Acceptance and Commitment Therapy (ACT): Contextual Therapy in the Approach to Psychosis

Full reference: Gil-Luciano, B., Ruiz, F. J., & Luciano, C. (2023). Acceptance and Commitment Therapy (ACT): Contextual Therapy in the Approach to Psychosis. In J. A. Díaz-Garrido et al. (Eds.), Psychological Interventions for Psychosis (pp. 225–246). Springer. https://doi.org/10.1007/978-3-031-27003-1_12

Type of work: Book chapter

Central thesis and objectives

The chapter presents Acceptance and Commitment Therapy (ACT) as the primary clinical application of Contextual Behavioral Science (CBS), emphasizing its philosophical anchoring, theoretical foundations, and utility in treating psychosis. The authors argue that ACT, as a form of contextual therapy, offers a fundamentally different approach to addressing psychotic symptoms: rather than attempting to eliminate or control hallucinations and delusions, ACT seeks to increase the patient's psychological flexibility, allowing them to relate differently to their private experiences.

The stated purpose is to briefly review the philosophical roots and theoretical trunk of ACT (considering it an application of CBS), present a model of psychosis based on Relational Frame Theory (RFT), explain three central clinical strategies for building psychological flexibility, and illustrate these concepts through a detailed clinical case (Ernest). The authors aim to demonstrate that ACT represents an important paradigmatic shift in understanding and treating psychotic symptoms.

Theoretical framework

The chapter develops the theoretical framework across three hierarchical levels. First, Functional Contextualism (FC) serves as the philosophical anchor of CBS. According to FC (Gifford & Hayes, 1999; Hayes, 1993), contextualism is a form of pragmatism that rejects Skinner's non-analytical psychological assumptions (Skinner, 1974) by asserting that psychological events cannot be understood disconnected from their historical and situational context. FC adopts the truth criterion of "action-in-context," where understanding a psychological event is achieved only by analyzing the context in which it occurs.

The second level consists of the Principles of Learning and Relational Frame Theory (RFT). RFT, developed significantly over the past two decades, explains human behavior through principles of learning derived from classical and operant conditioning. A central finding of RFT is that, through multiple exemplars with explicit contingencies, organisms develop the capacity to establish relationships between arbitrary verbal stimuli: coordination, distinction, comparison, reverse comparison, opposition, and perspective. This generative relational capacity causes human beings to have considerable fluency in framing stimuli, creating an abundance of derived relational events and transformations of functions. Thus, while a word like "dog" can acquire an aversive function directly, arbitrarily related words such as "wolf" can also acquire derived aversive functions even without direct exposure.

The third level describes how these principles apply to understanding psychological inflexibility and the generation of psychological problems. The authors propose that psychological flexibility comprises six interrelated processes: acceptance (active and conscious contact with private experiences without attempting to change their frequency), cognitive defusion (distancing from the immediate function of thoughts), contact with the present moment (non-judgmental contact with psychological events of the moment), perspective of self (sensation of self as locus or context), values (qualities of purposeful action), and committed action (actions linked to chosen values). Conversely, psychological inflexibility is characterized by experiential avoidance, cognitive fusion, dominance of the conceptualized past, content-self attachment, lack of values clarity, and disconnected impulsivity.

Argument development

The chapter develops its argument by showing how ACT, as an application of CBS, fundamentally differs from traditional models of psychological pathology. While conventional approaches attempt to reduce or eliminate specific psychotic symptoms, ACT recognizes that the presence of hallucinations, delusions, and other private experiences does not necessarily constitute a clinical problem. What becomes problematic is when the person acts according to the content of the hallucination or delusion in ways that generate counterproductive consequences, or when they develop patterns of experiential avoidance to escape these experiences.

The authors present three central clinical strategies for building psychological flexibility in psychosis. The first strategy helps the client contact the problematic consequences of the inflexible pattern, facilitating discrimination of: (a) the inflexible pattern experienced, (b) the types of inflexible responses practiced, (c) the short-term consequences of the inflexible response, and (d) the long-term consequences in terms of chronic discomfort and value impairment. The second strategy helps the client frame limiting private events hierarchically through the deictic "I" as an alternative functional class, involving relational processes such as deictics, hierarchical cue framing, and derivation of rules for courses of action with reinforcement. The third strategy helps the client clarify and amplify values as hierarchical positive reinforcers, facilitating contact with the hierarchy of positive reinforcers established throughout personal history.

In the section on ACT in psychosis, the authors emphasize that psychotic symptoms do not constitute a clinical problem solely by their presence. Drawing on Bach (2004), they argue that while hallucinations and delusions are symptoms that might be reduced, the inflexible behavior generated by these symptoms does constitute a clinical problem. Psychosis from a functional-contextual perspective involves the person responding to hallucinations and delusions in limited and rigid ways, engaging in counterproductive experiential avoidance patterns. The goal of ACT in psychosis, then, is to promote psychological flexibility in how the person responds to hallucinations and delusions, allowing them to direct their behavior toward valued directions.

The clinical case of Ernest illustrates practical application of these principles. Ernest, aged 47, presents with Major Depressive Disorder with psychotic features and recurrent episodes. His history reveals a deeply ingrained pattern of psychological inflexibility: from childhood, he was raised in a context of constant caution about the world's dangers, developing a central rule about himself as incapable of surviving under conditions of vulnerability. This pattern was amplified throughout his life, generating a complex system of avoidance behaviors that interfered with his life goals. During intervention, therapists used the three strategies in concert to: (1) help Ernest experientially contact how his avoidance pattern kept him trapped, (2) frame his behavior flexibly through perspective deictics, allowing him to see his pattern as a choice at each moment, and (3) clarify and amplify his values (independence, bravery, usefulness, affection), exploring metaphors and exemplars to connect with personal reinforcers that allowed him to take valued actions even amid significant discomfort.

The authors report that empirical evidence supports the utility of ACT in psychosis. They cite a recent systematic review by Jansen et al. (2020) that identified seven randomized controlled trials in which ACT-based interventions were tested in the United States, United Kingdom, Canada, Sweden, and Australia. Although they note these results should be considered preliminary, ACT has shown superior results compared to treatment as usual in terms of rehospitalization (Bach & Hayes, 2002; Gaudiano & Herbert, 2006; Tyrberg et al., 2017), positive symptoms and distress related to hallucinations (Shawyer et al., 2017), and negative and emotional symptoms (Gumley et al., 2017; Spidel et al., 2018; White et al., 2011).

Implications

One central implication is that ACT requires a significant shift in the clinical conceptualization of psychosis. Mental health professionals must recognize that the presence of psychotic symptoms is not necessarily the focal point of the intervention; instead, the patient's psychological flexibility in the face of these symptoms should be the primary goal. This has implications for therapist training, who need to move fluidly through the relational processes involved in the three clinical strategies and be capable of applying them flexibly according to each patient's initial inflexibility repertoire.

A second implication is that ACT offers a pragmatic alternative to treatment approaches focused exclusively on symptom reduction. Particularly in chronic patients with long trajectories of psychological inflexibility, where symptoms may be highly resistant to change, ACT provides a viable path toward meaningful functioning and valued living even in the presence of persistent symptoms. This is especially relevant given that many patients with psychosis show a tendency to reject or abandon interventions after periods of symptom remission, or to experience relapses when symptoms reappear.

Significance and contribution

This chapter makes an important contribution by providing an integrated theoretical framework for understanding ACT as a specific application of Contextual Behavioral Science in the context of psychosis. Unlike many ACT presentations that emphasize technical procedures, the authors explicitly establish how ACT is grounded in Functional Contextualism, how RFT explains processes of psychological flexibility and inflexibility, and how these foundations translate directly into three concrete clinical strategies. The detailed clinical case of Ernest demonstrates the practical application of this theoretical framework, providing a concrete example of how abstract concepts unfold in clinical practice. The synthesis of empirical literature on ACT in psychosis, while acknowledging its preliminary nature, establishes a useful reference point for future research. Collectively, the chapter advances the field by offering a coherent integration of philosophy, learning theory, verbal processing, and clinical practice in treating a complex and challenging disorder.

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