by Natalie Artinian, D.O., Bay Area Clinical Associates, Psychiatry, Child & Adolescent Psychiatry, who shares expert insight on how ACT works to help teens with psychosis.
Acceptance and commitment therapy is one of three types of mindfulness-based therapeutic modalities for the treatment of mental health disorders that first appeared in the late 1970s and early- to mid-1980s. The other two, dialectical behavioral therapy (DBT) and mindfulness-based cognitive behavioral therapy (MBCBT) – share some things in common with ACT, but ACT takes a unique approach in helping teens with psychosis.
For a teen or young adult with a clinical mental health disorder, the goal of ACT is not symptom reduction, but rather, creating workable behavior, i.e. daily actions that help patients promote balance, stability, and a grounded, realistic understanding of themselves and the world that promotes healing and growth.
Steven Hayes, a professor of psychology, shared his initial ideas about ACT with the world around 1986. Here’s a shortcut to understanding its basic tenets, using the letters A-C-T:
A: Acceptance.
- Patients learn to accept difficult things, including their own thoughts, behaviors, and emotions. In order to move forward, patients must accept the world as it is, not as they want it to be.
C: Choice.
- Accepting reality as-is and detaching subjective perception from objective fact – called cognitive defusion – allows patients to make proactive choices about their behavior.
T: Take action.
- Patients identify values that matter to them and give their life purpose and meaning, then take discrete steps to align their behavior with those values.
ACT can help treat a wide range mental and physical conditions, including:
- Prodromal psychosis
- Psychosis
- Schizophrenia
- Anxiety disorders
- Depressive disorders
- Obsessive-compulsivedisorder
- Eating disorders
- Substance use disorders
- Work-related stress
- Chronic pain
In this article, we’ll focus on how ACT helps teens and young adults with prodromal psychosis, psychosis, and mental health disorders with psychotic features.
Acceptance Paves the Way to Change
Acceptance and commitment therapy helps teens and young adults identify objective facts about themselves and their lives and use that knowledge to create positive behavioral change. When a teen with a mental health disorder learns to acknowledge difficult truths, they can move toward living a life that feels more safe, stable, and balanced, regardless of whether they still experience the symptoms of their disorder.
Helpful acceptance strategies common to ACT include:
- Allowing feelings and thoughts to process without acting on them
- Recognizing weaknesses but choosing to see strengths
- Understanding that everyone has challenges to work through
- Acknowledging the problems in life without avoiding them
- Realizing that each person has control over their own reactions, thoughts, and feelings
These acceptance strategies all work to empower people with complex mental health disorders. ACT can help patients develop the ability to make proactive choices based on their identified values and goals, as opposed to reactive choices driven by the symptoms of their disorder. Teens thrive on independence, which is one reason the most highly regarded adolescent treatment centers use ACT as a core treatment approach. The combination of acceptance, choice, and action, teens in treatment can create practical behavioral change that promotes long-term health and wellness.
But how does it work?
ACT, Teens, and Psychosis: From Avoidance to Acceptance
Humans practice what’s called experiential avoidance as a self-defense mechanism. The phenomenon is rooted in the nature of language itself. For instance, let’s say a person experiences auditory hallucinations uttered by a person named Joe, who is not real. In avoiding the hallucination, the person unintentionally increases its functional power. Rather than Joe, the not-real person is now also he-who-shall-not-be-named.
Just like Voldemort. We know fear of the name gave him more power over those who refused to say the name than those who didn’t.
However, this renaming/avoidance/denial creates an entire new set of verbal relationships and results in a negative cycle wherein language-based restructuring dominates other modes of behavioral regulation. Over time, adherence to the elaborate internal verbal rules leads to decreased openness to new experiences and results in cognitive fusion, which happens when we attach a thought to an experience.
Through the process of cognitive fusion, the thought then replaces the memory of the experience. This prevents accurate assessment of future experiences which share similar qualities but may be fundamentally different. It also prevents the person from understanding that new experiences are not the same as the same as previous experiences.
The result is that a person with serious mental illness creates a complicated web of language and meaning that increase – rather than reduce – entanglement in the literal content of unusual and frightening thoughts and emotions, i.e. the hallucinations and delusions common to psychosis. The result of this process is often unworkable behavior that disrupts life for a teen patient and their family.
ACT and Teens With Psychosis: Resolving Cognitive Fusion
In ACT, six core techniques combine to promote the psychological flexibility that can lead to changing unworkable behavior to workable behavior. Steven Hayes defines psychological flexibility as follows:
“The ability to contact the present moment more fully as a conscious human being, and to change or persist in behavior when doing so serves valued ends.”
The Six Techniques of Acceptance and Commitment Therapy (ACT)
1. Acceptance
Acceptance in ACT is the active, conscious acknowledgement of psychological thoughts and emotions without attempting to change how or how often they appear.
2. Defusion
Defusion in ACT is the counter to cognitive fusion, which creates many of the problems associated with psychosis and other mental health disorders.
It’s a process that disconnects or disentangles a person from their fixed thoughts and emotions. With distance and perspective, thoughts lose power, and a person can learn to see them as what they are: thoughts. They’re not facts, rules, or guides for behavior. This allows a person to learn that the thoughts themselves are not the problem: it’s how they respond and relate to the thoughts that can create problems.
3. Self-As-Context
This might sound esoteric and jargony, but it’s really simple. It means developing the skill to observe your own thoughts objectively. You experience your thoughts, but you are not your thoughts. Your thoughts aren’t you – you are you. You are the “one” who watches. This is similar – almost identical – to skills learned in mindfulness exercises, which teach you to observe and accept your physical sensations, ideas, and emotions without judging them or trying to change them.
4. Present Moment
ACT teaches and promotes continuous, nonjudgmental contact with both external events and internal thoughts and emotions as they happen. Staying connected to the present moment decreases the likelihood of getting lost in cognitive fusion and allows a patient to “experience the world more directly so that their behavior is more flexible and their actions more consistent with the values they hold.”
5. Values
In ACT, values refer to the conscious choices we make about what’s important in the core domains of life, such as family, school, work, and spirituality. In a nutshell, values are life goals. Think of them as a “direction rather than a destination.”
6. Committed Action
Committed action is the process of connecting behavior to values. Over time, ACT helps patients create effective, self-reinforcing patterns of behavior that promote feelings of hope, positivity, and overall wellbeing.
Acceptance and Commitment Therapy (ACT) for Teens With Psychosis
Initially, therapists developed ACT for adults, but evidence shows that ACT is an essential treatment modality for teenage populations, and is effective for treating teens with prodromal psychosis or symptoms of psychosis.
The publication “Applications and Adaptations of Acceptance and Commitment Therapy (ACT) for Adolescents” describes modifications necessary to tailor ACT to meet the needs of adolescents:
Age-Appropriate Material
Teens respond well to imaginative, interactive exercises. Therapists use creative imagery, dramatic role playing, visual art, journaling/writing, group activities, and fun worksheets to keep teens active, interested, and engaged in treatment.
Teen-Centric Activities
To keep teens on-task and interested, therapists identify activities that resonate with them. In the 21st century, this may mean interactive online games or apps. Or it may mean standard teen interests, like sports or music. In ACT, a therapist learns what a teen likes and motivates them, and leverages those drives to enhance engagement and improve treatment outcomes.
Family Engagement
When families can learn together, families can heal and grow together. When parents and siblings understand what a teen in treatment needs to align their behavior to their goals, they can better support them.
Family engagement may mean family groups where the teen patient is not present: this helps family members learn and understand in an environment designed specifically for them.
Family engagement may mean family therapy where everyone who needs to be present – as determined by the therapist and patient – is present. In this context, patients, teens, and therapists can help define family goals and expectations. They can also help practice new ways of communicating, resolving conflict, and living in harmony as a family unit.
When a therapist designs treatment exercises and adopts an overall approach that resonates with a teen, they can make real progress. It’s possible to help patients let go of the need for absolute control over details, accept difficult personal circumstances and events, and disconnect themselves from difficult thoughts. This mindful awareness allows teens to alter and direct their behavior toward end the define as worthy and valuable.
The Goal: ACT Creates Positive Change for Teens With Psychosis
One reason ACT is effective for teens is its non-judgmental nature. If you remember being a teen, you probably remember the powerful need to be seen, heard, and understood without judgment. ACT leaves all judgment aside, allows teens to define their own values and goals. It helps them engage in behavior that matches their values and moves them toward their self-defined goals.
An effective ACT therapist teaches teens to see thoughts and feelings as experiences instead of predetermined, structured reality. At the beginning of this article, we said that symptom reduction is not the goal. That may seem illogical, because most of us see symptom reduction as the goal of all treatment, for anything, whether psychological, emotional, or physical. While that’s true, it’s not the whole story. The goal of treatment is overall health and wellness that increases our ability to live a full and fulfilling life.
When a teen learns to see their atypical thoughts and feelings – i.e. the symptoms associated with psychosis – as experiences rather than reality, those thoughts and feelings lose their strength and salience. Then, the symptoms – i.e. thoughts and feelings that are not true – no longer drive their behavior away from their goals and values.
The symptoms may be there. They may come and go. But they no longer interfere with the ability of a teenager to live, thrive, and get on with the business of being a teenager. That’s the power of ACT.
