Mindfulness and Acceptance in Evidence-Based Psychotherapy

Only a small percentage of psychotherapy services in the United States are tightly linked to existing scientific knowledge. It is a bit strange if you think of it. Would anyone want surgery that was not based on a current scientific understanding of the body? Why should the mind and behavior be any different?

This problem has multiple faces. Psychology and psychiatry have a hard time agreeing on what we even mean by mental disorders. There is a proliferation of theories and approaches. Everyone has an axe to grind. Managed care companies have practice guidelines but often they just come down to ways to reduce cost. The American Psychiatric Association has practice guidelines, but medications are so emphasized that as a broad public information service, they are not very useful.

Normally you might hope that government could get reasonable scientists together to say what is known. The fact that economic interests sometimes want a particular answer can make that difficult. But there are at least two government efforts in the US worth noting in the area of psychotherapy, and fortunately both are exploring acceptance and mindfulness-based alternatives in the area of evidence-based care that now give consumers a much wider range of choices.

One worthwhile effort is by the Veteran's Administration to learn how to train, supervise, and monitor the impact of evidence-based practices when they are implemented in the VA system. It is a beautiful and well-organized project. The VA has put millions into selecting a small number of evidence-based methods to deploy throughout their system, training hundreds of clinicians in these methods, measuring whether they have acquired and continue to use the actual skills (not just talk the talk), and then examining whether these methods lead to good outcomes for veterans.

An acceptance and mindfulness-based method we have developed, Acceptance and Commitment Therapy (ACT), is one of a handful of methods the VA has decided to try to roll out into their systems of care, and we are anxiously waiting to hear how it has worked. Within the next year or perhaps two we should learn what happens, positive or negative, when ACT (and other well-known evidence-based methods, such as prolonged exposure or cognitive therapy) are implemented systematically in a large system. It could be a very important series of reports.

Right now in the US, the only publicly available and generally applicable governmental process for recognizing evidence-based mental health interventions is maintained by the U.S. Substance Abuse and Mental Health Services Administration. It is called the National Registry of Evidence-based Programs and Practices (NREPP).

After a three-year review process, last week Acceptance and Commitment Therapy was finally listed by NREPP as an evidence-based practice.

I really like the description of ACT that NREPP produced. It is simple and clear, and shows that there are alternatives in evidence-based care. (For the complete report on ACT, visit samhsa.gov)

Here is how they describe ACT:

Acceptance and Commitment Therapy (ACT) is a contextually focused form of cognitive behavioral psychotherapy that uses mindfulness and behavioral activation to increase clients' psychological flexibility—their ability to engage in values-based, positive behaviors while experiencing difficult thoughts, emotions, or sensations. ACT has been shown to increase effective action; reduce dysfunctional thoughts, feelings, and behaviors; and alleviate psychological distress for individuals with a broad range of mental health issues (including DSM-IV diagnoses, coping with chronic illness, and workplace stress). ACT establishes psychological flexibility by focusing on six core processes:

• Acceptance of private experiences (i.e., willingness to experience odd or uncomfortable thoughts, feelings, or physical sensations in the service of response flexibility)
• Cognitive defusion or emotional separation/distancing (i.e., observing one's own uncomfortable thoughts without automatically taking them literally or attaching any particular value to them)
• Being present (i.e., being able to direct attention flexibly and voluntarily to present external and internal events rather than automatically focusing on the past or future)
• A perspective-taking sense of self (i.e., being in touch with a sense of ongoing awareness)
• Identification of values that are personally important
• Commitment to action for achieving the personal values identified

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I've sometimes said jokingly that ACT is the evidence-based method for people who don't like evidence-based methods. I think this description makes clear that ACT is taking a different path—and yet the data say that it works. If traditional cognitive behavior therapy (CBT) methods have been tried and have failed, there is no reason to give up on scientifically supported methods. ACT and the other acceptance and mindfulness-based forms of "contextual CBT" prove that evidence-based approaches can include a wide variety of methods. Consumers can care about science and still have a choice.

Although perhaps a bit more parochial, you can also get useful information at the clinical division of the American Psychological Association, which maintains a list of evidence-based methods. ACT is listed for depression and chronic pain but other areas are being considered.

There are literally scores of ACT self-help books available, from many different authors; there are thousands of ACT clinicians around the world, and many more in sister approaches such as Mindfulness Based Cognitive Therapy or Dialectical Behavior Therapy.

Modern acceptance and mindfulness-based methods are giving consumers a sensible, evidence-based alternative to dealing with their suffering, and that is a big step forward. (For more information on ACT resources available, see contextualpsychology.org)