford, E. V., 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(4), 667–688.Find this resource:
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Levitt, J., Brown, T. Orsillo, S., & Barlow, D. (2004). The effects of acceptance versus suppression of emotion on subjective and psychophysiological response to carbon dioxide. Behavior Therapy, 35(4), 747.Find this resource:
Long, D. (2012, November 29). Joanne Steinwachs, first social worker peer-reviewed as an ACT trainer, tells her journey. [Interview]. Retrieved April 2, 2013, from http://contextualpsychology.org/joanne_steinwachs_first_social_worker_peerreviewed
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Montgomery, K. L., Kim, J. S., & Franklin, C. (2011). Acceptance and commitment therapy for psychological and physiological illnesses: A systematic review for social workers. Health & Social Work, 36(3), 169–181.Find this resource:
O'Brien, K. (2011, August) Evaluating the effectiveness of a parent training protocol based on an ACT philosophy of parenting. (Unpublished doctoral dissertation). University of North Texas, Dallas, TX.Find this resource:
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Twohig, M.P. & Woods, D.W. (2004). A preliminary investigation of acceptance and commitment therapy and habit reversal as a treatment for trichotillomania. Behavior Therapy. 35, 803–820.Find this resource:
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Walser, R. D., & Westrup, D. A. (2007). Acceptance and commitment therapy for the treatment of post-traumatic stress disorder and trauma-related problems: A practitioner's guide to using mindfulness and acceptance strategies. Oakland, CA: New Harbinger.Find this resource:
Wilson, K. G., Sandoz, E. K., Kitchens, J., & Roberts, M. E. (2010). The Valued Living Questionnaire: Defining and measuring valued action within a behavioral framework. The Psychological Record, 60, 249–272.Find this resource:
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Further Reading
Austin, J. (2006). Acceptance and mindfulness at work: Applying acceptance and commitment therapy and relational frame theory to organizational behavior management. Journal of Organizational Behavior Management, 26(1/2).Find this resource:
Bach, P. A., & Moran, D. J. (2008). ACT in practice: Case conceptualization in acceptance & commitment therapy. Oakland, CA: New Harbinger.Find this resource:
Baer, R. A. (2010). Assessing mindfulness & acceptance processes in clients: Illuminating the theory & practice of change. Oakland, CA: New Harbinger.Find this resource:
Blackledge, J. T., Ciarrochi, J., & Deane, F. P. (Eds.). (2009). Acceptance and commitment therapy: Contemporary theory, research and practice. Brisbane, Australia: Australian Academic Press.Find this resource:
Bond, F. (2009). Acceptance and commitment therapy: Distinctive features. York, NY: Routledge.Find this resource:
Ciarrochi, J., Bailey, A., & Hayes, S. C. (2008). A CBT practitioner's guide to ACT: How to bridge the gap between cognitive behavioral therapy & acceptance & commitment therapy. Oakland, CA: New Harbinger.Find this resource:
Dewane, C. (2008). The ABCs of ACT: Acceptance and commitment therapy. Social Work Today, 8(5), 34.Find this resource:
Eifert, G., & Forsyth, J. (2009). Acceptance and commitment therapy for anxiety disorders: A practitioner's guide to using mindfulness, acceptance, and values-based behavior change strategies. Oakland, CA: New Harbinger.Find this resource:
Fletcher, L., & Hayes, S. C. (2005). Relational frame theory, acceptance and commitment therapy, and a functional analytic definition of mindfulness. Journal of Rational–Emotive & Cognitive–Behavior Therapy, 23(4), 315–336.Find this resource:
Follette, V., Heffner, M., & Pearson, A. (2010). Acceptance and commitment therapy for body image dissatisfaction: A practitioner's guide to using mindfulness, acceptance, and values-based behavior change strategies. Oakland, CA: New Harbinger.Find this resource:
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.Find this resource:
Hall, M. L., & Palm, K. M. (2004). Acceptance-based treatment for smoking cessation. Behavior Therapy, 35(4), 689–705.Find this resource:
Harris, R. (2009). ACT made simple: An easy-to-read primer on acceptance and commitment therapy. Oakland, CA: New Harbinger.Find this resource:
Hayes, S. C., Barnes-Holmes, D., & Roche, B. (2001). Relational frame theory: A post-Skinnerian account of human language and cognition. New York, NY: Kluwer Academic/Plenum.Find this resource:
Hayes, S. C., Berry, K., Niccolls, R., Bissett, R., Roget, N., & Padilla, M. (2004). The impact of acceptance and commitment training and multicultural training on the stigmatizing attitudes and professional burnout of substance abuse counselors. Behavior Therapy, 35(4), 821–835. doi:10.1016/S0005-7894(04)80022-4Find this resource:
Hayes, S. C., Follette, V. M., & Linehan, M. M. (Eds.). (2004). Mindfulness and acceptance: Expanding the cognitive–behavioral tradition. New York, NY: Guilford Press.Find this resource:
Hayes, S. C., & Levin, M. (Eds.). (2012). Mindfulness and acceptance for addictive behaviors: Applying contextual CBT to substance abuse and behavioral addictions. Oakland, CA: Context Press.Find this resource:
Hayes, S. C., Levin, M. E., Plumb-Vilardaga, J., Villatte, J. L., & Pistorello, J. (2011). Acceptance and commitment therapy and contextual behavioral science: Examining the progress of a distinctive model of behavioral and cognitive therapy. Behavior Therapy. doi:10.1016/j.beth.2009.08.002Find this resource:
Hayes, S., & Pierson, H. (2005). Acceptance and commitment therapy. In Encyclopedia of Cognitive Behavior Therapy (pp. 1–4). New York, NY: Springer.Find this resource:
Herbert, J. D., & Forman, E. M. (2010). Acceptance and mindfulness in cognitive behavior therapy: Understanding and applying the new therapies. Hoboken, NJ: Wiley.Find this resource:
Hick, S. F. (2009). Mindfulness and social work. Chicago, IL: Lyceum Books.Find this resource:
McCracken, L. (2011). Mindfulness and acceptance in behavioral medicine: Current theory and practice. Oakland, CA: Context Press.Find this resource:
Orsillo, S. M., & Roemer, L. E. (2005). Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment. New York, NY: Springer Science + Business Media.Find this resource:
Roemer, L., & Orsillo, S. M. (2009). Mindfulness-and acceptance-based behavioral therapies in practice. New York, NY: Guilford Press.Find this resource:
Sandoz, E., Sandoz, E. K., Wilson, K. G., & DuFrene, T. (2011). Acceptance and commitment therapy for eating disorders: A process-focused guide to treating anorexia and bulimia. Oakland, CA: New Harbinger.Find this resource:
Törneke, N. (2010). Learning RFT: An introduction to relational frame theory and its clinical applications. Oakland, CA: New Harbinger.Find this resource:
Turner, F. J. (Ed.). (2011). Social work treatment: Interlocking theoretical approaches (5th ed.) New York, NY: Oxford University Press.Find this resource:
Twohig, M., Pierson, H., & Hayes, S. (2007) Acceptance and commitment therapy. In N. Kazantzis, & L. L'Abate (Eds.), Handbook of homework assignments in psychotherapy: Research, practice, and prevention (pp. 113–132). New York, NY: Springer.Find this resource:
Walser, R. D., & Westrup, D. (2007). Acceptance & commitment therapy for the treatment of post-traumatic stress disorder: A practitioner's guide to using mindfulness & acceptance strategies. Oakland, CA: New Harbinger.Find this resource:
Wilson, K., & DuFrene, T. (2009). Mindfulness for two: An acceptance and commitment therapy approach to mindfulness in psychotherapy. Oakland, CA: New Harbinger.Find this resource:
Wilson, K. G., & Sandoz, E. K. (2008). Mindfulness, values, and therapeutic relationship in acceptance and commitment therapy. In S. F. Hick & T. Bien (Eds.), Mindfulness and the therapeutic relationship (pp. 89–106). New York, NY: Guilford Press.Find this resource:
Wilson, K. G., Sandoz, E. K., Kitchens, J., & Roberts, M. E. (2010). The Valued Living Questionnaire: Defining and measuring valued action within a behavioral framework. The Psychological Record, 60, 249–272.Find this resource:
Wilson, K., Sandoz, E., & Slater, R. (2009). Acceptance and commitment therapy. In A. R. Roberts (Ed.), Social workers' desk reference (2nd ed., pp. 283–293). New York, NY: Oxford University Press.Find this resource:
Woods, D. W., & Twohig, M. P. (2008). Trichotillomania: An ACT-enhanced behavior therapy approach therapist guide (Vol. 1). New York, NY: Oxford University Press.Find this resource:
The author thanks Rebecca S. Traub, MLS, for her invaluable research and editorial expertise.


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Inspired by Haberdashery from designers Paula Barnes and Mary Ellen Robison of Red Crinoline Quilts
Quilt tester: Laura Boehnke; Machine quilter: Vicki Hoth of Handi Quilter
5⁄8 yard red print (blocks, binding)
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Using a vinegar rinse works just as well as Pantene conditioner!
I know it sounds crazy and unbelievable, but excluding that fact that your hair might experience a tiny more static in winter, it's true. After using a vinegar rinse, my hair was shiny, soft, and knot-free. And after it dried there was absolutely no smell. Even my boyfriend didn't notice it when I tested him. How awesome!
My Recipe
Here are the ingredients I used:
- Just under 1 liter of hot water (about 4 cups)
- 3/4 cup vinegar
- 1/4 sprig of rosemary, for fragrance
- 1 bag of chamomile apple tea, for fragrance
In the Shower
Before using my vinegar rinse, I shampooed my hair as usual, and then worked approximately 3/4 of a cup of the vinegar rinse into my hair. Afterwards, I rinsed well and let my hair air dry.
Boyfriend Smell Test
As I mentioned earlier, my boyfriend didn't notice any vinegar smell.
The test: I made sure to wash my hair while he wasn't home so that I could test it on him without him knowing what was going on. When he returned home and my hair was perfectly dry, I walked up to him and nonchalantly tossed my hair in his face (it was sort of funny at the time), and he didn't mention anything. Later, I told him why I did it, and asked him outright if he could smell the vinegar. His response: "No." Awesome! No vinegar smell!
I'm Not Scared Anymore
I'm not out of conditioner yet, but now I know that I no longer need to fear the day when I run out. I will have an effective conditioner to use that is plastic free, environmentally friendly, and healthy.
Additional Resources
- Experiences of a committed vinegar rinse user
- Interesting hair care info from the No' Poo Community
- Homemade beauty recipes from Eden Foods
- Additional natural hair care recipes from Styles 101
- Info on chemicals in shampoo and conditioner from the Green Guide
- More info on the harmful chemicals in shampoo from the Green Guide


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SOUTH PALM DESERT, Calif., Feb. 13 (UPI) -- Actor Ralph Waite died Thursday at his home in South Palm Desert, Calif., a family spokesman told the Hollywood Reporter. He was 85.
The cause of his death was not disclosed.
Best known for playing patriarch John Walton on the family drama "The Waltons," the native New Yorker was an ordained minister and former social worker who also acted in the miniseries "Roots," as well as the TV series "The Mississippi," "Carnivale" and "NCIS. His film credits include "Cool Hand Luke," "Five Easy Pieces," "Lawman," "The Grissom Gang," "Dime Box" and "Sporting Club."
He also founded the Los Angeles Actors Theatre in 1975 and served as its director, the Reporter said.
Waite is survived by Linda East, his third wife; and his daughters Kathleen and Suzanne Waite.


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Camp Delhi, Helmand Province
It's such a simple thing. After fifty plus years you'd think I'd have a handle on it, but I don't. I can't tell my right hand from my left. I have to physically make the writing motion to cue myself. I can add another bit of brain malfunctioning to an ever growing list of idiosyncrasies, the word Delhi, or is it Dehli?
While out here I had occasion to meet an Indian Buddhist German documentary film maker, Ashwin Raman. Ash, as he asks to be called, started his documentary film career with the Marines in Vietnam, and now, days away from his 66th birthday, is marking his retirement with a final trip covering them in Afghanistan. I shared my sketches with him and immediately he chided me for my mis-spelling of Delhi on a couple. I got a few right, but on most I didn't. Even now I have to write it both ways before my brain picks the correct one.
I arrived at Camp Delhi around midnight the night of June 1st on a CH-53 ride from Camp Bastion (or should I say the morning of June 2nd?…no matter). My hosts billeted me in a cave like room with a smokehouse smell and giant cotton candy spider webs in all the corners. Black Widow and Brown Recluse spiders are everywhere here. I got a broom first thing in the morning and reduced the webs to a tangle of fuzz on the bristle ends. Written in the soot covered walls and ceilings are graffiti from both American and British units. Judging by the bullet marks, both inside and out, this place saw heavy fighting. The Brits left a memorial to a bunch of their mates.
Delhi has a shower and I treat myself to one. These are Navy Showers-get wet, turn off water, lather up, turn water back on, rinse. Anything more than a minute's worth of water is a crime. The weak lukewarm stream of water hardly seems worth the effort. Most Marines use the hygiene pit, a matted area with an open square with football size river rocks at the center, and bordered on two sides by makeshift wash stations. At one corner of the pit is a metal brace with a large flare gun-like spigot attached to an oversize hose running to a large rubber bladder containing non-potable water. Each wash station has a mirror and a circular hole cut in the waist high plywood table that accommodates a stainless steel bowl. Each table has spots for six. The bowls are stacked up at the angle where the tables meet. You're expected to rinse yours out when finished. Even in this arachnophobes' worst nightmare of a place there are etiquettes to be followed.
At 0900, after breakfast and some sketching, I meet with the battalion's adjutant and arrange to get manifested on a convoy down to their Weapons Company at FOB Gorgak. Weapons is the furthest south unit in the hotly contested Helmand River Valley.
The poppy harvest is over and the Taliban is flush with cash. I'm eventually heading to the where the sidewalk ends, Patrol Base Karma. Beyond Karma there is nothing but bad guys. Just last week they lost two Marines to an IED along a canal path. In another incident just days before another guy, though he survived, lost all four limbs to a pressure plate bomb.
I have until 1030, when the convoy brief will be held and my vehicle assignment made. I pack up my gear and stage it by a row of huge tan MTAVs and MRAPs. Other Marines waiting for a ride south mill about while convoy drivers and embark guys with a fork lift fill the back of trucks with supply laden palettes.
A closer look at the vehicles reveals a riot of scrapes, dings, bent bumpers and an undercoating of rock hard mud splatter. They're as worn and dirty as the Marines sitting against underinflated tires in the shadows, and trying to catch forty winks in crew cabs stuffed with weapons, body armor, bottles of water and cases of MREs. This place is brutal on man and machine.
Off by the main ECP (entry control point) a patrol is forming up to leave the wire. This is a patrol party that virtually no Hollywood film has yet to capture. This is a FET (female engagement team) mission. Four of the Marines adjusting their gear and weapons are female.
There's a minor statistic that doesn't get a whole lot of play in the coverage of Afghanistan. In fact, based on my own observations, I would classify this bit of information as little more than a rumor. But the Marine Corps, being what it is, has decided to take this data and run with it. This is the unsubstantiated claim I'm referring to; half the population of Afghanistan is women. The mission of the FET Marines is to reach out to them. Those of us here can tell you there's a better chance of encountering a Yeti than an Afghan woman. Be that as it may, the Marines have organized and deployed groups of female jarheads to actively meet with and engage them in the political process.
Sergeant Melissa Hernandez is an MP (military police) by trade. Today she commands a FET. She's as geared up as any Marine I've ever seen, along with a team of two other female Marines and a female Navy corpsman. They're on their way outside the wire to meet with local women. In my humble opinion these women are doing more than the entire National Organization of Women put together.
Michael D. Fay
Michael D. Fay served as combat artist for the United States Marine Corps in multiple campaigns to Iraq and Afghanistan from 2000 to January 2010. His battlefield-inspired art is displayed in the James A Michener Art Museum and in Leatherneck Magazine, the official Marine Corps magazine. His war correspondence has been featured in the New York Times: Times Select and on his blog, Fire and Ice. He is currently embedded with Marines in Afghanistan.


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Dr. Molly Barrow Relationship Tips and Parenting Tips tweets and articles on Twitter
drmollybarrow Check out my latest articles: http://EzineArticles.com/expert/Molly_Barrow
Dr. Molly Barrow holds a Ph.D. in clinical psychology and is the author of Matchlines for Singles, Matchline for Couples, and Malia and Teacup: Awesome African Adventure and Malia and Teacup: Out on a Limb. As an authority on relationship and psychological topics,Dr. Barrow is a member of the American Psychological Association, Screen Actors Guild, and Authors Guild and is a licensed mental health counselor. Dr. Molly has appeared as an expert in the film, My Suicide, documentaries Ready to Explode and KTLA Impact, NBC news, PBS In Focus, WBZT talk radio, and in O Magazine, Psychology Today, Newsday, New York Times, CNN, The Nest, MSN.com, Yahoo, Match.com, Women's Health, Harvard Business School, Women's World, has a radio show on blogtalkradio.com and is a columnist for Menstuff.org.


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Football is done, now it's racing season
During Super Bowl XLV, I caught myself getting excited over the Daytona 500 commercials that were shown.
For those who have read my columns in the past, you know about my love for sports, including NASCAR. Well, when I saw those promos during the Super Bowl, I could not help but start thinking about the coming season that kicks off on Sunday.
You can bet that on Sunday, I will be in front of the television watching my favorite event of the season.
There is nothing quite like the Daytona 500. Even if you don't like racing, Daytona is a special race, and fun to watch.
Because of the size of Daytona International Speedway, the engines of the cars have to be restricted to keep speeds safe. This causes pack racing. Cars can't escape from the pack, and 20 to 30 cars get bunched up for all 500 miles.
By the time the cars come off of turn four on the last lap, a potential winner is still up in the air.
Another great thing about the Daytona 500 is that unpredictability. Last year, no one could have predicted that Jamie McMurray would win the race, but he did.
Personally, I think that this is going to be one of the most competitive seasons in NASCAR history. But until Jimmie Johnson gets defeated for the series championship, he has to be the favorite to win it all again.
Some up-and-coming drivers that could make a run at making the Chase for the Championship that fans should keep an eye on include Michigan's Brad Keslowski, A.J. Allmendinger, and Joey Logano. I expect all of these drivers to be in the top 15 by season's end.
As for true championship contenders, I have my list down to five drivers.
The first driver on the list is Johnson. Like I said, he is the favorite until someone can stop his five-year run as champion. I also like Denny Hamlin to challenge for the crown, much like he did last season. I believe his close loss to Johnson in the season's final race will only make him stronger.
I don't want to play favorites, but I think that, my favorite driver, Tony Stewart is close to being a top three contender once again. People forget how dominant he was in 2009 before his performance tailed off at the end of the season. With his equipment coming from Hendrick Motorsports, he has the best stuff under the hood, and his colleagues still claim that he is the most talented driver in the sport.
My top two drivers to challenge Johnson this season are Carl Edwards and Kevin Harvick. Edwards has always had the talent, but now it appears that Roush-Fenway Racing has made strides with their engine power and will be tough to beat this season.
As for Harvick, he proved last year that he was the most consistent driver in NASCAR. If he can repeat that consistency again this year, he will find himself in the hunt once more.
As for this Sunday, I will pick two drivers. One as a favorite, a second as a dark-horse pick. Someone people might think has no chance to win.
I think the winner will be Kyle Busch. He has been strong at Daytona in the past, and I think this year he will be the man to beat. My dark-horse is Allmendinger. A.J. was close in last season's Daytona 500; look for him to be in the top 5 with five laps to go.
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I will be watching Jeff Gordon take the checkered flag Sunday!
I was wrong, Jeff didn't win in Daytona, but he did win last Sunday! Jeff


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No matter where you live or who you are, dirt and grime are inescapable facts of life. As such, we all need to clean—and we spend a significant amount of time keeping our homes and clothes clean and fresh. In a Nielsen online survey about home-cleaning and laundry habits, nearly one-third of global respondents (31%) say they clean every day, and the same percentage (31%) say they do laundry daily.
"While cleaning is a common (and essential) practice everywhere around the globe, a one-size-fits-all strategy to get the job done doesn't work globally," said Sarah Peters, Nielsen Global Business Partner. "Home-care habits and preferences vary widely around the world. Taking an 'under-the-covers' look at today's in-home practices, coupled with an understanding of the larger forces influencing the home-care industry, provides insight about the products consumers want and need—now and in the future."
The Nielsen Global Home-Care Survey polled more than 30,000 online respondents in 61 countries to understand cleaning and laundry behaviors and sentiments around the world. We examine who's cleaning, the tools they're using and the benefits they're looking for in home-care products. We also explore the underlying macroeconomic forces affecting the home-care industry, and we offer insights into how to adapt to the changing environment by aligning offerings to consumer needs and desires.
When it comes to home care, who does the majority of the cleaning? Perhaps not surprisingly, it's predominantly still women. Around the world, 44% of respondents say the female head of household does the majority of cleaning, with the highest percentages in Europe and Africa/Middle East (49% each).
But even if they aren't leading the charge, men are sharing some of the load. Globally, 28% say housecleaning is a shared responsibility between the two heads of the household, and 17% of respondents say men do the majority of cleaning. In North America, men are contributing to the cleaning duties at the highest response levels: Nearly one-third of respondents (32%) say the male head of household does the majority of the cleaning, nearly double the global average.
Responsibility for product purchasing largely mirrors who is doing the cleaning—with even greater female influence. More than half of global respondents (51%) say the female head of household buys the majority of cleaning products. Nearly one-quarter (23%) say it's a shared responsibility, and slightly fewer (21%) say the male head of household is responsible for the majority of purchasing. Just as North America has the highest percentage of men who are primarily responsible for cleaning, the region also has the highest percentage of respondents who say men purchase cleaning products. One-third of North American respondents (33%) say the male head of household is primarily responsible for buying these items, 12 percentage points above the global average.
"The perception that home care is only women's work is inaccurate," said Peters. "The female head of household remains a key stakeholder in the cleaning process in many homes, but as more men play an active role in housework, marketing strategies need to reflect a more balanced approach—from product innovations to marketing messages. This will require a deeper understanding of how each gender approaches the task of cleaning and where gaps in current offerings may exist."
As males continue to take a more active role in housework, they present a strong growth opportunity. Perhaps products with masculine fragrances or rugged packaging designs are opportunities worth considering, but unlocking the segment's true potential will come from an in-depth understanding of how these users' needs aren't being met. In addition, marketers need to understand what motivates brand choice. Brands with higher equity tend to get considered more often, and typically represent a greater share of consumers' purchase requirement. For both men and women, brand choice is emotional and rational. To win consumers' hearts and minds, marketers need to capture attention and engage consumers to drive them to take action.
Other findings from the global Home Care report include:
For more detail and insight, download Nielsen's Global Home-Care Report. If you would like more detailed country-level data from this survey, it is available for sale in the Nielsen Store.
The Nielsen Global Home-Care Survey was conducted Aug. 10-Sept. 4, 2015, and polled more than 30,000 online consumers in 61 countries throughout Asia-Pacific, Europe, Latin America, the Middle East/Africa and North America. The sample includes Internet users who agreed to participate in this survey and has quotas based on age and sex for each country. It is weighted to be representative of Internet consumers by country. Because the sample is based on those who agreed to participate, no estimates of theoretical sampling error can be calculated. However, a probability sample of equivalent size would have a margin of error of ±0.6% at the global level. This Nielsen survey is based only on the behavior of respondents with online access. Internet penetration rates vary by country. Nielsen uses a minimum reporting standard of 60% Internet penetration or an online population of 10 million for survey inclusion.


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Sunday Sweets: Eastern Elegance
As you may know, Jen and I are at Dragon*Con this weekend, which means we are geeking out with the geekiest geeks in all of geekdom. Which is exactly why today's Sweets are the most elegant, Eastern-inspired cakes we could find. (See, I'm actually having nightmares about being chased through cavernous hotels by roving packs of storm troopers in kilts. Which is not only possible, but actually likely.)
So, onward and upward!
One of the things I most admire about Eastern tradition is the art of Henna, which works amazingly well on cake. Check it out:
I absolutely love the detail. And the elephants. (Which are edible.) But really, who doesn't love elephants? I mean, think about it. When is the last time you saw an elephant that wasn't doing something absolutely lovable? See? Never!
The bead work on this is fantabulous.
And for a little bit of structural goodness...
You can never go wrong with cobalt blue and gold. Beautiful.
Next, going a little further East for inspiration:
I love the texture on this cake. It's so... fabricy. (not entirely sure that's a word)
Some fabulous hand-painting:
A Kimono-inspired beauty:
And a tiara:
Finally, we were invited by the lovely folks at Highland Bakery to stop by while we're here in Atlanta, but I don't think we're gonna make it. Which is a shame, because they do stuff like this:
Yeah, I think we'll have to come back here some day.
Well, there it is! Next week we may be fully recovered from geek overload, so we'll probably do something really geeky with, I don't know, gears or capes or something. Until then, please send your nominations and ideas to sundaysweets (at) cakewrecks.com. And Wreck On!


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"Worms", Annelida etc
Taken in the Mediterranean around the southern Peloponnese (Greece) between 0 to 5 m water depth (I am no diver). Built in macro-mode, small size and flash allows imagery in small spaces where a bulky DSLR can not. So naturally small attached stuff is better than large moving objects. For info on camera type and locality please see individual images. I tried to keep the taxonomy as correct as possible. If you spot errors or have suggestions, please keep me updated.Read More


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Active Voice: Understanding Physical Activity for Asthmatic Patients
By Celso R.F. Carvalho, Ph.D., P.T., P.E. Share
Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily reflect positions or policies of ACSM.
Celso R.F. Carvalho, Ph.D., P.T., P.E., is Associate Professor in the Department of Physical Therapy, School of Medicine, at the University of São Paulo, Brazil. His research focus includes the benefits of aerobic exercise training in patients with persistent asthma. In the Feb. 2011 issue of Medicine & Science in Sports & Exercise® (MSSE), Dr. Carvalho coauthored related research entitled "Effects of Aerobic Training on Airway Inflammation in Asthmatic Patients."
Ten years ago, an asthmatic patient's mother asked me if her daughter could participate in sports and what benefits her daughter would obtain by exercising. The mother was afraid because some physicians recommended exercise for her daughter while others strongly suggested she avoid it. At the time, I did not know the answer, so I searched the literature, finding a systematic review showing that the only recognized benefits of exercise for asthmatic patients were increases in aerobic exercise capacity and reductions in the perception of dyspnea. However, the same review suggested there were more questions than answers. After that, I decided to begin a research program to determine the benefits of exercise for asthmatic patients. More
Headlines include recent stories in the media on sports medicine and exercise science topics and do not reflect ACSM statements, views or endorsements. Headlines are meant to inform members on what the public is reading and hearing about the field.
The Most Dangerous Thing You'll Do All Day
Men's Health (via Yahoo) Share
We stand around a lot here at Men's Health. In fact, a few of us don't even have office chairs. Instead, we write, edit, and answer emails—a lot of emails—while standing in front of our computers. All day long. Why?
It all started last summer, when Assistant Editor Maria Masters came across a shocking study in the Medicine & Science in Sports & Exercise (one of dozens of research journals we comb each month as we put together the magazine). Scientists at the Pennington Biomedical Research Center in Louisiana analyzed the lifestyles of more than 17,000 men and women over about 13 years, and found that people who sit for most of the day are 54 percent more likely to die of heart attacks. More
Early Milk Helps Athletic Performance, Research Finds
BBC News Share
Early milk is produced by cows in the 48 hours after giving birth
Drinking milk produced by cows in the 48 hours after giving birth could enhance athletic performance, scientists have found.
Athletes given early milk for two weeks before a trial had a big reduction in a rise in "gut leakiness". More


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TELL CITY – Cassandra Baumeister will graduate Saturday, May 14 from Kentucky Wesleyan College with a bachelor's degree in education with an emphasis on special education K-12 and social studies.
During her time at Kentucky Wesleyan College, she maintained a 3.40 grade average and was on the dean's list for seven semesters.
She was one of 38 nominees for the Oak and Ivy Award during the 2008-09 school year, of which four students received the award.
She is currently working at Cannelton High School as a part-time teacher.
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Video Tutorial: MAC To the Beach Look & How-to Apply Cream Bronzers
Video Tutorial: MAC To the Beach Look & How-to Apply Cream Bronzers
As promised, here's a tutorial of the look I did yesterday. It also includes a section where I talk about how I applied the new Cream Bronzer. Oh, and how to tone your blush down if you overdo it… 🙂 You can check out still photos and text directions over here.
Oh, and don't forget to SUBSCRIBE 🙂
You will need the following…
- Eyes: Shiseido Lemon Sugar Hydra Eyeshadow (soft lemon base), MAC Sweet & Punchy Eyeshadow (yellowed chartreuse), MAC Firecracker Eyeshadow (orange-coral), MAC Sand & Sun Eyeshadow (matte peach), MAC Femme-fi Eyeshadow (highlighter), MAC Amber Lights Eyeshadow (copper), MAC Float on By Eye Kohl (marine blue), Dior Extase Mascara (black)
- Face: Make Up For Ever HD Foundation (140), Laura Mercier Loose Setting Powder (translucent)
- Cheeks: MAC Beach Bronze Cream Bronzer (sheer bronze), MAC Marine Life High Light Powder (coral-red)
- Lips: MAC Thrills Lipstick (copper rose), MAC Flurry of Fun Lipglass (sheer tangerine)
- Brushes: 249 (flat, firm brush), 239 (fluffy shadow brush), 226 (fluffy crease brush), 219 (pointed crease brush), 116 (dense blush brush)
- Substitutes: Sweet & Punchy = Sour Lemon; Firecracker = Red Brick; Sand & Sun = Samoa Silk; Femme-fi = Shroom; Float on By = Urban Decay Deviant + Flipside; Beach Bronze = no dupe; Marine Life = NARS Deep Throat; Thrills = La Prairie Rose Bronze; Flurry of Fun = Reflects Transparent Teal + Enchantress


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How well do you know the Code? Think you can spot violations the original installer either ignored or couldn't identify? Here's your chance to moonlight as an electrical inspector and second-guess someone else's work from the safety of your living room or office. Joe Tedesco, who has a knack for finding shoddy electrical work, did the dirty work and found this mess. Now it's your turn to identify the violation.
Find the Answer
Peter A. Brengosz, P.E., senior engineer, Electrical/Process Controls, Marathon Engineers/Architects/Planners, LLC, Appleton, Wis., sent in these comments. "The picture shows an outlet box with a surface extension allowing the addition of a surface metal raceway (or surface nonmetallic raceway)."
However, he notes the following problems with the installation. "The receptacle and surface extension do not appear to be securely fastened in place, as per 314.23(A). The surface metal raceway is not securely fastened to the box extension. Section 386.30 states that surface metal raceways shall be supported at intervals in accordance with manufacturer's installation instructions. I'm sure the instructions do not call for a gap at the box, thus exposing conductors. And since the equipment is not 'installed in a neat and workmanlike manner,' the installation violates Section 110.12."
In addition to pointing out two of the three violations noted above by Brengosz, James W. Robertson, Jr., master electrician, J.E.C. Electric, Inc., Ft. Wayne, Ind., added this to the mix. "Per 386.100 surface raceways shall be electrically and mechanically coupled without the possibility of conductors being damaged. Per 314.22 the extension ring must be mechanically secured on a flush box."
Mike Whitco, maintenance electrician, Wheeling Corrugating, Beech Bottom, W. Va., believes the metal surface raceway box that dropped from its original position violates NEC rules in Article 386 and 300.11(A), which in part states, "Raceways, cable assemblies, boxes, and fittings shall be securely fastened in place".
Whitco also added, "This violation caused another violation by exposing the wires through the gap created between the box and raceway — 300.12 calls for mechanical continuity between the box and raceway."
There's one other important Code requirement to make note of here. As per 422.51, "Cord-and-plug-connected vending machines manufactured or re-manufactured on or after January 1, 2005, shall include a ground-fault circuit-interrupter as an integral part of the attachment plug or located in the power supply cord within 300 mm (12 inches) of the attachment plug. Cord-and-plug connected vending machines not incorporating integral GFCI protection shall be connected to a GFCI-protected outlet."


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Image was shot in Olympic National Park, WA in 2000.
Capturing a Moment of Experience For me, photography has always been an extension of my travels and of my curiosity. Unlike the artistry of most landscape and commercial photographers, early in my journey with photography, time did not always allow me to seek perfect conditions, take repeated exposures, or make numerous adjustments to the configuration and settings of my equipment. As a result, my early photographs are not so much artifacts, but rather attempts to record a brief moment of my own experience. The angle, hour, lighting, and weather didn't always cooperate. It was serendipity that the composition, color, emotion, and subject matter of some of the thousands of photographs I have taken successfully captured the moment as I...
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