Clinical Applications of Acceptance and Commitment Therapy

Introduction

• Presenters: Scott Palasik (University of Akron) and Jaime Hannan (Cincinnati Children’s Hospital) are experts in the field, focusing on innovative approaches to speech therapies.

• Disclosure: Both presenters have disclosed relevant financial and non-financial interests related to therapy practices and research, ensuring transparency in their presentation.

Abstract

• Cognitive Behavioral Therapy (CBT) has long been the cornerstone of therapeutic approaches to stuttering. It assists clients in managing maladaptive thoughts through cognitive restructuring, which aims to change negative thinking patterns that exacerbate stuttering.

• Acceptance and Commitment Therapy (ACT), developed in the 1990s based on the tenets of CBT and the principles of Relational Frame Theory (RFT), offers a contrasting approach focused on improving psychological flexibility instead of solely modifying thoughts.

• The aim of ACT is to help individuals who stutter accept their adverse thoughts and feelings concerning their speech while empowering them to make choices aligned with their personal values. This is achieved through mindfulness practices, which may enhance overall psychological resilience and adaptability.

Cognitive Behavioral Therapy and Its Evolution in Stuttering

• Historically, CBT has served as a foundational psychotherapy method for individuals who stutter, emphasizing cognitive changes to tackle underlying anxieties, fears, and unhelpful beliefs.

• Power2 Program: Developed by Blood (1995), this program integrates CBT techniques that promote empowerment, resilience, and emotional regulation to improve both speech fluency and emotional responses to stuttering incidents.

• ISTAR’s Comprehensive Stuttering Program: This program focuses on modifying attitudes, enhancing emotional awareness, and tailoring cognitive behavioral techniques based on clients' cognitive development and emotional needs.

• Numerous studies have corroborated the effectiveness of CBT in reducing speaking-related anxiety and other psychological constructs that heighten stuttering severity, showcasing its practical application across various contexts.

Introduction to Acceptance and Commitment Therapy (ACT)

• ACT Basics: A modern psychotherapy focused on cultivating psychological flexibility by fostering the capacity to connect with the present moment, particularly personal experiences, without resorting to avoidance strategies (Hayes et al., 2012).

• Relational Frame Theory (RFT): Acts as the theoretical underpinning of ACT, asserting that language and cognition profoundly shape human experiences and behaviors. Within this framework, humans develop relational frames, which are cognitive connections between disparate thoughts and experiences (e.g., associating dessert cake with joyful celebrations versus guilt).

  • Key principles of RFT encompass the dominance of language over experiences, the significant impact of linguistic constructs on individual perception and judgment, and the contextual nature of human conversations and interactions.

Research and Efficacy of ACT

• Although ACT has a robust foundation supported by research across various mental health domains, there is a noticeable lack of extensive studies specifically validating its effectiveness for clients who stutter. Currently, only one study (Beilby et al., 2012) has provided empirical data on the efficacy of ACT in this demographic, yielding significant advancements in stuttering intervention and mindfulness practice among participants.

• The findings from this limited research indicate that ACT may offer substantial opportunities for broader applications in the treatment of fluency disorders, encouraging further exploration into its mechanisms.

The Hexaflex Model: Six Core Principles of ACT

1. Contact with the Present Moment: Emphasizes the significance of mindfulness—being aware of one's thoughts, feelings, and surroundings in the current moment—while reducing the propensity to ruminate on past experiences or anxieties about the future.

2. Acceptance: Involves recognizing and allowing difficult thoughts and feelings to be present without judgment or the compulsion to alter them, facilitating emotional experience rather than avoidance.

3. Thought Defusion: A process that aids individuals in disentangling thoughts from personal identity, leading to decreased cognitive fusion with negative beliefs and fostering behavioral flexibility.

4. Self as Context: Encourages clients to observe their thoughts and feelings as temporary rather than fixed aspects of their identity, promoting a more expansive self-concept and reducing rigidity.

5. Defining Values: An essential component of ACT, this principle facilitates the identification of deeply held values and beliefs that can motivate purposeful actions and guide decision-making.

6. Committed Actions: Focuses on implementing actions that resonate with the individual's defined values, promoting a greater sense of agency and fulfillment in life.

Detailed Explanation of Each Core Principle

Contact with the Present Moment

• Emphasizes the critical role of mindfulness in mental well-being, helping clients avoid unproductive rumination and worry, which tend to divert attention from the richness of life experiences.

• Clinical Application: Instructing clients in mindfulness techniques, such as Vipassana meditation or guided imagery, can effectively assist clients in maintaining attention to the present, thereby reducing instances of dysfluency induced by anxiety.

Acceptance

• Defines acceptance as the active acknowledgment and experience of difficult thoughts and feelings, superseding avoidance behavior that may be linked to negative experiences around stuttering.

• Clinical Application: Utilizing exercises designed to expose clients to challenging speaking scenarios (e.g., eye contact challenges) can promote acceptance of their speech-related fears, ultimately desensitizing anxiety regarding stuttering situations.

Thought Defusion

• Employs various techniques that help clients view their thoughts more as products of mental processes rather than reflections of reality or integral components of identity, facilitating freedom over extreme negative cognitive patterns.

• Clinical Application: Practicing the use of verbal cues (e.g., “I notice I’m having the thought that…”) to highlight and detach from automatic negative thoughts can assist in diminishing their emotional impact.

Self as Context

• Focuses on reconceptualizing identity from static labels (who a person is) to a more fluid perspective (the context from which they can engage with experiences).

• Clinical Application: Utilizing activities like role-play and self-reflection allows clients to explore various communication styles and how different contexts elicit different aspects of their identity without fixedness.

Defining Values

• Highlights the notion that values are not static but evolving guiding principles that influence choices in life. Establishing clarity around one's values can empower individuals to make congruent life choices that enhance overall quality of life.

• Clinical Application: Implementing reflective exercises, such as the Eulogy Exercise, prompts clients to identify their core values and channel them into actionable life choices that align with their aspirations and true selves.

Committed Actions

• Concentrates on facilitating real-world actions that directly reflect and embody clients' defined values, promoting significant behavioral changes and fostering a sense of personal agency.

• Clinical Application: Commitment Scaling exercises enable clients to set achievable short-term and long-term goals grounded in their values, supporting their trajectory towards personal growth and fulfillment.

Conclusion

• Acceptance and Commitment Therapy (ACT) shows considerable promise in the treatment of stuttering, paralleling and potentially extending the benefits derived from traditional Cognitive Behavioral Therapy (CBT).

• While the current research base calls for further empirical studies to substantiate the efficacy of ACT in speech-language pathology interventions for stuttering, the existing principles and early findings offer a strong foundation for integrating ACT into practice.

• Future Directions: The exploration of ACT in addressing the multifaceted challenges associated with stuttering warrants additional robust research to assess its effectiveness and application in diverse clinical settings.