What is this thing called “ACT?”

First things first, let me start by clarifying what Acceptance and Commitment Therapy (ACT) is and is not.

ACT is a behavior therapy from the beginning to the end. Pause for a second and check with your mind what the words “behavior therapy” mean to you. I don’t know how familiar you are with different types of therapy, but behavior therapy can be a loaded term for some people. 

Most people understand it as a therapy approach that focuses on action, goals, or steps; there are some opinions that behavior therapy doesn’t take into consideration feelings, is robotic, ignores the relationship between client and therapist, dismiss family history, and focuses excessively in collecting data. Also, there is idea that behavior therapists can be like robots and do robotic things with clients (oh boy, did I capture all those misconceptions, or do you have a new one?).

Here is a big clarification: There is no question that ACT, as a behavior therapy, invites you to take action in your day-to-day living, but, there are specific characteristics that make ACT unique and different than any other behavioral therapy: 

ACT doesn’t just ask you to take any action or random actions; before asking you to take any action, ACT asks you to check the big picture stuff about what sort of person you want to be, invites you to get in touch with what gives you meaning, challenges you to figure out what you want to stand up for, and then, encourages you to take action based on to what truly matters to you. Pretty neat, right?

ACT teaches you to make room for the yucky stuff – disturbing obsessions, fears, worries – that shows up under your skin, and instead of pretending they are not there, or putting all your efforts to get rid of them, you learn to put all your energy on moving with your feet, hands, and mouth towards what matters to you.

Let’s put OCD episodes aside for a second, and bear with me for a moment while I elaborate more on what ACT is about. To start, think about this, how often does your mind come up with a variation of a story that you’re not good enough, you don’t know what you’re doing, or you’re not attractive enough, and so on?  How often do you feel overwhelmed by life circumstances to the point that you feel like screaming full longs? Have those stories every disappeared from your mind? Have those feelings stop coming your way? You may have managed to distract yourself from them by watching TV, listing your areas of success, or maybe even asking others about your accomplishments, but until the day you die, those narratives, those overwhelming feelings, those unbearable moments of panic are likely to show up. ACT doesn’t teach you to act as if those stories are not there, to power through those annoying emotions, to fake it until you make it. ACT, at its core, teaches you to develop a new relationship with all those painful thoughts, memories, stories, overwhelming feelings and challenging sensations that come your way.

You may be wondering, does that mean I’ll always have obsessions showing up and I can’t change that? 

You’re asking a very important question; my clients and students ask me that exact question often, and my honest response is to invite you to examine for yourself. What has happened each time you hoped to get rid of your obsessions and went out of your way to neutralize them with compulsions, organized your day around them, and made sure to not approach anything that would trigger them? Did your life get better? Did the obsessions go away? The answer to your question is your experience. On my side, I can tell you that those thoughts about not being a good daughter, not being caring enough with my family, or being too passionate about what I do, don’t just disappear; in fact, it’s the opposite, they show up as I’m writing this workbook, when walking on the street, even when I’m spending time with my family, who I deeply care about. Wherever I go, there they are, but, learning to have them – instead of the story having me – has made a humongous difference in my life.

My mind, your mind, and everyone else’s mind have a life of its own, it’s creating thinking patterns all the time, and while they can be extremely handy many times, it can also amplify our struggles a hundred times like a bluetooth speaker, especially if you have an overreactive brain. But, hold on, this doesn’t mean that our minds will constantly be running the show or that if you’re dealing with obsessions, it’s a lost cause, because we can all learn to have a new relationship with our mind: one where our minds don’t bossy us around, telling us what to do or not to do. It’s a relationship in which we just watch all the activity that goes on and on in our minds, including the stinky thoughts and the infamous feelings that come along, and still do the stuff that matters to us. This new relationship with your mind is doable, workable, and amazing things happen when you put into action all those ACT skills in your day-to-day living and simply live your life!

Now, that you got a sense of what ACT is about and what it can do for you, let me briefly tell you about its scientific background: ACT was developed by a group of psychologists, Steven C. Hayes, Kelly Wilson, and Kirk Strosahl in the mid-1980s; since then, ACT has become one of the most prolific and quickly disseminated approaches in clinical psychology, with over 250 randomized clinical trials -the gold standard of research- in less than 30 years. The clinical applications of ACT are too long to list here, but they range from specific psychological struggles, with OCD being one of them, to mental health prevention, behavioral medicine, education, organizational culture, resilience, sports, and so on.

ACT has been applied into different domains besides clinical psychology, because it’s based on functional contextualism, and as such, it seeks to understand human behavior as it happens in a given situation or historical context, which takes into consideration our learning history, biological variables, developmental milestones, and so on. Functional contextualism and ACT principles, therefore, can be applied to every single situation beyond clinical settings because every single human being is constantly interacting in a given context, 24/7, no exceptions!

At its core, ACT aims to promote a rich, meaningful, and purposeful life by fostering flexible responding to all experiences we encounter – including uncomfortable, annoying, and unpleasant stories, thoughts, doubts, feelings, or upsetting obsessions – regardless of anyone’s age, skin color, gender, socio-economic upbringing, relationship status, or religious beliefs.

What about ACT and Exposure Response Prevention?

Exposure is the frontline treatment for tackling OCD and anxiety (Samantaray, Chaudhury, & Singh, 2018). In lay terms, exposure is the process of facing whatever situation, person, sensation, image, or thought you’re scared of; exposure applied to obsessions means learning to face the content of your obsessions. Response prevention is all about preventing compulsions or rituals from happening. 

The first model to explain how exposure work was called the habituation or desensitization model. It posits that for exposure to work and be successful, a person’s level of anxiety needs to decrease within an exposure session and between-sessions. For example, a person scared of taking an elevator would stay in an elevator and taking it back and forth until their anxiety levels reduce to 40% than when they started. 

Over the years, most exposure-treatments, and books written about it, were based on this model. However, despite its success, there were still a significant number of clients that didn’t respond to it, had a relapse, and dropped out from treatment prematurely (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014).

Craske (2013) studied what drives change -mechanisms of change- when facilitating exposure-based interventions. Her studies led her to two findings: (1) demonstrate that a person feeling less anxious is not what makes exposure treatments effective and (2) the development the inhibitory learning model as a new frame to understand how exposure actually works and reconcile with the fact that our brain doesn’t work by subtraction of experiences but by addition of them.

When a person learns a new association between what he’s afraid of -aversive stimuli or obsession- and a new experience of it, that’s called “new safe-association;” with multiple experiences, in different locations, and in different ways, that new safe-association blocks the activation of the old learning. And that’s, how exposure works.

On a theoretical level, ACT capitalizes the research derived from the inhibitory learning model. On a practical level, ACT is already an exposure treatment because, by nature, the whole model invites you to get in touch with what you’re scared, anxious, or nervous about, regardless if you’re dealing with OCD, phobias, social anxiety, depression, and so on.

Even though ACT is an exposure model up front and all the way, certain struggles, like dealing OCD episodes, requires targeted interventions; and that’s how ACT blends with ERP. Within ACT, exposure, or exposure response prevention, is a process of “organized contact with repertoire-narrowing stimuli for the purpose of increasing response flexibility (Harris, 2019). 

Basically, when dealing with disturbing thoughts, ACT, in a targeted manner and blending ACT and ERP principles, teaches you skills to make room for those obsessions when what you care about is at stake in your life, and it encourages you to take step after step towards the life you want to live. 

As you can see, another uniqueness of ACT is that exposure practices are the means -not the goal, of treatment- towards a fulfilling, purposeful, and rich life.