1. Acceptance and Commitment Therapy
Scott Clark

2. ACT (Hayes, Masuda & De Mey, in press)
s 1st wave: Behaviour Therapy
focus on direct behaviour change, classical and operant conditioning
1970s 2nd wave: Cognitive Therapy
focus on changing content and frequency of cognitions
1980s 3rd wave: focus on changing relationship with thoughts and feelings – using mindfulness and acceptance strategies
Dialectical Behavior Therapy, Acceptance and Commitment Therapy, Functional Analytic Psychotherapy, Integrative Behavioral Couples Therapy, Mindfulness Based Cognitive Therapy (Hayes and De May, in press)

3. ACT (Morris & Oliver 2009) Psychotherapy technique that:
Attempts to expand a person’s behavioural repertoire by increasing the ability to respond flexibly in response to the opportunities presented by each situation for valued living.
Involves a degree of being in the present moment, connection with the direction given by values, and a letting go of or distancing from the rules and assumptions that can function as barriers to doing what matters.
Some of these rules and assumptions are a by product of/ are inherent in the use of language as thinking and communication.
Attempts to change the social and verbal contexts that link thoughts and feelings with overt action
Russ Harris intro video

4. ACT Developed by Stephen Hayes - 1984 Evolution from behaviourism
Classical and Instrumental conditioning
Learnt verbal and rule-governed behaviour
Functional contextualism (Hayes, Masuda & De Mey, in press)
“ACT conceptualizes psychological events as a set of ongoing actions of a whole organism interacting with historically and situationally defined contexts”.
……. Learning Theory…at mercy of learned associations…focusing on changing cognitions is not enough or can actually be counter productive by reinforcing dysfunctional thinking…..

5. Relational Frame Theory (www.contextualpsychology.org)
Language allows humans to link neutral stimuli such as words/thoughts with events. Pairings/networks can generalise (derived relationships) with reinforcement to become relational frames applied in an arbitary fashion.
Relational networks: If A = B and B = C then A = C
A child experiences seasickness on a boat and then associates the word boat with seasickness.
The child may then learn at school that a "Car Ferry" is a type of boat.
Later, on hearing that she is going on a car ferry, the child may show signs of anxiety despite having had no direct experience with car ferries.
Respondently acquired (conditioned) function of "boat" and the derived relation between "boat" and "car ferry".
The child does not need to experience the possibly aversive consequences of traveling on a car ferry in rough seas, in order to show signs of anxiety.

6. ACT Core Priniciples (Harris 2006)
Goal is psychological flexibility
Defusion
Thoughts/language are not truth/rules/threatening events….person not fused with thoughts….able to observe them….”leaves in the stream”
versus Fusion (Hayes et al. in press)
Behavior is guided more by inflexible verbal networks than by the contingencies of reinforcement in the environment…..reality
focus on:
Literality - treating symbols (e.g.“life is hopeless”) as one would their referents (i.e., a truly hopeless life)
Reason-giving (i.e., basing action or inaction excessively on the constructed “causes” of ones own behavior, especially when these processes point to non-manipulable “causes” such as conditioned private events)
Emotional control (i.e., focusing on proper manipulation of emotional states as a primary goal and metric of successful living)…..? In contrast to CBT

7. ACT Core Priniciples (Harris 2006)
Acceptance
Moment by moment process of actively embracing the private events evoked in the moment without unnecessary attempts to change their frequency or form, especially when doing so would cause psychological harm (Vs avoidance)
Contact with the present moment
Bringing full awareness to your here- and-now experience, with openness, interest, and receptiveness
The “Observing Self”
“A transcendent sense of self encourages clients to experience their own thoughts and feelings and to shift from identifying with the conceptualized self (“I am a bad person”, “I am depressed”)”.
Values
Clarifying what is most important to you; what sort of person you want to be
Committed action
setting goals, guided by your values, and taking effective action to achieve them

8. HEXAFLEX DIAGRAM

9. Acceptance and mindfulness Commitment and behaviour change
HEXAFLEX DIAGRAM
6. … at this time, in this situation?
Acceptance and mindfulness
Commitment and behaviour change
2. … are you willing to have that stuff, fully and without defense …
5. … of your chosen values …
3. … as it is, and not as what it says it is …
4. … and do what takes you in the direction …
1. Given a distinction between Context you and the stuff you are struggling with and trying to change …

10. HEXAFLEX DIAGRAM

11. Techniques (Harris 2006)
Less confrontational manner and less directive forms of verbal interaction, such as metaphor, paradoxes, and experiential exercises, to loosen the entanglement of language/thoughts and the self.
Identify unworkable behaviours and develop suitable metaphors
Homework exercises that highlight the cost of unworkable solutions in respect to valued living

12. Stages (Hayes, Masuda, & De Mey (in press))
Creative hopelessness – explore current strategies in motivational interviewing style - bring client toward new options.
Man in the hole metaphor
Control is the problem, not the solution
Polygraph metaphor
Acceptance as an alternative agenda
Two scales metaphor
Imagine an anxiety provoking situation
Notice its effects on the body
Examine these effects at a distance, “like a scientist”
Allow it to be there regardless of its aversive nature
Highlights the futility of struggle for control and undermines avoidance
Russ Harris exmples
Accepting emotions
Demons on a ship
MAN IN THE HOLE
imagine that they are a person who has been placed in an open field blindfolded with a tool bag to carry and who is told that living a life means running around that field. Unfortunately the field is filled with a variety of large holes. Inevitably, they fall into one of the holes, and are stuck at the bottom, much like they are stuck in the current predicament. After a while they feel inside the tool bag to see if there is something that that would help. It contains nothing but a shovel. So they dig, with big scoop or little, fast scoop or slow. But the hole is not getting smaller, it’s getting bigger. And here they are, seeing a therapist, in the secret hope that therapy is a really huge shovel. But shovels aren’t for getting out of holes – shovels make holes.
POLYGRAPH
Therapist: “Now suppose I have you hooked up to the world’s most sensitive polygraph machine. I want you to imagine that this machine is incredibly effective in measuring anxiety. The task is simple. All you have to do is stay relaxed. However, I know you want to do well, to try hard, so I am going to add an extra incentive here. I will have a loaded .44 Magnum trained at your skull. You must stay calm or I’m going to shoot you. I’ll kill you if you get anxious, which I’ll know you are based on this polygraph. What do you think might happen here? The tiniest bit of anxiety would terrify you, wouldn’t it? Client: Oh man, that is scary to think about. Therapist: It is because you know how difficult it would be to try and keep calm. This is the paradox with controlling emotion. If you aren’t willing to have it, you will.
Two scales
Imagine there are two scales, like the volume knobs on a stereo. One is right out here in front of us and it is called "Anxiety" (Use labels that fit the client's situationsuch as "Anger, guilt, urges, worry," etc. It may also help to move ones hand as if it is moving up and down a numerical scale). It can go from 0 to 10. In the posture you're in, what brought you in here was this: "This anxiety is too high." In other words you have been trying to pull the pointer down on this scale (the therapist can use the other hand to pull down unsuccessfully on the anxiety hand). But now there's also another scale. It's been hidden. It is hard to see. This other scale can also go from 0 to 10 (move the other hand up and down behind your head so you can't see it). What we have been doing is gradually preparing the way so that we can see this other scale. We've been bringing it around to look at it (move the other hand around in front). It is really the more important of the two, because it is this one that makes the difference and it is the only one that you can control. This second scale is called "Willingness." It refers to how open you are to experiencing your own experience when you experience it--without trying to manipulate it, avoid it, escape it, change it, and so on. When Anxiety (or whatever fit to the client) is up here at 10, and you're trying hard to control this anxiety, make it go down, make it go away, then you're unwilling to feel this anxiety. In other words, the Willingness scale is down at 0. But that is a terrible combination. It's like a ratchet or something. When anxiety is high and willingness is low, the ratchet is on and anxiety can't go down. That's because if you are really, really unwilling to have anxiety then anxiety is something to be anxious about. It's as if when anxiety is high, and willingness drops down, the anxiety kind of locks into place. So, what we need to do in this therapy is shift our focus from the anxiety scale to the willingness scale. You've been trying to control anxiety for a long time, and it just doesn't work. It's not that you weren't clever enough; it simply doesn't work. Instead of working on the anxiety scale, we will turn our focus to the willingness scale. Unlike the anxiety scale, which you can't move around at will, the willingness scale is something you can set anywhere. It is not a reaction--not a feeling or a thought--it is a choice. You've had it set low. You came in here with it set low--in fact coming in here at all may initially have been a reflection of its low setting. What we need to do is get it set high. If you do this, I can guarantee that if you stop trying to control anxiety, your anxiety will be low ...[pause] or ... it will be high. I promise you! And when it is low, it will be low, until it's not low and then it will be high. And when it is high it will be high until it isn't high anymore. Then it will be low again. ... I'm not teasing you. There just aren't good words for what it is like to have the willingness scale set high.
Chessboard
It’s as if there is a chess board that goes out infinitely in all directions. It’s covered with different colored pieces, black pieces and white pieces. They work together in teams, like in chess--the white pieces fight against the black pieces. You can think of your thoughts and feelings and beliefs as these pieces; they sort of hang out together in teams too. For example, “bad” feelings (like anxiety, depression, resentment) hang out with “bad” thoughts and “bad” memories; same thing with the “good” ones. So it seems that the way the game is played is that we select which side we want to win. We put the “good” pieces (like thoughts that are self-confident, feelings of being in control, etc.) on one side, and the “bad” pieces on the other. Then we get up on the back of the white queen and ride to battle, fighting to win the war against anxiety, depression, thoughts about using drugs, whatever. It’s a war game. But there’s a logical problem here, and that is that from this posture, huge portions of yourself are your own enemy. In other words, if you need to be in this war, there is something wrong with you. And even though these pieces are in you (they are different facets of your experience), from the level of the pieces they can be as big or even bigger than you. Plus, even though it is not logical, the more you fight the bigger they get. If it is true that “if you are not willing to have it, you’ve got it” then as you fight them they get more central to your life, more habitual, more dominating, and more linked to every area of living. The logical idea is that you will knock enough of them off the board and you eventually dominate them, except your experience tells you that the exact opposite happens. Apparently, the black pieces can’t be deliberately knocked off the board. So the battle goes on. You feel hopeless, you have a sense that you can’t win, and yet you can’t stop fighting. If you’re on the back of that white horse, fighting is the only choice you have because the black pieces seem life threatening. Yet living in a war zone is no way to live.
As the client connects to this metaphor, it can be turned to the issue of the self. Therapist: Now, let me ask you to think about this carefully. In this metaphor,
suppose you aren’t the chess pieces. Who are you? Client: Am I the player? Therapist: That may be what you have been trying to be. Notice, though, that a player has a big investment in how this war turns out. Besides, who are you playing against? Some other player? So suppose you’re not that either. Client: .... Am I the board?Therapist: It’s useful to look at it that way. Without a board, these pieces have no place to be. The board holds them. If you’re the pieces, the game is very important; you’ve got to win, your life depends on it. But if you’re the board, it doesn’t matter if the war stops or not.
Two mountains
Therapist: It’s like this. You and I are both kind of climbing our own mountains of life. Imagine that these mountains are across each other in a valley. Perhaps, as I climb my mountain I can look across the valley, and from my perspective, see you climbing your mountain. What I can offer to you as a therapist is that I can comment from my perspective, to give you my viewpoint from outside of your experience. It is not that you are broken; it is not that I am always skillful with my own barriers. We are both human beings climbing our mountains. There is no person who is “up,” while the other is “down.” The fact that I am on a different mountain means I have some perspective on the road you are traveling. My job is to provide that perspective in a way that helps you get where you really want to go.

13. Stages (Hayes, Masuda, & De Mey (in press))
A transcendent sense of self
Safe to expose yourself to fears
Chessboard metaphor – separated self and avoided psychological content
Defusing language and cognition
Mindfulness exercises: locate self in here and now
“AND” not “BUT” (which implies something is wrong)
Dealing with an unpleasant thought
Simply observe it with detachment
Repeat it over and over, out aloud, until it just becomes a meaningless sound
Imagine it in the voice of a cartoon character
Sing it to the tune of ‘Happy Birthday’
Silently say ‘Thanks, mind’ in gratitude for such an interesting thought
Exercise: Think of a negative self-judgement “(x)” – notice its effect. Compare to “I am having the thought (x)”
MAN IN THE HOLE
imagine that they are a person who has been placed in an open field blindfolded with a tool bag to carry and who is told that living a life means running around that field. Unfortunately the field is filled with a variety of large holes. Inevitably, they fall into one of the holes, and are stuck at the bottom, much like they are stuck in the current predicament. After a while they feel inside the tool bag to see if there is something that that would help. It contains nothing but a shovel. So they dig, with big scoop or little, fast scoop or slow. But the hole is not getting smaller, it’s getting bigger. And here they are, seeing a therapist, in the secret hope that therapy is a really huge shovel. But shovels aren’t for getting out of holes – shovels make holes.
POLYGRAPH
Therapist: “Now suppose I have you hooked up to the world’s most sensitive polygraph machine. I want you to imagine that this machine is incredibly effective in measuring anxiety. The task is simple. All you have to do is stay relaxed. However, I know you want to do well, to try hard, so I am going to add an extra incentive here. I will have a loaded .44 Magnum trained at your skull. You must stay calm or I’m going to shoot you. I’ll kill you if you get anxious, which I’ll know you are based on this polygraph. What do you think might happen here? The tiniest bit of anxiety would terrify you, wouldn’t it? Client: Oh man, that is scary to think about. Therapist: It is because you know how difficult it would be to try and keep calm. This is the paradox with controlling emotion. If you aren’t willing to have it, you will.
Two scales
Imagine there are two scales, like the volume knobs on a stereo. One is right out here in front of us and it is called "Anxiety" (Use labels that fit the client's situationsuch as "Anger, guilt, urges, worry," etc. It may also help to move ones hand as if it is moving up and down a numerical scale). It can go from 0 to 10. In the posture you're in, what brought you in here was this: "This anxiety is too high." In other words you have been trying to pull the pointer down on this scale (the therapist can use the other hand to pull down unsuccessfully on the anxiety hand). But now there's also another scale. It's been hidden. It is hard to see. This other scale can also go from 0 to 10 (move the other hand up and down behind your head so you can't see it). What we have been doing is gradually preparing the way so that we can see this other scale. We've been bringing it around to look at it (move the other hand around in front). It is really the more important of the two, because it is this one that makes the difference and it is the only one that you can control. This second scale is called "Willingness." It refers to how open you are to experiencing your own experience when you experience it--without trying to manipulate it, avoid it, escape it, change it, and so on. When Anxiety (or whatever fit to the client) is up here at 10, and you're trying hard to control this anxiety, make it go down, make it go away, then you're unwilling to feel this anxiety. In other words, the Willingness scale is down at 0. But that is a terrible combination. It's like a ratchet or something. When anxiety is high and willingness is low, the ratchet is on and anxiety can't go down. That's because if you are really, really unwilling to have anxiety then anxiety is something to be anxious about. It's as if when anxiety is high, and willingness drops down, the anxiety kind of locks into place. So, what we need to do in this therapy is shift our focus from the anxiety scale to the willingness scale. You've been trying to control anxiety for a long time, and it just doesn't work. It's not that you weren't clever enough; it simply doesn't work. Instead of working on the anxiety scale, we will turn our focus to the willingness scale. Unlike the anxiety scale, which you can't move around at will, the willingness scale is something you can set anywhere. It is not a reaction--not a feeling or a thought--it is a choice. You've had it set low. You came in here with it set low--in fact coming in here at all may initially have been a reflection of its low setting. What we need to do is get it set high. If you do this, I can guarantee that if you stop trying to control anxiety, your anxiety will be low ...[pause] or ... it will be high. I promise you! And when it is low, it will be low, until it's not low and then it will be high. And when it is high it will be high until it isn't high anymore. Then it will be low again. ... I'm not teasing you. There just aren't good words for what it is like to have the willingness scale set high.
Chessboard
It’s as if there is a chess board that goes out infinitely in all directions. It’s covered with different colored pieces, black pieces and white pieces. They work together in teams, like in chess--the white pieces fight against the black pieces. You can think of your thoughts and feelings and beliefs as these pieces; they sort of hang out together in teams too. For example, “bad” feelings (like anxiety, depression, resentment) hang out with “bad” thoughts and “bad” memories; same thing with the “good” ones. So it seems that the way the game is played is that we select which side we want to win. We put the “good” pieces (like thoughts that are self-confident, feelings of being in control, etc.) on one side, and the “bad” pieces on the other. Then we get up on the back of the white queen and ride to battle, fighting to win the war against anxiety, depression, thoughts about using drugs, whatever. It’s a war game. But there’s a logical problem here, and that is that from this posture, huge portions of yourself are your own enemy. In other words, if you need to be in this war, there is something wrong with you. And even though these pieces are in you (they are different facets of your experience), from the level of the pieces they can be as big or even bigger than you. Plus, even though it is not logical, the more you fight the bigger they get. If it is true that “if you are not willing to have it, you’ve got it” then as you fight them they get more central to your life, more habitual, more dominating, and more linked to every area of living. The logical idea is that you will knock enough of them off the board and you eventually dominate them, except your experience tells you that the exact opposite happens. Apparently, the black pieces can’t be deliberately knocked off the board. So the battle goes on. You feel hopeless, you have a sense that you can’t win, and yet you can’t stop fighting. If you’re on the back of that white horse, fighting is the only choice you have because the black pieces seem life threatening. Yet living in a war zone is no way to live.
As the client connects to this metaphor, it can be turned to the issue of the self. Therapist: Now, let me ask you to think about this carefully. In this metaphor,
suppose you aren’t the chess pieces. Who are you? Client: Am I the player? Therapist: That may be what you have been trying to be. Notice, though, that a player has a big investment in how this war turns out. Besides, who are you playing against? Some other player? So suppose you’re not that either. Client: .... Am I the board?Therapist: It’s useful to look at it that way. Without a board, these pieces have no place to be. The board holds them. If you’re the pieces, the game is very important; you’ve got to win, your life depends on it. But if you’re the board, it doesn’t matter if the war stops or not.
Two mountains
Therapist: It’s like this. You and I are both kind of climbing our own mountains of life. Imagine that these mountains are across each other in a valley. Perhaps, as I climb my mountain I can look across the valley, and from my perspective, see you climbing your mountain. What I can offer to you as a therapist is that I can comment from my perspective, to give you my viewpoint from outside of your experience. It is not that you are broken; it is not that I am always skillful with my own barriers. We are both human beings climbing our mountains. There is no person who is “up,” while the other is “down.” The fact that I am on a different mountain means I have some perspective on the road you are traveling. My job is to provide that perspective in a way that helps you get where you really want to go.

14. Stages (Hayes, Masuda, & De Mey (in press))
Values
Choose life directions in various domains (e.g. family, career, spirituality) while undermining verbal processes that might lead to choices based on avoidance, social compliance, or fusion (e.g. “I should value X” or “A good person would value Y” or “My mother wants me to values x”) (Hayes et al. in press).
The “Bulls eye” (Tobias Lundgren)
Formal assessment of ability to live life according to ones values in:
Work/education
Leisure
Personal Growth/Health
Relationships
Assessment of barriers in each area
Valued action plan addressing each area

16. Stages (Hayes, Masuda, & De Mey (in press))
Willingness and commitment
Development of larger and larger patterns of effective action linked to chosen values.
Identify barriers to achieving values
Similar to traditional behavior therapy
Select the appropriate components:
exposure
skills acquisition
shaping methods
goal setting,
The ACT therapeutic relationship
Two mountains metaphor
MAN IN THE HOLE
imagine that they are a person who has been placed in an open field blindfolded with a tool bag to carry and who is told that living a life means running around that field. Unfortunately the field is filled with a variety of large holes. Inevitably, they fall into one of the holes, and are stuck at the bottom, much like they are stuck in the current predicament. After a while they feel inside the tool bag to see if there is something that that would help. It contains nothing but a shovel. So they dig, with big scoop or little, fast scoop or slow. But the hole is not getting smaller, it’s getting bigger. And here they are, seeing a therapist, in the secret hope that therapy is a really huge shovel. But shovels aren’t for getting out of holes – shovels make holes.
POLYGRAPH
Therapist: “Now suppose I have you hooked up to the world’s most sensitive polygraph machine. I want you to imagine that this machine is incredibly effective in measuring anxiety. The task is simple. All you have to do is stay relaxed. However, I know you want to do well, to try hard, so I am going to add an extra incentive here. I will have a loaded .44 Magnum trained at your skull. You must stay calm or I’m going to shoot you. I’ll kill you if you get anxious, which I’ll know you are based on this polygraph. What do you think might happen here? The tiniest bit of anxiety would terrify you, wouldn’t it? Client: Oh man, that is scary to think about. Therapist: It is because you know how difficult it would be to try and keep calm. This is the paradox with controlling emotion. If you aren’t willing to have it, you will.
Two scales
Imagine there are two scales, like the volume knobs on a stereo. One is right out here in front of us and it is called "Anxiety" (Use labels that fit the client's situationsuch as "Anger, guilt, urges, worry," etc. It may also help to move ones hand as if it is moving up and down a numerical scale). It can go from 0 to 10. In the posture you're in, what brought you in here was this: "This anxiety is too high." In other words you have been trying to pull the pointer down on this scale (the therapist can use the other hand to pull down unsuccessfully on the anxiety hand). But now there's also another scale. It's been hidden. It is hard to see. This other scale can also go from 0 to 10 (move the other hand up and down behind your head so you can't see it). What we have been doing is gradually preparing the way so that we can see this other scale. We've been bringing it around to look at it (move the other hand around in front). It is really the more important of the two, because it is this one that makes the difference and it is the only one that you can control. This second scale is called "Willingness." It refers to how open you are to experiencing your own experience when you experience it--without trying to manipulate it, avoid it, escape it, change it, and so on. When Anxiety (or whatever fit to the client) is up here at 10, and you're trying hard to control this anxiety, make it go down, make it go away, then you're unwilling to feel this anxiety. In other words, the Willingness scale is down at 0. But that is a terrible combination. It's like a ratchet or something. When anxiety is high and willingness is low, the ratchet is on and anxiety can't go down. That's because if you are really, really unwilling to have anxiety then anxiety is something to be anxious about. It's as if when anxiety is high, and willingness drops down, the anxiety kind of locks into place. So, what we need to do in this therapy is shift our focus from the anxiety scale to the willingness scale. You've been trying to control anxiety for a long time, and it just doesn't work. It's not that you weren't clever enough; it simply doesn't work. Instead of working on the anxiety scale, we will turn our focus to the willingness scale. Unlike the anxiety scale, which you can't move around at will, the willingness scale is something you can set anywhere. It is not a reaction--not a feeling or a thought--it is a choice. You've had it set low. You came in here with it set low--in fact coming in here at all may initially have been a reflection of its low setting. What we need to do is get it set high. If you do this, I can guarantee that if you stop trying to control anxiety, your anxiety will be low ...[pause] or ... it will be high. I promise you! And when it is low, it will be low, until it's not low and then it will be high. And when it is high it will be high until it isn't high anymore. Then it will be low again. ... I'm not teasing you. There just aren't good words for what it is like to have the willingness scale set high.
Chessboard
It’s as if there is a chess board that goes out infinitely in all directions. It’s covered with different colored pieces, black pieces and white pieces. They work together in teams, like in chess--the white pieces fight against the black pieces. You can think of your thoughts and feelings and beliefs as these pieces; they sort of hang out together in teams too. For example, “bad” feelings (like anxiety, depression, resentment) hang out with “bad” thoughts and “bad” memories; same thing with the “good” ones. So it seems that the way the game is played is that we select which side we want to win. We put the “good” pieces (like thoughts that are self-confident, feelings of being in control, etc.) on one side, and the “bad” pieces on the other. Then we get up on the back of the white queen and ride to battle, fighting to win the war against anxiety, depression, thoughts about using drugs, whatever. It’s a war game. But there’s a logical problem here, and that is that from this posture, huge portions of yourself are your own enemy. In other words, if you need to be in this war, there is something wrong with you. And even though these pieces are in you (they are different facets of your experience), from the level of the pieces they can be as big or even bigger than you. Plus, even though it is not logical, the more you fight the bigger they get. If it is true that “if you are not willing to have it, you’ve got it” then as you fight them they get more central to your life, more habitual, more dominating, and more linked to every area of living. The logical idea is that you will knock enough of them off the board and you eventually dominate them, except your experience tells you that the exact opposite happens. Apparently, the black pieces can’t be deliberately knocked off the board. So the battle goes on. You feel hopeless, you have a sense that you can’t win, and yet you can’t stop fighting. If you’re on the back of that white horse, fighting is the only choice you have because the black pieces seem life threatening. Yet living in a war zone is no way to live.
As the client connects to this metaphor, it can be turned to the issue of the self. Therapist: Now, let me ask you to think about this carefully. In this metaphor,
suppose you aren’t the chess pieces. Who are you? Client: Am I the player? Therapist: That may be what you have been trying to be. Notice, though, that a player has a big investment in how this war turns out. Besides, who are you playing against? Some other player? So suppose you’re not that either. Client: .... Am I the board?Therapist: It’s useful to look at it that way. Without a board, these pieces have no place to be. The board holds them. If you’re the pieces, the game is very important; you’ve got to win, your life depends on it. But if you’re the board, it doesn’t matter if the war stops or not.
Two mountains
Therapist: It’s like this. You and I are both kind of climbing our own mountains of life. Imagine that these mountains are across each other in a valley. Perhaps, as I climb my mountain I can look across the valley, and from my perspective, see you climbing your mountain. What I can offer to you as a therapist is that I can comment from my perspective, to give you my viewpoint from outside of your experience. It is not that you are broken; it is not that I am always skillful with my own barriers. We are both human beings climbing our mountains. There is no person who is “up,” while the other is “down.” The fact that I am on a different mountain means I have some perspective on the road you are traveling. My job is to provide that perspective in a way that helps you get where you really want to go.

17. Studies of efficacy (Powers et al. (2009))
Metanalysis of 18 (n = 917) randomized controlled ACT trials
Range of conditions:
Psychosis, worksite stress, chronic pain, anxiety and depression, smoking, borderline personality disorder, diabetes self management, polysubstance abuse, weight, drug refractory epilepsy, trichotillomania, math anxiety.
Mixed comparators and outcome measures
ACT better than control (effect size = 0.42).
The average ACT-treated participant was more improved than 66% of the participants in the control conditions.
ACT was superior to:
Waiting lists and psychological placebos (effect size = 0.68)
Treatment as usual (effect size = 0.42)
ACT was not more effective than:
Established treatments - e.g CBT (effect size = 0.18, p = 0.13).

18. Studies of efficacy
Cohen’s convention of small (0.2), medium (0.5), and large (0.8) effects

19. Studies of efficacy (Powers et al. (2009))
When viewed individually only 4 studies had confidence intervals not crossing 0:
Smoking cessation
Supplementation of TAU for borderline PD
Treatment resistant epilepsy
Trichotillomania
Study quality poor
Jadad Scale 0-5
0=1; 1 = 7; 2 = 5; 3 = 5

20. Studies of efficacy Since 2008 (Smout et al. 2012)
Improved coherence and competence montoring
Good studies provide Level II RCT evidence for chronic pain, obsessive–compulsive disorder, and a subset of other anxiety disorders (panic disorder, social phobia, and generalised anxiety disorder)
The majority of studies demonstrated that ACT significantly improved primary outcomes but used comparison conditions that did not rule out therapy-unspecific factors, including use of concurrent treatments, as explanations for the improvements.
Use of treatment as usual unmatched for contact and unmonitored for competence, and unmonitored use of concurrent treatments are the primary factors preventing the attribution of better outcomes for ACT recipients to therapy-specific effects

21. References
Chris Cullen (2008) Acceptance and Commitment Therapy (ACT): A Third Wave Behaviour Therapy Behavioural and Cognitive Psychotherapy, 36, 667–673.
Fletcher L, Hayes S (in press) Relational Frame Theory, Acceptance and Commitment Therapy, and a Functional Analytic Definition of Mindfulness
Harris R (2006) Embracing Your Demons: an Overview of Acceptance and Commitment Therapy. Psychotherapy in Australia 12 (4): 2-8.
Hayes S, Luoma, J, Bond S, Masuda A, and Lillis J (in press) Acceptance and Commitment Therapy: Model, Processes and Outcomes.
Hayes S, Masuda A, and De May (in press) Acceptance and Commitment Therapy and the Third Wave of Behavior TherapyRelational Frame Theory, Acceptance and Commitment Therapy, and a Functional Analytic Definition of Mindfulness
Morris E & Oliver J (2009)ACT Early: Acceptance and Commitment Therapy in early intervention. Power point presentation
Powers M, Vörding M, Emmelkamp P (2009) Acceptance and Commitment Therapy: A Meta-Analytic Review. Psychother Psychosom 78:73–80.
Webster, M. (2011) Introduction to Acceptance and Commitment Therapy. Advances in Psychiatric Treatment 17:
Wilson, K. G. & Murrell, A. R. (In Preparation). Values-Centered Interventions: Setting a Course for Behavioral Treatment. In S. C. Hayes, V. M.. Follette, & M. Linehan (Eds.) (in preparation). The new behavior therapies: Expanding the cognitive behavioral tradition. New York: Guilford Press.
The empirically supported status of acceptance and commitment therapy: An update
Smout, M, Louise Hayes, Atkins, PWB, Klausen, J and Duguid, J E (2012) The empirically supported status of acceptance and commitment therapy: An update. Clinical Psychologist 16 (2012) 97–109
Relational frame theory simplified
Bulls eye values assessment