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Acceptance and Commitment Training (ACT) is focused on teaching individuals how to be psychologically flexible by accepting their thoughts, feelings, and experiences, connect with their values, and take effective action toward those values. The six principles of ACT are: acceptance; defusion; contact with the present moment; committed action; self-as-perspective; and values. The purpose of this paper is to give an overview of each principle and to argue whether applying those principles could aide in serving victims of intimate partner violence (IPV). An overview of theoretical underpinnings and a history review will provide the required background needed to determine if these principles could be effective for the intended populations. Then we will review the current literature for treatments with those populations. Next will be determining if there are any gaps in the research that need filling in order to determine effective methods for serving the intended populations of offenders and victims of IPV, specifically those who are a part of the LGBTQIA community. Finally, we will determine if ACT is behavior analytic in nature, what ethics apply to the use of ACT and what are the feasible next steps to appropriately serve victims of intimate partner violence and the LGBTQIA community.
Theoretical Underpinnings
ACT, according to Psychology Today on April 10, 2019, is an action-based approach to psychopathology (Acceptance and Commitment Therapy, n.d.). Psychotherapy is generally described as a way to aide individuals with various types of mental illnesses and difficulties with emotions such as anxiety, depression, PTSD and others. Most people might describe psychotherapy as laying on a sofa talking about your feelings to some therapist. One can also view psychotherapy as way to talk about and identify how your feelings and thoughts might be affecting your behaviors and then make effective changes to your behavior to live a more valued life. According to a podcast called ACT in Context: The History and Development of ACT with Steven Hayes (2011), Hayes gives credit to Sigmund Freud for bringing psychotherapy to the mainstream and setting the stage for culture to become more interested in psychological principles. Freud is most commonly known as the founder of psychoanalysis, a way to treat those with mental illness by “making the unconscious conscious”, and for his theories that explain human behavior. Steven Hayes, the founder of ACT, acknowledges Freud’s contribution as being able to describe “the life within and the role of the unconscious” (Dehlin, Plumb, & Hayes, 2011).
Although Hayes acknowledges the great contributions Freud made to the field, he goes on to say Freud had radical and controversial ideas and, “the way he went about theorizing and collecting data made it hard to disprove any of his findings” (Dehlin, Plumb, & Hayes, 2011). An in-depth discussion of the method Freud used would be beneficial but is beyond the scope of this paper. However, it is appropriate to state that Freud’s methods were not based in all 6 principles of science: determinism; experimentation, empiricism, replication, parsimony and philosophical doubt. In the same podcast, Hayes continued to say that B.F. Skinner, Ivan Pavlov, and other early behavior analysts were attempting to “use behavior therapy to link empirical and analytic precision of lab-based learning to psychology to a systematic effort to develop and evaluate methods to alleviate human suffering and behavioral problems” (Dehlin, Plumb, & Hayes, 2011). In short, these pillars of the field were using scientific methods like measurement of observable behaviors and replication to create meaningful and effective treatments in the area of alleviating human pain and suffering. Hayes goes on to say that he entered the field with an interest in a naturalistic, functional and contextual perspective in which he wondered how our behavior could move us from one state of affairs to another (Dehlin, Plumb, & Hayes, 2011).
In the late 1970s, clinicians were becoming increasingly frustrated with not having an adequate approach to human language and cognition. Hayes comments, “I knew we needed a new approach to understanding how people think, reason, talk about, analyze and interpret their problem and solutions to those problems” (Dehlin, Plumb, & Hayes, 2011). Hayes discusses the 3 waves of psychotherapy in this podcast, as well. The first wave, he explains, is centered around the rise of behavior therapy where there is a rebellion of psycho-analysis and the humanistic psychology of Carl Rogers (Dehlin, Plumb, & Hayes, 2011). The second wave was described by Hayes as “bringing clinical theories of cognition forward and freeing up the clinicians to pursue what people think, feel and remember as a target” (Dehlin, Plumb, & Hayes, 2011). John Dehlin, from ACT in Context, rephrases this as letting scientists dive into thoughts, cognition and feelings without the encumberment of difficult language of behaviorism (Dehlin, Plumb, & Hayes, 2011). Hayes summarizes that the second wave proposed that “people’s emotions and behavior were caused by cognition and as such, maladaptive behaviors and emotions were caused by maladaptive cognition; this was a revolutionary theory at the time because people weren’t used to catching, recording, categorizing and analyzing their thinking” (Dehlin, Plumb, & Hayes, 2011). The second wave is very align with the ideology behind CBT.
He states that he came into the field knowing that “progress would require principles that were robust, precise, that have broad scope and that the learning labs of animal research had failed in the area of human language and cognition… Skinner and cognitive behavioral therapy (CBT) principles and ideas were both right and both wrong. Both were making mistakes, and both had a point and we have to find a way to get the best of both” (Dehlin, Plumb, & Hayes, 2011). The third wave of psychotherapy was then described by Hayes as the idea that “your relationship to your own thoughts is determinative of how behavior and emotions congeal” (Dehlin, Plumb, & Hayes, 2011). These waves are all essential in the making of what is now known as ACT.
ACT argues that “challenging thoughts or controlling them is not beneficial to changing behavior but changing your relationships to the thoughts might be more helpful” (Dehlin & Plumb, 2011). In order to create an effective method for alleviating human suffering as it relates to language and cognition, one first needs to have a basic understanding of human language and cognition. That is exactly where the research began and in the 1980s by taking a bottom up approach to language and cognition. That bottom up approach to language and cognition is now commonly known as relational frame theory (RFT).
According to Jonathon Tarbox, ACT is an orientation to psychotherapy based on pragmatic functional contextualism and RFT (Cicoria & Tarbox, 2018). Functional contextualism is a modern term for radical behaviorism and helps to better convey in what way the philosophy of science relates to other modern approaches. Rational frame theory can be described as learning through derived relations. The term radical behaviorism was first used by Calkins in 1921 in an issue of Psychological Review (Calkins, 1921). Watson thought of behavior and consciousness as mutually exclusive ideas but he himself did not use the phrase radical behaviorism (Schneider & Morris, 1987). However, radical or “extreme” was a common term used during his time to describe behaviorism as a science. The use of the term radical behaviorism to describe a science that denied or ignored consciousness as a part of its science, continued until Skinner’s first use of the term in 1945 (Schneider & Morris, 1987). Skinner separated behaviorism into two distinct categories, methodological and radical, where methodological behaviorism was described as distinguishing between events available to be observed by the public, and private events unavailable to the public and therefore, untreatable (Schneider & Morris, 1987). In Skinner’s autobiography (1979) he states, “I preferred the position of radical behaviorism, in which the existence of subjective entities is denied. I propose to regard subjective terms ‘as verbal constructs, as grammatical traps into which the human race in the development of language has fallen’” (p. 117). The second time Skinner used the phrase radical behaviorism was in his 1974 book About Behaviorism, “The question, then is this: What is inside the skin, and how do we know about it? That answer is, I believe, the heart of radical behaviorism” (p. 233).
In order to understand and influence behavior, behavior must be understood in relation to the setting or context and can only be understood through knowing its function. As Jonathon Tarbox states in an episode of the Behavioral Observations podcast, “there is something going on in the brain, but in addition to that, there is something going on in the environment and that is where we can make a difference” (Cicoria & Tarbox, 2018). He even argues that human language and cognition is a specific kind of learned behavior. Tarbox talks about RFT and says, “the core of human language and cognition is that the learned and contextually controlled ability to arbitrarily relate events mutually and in combination with and to change the functions of specific events based on their relations to others” (Cicoria & Tarbox, 2018). Tarbox is referring to derived relations, which encompasses understanding that certain contexts will often contribute to how relationships are formed and that the context and relations formed can often alter the function of a behavior.
Törneke (2010) described derived relations as “relations between stimuli that appear without having been learned or trained specifically” (p. 60). This process may seem natural to us because it is universal among humans. Törneke (2010) has a great quote that establishes some social validity for this concept of derived relations:
If altering stimulus functions is dependent for operant and respondent conditioning, each and every connection must be trained directly or be stablished through generalization. But derived relations seem to establish stimulus functions without any such contingencies between stimuli. (p. 72)
For example, if an individual is trained that A=B, then they can produce the derived relation that B=A even without training that new relationship. This process is called mutual entailment (M. Dixon, personal communication, March 8, 2019). Mutual entailment can be taught by using a common behavioral analysis principle called matching to sample. By training that the written stimulus ‘apple’ goes with the picture of an apple, we can also create the derived relation that a picture of an apple goes with the written stimulus ‘apple’. This also applies to greater than and less than relationships (M. Dixon, personal communication, March 8, 2019). For instance, if an individual is trained that A<B, they can produce the derived relation that B>A.
This, however, is only one step in a derived relationship. Derived relations can extend to tens of relations just by training a few of them. An example would be, if an individual is trained that A=B and B=C, a derived relation of A=C can be formed. This process is called combinatorial entailment (M. Dixon, personal communication, March 8, 2019). An example would be if someone is trained that the verbal stimulus ‘a square’ is paired with the verbal stimulus, ‘has four sides’, and the verbal stimulus ‘a square’ is paired with a picture of a square, then a derived relation of the verbal stimulus ‘a square’ is equivalent to a picture of a square. This process applies to greater than and less than relationship as well (M. Dixon, personal communication, March 8, 2019). For instance, if an individual is trained that A<B and B<C, a derived relation of A<C and/or C>A can be formed.
This process of derived relations is very important when it comes to assessing and treating cognition and problematic behaviors that are believed to be occurring due to cognitions (M. Dixon, personal communication, March 8, 2019). When these derived relationships are made and they begin to change the behaviors of an organism, the phrase derived relational responding is used. To understand this concept fully, it must be put into context. This means, an actual stimulus must be used instead of replacing it with arbitrary letters. For example, to say that an individual’s learning history produced the relationships of a fear response in relation to stimuli C based on teaching that A<B and B<C, doesn’t quite bring to fruition the implications of such relationships. However, when real life stimuli are assigned instead of arbitrary letters, the connection and contextual impact begins to make more sense. Take the same scenario and replace A, B, and C with real life stimuli. A potent example could be, if an individual that has already developed a fear response to dogs and is then taught that dogs are less harmful/dangerous than snakes, and then taught that snakes are less harmful/dangerous than scorpions, a picture of a scorpion might begin to elicit a larger fear response than a picture of a dog (M. Dixon, personal communication, March 8, 2019).
This can be extended to things other than pictures. For instance, if someone were to shout at the individual who just learned that scorpions are more dangerous than dogs, “Watch out for that scorpion!”, a fear response might occur. These derived relations occur in everyday life and can help explain why some individuals might avoid seemingly neutral events or experiences. Derived relations can be responsible for some factors in anxiety disorders, phobia disorders, depressive disorders, PTSD, and other mental health concerns (S.C. Hayes, personal communication, March 8, 2019).
RFT proposes several different categories of derived relational responding; equivalence, distinction, spatial relations, temporal relations, casual relations, hierarchical relations, and relations of perspective (Törneke, 2010, p. 80). Equivalence relations refer to “same as” relationships (M. Dixon, personal communication, March 8, 2019). This would mean teaching the concept that big and large mean the same thing (Törneke, 2010, p. 80). Equivalence is often taught using a behavioral analysis principle called matching to sample. Distinction relations are referencing differences in stimuli (M. Dixon, personal communication, March 8, 2019). This could be the relationship between big and small, teaching that they are opposites (Törneke, 2010, p. 80). Spatial relations refer to relationships such as behind or in front of, above or below, to the left or to the right, over and under, on top of or underneath and others (Törneke, 2010, p. 80). Temporal relations encompass the before and after relationships (M. Dixon, personal communication, March 8, 2019). Causal relations are in reference to the if-then scenarios (Törneke, 2010, p. 80). These relationships are something the field of behavior analysis is extremely familiar with, similar to the if-then statements used when incorporating the Premack principle into an intervention program. Hierarchical relations include relationships that teach when things are “part of” something else (Törneke, 2010, p. 80). An example of this could be kitten, cat, stray cat, wild cat, tiger, and lions; each of these are part of the overarching category of felines (M. Dixon, personal communication, March 8, 2019). Relations of perspective include those relationships that refer to “I and you” or “here and there” (Törneke, 2010, p. 80).
The behavior analysis community generally rejects events that are not directly observable and able to be agreed upon by more than one individual. However, as Niklas Törneke (2010) states, “Skinner rejected this position, maintaining that just because an observation is jointly agreed upon does not necessarily make it scientific and, further, that a scientifically valid observation can be made by a single individual… the scientific validity of a statement is determined by whatever controls the statement” (p. 10). Törneke (2010) goes on to say that, “there is an intrinsic tension within behavior analysis between its affirmation of the validity of private events, on one hand, and the tendency to disregard them in practice, on the other” (p. 10). Another source, Wilson and Hayes (2018), state, “Behaviorists did not object to the study of thinking and reasoning per se. Skinner explicitly rejected the idea that behavioral psychology needed to limit itself to overt behavior (Skinner, 1945), and it is not generally known that even classical behaviorism developed creative methods for the study of such topics as problem solving and reasoning” (2018, p. 4).
A post-Skinnerian term that is synonymous with radical behaviorism is functional contextualism. Functional contextualism is associated with theoretical movements like RFT. The functional contextualism theory requires analysts to identify dependent measures that are operational and can then be used to assess truths behind scientific claims (Ruiz & Roche, 2007). A pragmatic stance on truth is adopted in contextualism with a root metaphor of act in context (Ruiz & Roche, 2007). As stated by Pepper (1942), acts have a satisfaction in their completion and this satisfaction applies equally to the observer and the observed.
While a more in-depth discussion of functional contextualism and RFT would be beneficial, it is beyond the scope of this paper. However, Russ Harris (2009) argues that one does not need to fully understand RFT to be able to apply ACT principles. He states in his book, ACT made Simple, “If ACT is like driving your car, RFT is like knowing how the engine works”. He goes on to argue the ACT is a behavioral therapy because at its core, it is about taking action (Harris, 2009).
Historical Overview:
ACT is focused on using six core principles to create psychological flexibility in individuals so they can lead rich and valuable lives: acceptance; defusion; contact with the present moment; committed action; self-as-perspective; and values. Psychological flexibility can be defined as “a broader, more flexible pattern of activities” (Wilson, Borieri, Flynn, Lucas, & Slater, in press, p. 282). Another source describes psychological flexibility as, “the ability to fully contact private experiences in the present moment in order to pursue values-based actions” (Hayes, Strosahl, & Wilson, 1999). Although public trainings in ACT started as early as 1982, the first book on ACT was published in 1999 (Dehlin, Plumb, & Hayes, 2011). Starting in the 2000’s a surge in research related to ACT principles took place. Now, one can find dozens of textbooks and self-help books related to learning and applying ACT principles in their own life or with clients.
ACT has some roots in CBT, which closely follows the second wave of psychotherapy, that describes faulty thoughts and feelings are caused by faulty cognitions and that treatment should focus on changing or modifying those faulty cognitions. This differs substantially from ACT theory, which states that the more time and energy you spend focusing on and “fusing” with those thoughts and cognitions, the less progress you make. ACT supports that these faulty thoughts and emotions do not have to negatively impact our everyday lives and the principles they apply help individuals accept and defuse from them, as well as helps identify individual values and ways to take committed actions to move closer to leading a valued life. An in-depth discussion of CBT would be valuable but is beyond the scope of this paper. Eifert, Craske, Vilardaga, Davies, Arch, & Rose (2012) compared ACT and CBT principles to patients diagnosed with anxiety disorders. Their research found that ACT, over the long term, was more effective in reducing the severity of principal anxiety disorder. A 12-month follow up also showed the those who received ACT displayed more psychological flexibility that those who received CBT treatment (Eifert et al., 2012).
The six core principles of ACT are acceptance, defusion, contact with the present moment, committed action, self as perspective, and values. Acceptance, according to Bach and Moran (2012) from ACT in Practice, can be defined as a “willingness to experience fully and without defense” (p. 8). The opposite of acceptance would be experiential avoidance. Experiential avoidance can be described as the general unwillingness to experience the negative or problematic thoughts and feelings or faulty cognitions. Some activities that teach and help foster acceptance practices are: putting the statement “I’m having the thought that…” before each thought you have; to sing the thoughts you have in a silly voice; to repeat the thought you are having as quickly as you can for thirty seconds (S.C. Hayes, personal communication, March 7, 2019). All of these activities can be implemented across settings, cultures and abilities. Acceptance is normally targeted when escape or experiential avoidance tendencies have become a barrier to individuals taking important actions in their life (S.C. Hayes, personal, communication, March 7, 2019).
Russ Harris (2008) describes defusion as “relating to your thoughts in a new way, so they have much less impact and influence over you” in his book Happiness Trap (p. 33). The opposite of defusion is cognitive fusion. This can be described as when an individual believes and therefore acts in accordance with the thoughts and feelings they have (Törneke, 2010). This can become problematic when the thoughts and feelings are all negative and cause you to take action that leads one farther away from living a valued life. “Dropping the rope” is a good exercise that can be used to teach and foster defusion with individuals. This activity encompasses individuals actually engaging in a tug of war, with a rope (S.C. Hayes, personal communication, March 7, 2019). The rope is said the symbolize the fault cognitions or negative thoughts and feelings the individuals has been experiencing or trying to avoid experiencing (S.C. Hayes, personal communication, March 7, 2019). This activity is aimed at teaching individual that the constant struggle to hold the rope or gain control over the rope is not necessary (S.C. Hayes, personal communication, March 7, 2019). Dropping the rope and allowing those things to just be there, is an option and likely an option that will lead individuals closer to living their valued lives. Defusion is normally targeted when private or internal events begin functioning as a barrier and affect the actions taken by individuals (S.C. Hayes, personal communication, March 7, 2019).
Bach and Moran (2012) describe contact with the present moment and being fully aware and attending to your current situation and surroundings (p. 8). Contact with the present moment has also been referred to as flexible attention to the now, flexible attention to the present moment, contact with the present moment and be here now. The opposite of this would be rigid attentional processes, or “Dominance of the Conceptualized Past and Future; Limiting Self-Knowledge” (Harris, 2009, p. 27). Several practices can be helpful for teaching and fostering present moment awareness with individuals. Some of the practices and activities include, following the patterns of breathing, giving emotions and thoughts a bodily form by contorting the body to look how it feels, and asking individuals to conduct a scan of their body and say/write down some things they are noticing in the moment (S.C. Hayes, personal communication, March 7, 2019). Contact with the present moment allows individuals the flexibility to not perseverate on their faulty cognitions or negative thoughts and emotions. Present moment awareness can be targeted when an individual appears scattered, unaware, or is inflexibly moving toward a past or future self (S.C. Hayes, personal communication, March 7, 2019).
The self-as-perspective has been described as viewing oneself as the observer (Ahles and Jenkins, n.d., p. 4). Self-as-perspective has also been described as “flexible perspective-taking of yourself as others see you. Being able to see yourself as a place in which stuff happens and not as a thing to make judgements on. It is verbal behavior directed toward the self and others, as well as the relations between those two” (Cicoria & Tarbox, 2018). Another way to refer to this process is, perspective taking sense of self. The opposite would be a conceptualized self. Conceptualized self would be an individual identifying so much with personal traits of characteristics that they don’t take actions that lead them to a valuable life. For example, “I can’t try out for the sports team because I’m a girl,” or, “I can’t have a healthy relationship because I have attachment and/or abandonment issues,” or “I can’t play basketball because I’m short”. While these statements about the self may be factual or true, it is does not always prevent us from taking actions that lead toward living a more valued life. A valuable exercise can be to ask individuals to move across person, place and time and try to describe themselves as someone else sees them, who they are in a different environment or around new people, and how they were/are in a different time (S.C. Hayes, personal communication, March 7, 2019). Self as perspective is also targeted when an individual appears scattered or is overidentifying with their conceptualized self and appears afraid to explore the world in new ways (S.C. Hayes, personal communication, March 7, 2019).
Values, which are different from goals, are explained as verbally construed global outcomes or chosen life directions that are always lived in the present moment, not to be attained (Bach & Moran, 2012, p. 10). Values are often things like honesty, professional growth, inclusivity, and the likes. Values never have an end, they are categorized as a way of being or living, the personal qualities one wants to portray across time, space, people and environments (S.C. Hayes, personal communication, March 7, 2019). The opposite of a value would be a goal or an outcome. An outcome has an end date and can be “accomplished” whereas, values are something one wants to continue doing or a way one wants to continue being. A good activity to try with individuals would be to have them identify a scenario that made them really angry or upset, and once they can pinpoint that, ask them why and this leads to a discussion about things they value (S.C. Hayes, personal communication, March 7, 2019). Values is targeted when there appears to be an issue related to motivation or lack of general direction in an individual’s life (S.C. Hayes, personal communication, March 7, 2019.
Committed action is arguably the most clinically relevant of the six principles of ACT. It involves the actions taken to bring one closer to their values (Bach & Moran, 2012, p. 8). Committed action has also been referred to as workable action. The opposite of this is sometimes called unworkable action. Committed action is just action that is taken to take individuals closer to contacting living their valued lives. This is where most of the behavioral and observable pieces of the model come into play. Committed action is getting out into the world and behaving to take oneself closer to a desired place. This could be closer to a goal or outcome or closer to a value. For instance, a committed action for a value of professional development would be attending conferences, reading new publications and collaborating with others in the field. Committed action is only targeted once a sense of psychological flexibility has been observed in an individual, it is targeted when the person displays ability to do work in the real world that could take them closer to their values or desired outcomes (S.C. Hayes, personal communication, March 7, 2019.
ACT has been applied in areas such as insect phobias, anxiety disorders, eating disorders, PTSD, depression, panic disorders, substance abuse, obsessive compulsive disorder (OCD), IPV, gender and sexuality issues and much more (Jones & Friman, 2006; Eifert et al. 2012; Matteucci, Timko, Butryn, Forman, Shaw, Lowe, & Juarascio, 2013; Twohig, M. P., 2009; Bohlmeijer, Fledderus, Rokx, & Pieterse, 2011; Zettle, Rains, & Hayes, 2011; Hayes, Wilson, Gifford, Byrd & Gregg, 2004; Twohig, Hayes, Plumb, Pruitt, Collins, Hazlett-Stevens, & Wordneck, 2010). There are also several self-help books that help individuals begin to apply these principles in their own lives. The books covering areas such as parenting, relationships, social anxiety, depression, anxiety disorders, trauma, and more (Coyne & Murrell, 2009; Walser & Westrup, 2009; Flowers, 2009; Robinson & Strosahl, 2008; Forsyth & Eifert, 2008; Follette & Pistorello, 2007).
Treatment for sexual offenders in the 1970s had three main focuses: modifying sexual preferences, broadening of cognitive processes so that it would incorporate cognitive processes, and a focus on creating a more comprehensive approach to treatment (Marshal & Laws, 2003). Marshall and Laws (2003) state that the 1980s was when an initial attempt to formulate social learning theories of sexual offending started to appear as well as the beginnings of relapse prevention models. They go on to review the 1990s, where two journals dedicated to sexual offender work and other research publications that helped treatment programs multiply (Marshall & Laws, 2003). The 1990s also featured developments of risk prediction instruments (Marshal & Laws, 2003). At the end of their history review on the treatment of sexual offenders, Marshal and Laws (2003) state, “It is evident from this review of the history of sexual offender treatment that cognitive behavioral procedures have developed into a comprehensive approach that is widely shared and appears to be effective” (p. 110).
However, IPV entails more than just sexual violence. IPV includes physical, sexual or emotional/psychological abuse of a romantic partner. Some common treatments for individual who have been arrested or convicted of IPV include the Duluth model and CBT model of batterer intervention plan. Babcock, Green, & Robie (2004) state that “implementation of mandatory arrest policies and court-mandated counseling, batterers’ interventions became a fusion between punishment and rehabilitation” (p. 1024). Babcock et al. (2004) goes on to say that recidivism rates do not increase significantly with the implementation of a batterer intervention programs (BIPs). In fact, some research even suggest that it may put the victims in even more danger by giving them false sense of security (Holtzworth-Munroe, Beatty, & Anglin, 1995).
The Duluth model is said to take a “feminist psychoeducational approach” that views domestic violence as a “patriarchal ideology and the implicit or explicit societal sanctioning of men’s use of power and control over women” (Babcock et al., 2004, p. 1026). This model has been the most common according to Babcock et al. (2004). The model uses something called a “Power and Control Wheel” and “Egalitarian Wheel” to help them change from using behaviors that results in authoritarian relationships to behaviors that lead to egalitarian relationships (Babcock et al., 2004).
In contrast, the CBT model makes violence the primary focus of treatment, claiming that violence is a learned behavior and can therefore be unlearned (Babcock et al., 2004). The model believes that violent behaviors occur because it serves a function, a theory that the field of behavioral analysis can generally agree with. However, the treatments used in the CBT model are not so behavioral as they focus more on the emotional components behind violent behaviors. By focusing on or targeting more of the emotional or cognitive aspect of violent behaviors, the treatment is less focused on changing the behavioral patterns.
Representative samples in a study found that between 25%-40% of lesbian women have experienced IPV in their total lifetime and 10% reported that they have experienced IPV within the last year (Brown & Herman, 2015, p. 8). The same study also found that there was a higher prevalence of IPV reported among bisexual women than their heterosexual counterparts, with bisexual women being 2.6 times more likely to report having experienced intimate partner sexual violence (IPSV) in their lifetime (Brown & Herman, p. 2). In regard to sexual minority men, a representative sample estimated 26.9% of gay men reported to have experienced IPV in their lifetime, with 12% having experience in within the last year (Brown & Herman, p. 2). Brown & Herman (2015) also provide statistics among the transgender population, with 31% having experience IPV compared to 20% of the cisgender population (p. 3). This review of existing research about IPV among the LGBTQIA community provides social validity for why looking at treatment and intervention for this specific population is of importance. Several studies even claim that the prevalence of IPV and intimate partner sexual violence (IPSV) is as high or even higher among the LGBTQIA population than that of the general population (Stotzer, 2009; Rothman, Exner, & Baughman, 2011; Edwards, Sylaska, & Neal, 2015).
Brown and Herman (2015) go on to review some barriers to treatment/seeking help and the quality of help received by the LGBTQIA community in regard to IPV. In fact, 46% of bisexual women reported that they experienced PTSD symptoms following an experience of IPV. Some barriers to seeking help and gaining treatment are: negative physical and emotional effects; money; risk of rejection and isolation from family, friends, and society; dependence of social networks; risk of retaliation; risk of outing self or partner; lack of understanding of what constitutes IPV; and lack of LGBTQIA friendly providers (Brown & Herman, 2015, p. 16-18).
Current Applications:
According to Casseillo-Robins and Barlow (2016) and Fernandez and Johnson (2016), anger has been linked to aggression and interpersonal problems. Anger is seen as problematic when it is expressed as aggression. Aggression can be defined as behaviors, physical or verbal, aimed at others that cause physical or emotional distress (Berkout, Tinsley, & Flynn, 2019). Although, CBT was the most widely used approach to treating problematic anger or aggression, the psychological flexibility model found in ACT serves as a promising alternative (Lee & DiGuiseppe, 2018).
The psychological flexibility model has been applied with a variety of problematic behaviors, and as such, can be applied to address anger and aggression. Greco, Lambert, and Baer, (2008) describe one of the six processes, cognitive fusion, as when an individual believes the literal meaning of their thoughts instead of viewing their thoughts as transient internal states. Greco, Lambert, and Baer (2008) give an example of cognitive fusion as when someone’s thoughts of “I am hopeless” are equivalent to the psychological experience of hopelessness. Another example of cognitive fusion could be not completing a homework assignment or presenting professional work at a conference due to thoughts of “I am not good enough, smart enough or competent enough in this area.” Fusing or becoming one with those thoughts, has made a change in behavior and could be leading one away from leading a valued life. For example, if the value is professional development or professional dissemination, then refraining from completing or presenting the work could be causing one to be led away from their values. Similarly, cognitive fusion can happen in partner relationships when thoughts like, “I am not masculine enough” occur and these faulty cognitions can lead partners to engage in behaviors that are sometimes socially categorized as masculine traits, like aggression.
Hayes, Strosahl, and Wilson (2012) propose that thoughts and cognitive fusion itself is not problematic, but rather when it is coupled with the avoidance of the thought (experiential avoidance), does it become problematic. Bardeen and Fergus, (2016) support this hypothesis that cognitive fusion by itself is not maladaptive or problematic but that it can become problematic when there are no alternatives to fusion that can be or are flexibly applied by individuals (p. 4). Cognitive fusion has been measured using a 7-item self-report questionnaire titled Cognitive Fusion Questionnaire (CFQ) (Gillanders, Bolderston, Bond, Dempster, Flaxman, Campbell, Kerr, Tansey, Noel, Ferenbach, Masley, Roach, Lloyd, May, Clarke, & Remington, 2014). The CFQ is self-report style questionnaire that is seven questions long that asks participants to rate if they agreed with each question using a Likert scale. The scale ranges from 1 (never true) to 7 (always true). Some examples of the questions or statements on the CFQ are: I struggle with my thoughts; I get so caught up in my thoughts that I am unable to do the things that I most want to do.
Experiential avoidance is the general unwillingness to experience unwanted inner experiences such as thoughts, feelings, memories and bodily sensations (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). Experiential avoidance can also be described as “the struggle to avoid or eliminate thoughts and feelings related to fear, guilt, shame, rejection, anger, anxiety, and so on by controlling their attention or behavior in certain ways” (Skinta & Curtin, 2016, p. 40). Skinta and Curtin (2016) state that you can look at combined patterns after filling out the Matrix, a tool used in ACT, to see what form an individual’s experiential avoidance might take and possibly even determine its function (p. 40). For example, someone who experiences anxiety might observe a rise in heart rate, shallow breathing, sweating, etc., when around large groups of people and therefore may choose not to attend events where there will be large crowds of people, even when the event features something they would otherwise enjoy. The avoidance of the large groups of people, even if the event adds value to their life, could qualify that situation as experiential avoidance, especially if similar avoidant strategies occur often in those similar situations. Gardner and Moore (2008) describe their Anger Avoidance Model and propose that aggression may serve as a way to avoid feeling threatened and vulnerable which is consistent with the idea of experiential avoidance.
Experiential avoidance has been found to be a primary coping mechanism for individuals that have lived and survived through trauma (Tull, Gratz, Salters, & Roemer, 2004). This established some social validity for populations of individuals that are victims or survivors of IPV and/or have PTSD symptoms. Experiential avoidance has been measured using a 7-item self-report questionnaire that uses a Likert rating scale titled Acceptance and Action Questionnaire – II (AAQ-II) (Bond, Hayes, Baer, Carpenter, Quenlow, Orcutt, & Zettle, 2011). The measurement tool called AAQ-II was “designed to assess a specific model of psychopathology that emphasizes psychological inflexibility” (Bond et al., 2011, p. 22). Bond et al. (2011) give some examples of questions on the AAQ-II, “the final scale contained items on negative evaluations of feelings (e.g., “anxiety is bad”), avoidance of thoughts and feelings (e.g., “I try to suppress thoughts and feelings that I don’t like by just not thinking about them”), distinguishing a thought from its referent (e.g., “when I evaluate something negatively, I usually recognize that this is just a reaction, not an objective fact”), and behavioral adjustment in the presence of difficult thoughts or feelings (e.g., “I am able to take action on a problem even if I am uncertain what is the right thing to do” (p. 4.) The AAQ-II is said to predict a variety of life quality outcomes such as depression, anxiety, work attendance, job satisfaction and general mental health conditions (Bond et al., 2011).
Several studies have linked experiential avoidance to aggressive behavior and even relationship violence (Bell, & Higgins, 2015; Reddy, Meis, Erbes, Polusny, & Compton, 2011; Shorey, Elmquist, Zucosky, Febres, Brasfield, & Stuart, 2014). IPV has been defined as, “physical violence, sexual violence, threats of physical/sexual violence, and psychological/emotional abuse perpetrated by a current or former spouse, common-law spouse, non-marital dating partner, or boyfriend/girlfriend of the same or opposite sex” (Breiding, Basile, Smith, Black, & Mahendra, 2015). Shorey et al. (2014) also suggest that psychological inflexibility and dating violence are linked. There have been some batterer intervention programs (BIPs) for men that have been charged with assault against an intimate partner. Many of these BIPs are based on the Duluth model and possess some patriarchal theories where male-to-female violence is conceptualized to be a societal sanctioning of men’s power and control over women (Pence & Paymar, 1993). An easily derived relation that can be formed here by those facing gender identity issues that desire to be more masculine, is that gaining more power and control over their partner is an acceptable way to appear more masculine. Most of these BIPs also include a CBT approach, where focus is centered around changing or modifying faulty cognitions to prevent future violent behavior.
However, many studies have reported that these Duluth and/or CBT based programs only produced limited reduction in recidivism. Recidivism can be defined as the tendency that a convicted criminal will reoffend. One study showed that someone who was arrested and sanctioned to complete a Duluth/CBT based BIP was only 5% less likely to reoffend than someone who was arrested and sanctioned but did not have to complete a BIP (Babcock, Green, & Robie, 2004). A new model, Achieving Change through Values-Based Behavior (ACTV) focuses on using ACT principles in their BIP. By focusing on ACT principles, ACTV aims to teach offenders to choose a behavior that is consistent with their values even when those faulty cognitions appear (Zarling, Bannon, & Berta, 2017).
ACTV was designed as 24-weekly session that lasted 1.5-2 hours each. Participants were required to pay for each session and could not be considered to complete the program until all payments were made. This program was divided into 5 modules: Big Picture/Core skills; Emotion Regulation Skills; Cognitive Skills; Behavioral Sills; and Barriers to Change (Zarling & Berta, 2017). Facilitators of this program were required to complete a 4-day training where ACT models were introduced and demonstrated, then the trainees were able to practice during some role play and feedback scenarios with their trainers. Then they moved on to implementing the 24-week ACTV sessions while being directly observed by a trainer to ensure treatment validity. Zarling & Berta (2017) wanted to compare the effectiveness on recidivism when Duluth/CBT models were provided versus the ACTV model. Their results found that in a 12-month follow-up ACTV participants were less likely to be arrested for any charge, including domestic assault charges, or any violent charges than their Duluth/CBT counter-participants (Zarling & Berta, 2017). These results suggest that an ACT model may be a promising alternative to BIPs for intimate partner violence offenders.
The first module of Zarling & Berta (2017), Big Picture/Core Skills, introduced mindfulness practices so that individuals can learn to notice their own behaviors and whether they are values-driven or if they can be categorized as experiential avoidance (p. 96). This part of the intervention might include discussion surrounding the participants’ beliefs about “how people should behave (including gender roles), childhood experiences, personality and stress/coping styles” (Zarling & Berta, 2017). This is also where the Matrix tool comes into play. The Matrix is an image that contains four quadrants. The top and bottom portion of the image helps to separate sensory experiences like observable actions that can be displayed or observed by the five senses (top two quadrants), from mental experiences like thoughts, feelings and memories (bottom two quadrants). The left and right portion of the image helps to separate decision that lead to moving away from living a valued life (left two quadrants) from decisions that lead to moving toward living a valued life (right two quadrants). The use of the Matrix is to help participants’ grasp the key concept of the module, which is, individuals can behave independently of their thoughts and emotions.
The second module, Emotion Regulation Skills, explores the functions of emotions and introduces acceptance practices to teach participants how to make space for those emotions without trying to alter them (Zarling & Berta, 2017, p. 96). This module spends time on how experiential avoidance can lead one away from living a valued life and helps participants differentiate between workable behavior (leading closer to values) and unworkable behavior (leading away from values) (Zarling & Berta, 2017, p. 98). The third module, Cognitive Skills, introduces defusion and identification of troublesome or problematic mental experiences and aides’ participants in accessing tools that allow them to gain some distance from those troubling mental experiences (Zarling & Berta, 2017, p. 98).
The fourth module, Behavioral Skills, teaches and requires the practice of communication skills such as reflective and active listening, assertiveness, boundary setting and conflict resolution (Zarling & Berta, 2017, p. 98). Role play is part of this module to allow for practice with effectively managing any emotional responding that occurs when engaging in these types of conversations (Zarling & Berta, 2017, p. 98). The fifth and final module, Barriers to Change, facilitates discussion around identifying barriers or potential barriers to participants engaging in values-based action and offer strategies and resource to combat those barriers (Zarling & Berta, 2017, p. 98).
The ACTV model is different from other BIPs in several ways. First, the model does not assume that aggression or partner violence is always an attempt for masculine figures to assert their power over feminine figures like the Duluth Model or the circular reasoning that aggressive behaviors are a result of angry thoughts like the CBT model (Zarling & Berta, 2017, p. 99). This is one reason that the ACTV model is being used with both male and female offenders in the state of Iowa (Zarling & Berta, 2017, p. 102). Zarling & Berta, (2017) state that the ACTV philosophizes that increased awareness of contributing factors to aggressive behaviors, which is promoted by the ACT concept of contact with the present moment, allows greater ability to alter that behavioral pattern (p. 99). This is consistent with ACT’s concept of psychological flexibility, that individuals are in control of their behavior and do not have to allow their behaviors to be governed by faulty cognitions. Second, ACTV doesn’t focus on changing faulty cognitions, like CBT models, but rather focuses on changing one’s relationship with and their responses to those faulty cognitions (Zarling & Berta, 2017, p. 100). Third, the ACTV model is experientially focused, requiring active participation and rehearsal of newly learned skills. Fourth, it is very values-based and places participants’ personal values at the center of all sessions. Fifth and finally, the facilitators of the model seek to not only be sympathetic and empathetic, but rather strive to adopt the ACT principles themselves by being psychologically present, open and effective while they engage in providing treatment (Zarling et al., 2017, p. 100).
While combating partner violence on the offenders’ side are taking steps in the right direction, treatments for survivors are also in huge demand. A study shows that many women who suffer from distress related to being a victim of IPV, do not seek treatment and that approximately a fifth of individuals who are enrolled in some type of trauma-related therapies drop out of their treatments (Fugate, Landis, Riordan, Naureckas, & Engle, 2005). At the same time, nearly one third of women who have experienced IPV meet the criteria for PTSD (Golding, 1999). Polusny & Follette (1995) state that some problematic behaviors that may arise after being exposed to traumatic events, such as IPV, involve experiential avoidance and the domination of trauma-related cognitions. Furthermore, experiential avoidance and other factors related to psychological inflexibility have been linked to a higher risk in re-victimization in survivors of IPV (Fiorillo, Papa, & Follette, 2013). This establishes a great need for treatment of survivors and Fiorillo, McLean, Pistorello, Hayes, & Follette (2017) believed that a web-based ACT program could be helpful in reducing some of the barriers to treatment that survivors faced.
The web-based model was adapted from the self-help book, Finding Life Beyond Trauma. The web model consisted of six sessions, each an hour long that covered areas such as: introduction and psychoeducation on interpersonal trauma and ACT, willingness and acceptance, mindfulness, defusion and self-as-context, clarifying values, and committed action consistent with values (Fiorillo et al., 2017). The sessions were comprised of video narration, text, exercises and worksheets. The researchers assessed acceptability, feasibility and efficacy of the web-based intervention and psychological flexibility after surviving IPV. Results from the study showed that there were statistically significant decreases in scores on depression, anxiety, and psychological inflexibility (Fiorillo et al., 2017). Fiorillo et al. (2017) found that there was a significant decrease in psychological flexibility scores, measured by the use of the AAQ-II, between pre-treatment and post-treatment (p. 108). These results are evidence that a web-based treatment model can be effective in combating psychological symptoms that arise in individuals who have suffered IPV.
Burrows (2013) conducted a case study on an adult that had survived a sexual assault. Burrows used measurements such as the AAQ-II, White Bear Suppression Inventory (WBSI), Trauma Symptom Checklist (TSC-40), and Valued Living Questionnaire (VLQ). All of these measures are self-reported and many of them use a Likert rating scale. The WBSI was designed to measure tendencies to suppress unwanted thoughts, similar to experiential avoidance using 15 questions. The TSC-40 aims to measure symptomology of individuals who have experienced a traumatic event. TSC-40 aims to measure this by the use of 40 questions that cover topics such as anxiety, depression, dissociation, sexual abuse trauma index, sexual problems, and sleep disturbances (Burrows et al., 2013). The VLQ aims to assess the extent to which the individual who takes the two-part questionnaire lives consistently within their values (Burrows, 2013). The first part uses a Likert scale grading system that is said to cover ten common life domains (Burrows et al., 2013). The second part of the VLQ asks individuals to rate their consistency with living in align with their values (Burrows, 2013).
Burrows et al. (2013) treatment intervention consisted of eighteen sessions that lasted fifty minutes long over a period of ten months. The treatment occurred in three phases. The first phase focused on present moment awareness, values clarification and defusion. The second phase focused on replacing experiential avoidance with acceptance practices and self-as-context. The third and final phase focused on the idea of workability or taking committed action. A powerful statement made by the individual in the case study was, “found it helpful to replace the word ‘but’ with the word ‘and’ when describing situations (e.g., ‘I want to go to work and I’m feeling anxious’) to remind herself that she had control over her actions, even in the face of internal experiences” (Burrows et al., 2013). Symptom reduction was not an explicit goal of this intervention model, however, reductions in both experiential avoidance and trauma symptoms were listed as progress for being a part of treatment (Burrows et al., 2013). The results from this case study showed improvement across all four measurement systems; AAQ-II, WBSI, TSC-40, VLQ (Burrows et al., 2013). Eight months after treatment ceased, a follow-up was conducted and it was determined that increased psychological flexibility that was said to be a result of the treatment, had been maintained when assessed at follow-up. The follow-up also showed further decreases in trauma symptomatology and a marginal decrease in the scores on the VLQ.
Ethics
One of the biggest concerns in the field of behavioral analysis is that all things we attempt to measure and areas we try to make changes in, must be directly observable. There is much debate surrounding the topic of whether ACT serves as a behavioral therapy and if it belongs in the category of applied behavior analysis. Much of the evidence offered is from the use of self-report questionnaires, usually with the use of a Likert rating scale. However, that begs the question of if we cannot see these internal of cognitive processes and the individual themselves are the only ones who can witness them, why should we then consider this an invalid method of measurement? More so, in the field of behavioral analysis, one might hear the phrase, “work yourself out of a job”. This often includes teaching an individual how to recognize, record, and manage their own behavioral patterns using self-management strategies that we then teach to them.
As a field, behavior analysts are already using methods and relying on self-report for accurate measuring. The same argument can be made when a behavior analyst asks or requires parents or guardians of a client to observe and take data on targeted behaviors. This measurement is not the most reliable method either, considering that parents can sometimes collect inaccurate or unreliable data. However, in circumstances where one cannot control all variables or be available to directly measure something, one must often settle for either permanent products (like bruises) or self-report. Even so, when teaching individuals self-management strategies, it is essentially teaching individuals to notice and record their own behaviors and experiences. Therefore, when no other acceptable alternative can reasonably be met, self-report can be used to measure behaviors (likely internal) that occur for the individual.
Many advocates for ACT will reference RFT to justify why ACT should be considered a behavioral science. Language is a learned skill, and without language, many faulty cognitions that contribute to problematic behavioral patterns, could cause treatment to fall short. RFT proposes several different categories of derived relationships; equivalence, distinction, spatial relations, temporal relations, casual relations, hierarchical relations, and relations of perspective (Törneke, 2010, p. 80). Although changing cognitions is not the aim of ACT, ignoring or not acknowledging the role language and cognition plays in an individual’s behavioral repertoire, is problematic.
While self-report may be a sufficient and acceptable measurement for internal behaviors like cognitions, thoughts and emotions, it will not suffice and constitute as strong empirical evidence for changes in behavior. However, this can be easily applied when we begin measuring the component of committed action and things like recidivism. We can also measure some aspects of internal behaviors or cognition once they become overt behaviors, such as negative self-statements.
A good way to make self-reporting more reliable would be to use behaviorally anchored rating scales (BARs) in place of the standard Likert scale. “The BARs format consists of the title and definition of a dimension, including descriptions of low, medium, and high amounts of the dimension and a vertical scale anchored with behavioral examples of the dimension” (Dickinson & Zellinger, 1980, p. 147). This means that each available rating has a clear objective definition which helps with reliability. Some benefits other greater interrater reliability of a behaviorally anchored rating scale would be that it is shorter and therefore less time consuming. BARS was developed in the 1960s and became popular in the 1970s (Ohland, Loughry, Woehr, Bullard, Finelli, Layton, Pomeranz, & Schmucker, 2012, p. 613). An example of a BARs would be having a question and a scale to rate that question, but each number or available rating has a definition attached to it. For example: 1 – Occurs less than once per week; 2 – Occurs two to four times per week; 3 – Occurs five or more times per week. The BARs method could be used for questionnaires that are commonly used in ACT practice, like the AAQ-II.
The next critique of ACT is on the abundance of and efficacy of self-help literature using the techniques. Self-help has four different variations: self-administered; predominantly self-help; minimal contact; and predominantly therapist-administered, with evidence supporting higher efficacy when more clinician input is incorporated (French, Golijani-Moghaddam, & Schörder, 2017). French et al. (2017) completed a systematic review that investigated efficacy of self-help ACT programs on depression, anxiety and psychological flexibility. Their results found the self-help formats of ACT were less effective than face-to-face formats of ACT. However, the analysis did show that increases in psychological flexibility were associated with reductions in both anxiety and depression (French et al., 2017). The study also suggests that the format or delivery of ACT has a low impact on outcomes with the exception of more clinician input resulting in greater outcomes. This can be concerning considering the huge interest in ACT and in self-help books around the globe currently. While self-help options may be beneficial for an introduction into the ACT world, and could even be effective for making changes in personal behaviors, it should not be allowed to qualify an individual to be competent and qualified to provide services with those newly acquired skills.
When taking the Professional and Ethical Compliance Code (PECC) for Behavior Analysts into consideration, there are a few concerns that arise. The following codes could be in danger of being violated if not addressed properly: 1.01, Reliance of Scientific Knowledge; 1.02, Boundaries of Competence; 1.04, Integrity; 2.09, Treatment/Intervention Efficacy; and 3.01, Behavior Analytic Assessment (Behavior Analysis Certification Board, 2014). 1.01, Reliance on Scientific Knowledge is at risk dependent upon which measurement systems are chosen and whether or not the individual providing ACT services has been properly trained in providing such services. Measurement is very important here, as self-reports are not the most scientific standards of measurement and should always be taken with a grain of salt. For example, if an individual finds session aversive but knows that lying on their self-reports will gain negative reinforcement in the form of needing less sessions, that could be valuable motivation for providing false self-reports.
Another concern is that ACT currently has no certification process and so standards of care/treatment fidelity are not there. Until a true standard measurement of whether an individual has enough knowledge and competency in ACT and even RFT principles, this also puts individuals at risk for violating code 1.02, Boundaries of Competence. An individual might think that after reading one self-help book or attending one 2-day bootcamp on ACT would be sufficient enough training but that does not make the individual competent in that skill set. If a certification process would be developed and implemented, then a clear line between who is implementing ACT procedures and who is just attempting to address cognitions while in a session could be clearly drawn and this would determine when someone would be violating the boundaries of competence code from the PECC.
Creating a standard certification process would also help eliminate the risk of violating code 1.04, Integrity. This would prevent someone from being able to claim they read a book, took a seminar or attended a conference in order to gain competency in that skill. This would require a display of competency in the skills they claim and then integrity would not be of question. This could be a simply administered exam that could be approved by the Behavior Analysis Certification Board (BACB) to qualify someone to have a certification in the specific skill set of ACT principles. This could also be separated into two subsets of exams, one for being certified to implement an ACT intervention that has been developed and written by someone else and another exam for being competent enough to develop and write an intervention plan that utilizes ACT principles.
Code 2.09, Treatment/Intervention Efficacy could be violated in many ways, especially if using self-report or not relying on scientific knowledge, as well as if boundaries of competency are not upheld. In order for a treatment or intervention to be considered effective in the field of behavior analysis, first the target behavior must be operationally defined. Being operationally defined means that the target must be observable and measurable. Without this feature, true effectiveness and experimental control cannot be determined or confirmed. Efficacy is also a factor in relation to ACT studies because many results are reported as group statistics and the field of behavioral analysis is very focus on single subject design.
Another code, 3.01, Behavior Analytic Assessment, is at risk of being broken if operational definitions are not provided. The PECC states that all individuals have a right to a functional assessment, and without a clear operational definition of a target behavior, conducting a functional assessment could be very difficult. Without identifying the function of a target behavior, one can design and implement a slew of ineffective, risky and time/resource consuming interventions. Since the PECC also states that individuals have the right to effective treatment as discussed in code 2.09, this is a risky situation for practitioners to be in.
Although there is room for improvement before ACT will be widely accepted in the field of behavior analysis, the concerns are able to be addressed and fix. Aside from these few concerns, there are a number of ethical codes that ACT principles closely align with a follow or could, once standardized, be closely aligned with: 4.02, Involving Clients in Planning and Consent; 4.03, Individualized Behavior-Change Programs; 4.07, Environmental Conditions that Interfere with Implementation; 6.02, Disseminating Behavior Analysis (BACB, 2014). ACT principles actively involve each individual receiving treatment, meaning consent is essential and inherently individualized to that person. Since the interventions are so individualized and clients are so involved and active in the processes, environmental conditions are built into the discussion. Even in the ACTV model used to address recidivism rates of individual arrested or convicted of IPV or IPSV, the sessions that address barriers to change incorporate some environmental conditions that might be affecting behavior.
As far as disseminating behavior analysis, ACT aligns with this ethical code by acknowledging that language and cognition is an essential part of the human condition and that in order to fully and comprehensively provide the most effective services to individuals, the field cannot ignore language and cognition. By disregarding language and cognition and the role it plays in human behavior, it would be hindering the ethical obligation to disseminate the practice of behavior analysis. By incorporating some cognitive practices, it also opens the door for more collaboration with other professionals which in turn would aide in disseminating the practice as well.
Other ethical considerations, specifically related to treatment options for victims and survivors of IPV, are the ethics of confidentiality when one is a mandated reporter. An ethical consideration for treatment related to the LGBTQIA community could be the risk of outing an individual or their partner and the general lack of a support system, especially if their partner was their sole support system.
Future Suggestions/Directions
Some considerations for treatment of victims would include media campaigning, the use of video modeling and an ACT treatment intervention that has a major focus on the self-as-context and present-moment-awareness processes. Other considerations could be incorporating ACT methods in the form of support groups, specifically led by an individual who is a survivor of IPV. For treatment and behavior change systems for the offenders, an adaptation of the ACTV model that incorporates features from the Program for the Education and Enrichment of Relational Skills, (PEERS®) model, could be beneficial. Of course, the most obvious form of treatment to address the concerns of intimate partner violence, would be to have better sex education programs provided in school systems. Although IPV does not only include sexual violence, proper sex education programs should have a general relationships component built into the curriculum.
Media campaigning can be beneficial resources for reaching victims of IPV if they are placed in public spaces such as bus stops and YouTube video ads that are not able to be skipped. This ensures that the individual will not be put at risk for being blamed by their partner or at risk for being confronted for reaching out or seeking help. Video modeling has been shown to be an effective method for teaching new skills to individuals. It can be relatively inexpensive and effective for teaching new skills to individuals. It is for this reason that one must consider the portrayal of intimate partner violence in the media, specifically within the LGBTQIA community. More research on this topic area needs to be done in order to take effective steps forward.
Some steps to completing this task would be to first gather participants from diverse backgrounds and cultures and administer a pretest. This test would be a knowledge check about examples and possible ramifications of intimate partner violence. The test should have generic questions as well, as to not signal to the individuals that they are being assessed on their knowledge on the topic of intimate partner violence. This is to avoid carry over effects. The next step would be to compile a list of movies and television shows that model intimate partner violence, particularly ones where that isn’t the main theme, but is still very prevalent and able t o be derived from the underlying theme. It is also important to include films and television series that model very subtle forms of IPV. Post-tests could then be given to that same individuals where they have to use a BARs system to answer questions on the film as it relates to IPV.
As far as treatment of victims or survivors of IPV in the more traditional sense, ACT could prove to be effective, especially if individuals are displaying PTSD symptoms. In this scenario, a focus on self-as-context and present moment awareness may be beneficial to the individuals. This is because often survivors of IPV identify strongly as survivors and many of their concepts about themselves, their beliefs, their thoughts, their feelings and therefore their actions are all in align with that conceptualized understanding of being a survivor. Present moment awareness is a good focus because often times a survivor will display PTSD symptoms which can include flashbacks to the periods of abuse or extreme fears of future periods of abuse. By teaching and fostering skills that allow the individual to be and stay present in the current moment for longer and longer periods of time, one can see huge changes in behavioral patterns. Experiential avoidance is another key factor to pay close attention to when treating victims or survivors of IPV. ACT has several studies that show empirical evidence of effective treatment with individual that display experiential avoidance and for individuals with PTSD.
Another option to treatment of victims or survivors of IPV could be to adopt some of the methods used ACT into a support group style of treatment. An important note here would be that whoever leads the support group, should also been a victim and survivor of IPV. If the consulting therapist and/or Board Certified Behavior Analyst (BCBA) is not a victim or survivor themselves, then they should seek out and provide supervision to an individual who is a victim or survivor so they can create the needed foundations of openness, trust, mutual understanding and therapeutic relationship needed to create and foster an environment for behavior change and personal growth. Support groups provide access to a multitude of resources for individuals. Not only professional help resources, but personal support system resources, which can be an area lacking for individual that are victims or survivors of IPV. A factor to consider here would be the use of an online model to provide access to individuals of a lower socioeconomic class.
The last suggestion, and likely the simplest suggestion, would be to advocate for and provide templates for an all inclusive and comprehensible sex education program to be offered to school aged individuals. It is true that IPV includes more than just sexual violence, but a truly comprehensive sex education program will incorporate all aspects of sex, which includes forming healthy lasting relationships. For example, proper sex education would start with clarification of personal values. This would quickly be followed by the ability to make decisions. Another aspect would be the incorporation of education on human anatomy of both the opposite and same sex. A truly comprehensive model would address common issues across all gender types, sexuality types, cultures, ethnicities, abilities, races and so on. This not only provides an educational aspect to individuals but fosters a place for inclusivity and acceptance of individuals different from oneself. The ability to accept someone that is different from oneself could play a big role in some forms of violent behavior.
The inclusive and comprehensive sex education program could use both ACT principles and be formatted similar to that of the social skills model PEERS®. This model has been empirically tested and shown to maintain treatment gains for up to five years after treatment has ended (Laugeson, Ellingsen, Sanderson, Tucci, & Bates, 2014, p. 2246). Some measurements used by the PEERS® model are: Social Responsiveness Scale (SRS); Social Skills Rating System (SSRS); Social Anxiety Scale (SAS); Friendship-Qualities Scale (FQS); Piers-Harris Self-Concept Scale-Second Edition (PHS-2); and the Test of Adolescent Social Skills Knowledge (TASSK).
The model consists of daily session that last half and hour long and occur at least five times per week (Laugeson et al., 2014). The first step was didactic instruction which was followed up by role-play (Laugeson et al., 2014). New skills were then required to be rehearsed in the classroom (Laugeson et al., 2014). An important component to note is the psycho-educational portion provided to parents (Laugeson et al., 2014). Behavior analysts can easily create a train the trainer model to allow parents/guardians or other family/friends to provide skills and guidance in needed areas with their individuals. This is a very important step in the process because without a support system outside of the educational component, competency cannot fully be assessed and generalization nor maintenance will occur. By allowing parents/guardians and other family/friends to learn how to best support their individuals, it creates and more open and honest exchange between the parties which fosters that sense of community and support that is often lacking in some environments.
Daily fidelity checks are conducted by having data tracking sheets filled out (Laugeson et al., 2014). Some of the didactic skills that are included in the PEERS® model that may be beneficial to include the inclusive and comprehensive sex education program are: communication skills; verbal and nonverbal forms of communication; electronic communication; online safety; developing friendship networks; paying attention to feedback from others (traditionally related to humor); how to enter into a conversation; how to exit a conversation; how to organize successful gathering with friends; strategies for handling teasing; handling physical bullying; long-term strategies for changing reputations; resolving arguments; and managing gossip (Laugeson et al., 2014). Laugeson et al. (2014) found that implementing PEERS in a school-based system for higher-functioning individuals was effective in improving the social functioning of those individuals (p. 2252).
The first step in an inclusive and comprehensive sex education program would be to use ACT principles to help individuals identify and clarify their values. This could look like having individuals identify the difference between values and goals or outcomes using examples and nonexamples of each. Then the individuals could complete a values sorting activity from least important to most important and sort their values into each category only once. The first module should also focus on the ability to make an important decision and provide steps to aide them in doing so. These modules should be written to be all inclusive, meaning that a script should be available to the person presenting the new information as well as options for responding and ways to prompt the individuals who are the intended audience.
The second module could touch base on the topic of how to enter and exit a conversation and should have a focus on verbal and nonverbal forms of communication because it is an essential part of both sex education and relationship education. Unless an individual can have a basic understanding of how to appropriately and effectively communicate with others in their lives, then values-based living can become a difficult task. The same module could cover online safety and electronic communication.
Once a basic knowledge of the different types of communication have been reviewed, the modules could address how to develop friendship networks and the review of the different types of relationships in one’s life. A review of how to make decisions and how to communicate with others based on what type of relationship they have with you is essential in this module.
The next module could be to teach paying attention to feedback received from others and provide strategies on handling teasing, cyber-bullying and physical bullying. Another topic that could be incorporated into this module would be strategies for coping with and managing gossip. These are important topics that can incorporate ACT principles such as defusion and self-as-context. This would allow individual to experience the feedback from others, make space between themselves and that feedback so that they do not become fused with it and provide them with tools and strategies to avoid conceptualizing that feedback to be a part of their identity.
Of course there will be several modules related to sexual education. An overview of such principles would be beneficial here but is beyond the scope of this paper. This will of course be inclusive and comprehensive of all genders, races, cultures, abilities and sexualities. To end the modules, it could address some strategies for resolving arguments, specifically related to sexual or romantic partners and what some long-term strategies for changing reputations could be.
This same model and approach should be used when adapting the ACTV model into a newer version of a BIP. This model will include direct scripts for trainers to use when presenting new information as well as a script that includes prompts to give the individuals intended to be participating. The incorporation of values identification, present moment awareness, self-as-context, acceptance, defusion, committed action into this model as well as the strict guidelines for presentation should create a further reduction in recidivism of IPV offenders. A huge benefit of the ACTV model is the inclusion of the Barriers to Change sessions, and this portion of the BIP should be expanded upon and could establish a good way to create committed action towards values-based living in IPV offenders. By continuing to provide education and strategies surrounding personal values and action plans for how to realistically achieve those values, this method could be effective in further reducing recidivism rates of arrest and conviction in previous IPV or IPSV offenders.
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