Beyond treating mental disorders: the broad impact of acceptance and commitment training

Psychotherapists know things that the world needs to know. Although research on psychotherapy has for the last half a century largely targeted psychiatric syndromes, an extensive body of knowledge has also been accumulated on how change happens when psychotherapy is successful. It turns out that these “processes of change” are also helpful in virtually every other area of human functioning.

Psychotherapy works when people learn to be more cognitively and emotionally open, and develop a deeper or more spiritual sense of self, consciously focusing their attention on what is of importance to them in the present. They then need to use these “mindfulness” skills to create values‐based behavioral habits that bring meaning and purpose into their lives, while also extending these skills to their relationships and taking care of their body ¹ .

Virtually every replicated mediator that empirically explains the impact of any form of psychotherapy on mental health outcomes can fit comfortably within the above two sentences. This set of processes is an extended version of the “psychological flexibility model” ² . It was first championed and targeted by acceptance and commitment therapy or training (“ACT” in either case, said as a single word) ³ , but we now know that other successful evidence‐based forms of psychotherapy commonly work by altering elements of this same set ¹ .

ACT was never just a form of psychotherapy, which is why the word “training” soon became necessary to describe the use of its methods in contexts outside of the treatment of mental disorders, such as in prevention, physical and behavioral health, social wellness and justice, and education or performance areas. There are now over 1,100 randomized controlled trials on ACT, and a review of that vast literature shows that less than one third of the existing studies have focused on alleviating existing psychiatric syndromes ⁴ .

The broad impact of ACT training outside of the domain of mental disorders suggests that other forms of evidence‐based psychotherapy also might be repurposed to solve problems and to promote human prosperity in a much wider range of use cases.

Here we mention a handful of areas as examples of the impact of ACT training. In all of them it is known both that ACT training can be helpful and that the processes of change that explain its impact fit within the extended psychological flexibility model.

One very important area is the use of ACT to help patients step up to physical and behavioral health challenges, such as in chronic pain and terminal illness. Multiple meta‐analyses in these areas suggest that ACT training can be helpful⁵.

An impressive recent example is a study on motor neuron disease ⁶ , a terminal illness with no known medical treatments, from which 300,000 people suffer and 40,000 persons a year die. When ACT training was used to increase psychological flexibility, the quality of life of patients improved substantially at 6 and 9 months post‐randomization, compared to usual care alone. The authors stated that improving quality of life is “vital given the progressive nature of the condition” and, while previously “guidelines have not been able to recommend evidenced psychological interventions for this population”, “this trial provides definitive evidence for one such intervention”. Similar findings have been reported in a wide range of other physical diseases, as well as traumatic injuries ⁵ .

Another set of high‐quality studies on ACT training have addressed the sequelae of war. When war happens, almost all forms of human functioning are disrupted: relationships, sleep, self‐care, eating, physical health, mental health, and so on. When the World Health Organization (WHO) identified the need for a method to address the broad range of human problems occasioned by war, it settled on ACT training as a possible option. An ACT‐based guided self‐help book in graphic novel or “cartoon book” form was created, called “Doing What Matters in Times of Stress”. This is generally used in combination with audio tapes (available in 32 different languages), with the help of non‐professionals who have received training in how to present the material in small groups (viewing the book, listening to the tapes, and discussing the material).

In a carefully done randomized trial published in this journal ⁷ , it was found that, compared to an enhanced treatment as usual condition, this scalable intervention reduced by 47% the future development of mental health problems among war survivors who were not yet showing a diagnosable disorder.

As an indication of its perceived relevance to the public, the ACT‐based book is now the most frequently downloaded document from the WHO website, and is being actively disseminated in Ukraine. Based on multiple studies, the WHO website itself says that “the guide is for anyone who experiences stress, wherever they live and whatever their circumstances”. As an indication of that assessment, when the COVID‐19 pandemic occurred and no validated psychological intervention was yet available, the WHO referred people to this guide.

The use of worksite‐based training to decrease stress and to foster work effectiveness is another example with positive evidence ⁸ . Simple employee workshops can be used to train people in how to apply ACT methods to their own lives to enhance their psychological flexibility, reduce stress, increase job satisfaction, and improve objective measures of performance such as the ability to learn new tasks. This is particularly likely to occur if the worksite itself affords employees the ability to have control over how to accomplish work‐related tasks. The formula is simple: flexible workers in a flexible workplace predict both employer and employee success.

A final example is addressing stigma. Across a wide range of specific forms, in groups who are the recipients of enacted stigma – ethnic and racial minorities; persons who are neurodiverse; lesbian, gay, bisexual, transgender, queer or questioning (LGBTQ+) populations; religious minorities; persons with high body weight; and so on – ACT training has been found to be both psychologically helpful and to empower steps needed to create social and environmental change and to promote social justice ⁹ .

The breadth of application of ACT and the apparently near‐universal relevance of the processes it targets raises the intriguing possibility that the core of what evidence‐based psychotherapies of many forms target could be helpful beyond the treatment of mental disorders per se. The size of the database on successful studies of processes of change in ACT and ACT training ¹ , the expansion of ACT into lower and middle income countries ⁴ , and the range of studies on applied areas outside of psychiatric syndromes ⁴ are large compared to most other forms of evidence‐based psychotherapy, but the takeaway point may be relevant to these other forms as well.

Psychotherapists know things that the world needs to know. In the context of the ongoing and worldwide crises of climate change, immigration, economic disparities, rapid social change, religious conflicts, political division, and war, that is a message of cautious hope for the world.