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Salimi et al. (2019) reported that developmental delays and the uncertainty that often comes with an unclear or poor prognosis can lead to intense psychological pressure on family and friends of the child. The stress this causes is significant for the entire family system, but it is reportedly more intense for mothers who often feel shame, depression, grief, and guilt. Salimi et al. (2019) note that the stress this causes a family changes over time as challenges pop up and advocate that professionals need to help families by preparing them for the challenges they will undoubtedly face. Acceptance Commitment Therapy (ACT) is a behavior therapy that can help these mothers with building a better relationship with their thoughts and emotions, allowing them to focus on the components of their life that are most important and valuable to them.
Acceptance Commitment Therapy (ACT) is based on the assumption that the connection between internal human language, or thoughts, and behaviors can lead to psychological suffering. Just as the thought and behavior interaction can lead to psychological suffering, these thoughts and behaviors can be altered to instead create psychological flexibility and move people toward their values. Psychological flexibility can be obtained by following the six principles in ACT: defusion, acceptance, being in the present moment, the observing self, values, and committed action (Harris, 2008). Harris (2008) who experienced having a child diagnosed with autism spectrum disorder (ASD), reported that ACT can be used when dealing with the grief of a diagnosis. Using these principles can help parents and families manage the cyclical thoughts and feelings associated with stress and grief, which hinder their ability to continue engaging in behaviors that are aligned with their values (Martinez, 2018).
Historical Overview
In 1885, Sigmund Freud discovered, under the influence of a colleague and physician, Josef Breuer, that he could get patients’ symptoms to occasionally subside by having the patient engage in talking about the earliest occurrences of symptoms. Josef Breuer found that this treatment – “the talking cure” – was cathartic and allowed the release of hidden emotions allowing for work on pathological behaviors. (Jay, 2019). When working with Breuer, Freud’s objective was to have his patients engage with traumatic thoughts, feelings, and memories which previously were beyond their consciousness (Thornton, n.d.). This led to Freud’s theory of levels of consciousness, and how one experiences sensations and experiences – conscious (aware), preconscious (can be retrieved), and unconscious (pushed away). His theory stated that the unconscious is where emotions, and memories which are threatening to the conscious mind are pushed (Sharf, 2007 p.31). While the idea of pushing thoughts away and not focusing on them is the opposite of the ACT principles, these ideas guided early social science to think about things on a deeper level (Plumb, 2011).
In 1945, B.F. Skinner introduced the idea of radical behaviorism as a new method to conceptualize human behavior. Skinner denoted this new form of behaviorism as radical to contrast it to methodological behaviorism. Like former behaviorism characteristics, Skinner did find that overt behavior was an essential variable. However, he also recognized that private and unobserved behavior, such as thoughts, were also worth acknowledging (Ahearn, 2010). Skinner was interested in understanding and fostering a more naturalistic perspective. He viewed behavior as an evolving system, and strove to find a pragmatic sequence to behavior within the current context of behavior. He argued that a fundamental understanding of a person’s psychological state was less important than the person’s behavior and environmental considerations. He was interested in the antecedent, behavior, and consequence contingency as a unit that drives behavior (Plumb, 2011).
Cognitive therapy, a system by Aaron Beck, sought to find more ground as clinicians became frustrated with the Skinnerian approach of radical behaviorism, as it was unclear how to approach language and cognition (Sharf, 2007). Clinicians using cognitive therapy assessed the way individuals perceived a situation and how their reactions connected to it (Plumb, 2011). Beck found great importance in treating clients by having them pay attention to their thoughts – especially those in which the individual may be unaware of and are important to their belief systems (Sharf, 2007). Moreover, Beck acknowledged the importance of clients being able to distance themselves from their thoughts – being able to observe their thoughts from the perspective of the listener – connecting it to the later founding of ACT. After cognitive therapy gained ground, cognitive behavior therapy (CBT), a form of psychological therapy that helps clients learn skills to change thinking and behavior to achieve lasting improvement in mood and functioning and a sense of well-being, became more popular. CBT principles state that unhelpful ways of thinking and unhelpful learned behaviors lead to psychological problems. According to CBT, people suffering from these problems can learn better ways to cope to live more effective lives free of symptoms (APA Division 12).
Another treatment approach that had considerable influence on, and made many contributions to, ACT methodology is Relational Frame Theory (RFT). The core of verbal behavior – both internal and external – is the learned and “contextually controlled ability to arbitrarily relate events mutually and in combination, and to change functions of specific events based on relations to others” (Hayes, et al., 2006, p. 5). There are three important aspects of RFT. These include human cognition which is a specific kind of learned behavior; behavioral processes and their effects, which are altered by cognition; and contextual features of situations regulate cognitive relations and functions. RFT research implies that one should not focus on the context of thoughts when providing treatment; rather, instead, one should look at the functions of these thoughts.
In the 1970s, Steve Hayes looked to address clinical issues with the application of Skinner’s work in rule-governed and verbal behavior. Hayes researched thinking as a behavior, due to Skinner’s view of self-control, noting that it could have a controlling aspect in the behavior relationship. This relationship was further built when cognitive control was reconceptualized. It was found that, in the context of therapy, verbal behavior (i.e., reason-giving) could support dysfunctional behavior and be problematic; however, it was possible to weaken control by thinking other thoughts. These ideas were the beginning of building the foundations of ACT (Zettle, 2005)
Theoretical Underpinnings
Psychological Flexibility
The unified model used in ACT is the model of psychological flexibility, which was “derived largely from laboratory science” and used for human functioning and behavior change (Hayes, 2012, p. 62). This model has a basis in psychopathology, psychological health, and psychological intervention. If people are psychologically flexible, they display the six core processes – showing awareness of values; living life through committed action; attending to the present moment; demonstrating acceptance; and engaging in defusion. On the other hand, if one is said to be psychologically inflexible, he or she is inflexible in attention; engaging in inaction or impulsively; attaching to conceptualized self; fusing to his or her thoughts; engaging in experiential avoidance; and has disrupted values. The psychological flexibility model shows that pain is natural, but when verbal and cognitive processes affect one’s repertoire in crucial areas through fusion and experiential avoidance, it causes unnecessary suffering (Hayes, 2012). When the behavioral repertoire is affected in this manner, it prevents people from changing when strategies do not work. It can also create aversive control causing them to attempt to engage in experiential avoidance – the act of avoiding and escaping thoughts, feelings memories, and/or body sensations. According to the psychological flexibility model, it is important to understand and work to uphold the six core processes (all of which interact with each other) – defusion, acceptance, attention to the present moment, self-awareness, values, and committed action – otherwise it leads to psychological rigidity, which Hayes (2012) reported leads to unnecessary human suffering (Hayes, 2006).
Defusion is the process of seeing private events – thoughts, memories, images, feelings – as simply verbal behavior (Hayes, 2012). Harris (2008) defines thoughts as, “words inside [one’s] head”; images as “pictures inside [one’s] head”; and sensations as “feelings inside [one’s] body” p. 38. Harris (2008) notes that the ability to distinguish between all three is important, as one uses different methods to deal with these private events. These distinctions that Harris defines are all in one’s mind, or, as Hayes (2012) more behaviorally explains, in one’s repertoire of verbal or cognitive activities (p. 68). Hayes (2012) explained that not taking private events as literal, or factual information, but rather verbal behavior, it can “weaken the functional dominance” of rule-based responding (Hayes, 2012, p. 65). In other words, private events have less behavioral impact (Harris, 2008). When one is not experiencing defusion, he or she is experiencing cognitive fusion. This means that he or she is in a state where, “verbal events exert strong stimulus control over responding,” to the extent that he or she responds to their private event verbal behavior, as though he or she is responding to physical or environmental situations directly (Hayes, 2012, p. 69).
Another of the six processes is acceptance. This is achieved when one no longer engages in experiential avoidance by trying to control or suppress unwanted private events, but by “mak[ing] room for” them (Hayes, 2012, p.65). Harris (2008) refers to acceptance as expansion; if given enough space, the private events no longer cause one to strain. Hayes (2012) does acknowledge that some experiential avoidance in certain contexts is not toxic, and can be adaptive, but in most instances, this is not the case. Once started, strategies one uses to seek to avoid aversive internal states are difficult to extinguish, and often result in the return of those undesired private events. Even when experiential avoidance is adaptive, it is often over-generalized to other contexts in which it is not adaptive, and possibly harmful. Also, socially-mediated positive reinforcement is often provided by social partners (family, friends, spouses, etc.) when one can suppress and control their private events and socially-mediated positive punishment is often provided by these social partners when one is not able to suppress and control their private events; this can make acceptance more difficult to achieve (Hayes, 2012). However, one can achieve this by not thinking about their emotions, but rather, observing them (Harris, 2008).
In addition to acceptance, attention to the present moment is another important process within the psychological flexibility model of ACT. Harris (2008) sometimes refers to attention to the present moment as “connection” – meaning being fully aware of one’s here and now experience, allowing one to engage with the thoughts, feelings, and experiences that are current. Hayes (2006) explains that the goal of being present is for one to be more directly present with his or her environment, so that their behavior is flexible, and closer to matching their values. Hayes (2012) states that it is important to not be too focused on past events and memories, or imagined future events, but rather, on the present moment. When one is not in the present moment, it impacts his or her ability to engage in other psychological flexibility processes, such as defusion and acceptance.
Self as context, or the observing self, is another one of the six processes of psychological flexibility. This process is a perspective of pure self- awareness, not a thought or feeling (Harris, 2008). Perspective and sense of self are gained by human language. It is this side of human language that functions as empathy, theory of mind, perspective-taking, and sense of self. Mindfulness exercises foster a sense of self as context. The goal with this process is that one is aware of his or her experiences, with no regard to them; however, the limits and extents of self as context is unknown. (Hayes, 2006).
Values are another process of psychological flexibility. Values are, “chosen qualities of purposive action that can never be obtained as an object but can be instantiated moment by moment” (Hayes, 2006). One’s values can be utilized to motive him or her to engage in behaviors that match these values (Harris, 2008). These values should not be imposed by others, but rather, be freely chosen (Hayes, 2006). While values should not be socially forced, the value can be social in nature (ex: friendship) (Hayes, 2012). Values are an “ongoing process of verbal relating” meaning that even if one value seems to counter another value, they can be related and serve each other well (Hayes, 2012, p. 93). For example, as Hayes (2012) explained, one could, “initially not see the connection between having a fulfilling work career and being an effective parent, however, examining what the client would like to model for their children as part of promoting long-term life satisfaction” might show that these values are verbally related, and have a constructed link (Hayes, 2012, p. 93). It is important to differentiate that values are not goals. Values are a “direction we desire to keep moving in– an ongoing process that never reaches an end” (Harris, 2008, p. 169).
Committed action is one of the six processes that is very connected to the values process of psychological flexibility. Committed action is a “values-based action designed to create a pattern of action that is itself values-based” (Hayes, 2012, p. 93). Committed action does not mean that one will not occasionally take actions that are not based on values; rather, it means that even when they engage in action that is not matched with his or her values, that they take action to get back on track to form a behavioral repertoire (Harris, 2008). While values are focused on the consequences, committed action focuses on the behaviors and patterns of behavior that one takes to sustain purpose.
While ACT has become a more popular approach in the field of ABA, there are still criticisms emerging. Powers (2009) carried out a study to determine if ACT was as effective as a treatment as other common treatment approaches. Results of his study showed that ACT was more effective than waiting lists and placebos, but not as effective or more effective than other common treatment approaches. Levin and Hayes (2009) found that the data Powers used in his study was inaccurate. When these inaccuracies were fixed and recalculated, the results showed that ACT was superior to other treatments (Levin and Hayes, 2009). Another criticism of ACT is that it is not distinctive, and is comparable to CBT (Arch & Craske, 2008). Hayes (2008) counters this criticism by noting that there are significant distinctions in the history and development of ACT versus CBT. He explains that ACT has “specific processes, principles and theories” while CBT is based on “tribal traditions” (Hayes, 2008, p. 286).
ACT is a treatment that must be used in a certain manner to meet all the dimensions of ABA and remain an ethical approach for BCBAs to utilize with clients. These dimensions include applied, behavioral, analytic, technological, conceptually systematic, effective, and generality. For a treatment to be considered applied, it must target socially significant problems. ACT has been used across many target behaviors and problems that are considered socially significant (e.g., grief, anxiety, anger, depression, eating disorders, chronic pain, addiction, post-traumatic stress disorder, and all the related behaviors that go along). Another important dimension is that the treatment must be behavioral, which means that the treatment must change behavior. While ACT is a treatment that may not directly target the behavior, it can be used to change thought processes that predict and lead to behavior change. This means that if one uses ACT treatment, and the client reports that his or her thoughts have changed, but there is no behavioral change and no follow-up modifications to bring about behavioral change, then one cannot consider it behavioral. Analytic is another dimension of ABA that states that we analyze behavior and demonstrate that the treatment has a functional relation to the behavior change. To maintain this dimension of ABA when using ACT, one must collect data to ensure that change is happening, and that it is due to treatment, and not do other variables. The next dimension is technological. While ACT may be interpreted differently by various providers, behavior analysts must be precise in their procedure describing how ACT will be utilized, so that others can read and replicate it. Conceptually systematic is another dimension of ABA that must be in place. This means that the procedures must reflect ABA principles. This is of utmost importance in ACT. Without connecting the pieces back to behavioral principles and terminology, one could easily get lost in more mentalistic language and drift far away from meeting this dimension. The next dimension is effective, meaning that it must produce socially significant results for those impacted by the intervention. The last of the seven dimensions is generality. It is important that treatment produces a change in multiple settings, and can be maintained by the natural environment. When done correctly, ACT techniques and strategies can be utilized across settings, and maintained by the natural environment.
Psychological Flexibility and Grief
Harris (2008) explains that ACT and psychological flexibility can be used during times of loss and grief. He references Dr. Elisabeth Kubler-Ross’s “five stages of grief”, which was initially created for death and dying. However, Harris (2012) explains that the stages she described can be applied across trauma, loss, crisis, and shock – they are not just reserved for death and dying. He also explains that when one experiences grief, he or she does not necessarily experience every stage of grief or each stage of grief in a specific order. Martinez (2018) explains that it is a “continual process that lasts a lifetime”. Moreover, these stages can be experienced multiple times and even sometimes simultaneously. After the shock of an event (loss, trauma, crisis, shock, etc.), one’s environment often suddenly shifts; the environment that is desired may look vastly different than the one he or she is having to live in. The larger the difference between these two, the more likely one will experience some form of the grief stages. When this occurs, Harris (2012) explains how to use ACT strategies to be able to accept life’s circumstances and continue moving forward.
Harris (2012) explains that an important initial component is practicing self-compassion. Compassion is something people may use with other people, but less often – sometimes not at all – with themselves. He recommends that people work on building up their repertoire of compassion responses so they can use them during times of grief. Some examples of a compassion response may be validating pain “(‘I can see you are in terrible pain’), allowing time to observe the pain being experienced, and taking care of oneself by practicing some form of self-care (Harris, 2012).
Martinez (2018) noted that it is important to remember that psychological flexibility is still the goal when it comes to dealing with grief. He explains that our behavioral repertoire breaks down when we have a loss. While this is normal, if this prevents one from people from engaging in committed action which aligns with their values. If the grief being experienced is due to a death of a loved one, Martinez (2018) recommends doing an ACT matrix specific to this topic to help those struggling choose values they admired about their loved one that they can add to their values and live out by engaging in committed action. Harris (2012) explains that connection or attention to the present moment is important to keep engaged in the current environment necessary tasks. Rather than continuing to allow thoughts of the past and/or future control behavior in a way that is not productive or helpful, he encourages to push forward with engaging in behaviors that have toward movement. After describing connection, Harris (2012) explains the process of defusion. When experiencing grief, people can focus on thoughts that are unhelpful such as those revolving around denial, anger, despair, and unfairness. While these are normal thoughts to have during times of grief, when experiencing fusion, these thoughts impact behavior by preventing them from engaging in behaviors that have toward movement. However, by viewing these thoughts as simply verbal behavior in which one does not have to allow to influence behaviors, one can experience defusion and continue engaging in behaviors that have toward movement, despite having these thoughts. Next, Harris (Harris, 2012) explains the importance of acceptance; if one is entirely consumed by his or her thoughts and feelings, they may be unable to do engaged in toward moves. This person would be in a state of fusion and unable to engage in committed action through toward moves. If one holds their emotions and thoughts so far away, trying to not come into contact with them, then he or she is not in the present moment or engaging in the observing self. All these processes impact one’s ability to engage in acceptance (Harris, 2012).
Applications
ACT Applied to Parent and Child Relationship
When looking at how ACT impacts the parents of children diagnosed with ASD, it may benefit to first look at how ACT affects parents of typically developing children. Whittingham et al. (2016) explained, “the parent-child relationship is important to all children, regardless of individual characteristics,” and impacts child outcomes and development (p.2). The parent and child relationship are interconnected and cyclical, meaning that if the parent has mental health issues, it impacts the child; as well as if the child has a disability or mental illness, this impacts the parent. Parent et al. (2010) explained that parent depression can affect the child, leading to an increase in problem behaviors. Flujas-Conteras and Gomez (2018) reported that maladaptive parenting behaviors, or styles, often increase in the number of problems their child ends up experiencing, such as depression, stress, aggression, and impulsivity. Brassell et al. (2016) explained that, due to the likelihood of psychological flexibility of an individual impacting others within the family system, it is important to examine the effects of parenting psychological flexibility on child outcomes.
Parent et al. (2010) reported that mindfulness has been said to help parents focus on the present moment and reduce ruminative thinking, which can play a role in parent depression, affecting the parent and child, as they often do not use positive parenting strategies. Parent et al. (2010) sought to determine if parent mindfulness would be negatively correlated with parent depression. They used data of 145 mothers, 17 fathers, and 211 children. Parents completed the Beck Depression Inventory-II (BDI-II), the Mindful Attention Awareness Scale (MASS), and the Child Behavior Checklist (CBCL). In addition, children completed the Youth Self-Report (YSR). The parents and children participated in submitting two videos of their dyadic interactions. Results showed that parent depressive symptoms were related to child externalizing problems due to lack of positive parenting (Parent et al., 2010).
Flujas-Conteras and Gomez (2018) reported that development of experiential avoidance behaviors, as a strategy to self-regulate, are a risk factor of family conflicts. When parents become fused with their thoughts, often they are not able to maintain their behavioral repertoires, which leads to them engaging in behaviors – possible maladaptive ones – that result in experiential avoidance. Since maladaptive parenting behaviors can be changed through acceptance and defusion, Flujas-Conteras and Gomez (2018) sought to provide a guide for using ACT in family interventions, that result in parental psychological flexibility. They did a functional assessment with a 43-year-old mother, Maria, who engaged in experiential avoidance behaviors that impacted her son’s private events, which turned into behaviors such as suicidal ideation. In order to determine a function of the behavior, a functional assessment was conducted, using specific variables which impacted behavior. They found that Maria was engaging in these behaviors to avoid the thoughts and feelings that occurred when around her family. Flujas-Contera and Gomez (2018) used the Valued Living Questionnaire (VLQ) to determine her values, as well as a Psychological Flexibility Sheet at the beginning and end of treatment. They did not use a session-by-session protocol, but used ACT components, including use of several metaphors and other exercises, within sessions, with the goal of promoting psychological flexibility within her role as mother, as well as increase committed action. The first session targeted creative hopelessness; the next 2 sessions targeted values and barriers. The following 4 sessions looked toward engaging in committed action. In session 9, Maria reported that she was engaging in more committed action and less experiential avoidance. She reported that her son also had an increase in psychological flexibility. According to the results of the Psychological Flexibility Sheet, she had much higher scores on all the processes of psychological flexibility. Experiential avoidance decreased and acceptance increased, and was maintained at the four-month follow up (Flujas-Contera and Gomez, 2018).
Brassell et al. (2016) reported that, while increased psychological flexibility greatly impacts the individual’s well-being, there is less research on how this impacts those within the individual’s family system. They reported that there is some research on parent psychological flexibility and outcomes on child’s well-being, but it is still unclear which mechanisms are causing this relationship. Brassell et al. (2016) sought to determine the effects of psychological flexibility through three steps. The first step was examining if psychological flexibility had an effect on parenting psychological flexibility. Brassell et al. (2016) discussed the importance of this distinction, as psychological flexibility is very context specific. Therefore, psychological flexibility that is parent specific looks at the parent’s ability to accept unhelpful thoughts and feelings that are prompted by parenting stress. The next step Brassell et al. (2016) examined was if increased parenting psychological flexibility resulted in an increased use of positive parenting strategies. They hypothesized this would occur due to the fact that increased parenting psychological flexibility being likely to result in the parent’s ability to stay in the present moment, in a state of defusion, and more able to engage in committed action of engaging in those strategies. The last step in Brassell et al. (2016) study was to look at child outcomes from the increased use of adaptive parenting in the form of using positive parenting strategies. Moreover, they created their study using children within 3 age ranges (3-7 years, 8-12 years, and 13-17 years of age) of 615 parents, to account for childhood developmental differences in the outcomes portion. Parents completed the AAQ-II, to determine their psychological flexibility as an individual, and the Parenting-Specific Psychological Flexibility Scale (PSPF), which Brassell et al. (2016) created from the AAQ-II, but focused each item on parenting. Adaptive parenting was assessed using the Multidimensional Assessment of Parenting Scale (MAPS). The child outcomes were assessed using the Brief Problem Checklist (BPC). Results of these assessments showed that parent’s psychological flexibility in the parenting role was associated with parent’s psychological flexibility as an individual. It was also found that positive parenting strategies were more often used when parent had higher psychological flexibility in the parenting role. Moreover, higher levels of parent’s psychological flexibility was associated with lower levels of youth internalizing and externalizing problems (Brassell et al., 2016).
ACT Applied to Parents of Children Diagnosed with ASD
One of the settings and situations in which ACT can be utilized is with parents of children diagnosed with ASD. When coping with their child’s diagnosis, parents will often cycle through at least some of the stages of grief outlined by Dr. Elisabeth Kubler-Ross. Grief is something that can occur when one experiences any kind of loss such as “divorce, death, disability; illness injury, or infirmity; depression, anxiety, or addiction: they all seem to be very different, but beneath the surface, they are all very similar” (Harris, 2012, p. 10). Moreover, having a child with ASD means increased pressure, and often means increased time restraints and limitations as parents have to take them to and from various therapy appointments. Parents may also struggle when their child does not meet milestones in which they expected him or her to meet within a certain timeline. This is where ACT can be utilized to support parents.
Gould et al. (2018) noted that parents who have a child with chronic challenges, such as a diagnosis of ASD, often experienced high levels of psychological suffering. Hahs et al. (2019) stated that a major financial burden is placed on parents, as children diagnosed with ASD require effective treatments, which can be expensive. Sairanen et al. (2019) also reported that parents of children with a disability have increased stress, depression, and anxiety. Mothers of children diagnosed with ASD have a greater level of stress, depression, guilt, and even shame (Salimi et al, 2019). Although this can cause problems in the whole family system; some fathers report the stress, depression, guilt, and shame that is experienced by mothers in these situations is more damaging to the family system than the diagnosis of ASD (Salimi et al. 2019). Due to problem behaviors that children with ASD often engage in, parents often isolate themselves as they worry about potential embarrassment leading to limiting social engagement, which ultimately impacts their psychological well-being (Hahs et al., 2019). The increases in the challenging thoughts and feelings and their impacts on behaviors parents engage in can impact the entire family system. These researchers determined that parents need treatment to help them handle their thoughts and feelings through the challenges they experience (Sairanen et al, 2019).
Sairanen et al. (2019) chose to look at web-based treatment due to parents of children with disabilities often having limited time and not being able to always be face to face. The web-based treatment approach they chose was ACT due to promising results having been found in previous studies when people struggle with stress, anxiety, chronic pain, and depression. Sairanen et al. (2019) sought to evaluate the effects of web-based ACT intervention vs. control on burnout and psychological symptoms of depression, anxiety, and stress. There were 74 parents (37 in ACT group and 37 in the control group), who participated in this study had children with either diabetes or functional disabilities, and scored on the Shirom-Melamed Burnout Questionnaire (SMBQ) 2.75, indicating that had significant burnout. The SMBQ measures emotional exhaustion and physical fatigue, listlessness, tension, and cognitive weariness. The researchers used the AAQ-II to measure experiential avoidance, Five Facet Mindfulness Questionnaire (FFMQ) to measure mindfulness, and Cognitive Fusion Questionnaire (CFQ) to measure cognitive fusion. Sairanen et al. (2019) provided a “10-week intervention to teach parents skills and strategies to prevent and handle stress and worries in everyday life” that was guided by a personal coach (p. 96). Personal coaches were undergraduate psychology students who received a 4-hour training in ACT and web coaching before the start of the intervention. They also received 2 hours of supervision and continued supervision as needed. The personal coaches provided semi-structured feedback to parents. The researchers also tracked adherence to programming by tracking login times and actions. Parents were able to log in and complete modules during the 10 weeks of intervention. Results showed that while before treatment there were no significant differences between the ACT group and control group, there were significant differences during intervention which were maintained at follow-up. Improvements in depression symptoms were made when couples participated in the treatment together; when spouses or significant others did not participate, this improvement was not seen. They did not find significant differences across mindfulness questionnaires. While they found a significant impact on burnout and depressive symptoms, this was not the case for anxiety and stress symptoms. Limitations included a short follow-up period (4 months), the number of participant dropouts, the number of patients who were female, and the use of self-report measures. Overall significant differences indicate that web-based ACT intervention can be an effective approach to supporting parents of children with disabilities (Sairanen et al., 2019).
Blackledge & Hayes (2006) reported that parents of children who have ASD “experience high levels of chronic stress, even more so than parents of Down Syndrome and psychiatrically diagnosed children” (p. 2). It can cause parents to experience unhelpful feelings and thoughts and cause marital problems. Despite these effects, parents’ mental health is often ignored as parent training originally only focused on the child. Since ACT has been used to address many mental health issues, they chose to determine the effects of two 14-hour days of intervention on stress and depression experienced by parents who have children diagnosed with ASD. Blackledge & Hayes (2006) recruited 20 parents (15 mothers and 5 fathers) of children diagnosed with ASD to be participants in this study. They used the Global Severity Index (GSI) to measure psychological distress symptoms, the Beck Depression Inventory II (BDI) to measure depression, the General Health Questionnaire-12 (GHQ-12) to screen for psychiatric problems, the Parental Locus of Control Scale (PLOC) to measure parenting ability, the Acceptance and Action Questionnaire (AAQ) to measure psychological flexibility, and the Automatic Thoughts Questionnaire (ATQ) to measure automatic negative statements. These assessments were filled out three weeks prior to treatment, one week prior to treatment, one week following treatment, and three months following post-treatment assessment. The intervention started with a creative hopelessness exercise, followed by cognitive defusion, self-as context, and values exercises. Results showed statistically significant changes, but the average changes were not large. From pre to post-testing, the ATQ-B improved. From pre-test to follow up, the AAQ and ATQ-B showed significant improvement. Overall, this study showed that ACT can produce beneficial outcomes for parents who have children diagnosed with ASD (Blackledge & Hayes, 2006)
Gould et al. (2018) studied how parents of children of ASD respond to acceptance and commitment training. When it comes to implementing behavior plans and managing their child’s behaviors, parents often struggle to meet treatment fidelity due to the psychological distress they experience (Gould et al., 2018). Gould et al. (2018) defined psychological distress as “experiencing high levels of aversive private events evoked by environmental stressors” p. 81. These private events are “any covert stimulus (e.g., thought, image, physical sensation, emotion) or response (thinking, visualizing, remembering)” (Gould et al., 2018, p. 81). Hayes (2018) noted that one’s behavioral repertoire is often narrowed when he or she is under a great deal of stress. This can cause parents to behave in inflexible ways, often rule-governed, such as social disapproval, questioning of parenting abilities, or inability to face the challenge, instead of based on environmental contingencies. Cognitive fusion, opposite of defusion and explained earlier, makes these rule-governed responses stronger and decreases the likelihood that parents will respond in a way that is needed to decrease their child’s maladaptive behaviors. This often leads to parents engaging in experiential avoidance of the thoughts and feelings they find aversive. Continuing to engage in experiential avoidance at a frequent rate is associated with higher levels of mental health issues and parent stress. Another process to moving away from experiential avoidance and toward committed action is identifying parent’s values. Gould et al. (2018) defined values as “verbal statements that alter the degree to which consequences function as reinforcers or punishers” (p.82). The goal when working on values is to use rule-governed behaviors that are oriented toward the bigger goal, which leads to positive reinforcers, resulted in committed action. The researchers defined mindfulness as action “intended to reduce contingency insensitivity and control by previously established verbal rules, by strengthening one’s repertoire of attending to stimuli in the present moment environment” (p. 82). They defined the last process, acceptance, as “an approach response and/or the absence of an escape response in respect to aversive stimulation – unconditioned, conditioned, or derived” (p. 82). Gould et al. (2018) used a multiple-baseline design across participants to assess how these processes could be utilized in an ACT protocol and affect parent behavior. The study had three participants, all mothers of children who had a diagnosis of ASD, and who were already receiving in-home ABA services, but had no exposure to ACT. All sessions took place in the participant’s home. The researchers had each parent take data on “frequency of values-directed parent behaviors (any action resulting in a tangible outcome directly related to an individual parent-identified value) per calendar day” (p. 83). The researchers used the Acceptance and Action Questionnaire-II (AAQ-II), Self-Compassion Scale (SCS), and Family Impact of Childhood Disability Scale (FICD). Interobserver agreement was found by using a third party such as a friend or significant other. Training was conducted in six 90-minute 1:1 sessions to allow for individualization. Each session provided a summary of one of the six ACT psychological flexibility processes. Sessions consisted of “lecture, discussion, modeling, role-play, and practice” with supplemental homework activities assigned to be completed between sessions (Gould et al., 2018, p. 84). The first parent was engaged in zero values-directed behaviors in baseline or training and this increased in post-training and follow up. The second parent engaged in zero values-directed behaviors in baseline, engaged in some values-based directed behaviors during training, and engaged in higher levels of values-based directed behaviors post-training; the researchers did not follow-up on this case. The last parent had zero value-directed behaviors in baseline, low frequency of value-directed behaviors during training, and low frequency during post-training; in follow up, this parent had a significantly higher frequency of values-directed behavior. Some limitations these researchers noted included parent recording self-report data; however, the researchers attempted to offset this by ensuring that behaviors were discrete and well-defined, which made it easier to recognize and record (Gould et al, 2018).
Despite the need to support parents, Hahs et al. (2019) also reported that few treatments have targeted the needs of the parents directly. Findings in his research proposed that ACT could be utilized to help parents of children with ASD. Participants included 18 parents of children diagnosed with ASD who received 150 to 300 minutes of ABA per week. Participants completed eight self-report measures, including AAQ-II, White Behar Suppression Inventory (WBSI), Internalized Shame Scale (ISS), Cognitive Fusion Questionnaire (CFQ-13), Frieberg Mindfulness Inventory (FMI), Mindful Attention Awareness Scale (MAAS), Personal Values Questionnaire-II (PVQ-II), and Beck Depression Inventory-II (BDI-II). Hahs et al. (2019) used between-subjects pre-test and post-test experimental design, with matched assignment into treatment, and control groups were used. Nine participants were in the ACT group and nine participants were in the control group dependent on their scores on the BDI-II and AAQ-II. The control group completed the pre-test and a week later returned to complete the post-test. The ACT group completed two 2-hour training sessions during the workshop; these trainings were held one week apart. The first 3 processes (values, self-as-context, and cognitive defusion) were discussed in the first session and the second 3 processes (acceptance, present moment, and committed action) were in the second session. Results showed that there were statistically significant changes between groups for six of the eight measures and these differences indicate that brief ACT interventions “could be effective for increasing elements of psychological flexibility and mindfulness as well as decreasing reports of depression and shame” (Hahs, 2019, p. 157).
Salimi et al. (2019) cited research that due to ever-changing challenges that families face, it is important that professionals prepare families by teaching cognitive-emotional regulation. Cognitive emotion regulation can be utilized during stressful events. It was noted that some of these strategies fall into experiential avoidance behaviors, which is associated with emotional problems. Salimi et al. (2019) sought to determine if ACT has any influence on cognitive emotion regulation strategies in mothers of children with ASD. Participants in this study were 30 mothers of children diagnosed with ASD. Researchers used the Cognitive Emotion Regulation Inventory to assess cognitive emotion regulation looking at seven factors: self-blaming, blaming others, positive reevaluation, rumination, considering a situation as disastrous, reception, and planning. Salimi et al. (2019) held eight 2-hour group sessions during treatment. These sessions allowed practice and tasks were assigned at the end of each session. No treatment occurred in the control group. Results showed there were significant statistical differences between the experimental group and the control group. These meaningful differences occurred for self-blaming, blaming others, positive reevaluation, considering a situation as disastrous, reception, and planning (Salimi et al., 2019).
Corti et al. (2018) reported that past research shows that parents are better equipped to respond to behavior problems and lessen stress levels when provided with behavioral parent training (PT). Through behavioral parent training, parents learn various strategies to use when engaging and teaching their child to use at home. However, thus far, behavioral PT does not take any psychological aspects into account. Since parents’ behavior is a direct result of environmental factors – public or private events – it is important to take the private events into consideration. If parents are depressed or in a state of fusion, this may impact their ability to engage and interact with their child as frequently or for longer duration. Since it is clear that private events also play a role in parent behavior, any barriers in this area should be addressed in order to produce optimal PT effects. Moreover, a good parent and therapist relationship with good communication is essential for PT. For example, if a therapist is too direct and does not show appropriate affect or empathy, this could impact parents’ willingness and comfortability with PT. Corti et al. (2018) proposed that the use of ACT could fill the gaps of traditional PT as it addresses both private and public events, as well as providing therapists who are often nonjudgmental and open-minded. In addition, ACT works to help parents be responsive rather than reactive. Parent psychological flexibility is associated with psychological adjustment and responsiveness to child behavior. This allows parents to respond with validation and acceptance, resulting in a reduction in child problem behavior. Corti et al. (2018) sought to evaluate the effectiveness of ACT PT for parents with a recent diagnosis of ASD. This training was designed to address parent stress, cognitive fusion, and experiential avoidance. Since all the children in the study were receiving early intensive behavioral intervention, they used an ACT-PT (21 participants) and a control group that only received EIBI (22 participants). This study included parents of children ages 2-4 years, with a diagnosis solely of ASD. Each series was conducted across 6 months and coincided with early intensive behavioral intervention. It consisted of 12 hour and a half long sessions every two weeks. Every session was preplanned with content and exercises, as well as with assigned homework. The series was conducted in a group format so that parents could give and receive support to other parents that are having similar difficulties. Corti et al. (2018) used pre-treatment post-treatment self-report questionnaires, as well as the Parenting Stress Index-Short Form (PSI-SF), Mindfulness Attention and Awareness Scale (MAAS), and Cognitive Fusion Questionnaire (CFQ). Results showed that psychological suffering and inflexibility are issues that parents of children with ASD experience. Corti et al. (2018) found that there were not significant differences between the ACT-PT group and the control group. In fact, there was a decrease in mindful awareness and no change in cognitive fusion. They note this could be due to the self-report measures not being reliable.
Poddar et al. (2015) also wanted to evaluate the effects of ACT on parents of children and adolescents with ASD. They explained that parents of children with ASD often report to feeling overwhelmed, blame, and guilt, as well as having high levels of chronic stress. Parents of children with ASD often have anxiety and depression, or depressive symptoms. Due to ASD being a diagnosis that often stays for a lifetime, with changing challenges, Poddar et al. (2015) explained it is important to work toward accepting the diagnosis rather than constantly challenging, which is where ACT comes in. The study included five mothers of children and adolescents with diagnoses of ASD. Since the researchers wanted to assess just state anxiety that is likely caused by the diagnosis, rather than trait anxiety, they used the State-Trait Anxiety Inventory (STAI) to make the distinction. In addition to the STAI, they use the BDI to assess depression, the AAQ to assess psychological flexibility and the World Health Organization Quality of Life Assessment-BREF (WHOQOL-BREF) to assess areas such as physical and psychological health, social relationships, and the environment. The intervention included ten sessions across two months. The first six sessions focused on the diagnosis and accepting the diagnosis, as well as teaching metaphors, paradoxes, and experiential exercises used in ACT. The following sessions focused on values, goals, and future behaviors. Results showed that there was a significant decrease of state anxiety at post-assessment. There was also a significant decrease in levels of distress at post-assessment. Moreover, there was a significant change in psychological flexibility and quality of life.
Fung et al. (2018) reported that there are few interventions that help parents of children with ASD. They found that most parent interventions can do the opposite of the intention and add to parent stress by adding another obligation onto their plate. They stated that mindfulness-based training may be an effective approach to help parents as it has been found to “reduce stress and increase well-being” (Fung et al., 2018, p. 2740). Since parents are able to not be controlled by their thoughts and feelings they describe as being distressing through psychological flexibility, Fung et al. (2018) sought to help parents by targeting psychological flexibility, fusion, and values. Participants were 33 mothers of a child under the age of 22, with a diagnosis of ASD. They agreed to participate in a hour and half long day group, followed by a refresher course a month after. They found two mothers (a registered nurse and a social worker) to train to be facilitators of the group. Fung et a. (2018) used ACT group activities followed by debriefing. They did sessions in the community in a setting with candles and music to increase participant comfortability. The researchers used several measures to determine if the intervention was effective. They used the AAQ-II to assess overall psychological flexibility, CFQ to assess fusion, the VLQ to assess values, and the Depression Anxiety Stress Scales (DASS-21) to evaluate perceived stress and depressive symptoms. Results of the AAQ-II showed that there was a significant improvement in psychological flexibility post-intervention and at follow up. The CFQ results showed that there was a significant decrease in cognitive defusion post-intervention and at follow up. The results of the VLQ showed that there were significant changes across all areas except for fun (family, marriage, parenting, friends, community life, and self-care). It was found that the change in the scores on the VLQ was a mediator for changes at post-intervention and the CFQ at follow-up. Corti et al. (2018) discussed that the effects of these improvements may improve parenting skills based on previous research. Some of the mothers reported that when they used their ACT skills, they were able to engage in behaviors that were more aligned with their values when in difficult situations with their children. Overall, mothers reported improvements in psychological flexibility, cognitive fusion, and values.
Ethical Considerations
Ethics is an essential component within the field of behavior analysis. Considering that behavior analysis is based on the science of behavior, the Professional and Ethical Compliance Code (PECC) for Behavior Analysts becomes even more important when addressing private events as they are not observable and are only measurable by self-report. While it benefits the field of ABA to take these private events and their effects on behavior into consideration, several PECC codes become even more important when using ACT as a behavior analyst. All the codes are pertinent to ACT, however, the ones that are most important exclusively to providing ACT as behavior analyst are 1.01, Reliance on Scientific Knowledge; 1.02, Boundaries of Competence; 2.09, Treatment/Intervention Efficacy; 3.01, Behavior Analytic Assessment; 4.01, Conceptual Consistency; 4.07, Environmental Conditions that Interfere with Implementation; 6.0, Behavior Analysts’ Ethical Responsibility to the Profession; 6.01, Affirming Principles (Behavior Analysis Certification Board, 2014).
Reliance on scientific knowledge (code 1.01 in the PECC) describes the need for behavior analysis to be dependent on scientific evidence (Behavior Analysis Certification Board, 2014). It calls that behavior analysts stay objective by basing decisions on collected data. This is an area that is called into question when using ACT due to it highly relying on self-report data. There are several ways behavior analysts can ensure they are still relying on scientific knowledge when using ACT (Bailey & Burch, 2016). One way is by measuring overt behaviors that are said to occur in the presence of the target covert behaviors. Sometimes this may not be a possibility, in which case the covert behaviors must be described in measurable and objective terms. It may be helpful to use self-report assessments that have clear rating scales where each number is associated with an example to ensure clarity in responding. This can be done by using Behaviorally Anchored Rating Systems (BARS) to increase consistency, accuracy, standards, clear and independent dimensions of measurement, and feedback (Behaviorally Anchored Rating Scale (BARS) Definition, Advantages, Example, Steps, & Overview, 2020).
Another PECC that is important to consider is 1.02, boundaries of competence (Behavior Analysis Certification Board, 2014). This code requires that behavior analysts only work within areas in which they have demonstrated competency. If there is a service that they are not competent in, they must seek appropriate levels of support before providing said service or be at risk of violating this code. Some ways to receive support include training, relevant coursework, or mentorship, supervision, and consultation with another behavior analyst that is competent in that area. ACT is an area that one is not competent in just from going to school and learning about ABA. There are some trainings on ACT, but this alone is not sufficient. While it is possible to become a certified ACT therapist, the methods of becoming one are somewhat unclear and may not match the necessary components within behavior analysis. It is important to note that the way ACT is approached may be different depending on the type of provider (ex: counselor/psychologist vs. behavior analyst). While the processes being discussed are the same, behavior analysts must approach it from the behavioral lens. Therefore, one would need to seek mentorship and consultation from a behavior analyst that has experience in using ACT. If all of these are followed, then it is possible to stay within the boundaries of competency (Bailey & Burch, 2016).
Treatment and intervention efficacy (code 2.09 in PECC) describes that clients have the right to effective treatment (Behavior Analysis Certification Board, 2014). This code requires that behavior analysts educate their clients about evidence-based treatment procedures. Treatments that behavior analysts use must come from research and literature that is peer-reviewed and within behavior analytic journals. While there has been considerable ACT research, not many articles exist within the behavior analytic journals and much of the research is not single-subject design. Therefore, there is no way to evaluate if the treatment was effective by the ways behavior analysts typically would (visual inspection of graphs – level, trend, variability – and various single-subject designs which allow functional relations) and rather look at statistical significance results. More single-subject design research is needed to ensure that this code is not violated (Bailey & Burch, 2016).
Another area that behavior analysts need to be mindful of when using ACT is ensuring the use of behavior analytic assessments (PECC 3.01) to support treatment and programming (Behavior Analyst Certification Board, 2014). Behavior analysts using ACT should perform a functional behavior assessment (FBA) or functional analysis (FA) to determine the function of the behavior. This allows for the treatment package to match the function of the behavior, increasing the likelihood of success. This needs to remain the same with ACT. When possible, FBAs and FAs should be done with overt behaviors; however, these can be modified to address covert behaviors through environmental manipulation and client self-report data. If behavior analysts proceed to treatment before using behavior analytic assessment, they are at risk of violating this code (Bailey & Burch, 2016).
Maintaining conceptual consistency (PECC 4.01) is another area that could easily be violated. In order to be conceptually consistent, behavior analysts must follow the principles of ABA. It coincides with affirming principles (PECC 6.01) which state the 7 dimensions of behavior analysis (explained in theoretical underpinnings) must be maintained, which includes being conceptually systematic (Behavior Analyst Certification Board, 2014). This is an area that even if behavior analysts go into using ACT maintaining those affirming principles, they can easily experience behavioral drift and not continue providing assessment and treatment that is conceptually consistent with ABA. It would likely benefit behavior analysts to create a checklist that they use to run through with their treatment plans to ensure that they are conceptually consistent and not at risk of violating the code (Bailey & Burch, 2016).
The next code to consider is 4.07, environmental conditions that interfere with implementation (Behavior Analyst Certification Board, 2014). This states that behavior analysts must provide alternative referrals for other services if environmental conditions prevent implementation. It also states that if environmental conditions hinder implementation, behavior analysts seek to eliminate these constraints or put it in writing. As stated before, it can be a bit of a slippery slope when using ACT to go beyond the scope of ACT with behavior analysis. In an instance where this is the case and the environment is not lending to behavior analysis being able to be implemented, then the behavior analyst must refer out to another professional, such as a counselor, psychologist, family therapist, etc. It is important to note that environmental constraints may be different. When using ABA, behavior analysts often try to put in proactive strategies to make the environment less likely to cause target behaviors from occurring – making it more likely for the client to respond appropriately; sometimes they may build up a tolerance for non-preferred situations, but proactive strategies often remain in place. However, when using ACT, behavior analysts work on helping clients build up their repertoire of behaviors to be able to be in those challenging contexts while continuing to engage in behaviors that align with their values. Understanding the environmental conditions that truly constrain the ability to provide ACT in a behavior analytic manner is important to try to avoid the risk of violation of this code (Bailey & Burch, 2016).
The last code to consider when doing ACT as behavior analysts is 6.0, behavior analysts’ ethical responsibility to the profession (Behavior Analyst Certification Board, 2014). This code states that behavior analysts have an obligation to the field of behavior analysis rather than any other field. For example, if someone from another profession, like a Speech and Language Pathologist becomes a BCBA, he or she would be obligated to follow the science of behavior even if it was in direct contradiction to something that he or she learned before becoming a behavior analyst. In turn, this also applies to behavior analysts that provide ACT. If there was a new process, strategy, exercise, etc. within ACT is contradictory to ABA and/or was not evidence-based, then behavior analysts would not be able to recognize that process or use those strategies and exercises. If behavior analysts start to veer into non-ABA or non-evidence-based territory, they are at risk of violating this code (Bailey & Burch, 2016).
Future Directions
As always, more research is needed. One major need is for more researchers to do more single-subject design studies with ACT. This is a missing component that makes it difficult to determine effectiveness when reviewing articles as a behavior analyst. Behavior analysts view clients as individuals and the ability to see the outcomes at an individual level is more helpful than seeing the group effects when choosing treatments.
Another area that needs more research on evidence-based methods of approaching data collection on private events. While private events will always be hard to measure as it is self-report based, there are likely ways that data could be collected to ensure data is clearer and more accurate. For example, using very discrete terminology, descriptions, and examples. Most research on scales such as the BARS have been in the area of Organizational Behavior Management (OBM). More research on the most effective scales to use when using self-report data in ACT would be helpful.
Further research is also needed in the most effective settings and modalities in which ACT is used. More specifically, research looking if ACT most effective in individual or group settings, as well as web-based or face-to-face. In addition, research to determine if providing ACT via a couple of sessions in a more concentrated form or shorter sessions further spaced apart is most effective.
Another area needing more research are the effects of self-care within ACT. Self-care has become a buzz word that many push as something people need to maintain their mental health. Behavior analysts often mention to clients’ parents to make sure they are taking care of themselves or engaging in self-care as they notice the emotional toll that their child’s ABA treatment can take on the parent. However, identifying true self-care can be difficult for some. For example, watching a movie may be stress relieving for certain people and they feel better after, while others feel good while watching it but are back to the same level as soon as the movie is over. It could be argued that when self-care is used incorrectly, it is more of an experiential avoidance strategy rather than as an activity that rejuvenates them. More research is needed to determine if self-care, when used correctly, shows significant benefits in reducing parental stress for parents of children with a diagnosis of ASD.
Future research should also look at training therapists to use ACT in a behavior analytic way. Based on the research in this paper, ACT is helpful for parents of children diagnosed with ASD. This calls the need for more behavior analysts to use this approach to support parents. However, without an effective basis on teaching ACT to others within a company, it is challenging to ensure that they can effectively use ACT to truly help clients. It would be beneficial to evaluate the effects of various training programs in teaching the use of ACT to behavior analysts.
Another area to research is the impacts of ACT on others in the family when parents participate in ACT. Specifically researching the child outcomes when his or her parents participate. In addition, looking at if parents participating in ACT affects their ability to follow through with behavior reduction and behavior acquisition protocols. The use of ACT to help parents may have effects beyond just the benefit to themselves. Further research is needed for ACT to be used to its full benefit to support parents of children with a diagnosis of ASD.
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