Acceptance and Commitment Therapy (ACT) is a behavioral therapy that helps clients to sit with uncomfortable emotions and release attachments to maladaptive thought patterns. Originally ACT was created to help adults, but research has shown that, when properly adapted it is also effective for treating children.
How is ACT different than CBT?
ACT differs importantly from other talk therapies such as CBT because rather than focusing on changing maladaptive thoughts, ACT emphasizes acceptance of all psychological events, and therapists concentrate their attention on how a person’s behavioral responses to these events work for them in terms of their self-identified values or goals. The focus on increasing acceptance within ACT has been shown to increase self-esteem and resilience (Black, 2022).
How is ACT modified for children?
When treating a client with ACT, practitioners use something called the ACT Hexaflex, which was developed for adults. The ACT Kidflex has been adapted for younger clients and encompasses the same six core ACT processes, which include: acceptance, defusion, values, committed action, contact with the present moment and self-as-context. When working with children, practitioners might borrow the modified Kidflex language from Dr. Tamar Black and teach them: Notice yourself, let it go, let it be, stay here, choose what matters, and do what matters. Together the goal of these processes is to increase psychological flexibility. Hayes et al (2006) defines psychological flexibility as “the ability to contact the present moment more fully as a conscious human being, and to change or persist in behavior when doing so serves valued ends”. In other words—be mindful and present and adjust your behaviors as necessary.
The Core ACT Processes when working with children
Let It Be
“Let it be” refers to letting undesirable private experiences exist, without trying to change, modify or eliminate them. Behaviorally speaking, a private experience is something that an individual experiences that are not visual to an outside observer. Thoughts, emotions, memories, and physical urgers are private experiences. You might be thinking that there are plenty of times when mitigating an unpleasant experience is preferable and adaptive, and you’d be right. Letting my two-year-old watch a five-minute YouTube video on my phone while she got her hair cut for the first time reduced her anxiety and made it less likely that she injure herself flailing in a panic around scissors. After getting her hair cut once and realizing she liked the outcome, she wasn’t afraid anymore and no longer requires a video to stay calm. For a short, discrete event, these distractions can be adaptive. When a long-term stressor exists, this strategy stops being adaptive. For example, if my child wasn’t very good at soccer and felt self-conscious about it, they might stop going to soccer practice. Having social time with their friends on the soccer team might be important to them, and the outcome of missing soccer practice would lead to less social opportunities which then leads to stress. As a result, the long-term strategy of avoiding their thoughts and feelings about not being very good at soccer is not serving them well. An ACT therapist would counsel this child to observe their feelings of discomfort with their soccer skill level, without trying to change them, and then gently bring their attention to what their goal is, whether that is socializing or practicing a soccer skill so practice can feel less uncomfortable.
Let it Go
“Let it go” means putting some distance between our thoughts and ourselves so we are not stuck or attached to them. Thoughts do not need to be eliminated or replaced. Let it go involves teaching children to see thoughts for what they are without letting them have power over us. My soccer-anxious child might say to herself “I am having the thought that I am bad at this and everyone knows it.” This response encourages the child to see their feelings and thoughts as just feelings and thoughts, not facts or laws. This makes it easier to give that thought or feeling less power and do what matters even when the thought or feeling is present.
Choose What Matters
“Choose what matters” refers to a client’s values. What that person cares about and is willing to work on. Values differ from goals in important ways. Goals can be temporary events with a final outcome. The goal for my soccer player may be for her team to win a game, but the value (for her) is her connection to her team.
Do What Matters
“Do what matters” are the behaviors that tie into the values identified in “choose what matters”. In this respect ACT can look a lot like a more traditional behavior therapy. ABA strategies like shaping, exposures and skill acquisition can all be utilized when helping clients learn to “do what matters”. For our example of the soccer player, do what matters would mean go to practice and connect with your team.
“Stay here” endeavors to help individuals remain present with uncomfortable thoughts or feelings without trying to minimize or dismiss them to be present and functional. When trying to encourage my child to “stay here” during soccer practice, I may encourage her to notice how the ball feels against her toes, the smell of the grass, or the sound of her foot against the ball when she kicks.
“Notice yourself” aims to teach clients to see what they are doing and what the impacts of their behaviors are. Clinicians might tell a child to imagine they are a ghost, watching themselves, and ask what do they notice? A child might notice “When I come home from school and feel cranky or tired, I go to my room and play video games until I start to feel differently. But wow, after floating around observing myself, I’m realizing that I spend a lot of time playing video games while my family is together. I’m missing out on time to be with them.” As a result of this exercise, a child may start noticing at home when they are missing out on other opportunities and change their behaviors, even though the emotions that led to those behaviors haven’t necessarily changed.
In concert, the goal of all these core processes is to help kids become flexible. Some kids already have mastery over one or more of the core processes, and might only need to address one or two. Others may need coaching on all six. Your child’s ACT clinician will help make those assessments.
Manhattan Psychology Group’s evidence-based focus team of therapists are especially qualified to provide this behaviorally rooted therapy. If you think ACT could be a good fit for your child, please reach out to us!
Written by Dorrie Barbanel, LMSW, BCBA, LBA