Applications and adaptations of Acceptance and Commitment Therapy (ACT) for 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.
References (99)
- et al.
Adolescent self and identity development in context
Journal of Adolescence
(2008) - et al.
Determinants and mechanisms in ego identity development: A review and synthesis
Developmental Review
(2001) - et al.
Do changes in dysfunctional attitudes mediate changes in depression and anxiety in cognitive behavioral therapy?
Behavior Therapy
(2001) - et al.
Acceptance and commitment therapy (ACT): Advances and applications with children, adolescents, and families
Child and Adolescent Psychiatric Clinics of North America
(2011) - et al.
Acceptance-enhanced behavior therapy for trichotillomania in adolescents
Cognitive and Behavioral Practice
(2012) Öst׳s (2008) methodological comparison of clinical trials of acceptance and commitment therapy versus cognitive behavior therapy: Matching apples with oranges?
Behaviour Research and Therapy
(2009)- et al.
Is pubertal timing associated with psychopathology in young adulthood?
Journal of the American Academy of Child and Adolescent Psychiatry
(2004) - et al.
Correlates and consequences of uncertainty in career aspirations: Gender differences among adolescents in England
Journal of Vocational Behavior
(2012) - et al.
Biological substrates of emotional reactivity and regulation in adolescence during an emotional go-nogo task
Biological Psychology
(2008) Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies
Behavior Therapy
(2004)
Acceptance and commitment therapy: Model, processes and outcomes
Behaviour Research and Therapy
Acceptance and commitment therapy and contextual behavioral science: Examining the progress of a distinctive model of behavioral and cognitive therapy
Behavior Therapy
Acceptance and commitment therapy in the treatment of an adolescent female with anorexia nervosa: A case example
Cognitive and Behavioral Practice
Caution: The differences between CT and ACT may be larger (and smaller) than they appear
Behavior Therapy
Acceptance and mindfulness-based therapy: New wave or old hat?
Clinical Psychology Review
The empirical status of the “new wave” of CBT
Psychiatric Clinics of North America
Cognitive-behavioral therapy and dialectical behavior therapy: Adaptations required to treat adolescents
Psychiatric Clinics of North America
Do we need to challenge thoughts in cognitive behavior therapy?
Clinical Psychology Review
A randomized controlled trial of a behavioral intervention to reduce high-risk sexual behavior among adolescents in STD clinics
Behavior Therapy
Inventing the wheel once more or learning from the history of psychotherapy research methodology: Reply to Gaudiano׳s comments on Öst׳s (2008) review
Behaviour Research and Therapy
The efficacy of acceptance and commitment therapy: An updated systematic review and meta-analysis
Behaviour Research and Therapy
Mapping brain maturation and cognitive development during adolescence
Trends in Cognitive Sciences
Fostering symbolic interpretation during adolescence
Journal of Applied Developmental Psychology
A mindfulness-based strategy for self-management of aggressive behavior in adolescents with autism
Research in Autism Spectrum Disorders
Clinical considerations in using mindfulness- and acceptance-based approaches with diverse populations: Addressing challenges in service delivery in diverse community settings
Cognitive and Behavioral Practice
Cognitive and affective development in adolescence
Trends in Cognitive Sciences
A pilot of an acceptance-based risk reduction program for relational aggression for adolescents
Journal of Contextual Behavioral Science
Tai chi and mindfulness-based stress reduction in a Boston public middle school
Journal of Pediatric Health Care
The development of metacognitive ability in adolescence
Consciousness and Cognition
Using acceptance and commitment therapy in the rehabilitation of an adolescent female with chronic pain: A case example
Cognitive and Behavioral Practice
Evaluating the effectiveness of exposure and acceptance strategies to improve functioning and quality of life in longstanding pediatric pain: A randomized controlled trial
Pain
Acceptance and commitment therapy for self-stigma around sexual orientation: A multiple baseline evaluation
Cognitive and Behavioral Practice
Examination of the core cognitive components of cognitive behavioral therapy and acceptance and commitment therapy: An analogue investigation
Behavior Therapy
Innovations in practice: Mindfulness-based cognitive therapy for depression in adolescents
Child and Adolescent Mental Health
Acceptance and commitment therapy and cognitive behavioral therapy for anxiety disorders: Different treatments, similar mechanisms?
Clinical Psychology: Science and Practice
Emerging adulthood: A theory of development from the late teens through the twenties
American Psychologist
The use of acceptance and commitment therapy to prevent the rehospitalization of psychotic patients: A randomized controlled trial
Journal of Consulting and Clinical Psychology
Mindfulness-based stress reduction for the treatment of adolescent psychiatric outpatients: A randomized clinical trial
Journal of Consulting and Clinical Psychology
Acceptance and commitment: Implications for prevention science
Prevention Science
Social values survey
The role of puberty in the developing adolescent brain
Human Brain Mapping
Mindfulness for adolescents: A promising approach to supporting emotion regulation and preventing risky behavior
New Directions for Youth Development
Investigating the similarities and differences between practitioners of second- and third-wave cognitive-behavioral therapies
Behavior Modification
Acceptance and well-being in adolescents and young adults with cystic fibrosis: A prospective study
Journal of Pediatric Psychology
Treatment of three anxiety disorder cases with acceptance and commitment therapy in a private practice
Journal of Cognitive Psychotherapy
After the assessment: Introducing adolescents to cognitive-behavioural therapy
Australian Journal of Guidance and Counselling
Identity formation in early and middle adolescents from various ethnic groups: From three dimensions to five statuses
Journal of Youth and Adolescence
Cited by (52)
A Review of Acceptance and Commitment Therapy for Adolescents: Developmental and Contextual Considerations
2024, Cognitive and Behavioral PracticeCitation Excerpt :This means that ACT is not delivered in a manualized or structured format but with whatever the individual is presenting with in session (see Hofmann & Hayes, 2019, for a discussion; Ong et al., 2020). Skills promoting psychological flexibility (e.g., ACT processes) can be fluidly applied and adjusted to the range of developmental considerations needed for the moment at hand (Halliburton & Cooper, 2015). Building psychologically flexible responses and attitudes in adolescence may be beneficial for cognitive and emotional development.
Acceptability of ACT group intervention for adolescents with type 1 diabetes
2024, Journal of Contextual Behavioral ScienceThe acceptability, feasibility and preliminary efficacy of acceptance and commitment therapy for adolescents in the management of overweight or obesity: A scoping review
2024, Journal of Contextual Behavioral ScienceThe effect of DNA-V model intervention on learning behaviors and stress in Chinese adolescents: A randomized controlled trial
2023, Journal of Contextual Behavioral ScienceTemperament and symptoms of stress and depression among adolescents: The mediating role of psychological flexibility
2023, Journal of Affective Disorders ReportsMagis – A magical adventure: Using a mobile game to deliver an ACT intervention for elementary schoolchildren in classroom settings
2023, Journal of Contextual Behavioral Science