Professional Documents
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art ic l e i nf o
a b s t r a c t
Article history:
Received 27 June 2014
Received in revised form
22 December 2014
Accepted 19 January 2015
Acceptance and Commitment Therapy (ACT) is an emerging cognitive-behavioral therapy that uses mindfulness, acceptance and other skills to treat psychological problems. ACT differs from traditional cognitivebehavioral therapy (tCBT) in some ways, but the two therapies share several similarities. Though ACT has some
empirical support when used with adults, there is very sparse literature to date on using ACT with adolescents.
This review will discuss the state of the eld with regard to using ACT with adolescents with a special focus on
developmental adaptations and considerations that could enhance cognitive-behavioral treatment of this
population. Ten studies that utilized multiple or all ACT components with adolescents are the focus of this
review. The review will explore adaptations that are currently used in ACT research with adolescents, considerations that have been suggested but were not implemented in these studies, and other adolescent problems
that could potentially be ameliorated with the use of ACT techniques. The review will conclude with a discussion of salient methodological and assessment-related limitations, suggestions for choosing whether ACT might
be appropriate for use with adolescent clients, and ideas for future research on using ACT with adolescents.
& 2015 Association for Contextual Behavioral Science. Published by Elsevier Inc. All rights reserved.
Keywords:
Acceptance and Commitment Therapy
Adolescents
Treatment adaptations
Child development
Contents
1.
2.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The ACT treatment process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1.
Contact with the present moment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2.
Acceptance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3.
Defusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.4.
Self as context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.5.
Values. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.6.
Committed action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. The effectiveness of ACT and comparisons to tCBT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Using ACT components and processes with adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Building a developmentally sensitive treatment protocol for adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.1.
Adaptations based on biological development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.2.
Adaptations based on psychological development. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.3.
Adaptations based on social development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6. Other suggested developmental considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7. Other hypothetical applications of ACT for adolescent problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8. Methodological and assessment considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9. Summary and conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10. Future research directions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
http://dx.doi.org/10.1016/j.jcbs.2015.01.002
2212-1447/& 2015 Association for Contextual Behavioral Science. Published by Elsevier Inc. All rights reserved.
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1. Introduction
In recent years, some basic tenets and processes of traditional
cognitive-behavioral therapy (tCBT) have been the subject of
debate among psychotherapists and clinical researchers (Hayes,
Levin, Plumb-Vilardaga, Villatte, & Pistorello, 2013). In particular,
there have been questions about whether thought content needs
to be targeted (Hayes, 2004). Additionally, some nd it troublesome that common cognitive techniques cannot be scientically
linked to basic cognitive psychology (Hayes, Luoma, Bond, Masuda,
& Lillis, 2006) or worry that tCBT is too symptom-focused
(Hofmann & Asmundson, 2008). Change sometimes occurs before
the relevant tCBT techniques are introduced, and there is unclear
support for proposed mediators of change (Longmore & Worrell,
2007), like coping skill development (Morganstern & Longabaugh,
2000) or dysfunctional attitude changes (Burns & Spangler, 2001).
New styles of cognitive-behavior therapy have emerged in
response to these critiques, one being Acceptance and Commitment Therapy, or ACT (Hayes, Strosahl, & Wilson, 1999). Generally speaking, these therapies take a contextual approach, with
the goal of helping clients respond to the function rather than the
content of thoughts (Hayes, 2004). Context becomes problematic
when clients desire to control, explain, or otherwise cope with the
thought rather than simply experience it (Hofmann & Asmundson,
2008). These therapies promote greater mindfulness and thought
acceptance instead of direct challenging of thoughts, as in tCBT
(Hayes et al., 2013).
The following review will focus on ACT and its relevance and
application for clinicians who work with adolescents. In particular,
the review will discuss similarities and differences between an
ACT approach and a tCBT approach and provide suggested guidelines for determining which approach might be a better t for
individual adolescent clients. Special attention will be paid to
identifying developmental adaptations and considerations, drawn
from various cognitive-behavioral approaches that can facilitate
the use of ACT and other therapies with adolescents. Studies that
have used an ACT approach and incorporated these ideas will be
highlighted. Finally, salient methodological concerns and potential
solutions will be discussed.
remove good and bad labels. In doing so, they reduce the
perceived power of feared stimuli. Though tCBT also uses selfmonitoring of experiences, ACT differs in that clients are not asked
to categorize, count or analyze their experiences, just notice them.
2.2. Acceptance
Acceptance involves engaging in mindfulness without attempting to interact with thoughts. In taking an acceptance stance,
clients end the struggle with thoughts and feelings without having
to change or eliminate them (Hofmann & Asmundson, 2008).
Together, the therapist and client examine the workability of prior
control behaviors and attempts to change thoughts or feelings, and
the client is shown that controlling automatic thoughts and
feelings is impossible (Hayes, 2004). Exposure exercises are used
in both tCBT and ACT to reduce avoidance, though symptom
reduction is not a goal in ACT (Hayes, Follette, & Linehan, 2004).
2.3. Defusion
Defusion is used to weaken the link between the verbal content
of thoughts and feelings and their function. Defusion techniques
promote a neutral perception of internal events (Springer, 2012),
allowing for greater variability in perceived possible responses.
The believability of private events is reduced despite thought
recurrence (Hayes et al., 2006). Defusion aims not to challenge
thought content, as in tCBT, but instead to alter the client's
interactions with and assumptions about the thought and allow
it to be experienced exibly.
2.4. Self as context
ACT encourages clients to move from the conceptualized self,
who is built by specic dening attributes, to the observing self,
who takes in experiences as a separate entity (Hayes et al., 1999).
The observing self is a separate being who experiences many
thoughts, feelings and behaviors but is not dened or dominated
by any of them; while experiences may change, the conscious,
observing self is constant (Hayes, 2004). Instead of targeting
individual dening or threatening thoughts, ACT self as context
work broadly targets many such internal experiences, evaluating
them on how they help or hinder the client's workability for
general functioning.
2.5. Values
Values are not meant to be reached nor fullled but instead are
used to continually guide behavior and choices about the best
directions in which to take a person's life. It is extremely important
that values be freely chosen and not selected based on societal or
family expectations, as feeling persuaded to live according to
certain values carries the risk of a return to the conceptualized
self (Hayes et al., 1999). Though the client once lived in service of
his or her symptoms or stressors, now his or her life will be guided
by values. tCBT may use values to help a client nd motivation, but
in ACT values are an explicit part of the treatment process.
2.6. Committed action
Committed action operationalizes the values clarication process and begins the journey of value-directed living. The process of
committed action naturally invites the chance to face and overcome obstacles to value-directed living, such as pain or difculty
that must be accepted in order to move forward and prevent it
from determining the course of the client's life (Hayes et al., 2004).
The client is not committing to success in the process of pursuing
A.E. Halliburton, L.D. Cooper / Journal of Contextual Behavioral Science 4 (2015) 111
A.E. Halliburton, L.D. Cooper / Journal of Contextual Behavioral Science 4 (2015) 111
Table 1
Characteristics of studies that used ACT with adolescents.
Sample
size
Outcome measures
Primary ndings
Self-reported daily
compulsion frequency; CYBOCS; CDI; MASC; COIS-R
Group treatment
Hayes et al.
(2011)
Depression
Peerreviewed
Full ACT
30
RADS-2; SDQ
Heffner et al.
(2002)
Anorexia
Nervosa
Case study
Peerreviewed
Full ACT
EDI-2
Livheim et al.
(in press)
Depression
(Australia);
Stress
(Sweden)
Full ACT
51
(Australia);
32
(Sweden)
Myles (2002)
Disruptive
behavior
disorders
Multiple-baseline
single-case design
Thesis
Full ACT
Parent-reported behavior
monitoring; ECBI; SDQ;
AAQ; BDI-II
Decreases in disruptive behavior (e.g., arguing, noncompliance, verbal or physical aggression) from
baseline to post-treatment
Sabaini (2013)
Disruptive
behavior
disorders
(varied
diagnoses)
Thesis
Full ACT
18
Wicksell et al.
(2005)
Case study
Peerreviewed
Full ACT
Wicksell et al.
(2009)
Chronic pain
RCT
Peerreviewed
Acceptance
and
Exposure
32
Woidneck
(2012)
PTSD
Nonconcurrent
multiple baseline
single-case design
Self-monitoring of PTSD
symptoms (frequency,
distress, interference)
Citation/
diagnosis
Study design
Study type
Armstrong
(2011)
OCD
Nonconcurrent
multiple baseline
single-case design
Cook (2008)
Highfunctioning
ASD;
nonverbal
learning
disorder
Treatment
approach
Chronic pain
Note: CY-BOCS: Children's Yale-Brown Obsessive Compulsive Scale; CDI: Children's Depression Inventory; MASC: Multidimensional Anxiety Scale for Children; COIS-R: Child
Obsessive-Compulsive Impact ScaleRevised; AFQ-Y/AFQ-Y8/AFQ-Y17: Avoidance and Fusion Questionnaire for Youth; VLQ-A: Valued Living Questionnaire for Adolescents;
BSI: Brief Symptom Inventory; RADS-2: Reynolds Adolescent Depression Scale2; SDQ: Strengths and Difculties Questionnaire; EDI-2: Eating Disorders InventoryTwo;
PSS: Perceived Stress Scale; DASS-21: Depression, Anxiety, and Stress Scale; SWLS: Satisfaction with Life Scale; GHQ-12: General Health Questionnaire; MAAS: Mindful
Attention Awareness Scale; ECBI: Eyberg Child Behavior Inventory; AAQ/AAQ-II: Acceptance and Action Questionnaire, Version Two; BDI-II: Beck Depression Inventory,
Second Edition; FDI: Functional Disability Inventory; PAIRS: Pain Impairment Relationship Scale; SF-36: Short Form-36 Health Survey.
(Steinberg, 2002; Weisz & Hawley, 2002). Some ideas for useful
adaptations and considerations, drawn from a collection of studies
that used most or all components of ACT as well as reviews of
other cognitive-behavioral treatment protocols that have been
implemented with adolescents (e.g., tCBT, Dialectical Behavior
Therapy (DBT)), will be discussed in the paragraphs to come.
These adaptations and considerations span several domains of
adolescent development (biological, psychological, and social) and
can be used broadly to augment the use of cognitive-behavioral
strategies with adolescents. Creative methods for implementing a
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A.E. Halliburton, L.D. Cooper / Journal of Contextual Behavioral Science 4 (2015) 111
A.E. Halliburton, L.D. Cooper / Journal of Contextual Behavioral Science 4 (2015) 111
The recent U.S. recession has implications that stretch to adolescents and emerging adults, including a need to nd a stable job and to
rely less on parents for monetary support (Danziger & Ratner, 2010).
Despite individual differences in nancial feasibility, many students
are being pressured to attend college (Gutman & Schoon, 2012).
Practicing mindfulness may reduce the harmful effects of stress on
the cardiovascular and hormonal systems (Broderick & Jennings,
2012). Mindfulness and acceptance strategies could also be used to
reduce anxiety related to achievement and career selection by
increasing psychological exibility and opening the way for valuesdirected decision-making (Greco et al., 2005). Values clarication can
be a good way to explore an adolescent's career aspirations and
formulate appropriate career goals.
Finally, adolescence is a critical period for identity formation
(Bosma & Kunnen, 2001). This process is affected by parental, peer
and community inuences (Beyers & ok, 2008). Minority adolescents, particularly those who immigrate with their families, have
the dual task of searching out a personal identity and integrating
their cultural values with those of the society in which they now
live (Crocetti, Rubini, Luyckx, & Meeus, 2008). Due to the rise of
emerging adulthood, older adolescents prolong the process of
identity exploration for much longer than people their age did in
previous generations (Arnett, 2000) and experience greater frustration and identity stress. Though some identity shifting is
common, continual shifts can lead to adverse clinical outcomes,
particularly internalizing problems (Klimstra, 2013). ACT has been
effective in reducing adult self-stigma related to substance use,
body weight, and internalized homophobia (Yadavaia & Hayes,
2012). Defusion and self as context work can reduce the pressure
to establish a single, solidied identity and make room for a
multifaceted life directed by values (Luoma, Kohlenberg, Hayes,
Bunting, & Rye, 2008). Mindfulness and acceptance could also
increase individual tolerance of identity stress (Lillis, Hayes,
Bunting, & Masuda, 2009).
A.E. Halliburton, L.D. Cooper / Journal of Contextual Behavioral Science 4 (2015) 111
have been suggested and previously used as a method for retaining adolescents in treatment (Sabaini, 2013), though it is possible
that incentives could be deemed coercive (Hayes et al., 2011).
Sampling problems could also lead to difculty obtaining a
control group (Metzler et al., 2000). Problems with recruiting
heterogeneous samples have been noted (Coyne, McHugh, &
Martinez, 2011). Most participants across the studies in the review
were female, Caucasian, and from middle to high-income families,
limiting the generalizability of results. Convenience samples may
have been drawn from existing programs or schools, or perhaps
high-income participants were desired due to greater education
and apparently stronger cognitive abilities. To fully understand
ACT's breadth of applicability, sample diversity in future studies
will be key.
Ensuring treatment compliance also presented as a common
problem. Fidelity coding can reduce the likelihood of protocol
deviation, which may be especially important for research therapists who have been newly introduced to the use of ACT (Yadavaia
& Hayes, 2012). Researchers could also encourage participants to
complete at-home assignments by providing structured handouts,
setting small, achievable weekly goals, and asking participants to
share the results of their practice during the next session; sharing
results may have the additional benet in group settings of
assisting other group members who struggle with homework
(Hayes & Rowse, 2008). Parents, especially those who are given
psychoeducation about ACT in separate sessions, can also help
ensure between-session assignment completion and assist with
at-home skills practice. Additionally, it is important to rule out
alternative explanations for treatment successes. Factors to consider include rapport with the therapist (Woidneck, 2012), parental support (Heffner et al., 2002), time spent in therapy
(Gauntlett-Gilbert et al., 2013), education and training of the
participants or staff members (Sabaini, 2013) and participants'
downward social comparisons to others who are perceived to be
doing worse (Gauntlett-Gilbert et al., 2013).
Several studies noted limitations related to measurement, namely
that of using self-report surveys (e.g., Wicksell et al., 2009). Selfreport questionnaires provide meaningful information for clinicians,
especially with older, cognitively capable adolescents, but they can
also be unreliable and subject to social desirability. To overcome this
difcult problem, clinicians can use structured interviews (Swain,
Hancock, Dixon, Koo, & Bowman, 2013), gather observer reports
(Casier et al., 2011), or take physical or behavioral measurements
(Heffner et al., 2002) alongside self-report surveys. The measures
used must also demonstrate good psychometric properties, particularly when measures written for adults have been adapted for a
younger population. Reliability and validity issues were cited as a
limitation for outcome measures in several studies (e.g., Cook, 2008).
Notably, while there are many symptom measures that have
been adapted for children and adolescents, the process measures
commonly used in ACT with adults are only beginning to be
adapted for children. This represents a signicant measurement
issue for ACT research with adolescents because ACT does not
target symptom reductionit focuses instead on processes that
can be generalized beyond symptom complaints (Murrell &
Scherbarth, 2011). Some measures have been adapted, such as
the Avoidance and Fusion Questionnaire for Youth (Greco,
Lambert, & Baer, 2008) and the Social Values Survey (Blackledge
& Ciarrochi, 2006), but more are needed to allow a varied selection
of ACT measures for clinicians who work with youth.
A.E. Halliburton, L.D. Cooper / Journal of Contextual Behavioral Science 4 (2015) 111
Acknowledgments
I thank my doctoral committee members, Dr. George Clum,
Dr. Kirby Deater-Deckard, and Dr. Bradley White, for their contributions and support in preparing this manuscript, which was
part of my preliminary exam. I also thank Neville Galloway-Williams,
M.S., for her help and encouragement in deepening my understanding of core ACT concepts.
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