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Acceptance and commitment therapy for long-term conditions

Acceptance and commitment therapy (ACT) is underpinned by relational frame theory (RFT) and applied behavioural analysis (ABA). It uses acceptance and mindfulness strategies, together with commitment and behaviour change strategies, to improve psychological flexibility (Hayes et al. ,1999).

ACT is considered a newer, third wave of CBT. There are six processes involved in ACT (Hayes et al., 2013; Harris, 2019):

Acceptance: acceptance encourages action that will lead to more-positive results. In other words, acceptance is an active choice to allow natural negative experiences to occur without trying to avoid or change them.

Cognitive defusion: cognitive defusion relates to techniques aimed at changing an individual's reactions to their thoughts and feelings, rather than changing the nature of those thoughts and feelings. Rather than limiting negative experiences, ACT focuses on facing these experiences but changing the way these experiences may guide behaviour and feelings.

Being present: being present involves being actively aware of the present moment without attaching judgement to that experience.

Self as context: self as context outlines that we are more than our experiences. We are not what happens to us.

Values: values involve the qualities and ideals that are important to us and that we find fulfilment in working towards.

Committed action: committed action involves the therapist supporting the client to commit action that will further their goals, through positive behaviour change. This can be considered through:

An example of committed action might be as follows:

Although ACT is traditionally face to face, it can also be delivered in other formats, including self-help (French et al., 2017).

Efficacy of ACT

While there is less evidence of the efficacy of ACT, compared with CBT , research has indicated that ACT is effective in improving outcomes in psychological conditions and in chronic disease (Bai et al., 2020; Brassington et al., 2016; Gloster et al., 2020; Graham et al., 2016). Considering that ACT is used clinically, more high-quality studies (i.e. randomised controlled trials) are needed. This evidence will come with time; the evidence base for CBT has been developed over a long period of time, so while there is less evidence for the efficacy of other approaches, this doesn't mean that other approaches do not work.

Further reading

This paper from Graham et al. (2016) provides a good brief overview of CBT and ACT in LTCs and is available via the Digital Reading List:

Graham, C. D., Gouick, J., Krahé, C., & Gillanders, D. (2016). A systematic review of the use of acceptance and commitment therapy (ACT) in chronic disease and long-term conditions. Clinical Psychology Review, 46, 46–58.

An example of ACT applied to chronic pain

Chronic pain is defined by the International Association for the Study of Pain (IQASP, 2023) as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage". Chronic pain is pain that continues for more than 12 weeks despite medication or treatment (NHS Inform, 2023). Chronic pain can affect people with a range of LTCs, including diabetes, arthritis and irritable bowel syndrome.

Godfrey et al. (2020) outlined that physical therapy informed by ACT was related to significantly better functioning compared with standard physiotherapy care in patients with chronic lower back pain. The sessions consisted of two 60-minute face-to-face sessions and a 20-minute telephone call one month after the sessions.

Treatment included identification of values-based goals, individualised physical exercise prescription, examining barriers and facilitators to self-management, and skills training to promote psychological therapy.

The intervention was delivered by trained physical therapists, and the total contact time was designed to be similar to the average time that patients with lower back pain received as part of standard physical therapy care.

The study indicated that including ACT in standard care for patients with chronic lower back pain was feasible and well tolerated by patients and healthcare practitioners.

Further reading

Much research has examined the impact of ACT on chronic pain. You may wish to read an overview from McCracken et al. (2014), which provides a good overview of the literature on ACT and chronic pain:

McCracken, L. M., & Vowles, K. E. (2014). Acceptance and commitment therapy and mindfulness for chronic pain: Model, process, and progress. American Psychologist, 69(2), 178–187.

Strengths and limitations of ACT

Click to view a few of the strengths and limitations of ACT:

ACT is person centred and relates to the individual's specific needs. It encourages the development of patterns of behaviour linked to the client's values by setting achievable goals

ACT is considered as efficacious as traditional CBT

ACT is not suitable for people with impaired cognitive functioning (difficulties comprehending and generating answers to routine questions or with no substantive memory of previous conversations)

ACT does not address underlying issues, which can be a barrier to gaining the full effect of ACT

ACT requires an acceptance of the concepts and ideas to put them into practice

CBT and ACT are just two therapies that can be used to improve psychological outcomes in patients with LTCs. There are a range of methods that may be helpful to improve mental health-related and patient-reported outcomes in individuals with LTCs. In the next section, we will discuss mindfulness, meditation and spiritual practices.