Why doesn’t ACT focus on symptom reduction?
When practitioners discover Acceptance and Commitment Therapy, they are often surprised by the message that symptom reduction is not so significant. For many years psychology services have used self-report measures such as the PHQ9 and GAD7, which focus on specific so-called ‘symptoms’ of depression and anxiety. These tests and many others ask about thoughts and feelings, and case management supervision pays close attention to changes in these scores.
RCTs in Cognitive Behavioural Therapy tend to use symptom-reduction measures to show how effective a treatment is for a specific problem. Cognitive therapy uses the principle that if people rationalise their thoughts, they will start to feel better. In other words, there is a culture of symptom reduction inside psychology, which I think is why newcomers to ACT are often puzzled by the idea that symptom reduction is unnecessary.
What does ACT focus on instead?
ACT works by increasing psychological flexibility, a combination of six interrelated behavioural processes—organised into three pillars commonly known as open, aware and active. Research shows that when you build psychological flexibility, the quality of a person’s life improves, and the symptoms of the so-called psychiatric disorders also reduce.
Why not focus on symptom reduction as well as psychological flexibility?
ACT is concerned with developing science that is adequate to the human condition. Despite the advancements in psychological treatments for mental health problems, there are multiple issues with the current psychiatric characterisation of disorders and the prioritisation of symptom reduction.
The DSM and ICD are the chief diagnostic tools in psychiatry, and they dominate the way professionals think about mental health problems in the UK. Unfortunately, classifying the issues into ‘disorders’ is not a scientific process. It’s merely done by consensus among psychiatrists. Therefore, if a psychiatrist says you have depression, it is only valid because they say so. There is no blood test or biological process that can support the diagnosis.
Have you ever heard of a person receiving more than one diagnosis?
Sadly, it is expected because the process is subjective rather than objective. Medicine, by comparison, is a more objective process with clear biological markers for disease. You cannot measure mental health problems like that, and so we cannot rely on the psychiatric system of diagnoses to provide us with accurate information.
Practitioners need to know what keeps a problem going because it allows them to target the specific processes that are not working. The ACT model of psychological flexibility attempts to give you and your client a practical framework.
Experiential Avoidance increases suffering.
Research studies using ACT show that experiential avoidance increases anxiety and depression. Avoidance is the process of pushing away, trying to get rid of or escaping thoughts and feelings. It shows that the more you try to do that, the more distressed you become.
It wouldn’t make sense if ACT suggested you focus on doing more of that. It would only make the situation worse, would it not?
ACT teaches skills in mindfulness and acceptance that do help with emotional regulation. However, they are only tools to help you better look after yourself and other people. The main aim of ACT is to get you moving your feet and to live fully in your experience. That is proper well-being – living well!
It sounds simple, but it is far harder to do that. We are often lost in our minds worrying, analysing and overthinking. We adopt and follow the rules for living that usually function to drive you away from discomfort. We run away from feelings that we don’t like.
Many people arrive at therapy wanting you to help them be less anxious or depressed. They just want to feel happier and more relaxed. However, these goals are vague and don’t tell you what a person wants to do with their life.
Well-being isn’t merely the absence of anxiety or depression. Well-being is about building patterns of health and wisdom. ACT helps you make your life bigger instead of making the problems smaller. It just so happens that as you grow, the obstruction inside you gets smaller proportionately, and it loses its power. It no longer fills up your entire experience.
Studies in well-being show that reductions in anxiety and depression don’t correlate well with improved quality of life. If you just focus on bringing these symptoms down, you aren’t helping a person as much as possible. Fear, disappointment, hurt, guilt and anger are part of life. You can’t grow and not have these feelings. One needs to be better at navigating these emotions and keep moving. As Winston Churchill said: ‘if you’re going through hell, keep going.
In ACT, our aim is not to help our clients feel better but to help them be better at the feeling. It is an important distinction, and hopefully, one that captures the spirit of psychological flexibility.
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