The Six Core Process of ACT

• 1. ‘Acceptance’ is introduced as the alternative to experiential avoidance and can be conceptualized as willingness to contact previously avoided events and experiences without attempting to alter their form or frequency, so that the individual can engage more flexibly in behaviors that cohere with their personal values (see below).
• 2. ‘Contact with the present moment’ involves conscious and flexible contact with environmental and psychological events as they occur.

• 3. ‘Cognitive defusion’ are strategies that alter or disrupt the literal and behavior-regulatory functions of aversive thoughts and feelings by changing the contexts in which they are usually related to behavior. For example, an individual’s behavior can become governed by the literal content of thoughts like ‘I am stupid’ leading to the consequence of giving up on their studies. This individual could utilize defusion techniques, such as prefacing this thought with ‘I am having the thought that I am stupid’, to create ‘psychological distance’ from it, thereby interrupting the relation between thoughts and behavior and increasing behavioral flexibility (e.g., ‘I can have the thought that “I am stupid” and continue studying’).
• 4. Creating a sense of ‘self-as-context’, whereby one adopts a perspective from which a ‘coherent sense of self is greater than, and distinguishable from, one’s thoughts, feelings, and emotions’ (Foody et al. 2012, p. 130). Self as context is important because from this perspective one can be aware of one’s own flow of experiences without attachment to them.
• 5. ‘Values’ are chosen qualities of purposive action or life directions (e.g., family, career) that can never be obtained as an object but can be instantiated moment by moment. Although values may vary between cultures and between individuals within the same culture, it is clear that the existence of values is common to all cultures and individuals. According to Wilson and Murrell (2004), values work in ACT:

has the potential to fundamentally alter our client’s relationship with adversity. Answers to questions about acceptance are always context-dependent. When acceptance of adversity is placed in the context of making a difference in an important life domain, acceptance becomes more acceptable (p. 20)

6. ‘Committed action’ via developing and working toward concrete goals that are values-consistent. ACT encourages the development of larger and larger patterns of effective action linked to one’s chosen values.

ACT has a growing evidence-base of its effectiveness across a variety of problem areas (Ruiz 2010), including anxiety (e.g., Twohig et al. 2006), burnout (e.g., Hayes et al. 2004a), depression (e.g., Zettle and Hayes 1986) and psychosis (e.g., Gaudiano and Herbert 2006). In general, the effect sizes are large and typically even better at follow-up (as measured by RCTs, clinical trials, analogue studies etc.). Moreover, the data seems to suggest that the main processes of change within these ACT intervention studies are those hypothesized, namely reduction of experiential avoidance and cognitive fusion (Ruiz 2010). Also, a growing number of studies have applied very short interventions (e.g., a one-day workshop) that have demonstrated similar effects (e.g., Lillis et al. 2009).

Recently, ACT has been applied to various issues within non-Western populations, such as prevention of long-term disability associated with epilepsy in South Africa (Lundgren et al. 2006) and India (Lundgren et al. 2008), and to chronic headache (Mo’tamedi et al. 2012) and management of Type 2 diabetes (Hoseini et al. 2014) in Iran. Also, some studies have examined the impact of ACT on ethnic minorities within high-income countries such as Asian and Caucasian Americans within the United States (Cook and Hayes 2010). Following their investigation of the practice of cultural competence in ACT outcome research, Woidneck et al. (2012) concluded that while ACT studies have often provided insufficient detail about demographic and other characteristics of their samples (e.g., ethnic or racial information), studies with ethnic minorities provide preliminary evidence that ACT may be effective with diverse groups. Hayes et al. (2011) suggested that successful adaptation of ACT in non-Western contexts may be achieved by adopting a bottom- up functional approach of creating a therapy model from procedures and processes that are linked to basic behavioral principles in conjunction with cultural knowledge and understanding.