Whereas psychological flexibility is considered to be fundamental to psychological health (beyond the absence of psychological symptoms or ‘disorder’), its opposite, psychological inflexibility, occurs when behavioural repertoires become rigid and insensitive to context, limiting personal and social functioning. ACT therefore aims to increase psychological flexibility, through the six, interconnected core processes demonstrated in the hexaflex below (Figure 4). Here, both the presence and absence of psychological skills are shown, with the model demonstrating both psychological wellbeing and psychopathology. The six-process model informs ACT interventions, with the goal of creating a rich and meaningful life through present-moment contact and valued action; whilst being aware and accepting of painful experiences (Harris, 2006; Hayes et al., 2006). Five ACT process will be outlined briefly, but as acceptance is most relevant to this research, and also underpins many other ACT processes, it will be explored separately in section 1.7.
Figure 4: The ACT hexaflex of psychological wellbeing and psychopathology (adapted from Hayes et al., 2006).
1.6.1 Contact with the Present Moment
Each of the ACT core processes is linked to the present-moment, without awareness of which clients would not benefit from ACT interventions (Hayes, Strosahl, & Wilson, 2011). Contact with the present moment is bringing awareness to what is being experienced in the here-and-now, as it shifts and occurs, i.e. developing an observing self. Through this increased access to direct experience, activities can be focused on and fully engaged with. Such contact has previously been lost, due to preoccupation with avoidance strategies. Language is used to describe and label events as they occur moment-to-moment, noticing them in the present rather than considering the past or future with judgement and prediction. This process enhances our ability
Psychological flexibility / inflexibility
Contact with the present moment / Dominance of conceptualised events
Values / Lack of values clarity Committed action / Inaction Self-as-context / Attachment to the conceptualised self Acceptance / Experiential avoidance Defusion / Cognitive fusion
to be flexible in our interactions with the environment, where they were previously limited by rigid attentional control.
Present moment awareness also requires an accepting stance, in order that there is a receptiveness to focus on and engage with whatever experiences are occurring. Furthermore, present moment awareness, acceptance, and defusion are all processes used in and enhanced by mindfulness: an awareness developed through “paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment” (Kabat Zinn, 2003; see extended paper 1.6.2). With the acceptance of aversive internal experiences, these attentional processes allow a person to pursue valued activities, rather than continuing to engage in problematic avoidance behaviours.
1.6.2 Self-As-Context
Self-as-context, or the ‘observing self,’ is the ability to adopt a perspective- taking position, and so to separate experiences from a sense of self. There is a distinction between a) thoughts and feelings that arise in any given context, and b) the person observing those thoughts and feelings. Thus, a person does not need to be threatened or defined by the content of thoughts and feelings when they occur. ACT uses metaphors, mindfulness, and experiential exercises to develop ‘self-as-context’, thus undermining ‘self-as-content,’ and enhancing psychological flexibility.
1.6.3 Defusion
Cognitive defusion is the process by which the undesirable function of thoughts and private events is altered, shifting a person’s relationship to those experiences, rather than attempting to alter the form or content of the events themselves. This is achieved by creating contexts within which the unpleasant functions become lessened, and the dominance of relational frames over behaviour become weakened. Cognitive fusion is the state where people take their thoughts literally, leading their behaviour to become excessively ‘rule governed.’
In defusion, thoughts, memories, and images are mindfully observed and perceived as those very occurrences, rather than as truths or rules to be obeyed. An example of this might be learning to separate the thought “I am a bad person and do not deserve to be happy” from noticing “I am having the thought that I am a bad person who does not deserve to be happy.” Techniques which encourage defusion include repeating words until they become only sounds, thanking the mind for a thought, and acting in a way that contradicts the thought. By reducing the literal attributes of thoughts, people become able to respond to what the thought or image represents (some words strung together in a sentence; a picture in the mind), rather than to the content as bona fide truth. Word repetition has been shown to decrease the believability of self- attacking thoughts, as well as the distress they once evoked (Masuda, Hayes, Sackett, & Twohig, 2004).
1.6.4 Values
Goals in ACT are informed by values, i.e. what truly matters to a person in terms of their life and what is meaningful to them. Values are seen as chosen life directions, described by Hayes and Smith (2005) as being qualities joining a string of unfolding actions together into a meaningful path. Values can never be entities that are owned or achieved, but rather guide actions and are something that is worked towards in an ongoing manner. Values are therefore overarching directions, whereas goals are temporary, concrete, measurable entities which act as milestones and can be used to monitor progress in living a valued life. ACT interventions are evaluated by the extent to which a person is reaching goals and acting in line with their chosen values, and whether they are successfully changing their behaviour in order to do so.
Although they have benefits in themselves, mindfulness and acceptance processes in ACT are not standalone exercises. They are employed with the aim of helping a person to live a values-consistent life. ACT places great emphasis on striving towards values (which are often defined on domains such as relationship; career; friendship; leisure; health), which practitioners can use in motivating people to experience the pain and aversive experiences they have
previously attempted to avoid, in the service of working towards a more meaningful life.
1.6.5 Committed Action
Committed action is behaviour undertaken to achieve goals and work towards verbally-stated personal values, i.e. the translation of values into behaviours. Behaviour change in ACT is subject to many traditional behavioural techniques which increase or decrease the frequency of certain behaviours, such as positive reinforcement and exposure (Hayes et al., 2006). However, ACT processes of acceptance and awareness can add an advantage in addressing potential barriers to change, for example when values-consistent behaviour will involve making contact with feared experiences, or when previous attempts to do so have been unsuccessful. Furthermore, as each of the ACT processes are interdependent, it is unlikely that valued, committed action would be taken successfully until a person gains the psychological flexibility required to become more sensitive to reinforcement contingencies, as this ability is compromised when under rigid, rule-governed control (Hayes et al., 2011). The successful enactment of, and choosing of, values is therefore contingent on each of the other ACT processes, which in turn are best understood and undertaken in the context and service of valued action (as represented by Figure 4).