ACT and

Process-Based Therapy

Steven C. Hayes
University of Nevada
My Intention

Hmmmm
 ACT is 40 years Old the October

First workshop in 1982 in Broughton North Carolina

First book on ACT was almost 2 decades later; the “3 wave” was 22
years after that first book

Based on what? 4 RCTs, RFT, FC, EA and Psych Flex, a few dozen
single cases

And DBT, MBCT, FAP, BehActiv, (& MI, CBASP) AND in the
distance MCT, CFT
 ACT Research Strategy:
Universalist
Not protocols for syndromes: Universalist

First 25 years of work (1986 – 2009). 33 RCTs ranging from zero to

seven a year

Topics: depression, pain, stress, coping with hallucinations and

delusions, anxiety, substance use, weight loss, clinician burnout,
clinicians’ ability to be trained in other evidence-based methods,
smoking cessation, trichotillomania, reducing epileptic seizures,
quality of life in dermatitis patients, reducing self-harm, managing
diabetes, reducing the impact of self-stigma, and reducing
prejudicial beliefs.
 We Took a Hit for That

The failure to focus on syndromes meant as late as just 8 years ago

Lars-Goren could say that ACT is “not well established for any
disorder” (2014, p. 105)
 Multi-Dimensional and Multi-Level
Processes of Change
Linked to Basic Science
First two RCT, Zettle and Hayes, 1986; Zettle & Rains, 1989 were
mediated by defusion

Processes emerged from RFT scaled to “Middle level terms”

Open

Acceptance

Essential
Components
of ACT

Defusion
 Contact with the
Present Moment

Acceptance

Essential
Components
of ACT

Defusion

Self as
Context

Aware
 Contact with the
Actively
Present Moment
Engaged

Acceptance Values

Essential
Components
Psychological
Flexibility
of ACT

Defusion Committed
Action

Self as
Context
 Focus on Processes of Change
Can Be Broadened
• A sequence of changeable events that
lead to good outcomes, that are
theoretically sensible, dynamic,
progressive, multi-level, and contextual
bound
• Think if them as empirically established
pathways of change
Process Based Therapy

Treatment based on the

coherent application of
changeable evidence-
based processes linked
to evidence-based
procedures that
ameliorate the problems
and promote the
prosperity of people
 Extended Evolutionary Meta-Model
(EEMM)

Variation Selection Retention Context

Affective
Cognitive
Attentional
Self
Motivational
Overt Behavioral

Biophysiological
Adaptive
Sociocultural
Maladaptive

ACT has been a 40 year “pilot test” of a process-based approach

 Selected and
In Context Retained

Variation Attentional
Flexibility

Emotional Intrinsic
Flexibility Meaning
Expanding by Choice

ACT’s Psychological
PsyFlex Flexibility

Cognitive Behavioral
Flexibility Flexibility

Flexible
Perspective-Taking
 Feeling
Coherence
Orientation
Belonging
Self-Direction

Competence

Vitality/Health
Nurturance

14
Sociocultural Extension of the Psychological Flexibility Model
Socially Extending Adaptive Psychological Flexibility Dimensions
Healthy Selection
Retention Context
Variation Criteria

Mutual Functional Use conscious

Cognition
understanding coherence attention to
Broaden and
maintain
build using
balance
Affect Compassion Feeling practice, and
integration
Attachment and into larger
Self Belonging patterns Key strength
conscious connection
of this process
Dyadic Attention Joint attention Orientation
Social
dimensions
Shared values and
Motivation Meaning Use
acknowledgment
monitoring to
Key strength detect
of these maintenance
processes of values
based commit-
Overt Behavior Shared commitments Competence
ment

Other Groups of groups

Levels
Psychology

15
 1000

Progress Made 900

by Acceptance Total Number of ACT RCTs

800

and 1986 through 2021

Commitment
700

N = 902
Therapy (ACT) 600

as a Process- 500

Based Approach
400

300

200

100

2021…
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Source: bit.ly/ACTRCTs
What Are the
Processes that
Empower?
 We examined every single randomized trial
ever done on any psychosocial intervention
that claimed to properly identify a process of
change (“mediational analysis”)
 Just under 54,633 studies each rated twice
 73 replicated measures in 281 statistically
correct analyses
 Percentage of Mediational Findings
0,0% 5,0% 10,0% 15,0% 20,0% 25,0% 30,0%
Psychological flexibility other than mindfulness
Mindfulness
Negative, unrealistic, or dysfunctional thoughts
Anxiety sensitivity or fear of sensations
Self-efficacy
Parenting or family functioning
Physical activity, or exercise beliefs / goals
Attrib style, interp' bias, implicit cog, reappr
Drinking behavior or norms
Rumination and Worry
Mood
Coping skills
Social support or loneliness
Emotional dysregulation
Self-regulation
Therapeutic alliance
Interpersonal functioning
Self esteem
Personality
Grey matter volume
Conceptual Clusters Stated Focus Findings

✓
✓
Psychological flexibility other than mindfulness 22.1% 64 22.1%

✓
Mindfulness 19.4% 56 19.4%

✓
Negative, unrealistic, or dysfunctional thoughts 8.7% 25 8.7%
Anxiety sensitivity or fear of sensations 8.0% 23 8.0%

✓
Self-efficacy 4.8% 14 4.8%

✓
Attrib style, interp' bias, implicit cog, reappr 3.8% 11 3.8%
Parenting or family functioning 3.5% 10 3.5%

✓
Physical activity, or exercise beliefs / goals 3.5% 10 3.5%
Self-compassion 3.1% 9 3.1%

✓
Drinking behavior or norms 3.1% 9 3.1%

✓
Rumination and worry 3.1% 9 3.1%
Social support or loneliness 2.1% 6 2.1%
Coping skills 1.7% 5 1.7%
Emotional dysregulation 1.7% 5 1.7%

✓
Self-regulation 1.7% 5 1.7%

✓
Therapeutic alliance 1.7% 5 1.7%
Interpersonal functioning 1.7% 5 1.7%
Self esteem 0.7% 2 0.7%
Personality 0.7% 2 0.7%

✓
Brain structure 0.7% 2 0.7%

✓
Decentering 0.7% 2 0.7%
Behavioral activation 0.7% 2 0.7%

281
 Psychological Flexibility is the
Process Elephant
60
% 55% of all Findings:
50
Psychological flexibility – 22%
%
Mindfulness – 19%
40 Anxiety sensitivity – 8 %
% Self-compassion – 3%
Decentering – 1%
30 Behavioral activation – 1%
%
20
%
10
%
0%
Psychological flexibility Negative Parenting, Exercise, Self-efficacy Self-esteem;
and mindfulness (inc thoughts; social diet. Brain
self-compassion, anx Rumination support, moderation structure,
sensitivity, behavioral and worry interpersonal in drinking coping,
activation) personality
 BREADTH OF DATA
Pain / Chronic Pain Asthma
Anxiety Cancer Psychosis Diabetes
Depression Eating Disorders
Social Anxiety Weight Loss
Obsessive Compulsive Disorder Smoking Gambling
Parenting Pornography
Trichotillomania Substance Abuse
Fibromyalgia Aggression
Bowel Diseases Confidence
Multiple Sclerosis 902 RCT S Occupational Outcomes
HIV
Stress Burnout
Tinnitus
Sleep
Borderline Personality Disorder
Suicide
Epilepsy
Training Quality of Life
Health Behaviors Shame
Psychological Flexibility Prejudice Stigma
Couples / Marital Relations Somatic Syndromes
Skill Coaching Attention Stroke
Procrastination
Exercise Prevention

https://contextualscience.org/state_of_the_act_evidence
What a Process Based Approach Gives You

Bit.ly/WHO_ACT

https://www.who.int/publications-detail/9789240003927
 ACT is Recommended for Multiple
Syndromal Disorders

https://www.who.int/publications/i/item/
9789240017870
https://www.nice.org.uk/guidance/ng193
 Skills Needed in
Process-Based Therapy

• Get centered in yourself & the interaction

• Read and formulate processes
• Open the door to a process area
• Use a kernel or method
• Purposefully recycle based on impact
 Reading Processes

Generate client statements

that exemplify this process
 Emotional Inflexibility Reads
• Alexithymia – cannot describe emotions
• Lack of emotional depth
• Can’t differentiate emotions
• Cannot use emotional information to guide
action
• Hiding, running, or fighting when painful
experiences come up
• Physical metaphors for the same (e.g.,
freezing; clenched fist; grip chair; eyes
down)
• Cannot enjoy positive emotions without
clinging or fear of loss
• You think “how did we get here?”
Create Items Linked to the EEMM
Process Target Negatively Worded Items Positively Worded Items

Affect I did not find an appropriate outlet for my emotions I was able to experience a range of emotions appropriate to
the moment

Cognitive processes, including My thinking got in the way of things that were I used my thinking in ways that helped me live better
those related to self important to me

Attention I struggled to connect with the moments in my day I paid attention to important things in my daily life;
to day life

social/Connection I did things that hurt my connection with people I did things to connect with people who are important to
who are important to me me

Motivation/Autonomy I chose to do things that were personally important I did things only because I was complying with what others
to me wanted me to do

Overt Behavior/ I found personally important ways to challenge I did not find a meaningful way to challenge myself
competence myself

Health I acted in ways that helped my physical health I acted in ways that hurt my physical health

Variation I felt stuck and unable to change my ineffective I was able to change my behavior, when changing helped
behavior; my life

Retention I stuck to strategies that seemed to have worked I struggled to keep doing something that was good for me
 Our First Study of
Idionomic Assessment
• 50 volunteers
• 2 assessment occasions a day for 30 days
• Analyze S-GIMME (Subgrouping Group
Iterative Multiple Model Estimation)
• Dynamical networks within person that are
then fitted to subgroups if an only if they
improve idiographic fit for most
 Outcomes Tested
• Distress over
• sadness,
• anxiety,
• anger,
• stress,
• lack of social support
• Burnout
• Life satisfaction
Examples
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If people are interested in online training with me

they need to be warned that courses are out
there claiming to be by me that I had nothing to
do with. Companies bought the rights to old
videos of mine and they then market them in a
way that sounds as though this is a "course" I
developed.

The only online courses of mine that I personally

stand behind are the ones at Praxis
(www.praxiscet.com). I am very proud of the first
one, ACT Immersion, and you can learn more
about it here: www.act.courses. It has Portuguese
subtitles. After that course is mastered there is a
follow on course from that same company
called ACT in Practice. It too has Portuguese
subtitles. If the prices are too high email
team@act.courses and ask about the scholarship
program.