Applications and adaptations of Acceptance and Commitment Therapy (ACT) for adolescents

https://doi.org/10.1016/j.jcbs.2015.01.002Get rights and content

Highlights

  • ACT responds to critiques of traditional cognitive-behavioral therapy (tCBT).

  • ACT and its components have been utilized in few studies with adolescents.

  • ACT can be adapted to the developmental needs of adolescents.

  • ACT is applicable to typical adolescent problems, even at low distress levels.

  • More research is needed to determine the appropriateness of ACT for adolescents.

Abstract

Acceptance and Commitment Therapy (ACT) is an emerging cognitive-behavioral therapy that uses mindfulness, acceptance and other skills to treat psychological problems. ACT differs from traditional cognitive-behavioral therapy (tCBT) in some ways, but the two therapies share several similarities. Though ACT has some empirical support when used with adults, there is very sparse literature to date on using ACT with adolescents. This review will discuss the state of the field with regard to using ACT with adolescents with a special focus on developmental adaptations and considerations that could enhance cognitive-behavioral treatment of this population. Ten studies that utilized multiple or all ACT components with adolescents are the focus of this review. The review will explore adaptations that are currently used in ACT research with adolescents, considerations that have been suggested but were not implemented in these studies, and other adolescent problems that could potentially be ameliorated with the use of ACT techniques. The review will conclude with a discussion of salient methodological and assessment-related limitations, suggestions for choosing whether ACT might be appropriate for use with adolescent clients, and ideas for future research on using ACT with adolescents.

Introduction

In recent years, some basic tenets and processes of traditional cognitive-behavioral therapy (tCBT) have been the subject of debate among psychotherapists and clinical researchers (Hayes, Levin, Plumb-Vilardaga, Villatte, & Pistorello, 2013). In particular, there have been questions about whether thought content needs to be targeted (Hayes, 2004). Additionally, some find it troublesome that common cognitive techniques cannot be scientifically linked to basic cognitive psychology (Hayes, Luoma, Bond, Masuda, & Lillis, 2006) or worry that tCBT is too symptom-focused (Hofmann & Asmundson, 2008). Change sometimes occurs before the relevant tCBT techniques are introduced, and there is unclear support for proposed mediators of change (Longmore & Worrell, 2007), like coping skill development (Morganstern & Longabaugh, 2000) or dysfunctional attitude changes (Burns & Spangler, 2001). New styles of cognitive-behavior therapy have emerged in response to these critiques, one being Acceptance and Commitment Therapy, or “ACT” (Hayes, Strosahl, & Wilson, 1999). Generally speaking, these therapies take a contextual approach, with the goal of helping clients respond to the function rather than the content of thoughts (Hayes, 2004). Context becomes problematic when clients desire to control, explain, or otherwise cope with the thought rather than simply experience it (Hofmann & Asmundson, 2008). These therapies promote greater mindfulness and thought acceptance instead of direct challenging of thoughts, as in tCBT (Hayes et al., 2013).

The following review will focus on ACT and its relevance and application for clinicians who work with adolescents. In particular, the review will discuss similarities and differences between an ACT approach and a tCBT approach and provide suggested guidelines for determining which approach might be a better fit for individual adolescent clients. Special attention will be paid to identifying developmental adaptations and considerations, drawn from various cognitive-behavioral approaches that can facilitate the use of ACT and other therapies with adolescents. Studies that have used an ACT approach and incorporated these ideas will be highlighted. Finally, salient methodological concerns and potential solutions will be discussed.

Section snippets

The ACT treatment process

ACT centers on the problem of psychological inflexibility, the impact of which increases as people become dependent on familiar control strategies for dealing with unpleasant experiences without realizing that these apparent solutions are ultimately ineffective (Hayes et al., 1999). In ACT, clients work on increasing contact with the present moment and accepting problematic thoughts or feelings rather than attempting to control or avoid them. Clients practice disentangling their thoughts,

The effectiveness of ACT and comparisons to tCBT

ACT has been found to be more effective than control conditions, including waitlist controls, treatment as usual (TAU), and placebos (Powers, Zum Vörde Sive Vörding, & Emmelkamp, 2009). Across adults, children and adolescents, ACT is thought to be probably efficacious for chronic pain and tinnitus, and possibly efficacious for stress, weight problems, substance use disorders, anxiety disorders, psychotic disorders, and depression (Öst, 2014). In addition, brief ACT interventions seem to be no

Using ACT components and processes with adolescents

Some processes similar to those used in ACT have previously been implemented with adolescents, suggesting that ACT could be adapted for use with this population. Mindfulness-based stress reduction has been used to lower anxiety and somatic distress and increase self-esteem and sleep quality in teens (Biegel, Brown, Shapiro, & Schubert, 2009). Ames, Richardson, Payne, Smith and Leigh (2014) found that mindfulness-based cognitive therapy reduced depressive symptoms in adolescents. Mindfulness has

Building a developmentally sensitive treatment protocol for adolescents

Multiple scholars have called for more integration of adolescent development research with treatment protocols for adolescents (Steinberg, 2002, Weisz and Hawley, 2002). Some ideas for useful adaptations and considerations, drawn from a collection of studies that used most or all components of ACT as well as reviews of other cognitive-behavioral treatment protocols that have been implemented with adolescents (e.g., tCBT, Dialectical Behavior Therapy (DBT)), will be discussed in the paragraphs

Other suggested developmental considerations

The onset of puberty is an important biological event that typically coincides with the early stages of adolescence (Blakemore, Burnett, & Dahl, 2010). Family conflict and abuse have been linked to early onset of puberty, particularly in girls (Short & Rosenthal, 2008). In addition, early maturing girls and late maturing boys may be at a higher risk of demonstrating psychopathology, deviant behavior, and substance use later in life (Graber, Seeley, Brooks-Gunn, & Lewinsohn, 2004). Thus, it is

Other hypothetical applications of ACT for adolescent problems

Adolescents often get involved in multiple activities (e.g., school, teams, clubs, community groups), which may create stress and make focusing on everyday tasks difficult. Mindfulness training may help adolescents disengage from stressful thoughts and focus on the present moment (Biegel et al., 2009) as well as promote increased self-care and improved sleep (Wall, 2005), thereby balancing out the negative effects of stress. Additionally, participation in extracurriculars could be enhanced with

Methodological and assessment considerations

As might be expected with a newly emerging literature, the studies in this review cited some important limitations related to methodology and assessment. The most commonly cited problems were selected for special mention here in order to highlight their importance for future studies in this area. However, it should be noted that many of these limitations are not specific to the studies in this review, ACT, or adolescent treatment but apply broadly to clinical literature. The pervasive nature of

Summary and conclusions

ACT emerged as part of the third wave of historical developments in cognitive and behavioral therapy traditions. It primarily differs from its predecessor, tCBT, in the areas of cognitive techniques (using defusion and acceptance as opposed to cognitive restructuring), emotional coping (focusing on how to respond to emotions with mindfulness and acceptance instead of focusing only on the antecedents of emotion), and outcomes (emphasizing workability of strategies and psychological flexibility

Future research directions

This review revealed that acceptance and mindfulness have been utilized successfully with adolescents in several studies. Other components and processes used in ACT have not yet been implemented pervasively with adolescents. Only one study was found that used defusion and self as context work with adolescents (Luciano et al., 2011). Also, few studies were found that used values and committed action specifically with adolescents. More research on these components is needed to fully understand

Acknowledgments

I thank my doctoral committee members, Dr. George Clum, Dr. Kirby Deater-Deckard, and Dr. Bradley White, for their contributions and support in preparing this manuscript, which was part of my preliminary exam. I also thank Neville Galloway-Williams, M.S., for her help and encouragement in deepening my understanding of core ACT concepts.

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