Digital ACT

CHAPTER 9
Digital Acceptance and

Commitment Therapy
Maria Karekla, Angelos P. Kassianos and Danae Papageorgiou
Acceptance and Commitment Therapy (ACT; Hayes, Strosahl and Wilson

1999) is a third wave behavioural therapy grounded in functional con-
textualism (Hayes et al. 2013). ACT is based on Relational Frame Theory
(RFT), a theory of human language, emotion and cognition stemming from
operant processes and behavioural analysis (Levin and Hayes 2009). While
ACT incorporates key elements of both traditional behavioural approaches
and Cognitive Behavioural Therapy (CBT), it brings new components for
changing behaviour within its context (Eifert and Forsyth 2013).
ACT aims to empower individuals to interact more flexibly with their
environment so as to be able to live in accordance with their chosen values
(Hayes et al. 1999). This ability in ACT is termed ‘psychological flexi-
bility’ and is the primary goal of treatment (Gloster and Karekla 2020).
In essence, it encourages the capacity to be aware and accepting of any
‘negative’ thoughts or emotions that may arise in each moment, and to be
Copyright © 2022. Jessica Kingsley Publishers. All rights reserved.
able to adapt to situational demands (internal and external) in order to

behave in a way that is in agreement with what gives one’s life meaning.
ACT aims to increase psychological flexibility in individuals by targeting
six core processes of change: acceptance of internal events (e.g. thoughts,
emotions), cognitive defusion (i.e. becoming unstuck from the literal
content of thoughts), awareness of the present moment, self as context
(i.e. seeing the self as more than the collection of difficulties with which one
struggles), values clarification, and committed action (Karekla, Karademas
and Gloster 2018).
While ACT is relatively new, there has been an increasing number of
studies supporting its use in the treatment of mental health difficulties,
including anxiety, depression, chronic pain, substance use and disordered
119
Digital Delivery of Mental Health Therapies : A Guide to the Benefits and Challenges, and Making It Work, edited by Hannah
Wilson, Jessica Kingsley Publishers, 2022. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/purdue/detail.action?docID=6933477.
Created from purdue on 2023-01-17 14:01:07.
120 DIGITAL DELIVERY OF MENTAL HEALTH THERAPIES
eating (e.g. Bai et al. 2020; Lee et al. 2015; Levitt and Karekla 2005; Linardon
et al. 2019; Vasiliou et al. 2020). Moreover, a recent review of meta-analyses
indicates ACT’s superiority over inactive control conditions, treatment
as usual and most active interventions, with indications that ACT out-
performs CBT in certain outcomes, such as quality of life post-treatment
(Gloster et al. 2020).
Digital adaptations and applications of ACT

Recent years have seen a rise in technological advances, and a large num-
ber of digital ACT interventions have been developed. A list of available
digital ACT interventions can be found on the Association for Contextual
Behavioral Science’s website (ACBS). Next, we discuss ACT’s adaptations
to various digital modalities.
Teletherapy: videoconferencing and telephoning

Teletherapy methods are increasingly used by therapists to contact clients
and deliver numerous types of psychological interventions, and anecdotal/
informal evidence suggests that numerous ACT therapists have embraced
this method of delivering services. However, no research exists yet as to
how such methods are being applied in clinical settings. Only Borges
(2019) and Smith, Coe and Meyer (2020) presented case studies where
ACT was employed using telehealth (specifically videoconferencing).
Both highlight telehealth methods being used to provide treatment in a
manner analogous to face-to-face interventions. Thus, treatment follows
the same ACT approach with some key methods, such as use of metaphors,
still employed in the same way. The metaphor of ‘two mountains’ as a

representation of the therapeutic relationship can be helpful here in that
individuals may recognize that even from afar, we can connect and notice
things happening to someone else who may be on an opposite mountain
(Smith et al. 2020).
Research highlights that teletherapy is an easy way to deliver brief
and structured ACT treatment, while also allowing for client questions/
feedback, which can be fast and cost-effective for therapists (Bricker et al.
2014). At the same time, such methods can still provide therapy that is cul-
turally sensitive. For example, Mak, Leung and Loke (2020) incorporated
a face-to-face meeting to telephone sessions with the aim of augmenting
engagement and relevance to the extremely busy and fast-paced Hong
Digital Acceptance and Commitment Therapy 121
Kong Chinese population in their study. They also used particular ACT
metaphors, such as the ‘two sides to a coin’, to make it more relevant to
their participants. Additionally, ACT aims to by-pass literal language as
part of the intervention and as such utilizes experiential exercises within
treatment. Therapists can become creative and utilize probes to achieve
a similar effect as in session. For example, the authors ask the client to
tie a rope on the computer desk’s leg and to pull the rope, simulating the
metaphor of ‘tug of war with a monster’. In our experience, this achieves
similar experiential contact with the intervention content and highlights
how teletherapy can still be personalized, culturally relevant and allow for
therapeutic activities to occur.
Digital interventions via a website

Websites are by far the most utilized digital medium to deliver ACT
(known as iACT; Thompson et al. 2020). Apart from websites developed
by research teams investigating iACT, there are websites offering ACT for
numerous difficulties, usually for a fee; however, these may not have been
evaluated for effectiveness or efficacy (Gentili et al. 2020).
Most iACT interventions developed by research teams include all ACT
components provided in a tunnelled approach (i.e. following a specific
order based on targeted difficulties). Many programs combine the digital
intervention with additional psychoeducation, supplementary material
(e.g. mindfulness exercise recordings and paper exercise books) and
homework to enable better learning. Such programs tend to make use of
multimedia within treatment (e.g. videos, animations and narration) and
are interactive in nature, an aspect that fits well with ACT metaphors and
experiential components (Kasinopoulos 2019; Levin et al. 2017). Using

interactive features can increase engagement and also allow tailored feed-
back to individuals based on their responses.
The number of sessions for iACT interventions ranges from two ses-
sions (Levin et al. 2014) to 40 sessions (Rickardsson et al. 2020). Some are
fully self-directed, while some may provide automated email reminders
(e.g. Karekla et al. 2020). Others include guidance such as phone calls
before sessions (Lappalainen et al. 2015), personalized and standardized
feedback by trained individuals (Lin et al. 2017) or a blended method
(Lappalainen et al. 2014). While most iACT interventions ‘unlock’ or
encourage moving to the next session after a few days, Rickardsson et al.
(2020) suggest adopting a micro-learning approach. Their iACT includes
40 short sections delivered over ten weeks with an aim to provide partici-
pants with daily treatment: a brief theory section followed by experiential
or practical exercises aiming to encourage practice and mastery of skills
without overloading participants with information.
Again, when developing iACT interventions, cultural adaptations need
to be considered. This might include practical and content considerations,
for example, using videos adapted to interests of individuals and which res-
onate with their milieu (Kasinopoulos 2019). Similarly, Yang, Moss-Morris
and McCracken (2017) delivered their intervention in English, but audio
recordings were made by a Singaporean Chinese therapist, and changes
were also made to words used and sentence structure so that voice, accent
and rhythm matched that of the participants. Karekla and Savvides (2019)
adapted a number of ACT metaphors and exercises using Greek mythology
concepts and characters, with positive impacts on engagement, interest
and utilization of ACT techniques.
Smartphone applications
The rise of smartphones has also led to vast growth in the number of apps
available for psychological wellbeing. Chapter 8 includes a thorough review
of how to ensure efficacy and safety when recommending apps. ACT-based
apps, similarly to iACT, often provide an intervention encompassing all or
some of the ACT components as modules. O’Connor et al. (2020) provide
a good example of how to employ apps to augment ACT group therapy
outcomes for smoking cessation. They found that such apps can be crucial
in providing participants with support in moments when they experienced
cravings and found it hard to apply ACT principles without guidance.
Most research on apps indicates the need for simple language and a
micro-learning format (Gentili et al. 2020), dividing therapy into smaller
chunks (usually around 15 minutes long) and encouraging interacting
with the app daily (O’Connor et al. 2020) or even numerous times a day
(Batink et al. 2016). Bricker et al. (2014), for example, adapted their ACT
smoking cessation website and telephone intervention to an app with
email reminders to use the app. The main difference between the iACT
and the app was that the app was self-paced, leaving responsibility of when
treatment would be completed up to the individual.
What is perhaps most helpful about ACT-based apps is that they can
provide immediate feedback for real-life situations, which can be key when
exposure and experiential exercises are a big part of treatment (Gentili

et al. 2020). For example, in Li (2018), participants received immediate
feedback when using ACT skills in real life, as well as a ‘flexibility score’:
how flexible they were in each situation. This can increase engagement
with treatment, but also allow individuals to make greater improvements
in real-life settings. At the same time, apps can also record real-time data.
Batink et al. (2016) employed an Experience Sampling Method (ESM),
requiring participants to complete assessments of experiences, activities
and symptomatology numerous times a day and at random times. The
authors reported that their approach paid attention to the context in which
behaviours occur and was, thus, valuable for teaching ACT processes
of ‘being in the present moment’ and ‘self as context’. Such assessments
encourage individuals to be aware of experiences (internal and external)
as they are unfolding, as well as becoming aware of the context in which
they face difficulties. At the same time, the apps, installed on smartphones
carried continuously through the day, provide new means of exploring
interesting concepts that researchers were previously unable to study in a
laboratory, yet bear direct implications for therapy implementation. For ex-
ample, Gloster et al. (under submission), recently utilized GPS technology
from patients’ smartphones to examine spatiotemporal movement patterns
of patients receiving ACT. Such innovative uses of technology can offer
new insights into how to best intervene and provide timely intervention
when and where individuals need them.
Virtual reality
In recent years, virtual reality (VR) has been increasingly used in thera-
peutic ways – particularly as a method for undertaking exposure therapy

(VRET) – and can allow an easy, fast, more controlled and tolerable way
to provide exposure to fearful or avoided experiences (Eichenberg and
Wolters 2012). VR fits well with ACT, which encourages confronting of
avoided experiences in the context of pursuing valued living. Chapter 19
describes the use of VR for treatment of anxiety, and Çelik, Alptekin and
Yavuz (2020) provide two case studies of how VR exposure complements
ACT for acrophobia. Users were guided to employ ACT skills learned
within the VRET with the therapist providing immediate feedback on
how to do so in the moment, such as accepting emotions and proceeding
with exposure, instead of employing avoidance behaviours when anxiety
increased.
Prudenzi et al. (2019) went beyond using VR as a way to provide ACT

exposure, to create and test a cognitive defusion VR environment. In ACT,
cognitive defusion is usually accomplished through methods varying from
repeating the phrase of a disturbing thought to using language exercises,
such as ‘I am having the thought that…’ (Harris 2009). Selecting a nega-
tive self-referential thought, and then playing with the words (e.g. colour,
shape, size) using ‘virtual hands’ in the digital environment, was effective
in enabling defusion by being able to see the thought rather than seeing
the world from behind the thought. However, it is still unclear whether
this is a more effective modality to conduct defusion than those used in
traditional therapeutic settings.
Digital theory driven approaches: persuasion

technology, gamification and avatars
Gamification, the application of game design elements (e.g. levels, score
or rewards and prizes) can be used to improve ACT websites, apps or even
virtual reality (Karekla et al. 2019a). As aforementioned, Li (2018) utilized
gamification in providing feedback regarding participants’ ‘flexibility score’
as exhibited in real-life situations. Unfortunately, to date there are few
programs available which employ gamification principles for therapeutic
processes (Litvin et al. 2020).
Our team has recently developed programs providing ACT-guided
interventions utilizing digital theory driven approaches and particularly
persuasive technology and gamification principles (e.g. Kasinopoulos 2019;
Nikolaou, Merwin and Karekla, under submission) in delivering the treat-
ment content in a more playful and vivid way. In these interventions, ACT
content (metaphors, exercises, etc.) is adapted for digital presentation. For

example, the now classic bulls-eye values clarification exercise (Lundgren
et al. 2012) was adapted as a game where the participant digitally throws
darts to indicate where they lie in terms of their valued areas of living.
Use of avatars (i.e. digital characters in electronic and online gaming)
can also be an important component in delivering digital ACT inter-
ventions, particularly to youth, where they can be utilized as guides or
co-travellers (e.g. Karekla and Savvides 2019; Karekla et al. 2020; Kasi-
nopoulos 2019). Avatars allow for the delivery of persuasive technology
principles of trustworthiness, expertise (i.e. system demonstrates knowl-
edge, competence and experience), surface credibility (similar to face
validity), real-world feel, authority and verifiability (Karekla et al. 2019a).
Building programs based on these principles is important for engagement

purposes in digital interventions as well as limiting therapist bias with the
potential to allow for culturally sensitive presentations and adaptations of
content. Avatars have been found to elicit surprisingly strong feelings, with
users attributing characteristics to the avatar beyond what was expected
(e.g. ‘I love her’ and ‘she gets me’ were reported by participants; Watson
et al. 2019).
In contrast, Matsangidou et al. (2020) found that participants chose the
avatar of the therapist to be a talking box (no anthropomorphic features).
This therapist-box was attributed characteristics of a warm, compassionate
person that did not judge or criticize the participants. The adaptation of
avatars as guides or therapists allows for new explorations into delivering
treatments such as ACT and has the potential to address additional treat-
ment factors that impact its effectiveness (therapeutic relationship, time
demands, etc.).
Summary of evidence for digital ACT interventions

Given the rise of digital advances and the increased need for digital int
erventions, it is important for research to investigate whether digitized
ACT can be effective. Telehealth ACT interventions demonstrated effec-
tiveness for a range of difficulties including smoking cessation (Bricker
et al. 2014), pain interference and severity reduction (Kasinopoulos 2019),
increasing quality of life in chronic pain sufferers (Herbert et al. 2017) and
reducing symptom interference in metastatic breast cancer (Mosher et al.
2018). However, some studies indicated no differences between such ACT
interventions and control groups (Mak et al. 2020), though the authors
stated that lack of significant findings may have been related to the brief-
ness of treatment. Moreover, dosing of treatment provided is an important
issue that needs to be considered when examining any type of digital
intervention. Importantly, all of the aforementioned research aimed to
examine ACT’s effectiveness in being delivered using these modalities. Yet,
telephone-collected data is starting to be used to examine mechanisms of
intervention change (e.g. Vilardaga et al. 2014). Thus, digital interventions
can also give important research information, providing novel ways to
investigate the contribution of individual components of ACT to treatment.
Furthermore, systematic reviews and meta-analytic evidence provide
encouraging results for website-delivered ACT (e.g. Brown et al. 2016;
French et al. 2017; Kelson et al. 2019; Thompson et al. 2020). Despite
iACT’s effectiveness, overall effects remain lower compared to face-to-

face ACT. Yet, some studies demonstrate large and significant effect sizes
comparable to those of face-to-face ACT. For example, Lappalainen et al.
(2014) found large effects in depression symptom reduction and wellbe-
ing, present at 18-month follow-up in an iACT study. Further research is
needed, specifically examining under which conditions (larger dosing,
inclusion of guidance, etc.) iACT interventions may result in higher effect
sizes on intended outcomes.
As with teleconferencing, research in this area has also begun to
move beyond testing iACT’s effectiveness. Both Kasinopoulos (2019)
and Probst et al. (2019) used iACT interventions for chronic pain and
examined processes of change during treatment. Their findings indicate
that psychological flexibility at baseline moderated pain interference levels
at end of treatment (Probst et al. 2019), whereas changes in willingness
to experience pain contributed significantly to outcome improvement in
the intervention group (Kasinopoulos 2019). Such work is key in light
of new advances in evidence-based care emphasizing the need to treat
disorders using process-based rather than symptoms-based therapies,
which target important moderators and mediators of change (Hofmann
and Hayes 2019).
In terms of ACT apps, there are no meta-analytic studies, yet individual
studies have begun to shine light into their effectiveness. Li (2018) used a
single-case design and found that ACT apps can be effective in improving
wellbeing in university students. Mattila et al. (2016) showed that greater
use of an ACT app was associated with increased psychological flexibility
suggesting a dose-response relationship. ACT apps can also be used to
augment face-to-face treatment (see O’Connor et al. 2020). Overall, ACT
apps are a recent development, and more exploration of the range of areas
they can impact and their effectiveness in relation to other forms of therapy
is needed.
In regard to VR, research indicates that ACT can fit well with this mo-
dality of intervention delivery (e.g. Matsangidou et al. 2020). The ability of
the therapist to be present during exposure (in the same room or within the
virtual environment) can facilitate live use of ACT skills during exposure
(Çelik et al. 2020). VR can also be used to examine particular components
of the intervention, and ACT exercises lend themselves well for digital
adaptations (Prudenzi et al. 2019).
Suggestions and future directions

It is inevitable that the rise in technological advances will continue. ACT
researchers and clinicians need to prioritize high-quality research to
provide robust evidence on the usefulness, feasibility and efficacy of ACT
digital interventions for a range of problems. Future research should aim
to provide evidence on the ecological validity of ACT-based digital inter-
ventions by testing how these work with patients in real life. This requires
the development and use of complementary and non-intrusive methods to
capture the processes of sufficient engagement of users with interventions
to achieve intended outcomes (‘effective engagement’; Yardley et al. 2016).
Co-creating digital interventions by involving end users from the start is
crucial in overcoming high levels of dropout and attrition problems that
undermine evidence quality of digital interventions (Karekla et al. 2019b;
Van Daele et al. 2020).
The ACT community is finally encouraged to focus on widespread
attempts to provide access to tested programs to the wider community
and continue to investigate effectiveness of delivering such interven-
tions through new mediums. ACT clinicians need to embrace advances
in technology and advocate for the greater need for integrating digital
interventions in healthcare delivery. Yet, we need to be mindful of indi-
viduals’ knowledge, abilities and ease of access to digital interventions.
Not everyone has access to the internet, owns a smartphone or has the
ability to use it. Future research needs to account for inequalities in digital
intervention use as we may be inadvertently excluding older or less priv-
ileged populations (Robinson et al. 2015). With the advent of technology,
we foresee that digital developments in treatment delivery of ACT and its
evaluation will continue and flourish. We also believe that digital means
can be used to answer questions (e.g. of contexts’ impact in the moment

interacting with individual difference parameters) that limited previous
generations of researchers.
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Digital ACT

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CHAPTER 9

Digital Acceptance and

Acceptance and Commitment Therapy (ACT; Hayes, Strosahl and Wilson

able to adapt to situational demands (internal and external) in order to

Digital adaptations and applications of ACT

Teletherapy: videoconferencing and telephoning

still employed in the same way. The metaphor of ‘two mountains’ as a

Digital interventions via a website

experiential components (Kasinopoulos 2019; Levin et al. 2017). Using

exposure and experiential exercises are a big part of treatment (Gentili

peutic ways – particularly as a method for undertaking exposure therapy

Prudenzi et al. (2019) went beyond using VR as a way to provide ACT

Digital theory driven approaches: persuasion

content (metaphors, exercises, etc.) is adapted for digital presentation. For

Building programs based on these principles is important for engagement

Summary of evidence for digital ACT interventions

iACT’s effectiveness, overall effects remain lower compared to face-to-

Suggestions and future directions

can be used to answer questions (e.g. of contexts’ impact in the moment

status of Acceptance and Commitment Therapy: a review of meta-analyses.’ Journal of

established treatment comparisons?’ Psychotherapy and Psychosomatics, 78, 6, 380.

You might also like

Digital ACT

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Document Information

Copyright

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Share this document

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Did you find this document useful?

Is this content inappropriate?

Copyright:

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Digital ACT

Uploaded by

Copyright:

Available Formats

CHAPTER 9

Digital Acceptance and

Acceptance and Commitment Therapy (ACT; Hayes, Strosahl and Wilson

able to adapt to situational demands (internal and external) in order to

Digital adaptations and applications of ACT

Teletherapy: videoconferencing and telephoning

still employed in the same way. The metaphor of ‘two mountains’ as a

Digital interventions via a website

experiential components (Kasinopoulos 2019; Levin et al. 2017). ­Using

exposure and experiential exercises are a big part of treatment (Gentili

peutic ways – particularly as a method for undertaking exposure therapy

Prudenzi et al. (2019) went beyond using VR as a way to provide ACT

Digital theory driven approaches: persuasion

content (metaphors, exercises, etc.) is adapted for digital presentation. For

Building programs based on these principles is important for engagement

Summary of evidence for digital ACT interventions

iACT’s effectiveness, overall effects remain lower compared to face-to-

Suggestions and future directions

can be used to answer questions (e.g. of contexts’ impact in the moment

status of Acceptance and Commitment Therapy: a review of meta-analyses.’ Journal of

established treatment comparisons?’ Psychotherapy and Psychosomatics, 78, 6, 380.

You might also like

experiential components (Kasinopoulos 2019; Levin et al. 2017). Using