Which of the following is a social psychological principle that can be applied to the treatment of psychological difficulties?

Psychological flexibility

Psychological flexibility refers to an individual’s ability to cope with, accept, and adjust to difficult situations (Burton & Bonanno, 2016; Kashdan, Barrios, Forsyth, & Steger, 2006; Kashdan & Rottenberg, 2010; Kashdan et al., 2006). When experiencing stressful life events psychological flexibility is protective against negative feelings and can promote positive mental health (Masuda et al., 2011). That is, psychological flexibility can act as a buffer between stress and negative psychological outcomes (Gloster, Meyer, & Lieb, 2017). For example, those who are more psychologically flexible typically report lower levels of depression, anxiety, and distress during stressful life events (Masuda et al., 2011). Understanding the role of psychological flexibility during the COVID-19 pandemic will help identify how well an individual can successfully navigate the negative effects of quarantine, self-isolation, and social distancing. Further, identifying how psychological flexibility can be used to build resilience and reduce negative psychological outcomes (i.e., distress) during COVID-19 could have important clinical and therapeutic implications (Kroska, Roche, Adamowicz, & Stegall, 2020).

Kroska et al. (2020) investigated the association between psychological flexibility, pandemic-related adversity, and psychological distress. A hierarchical regression confirmed previous research that COVID-19 circumstances significantly increase levels of psychological distress (Casagrande et al., 2020; Fernández et al., 2020; Kroska et al., 2020; Petzold et al., 2020; Satici, Gocet-Tekin, Deniz, & Satici, 2020; Zhang, Wang, et al., 2020)—this remained significant after adding psychological flexibility to the model. However, higher levels of psychological flexibility were significantly associated with lower levels of psychological distress. These results show the importance of psychological flexibility within the context of COVID-19. For example, where an individual is lacking social support and experiencing high levels of psychological distress, targeted interventions could be developed to promote psychological flexibility. While there may be some distress still present due to the current situation, building psychological flexibility could significantly reduce overall levels of psychological distress.

Several studies have investigated the mitigating role of psychological flexibility during the COVID-19 pandemic (e.g., Arslan et al., 2020; Dawson & Golijani-Moghaddam, 2020; Kroska et al., 2020). These studies have focused on identifying how psychological flexibility can enhance well-being, psychological health, and reduce psychological distress. During the pandemic, psychological flexibility seems to moderate the negative effects of COVID-19 on mental health (Pakenham & Bursnall, 2006). Whereby, the effects of COVID-19 (i.e., lockdowns, quarantine, and self-isolation) on mental health outcomes are dependent on psychological flexibility. The protective nature of psychological flexibility can be observed when an individual is more self-aware and flexible on different perspectives (i.e., self-as-context), have a strong connection to personal values, and can recognize their feelings but not ruminate on those feelings (i.e., diffusion; Pakenham et al., 2020). Conversely, psychological inflexibility can exacerbate the effects of COVID-19 on mental health outcomes (Pakenham et al., 2020). Specifically, rigid beliefs, an unwillingness to adapt to the changing social restrictions, and ruminating on negative thoughts will increase psychological distress and lead to poor mental health.

Psychological inflexibility might mediate the relationship between COVID-19 related stress and psychological problems (Arslan et al., 2020). For example, COVID-19 related stress directly impacts on psychological problems (i.e., depression, anxiety, and distress) but also indirectly through psychological inflexibility. This suggests that the negative impact of COVID-19 stress on depression, anxiety, and distress is exacerbated when an individual is psychologically inflexible. Further, psychological inflexibility is also moderated by pessimism which can contribute to more psychological problems associated with COVID-19 stress. Conversely, therapeutic techniques aimed at modifying psychological flexibility and promoting optimism could help individuals reduce feelings of depression, anxiety, and distress. Taken together, when an individual is psychologically flexible and optimistic the negative impacts of COVID-19 on psychological problems can be mitigated or reduced. Psychological flexibility is an important factor to consider within the context of COVID-19 and reducing the negative psychological impacts of the pandemic.

The aforementioned studies have found that psychological flexibility mediates the effects of distress, psychological health. However, a person’s level of psychological flexibility can also contribute to the type of coping strategies they will employ when they face with a stressful event. For instance, psychological inflexibility is associated with more avoidant coping styles (i.e., self-distraction, denial, substance use, behavioral disengagement, venting, and self-blaming; Eisenberg, Shen, Schwarz, & Mallon, 2012) and an increase in psychological distress. Conversely, psychological flexibility is associated with approach coping styles (i.e., emotional support, instrumental support, positive reframing, planning, and acceptance; Eisenberg, Shen, Schwarz, & Mallon, 2012).

Dawson and Golijani-Moghaddam (2020) investigated how coping mechanisms mediate the relationship between psychological flexibility and COVID-19 outcomes (i.e., well-being, anxiety, depression, distress, and worry). Using mediation analysis, they showed that psychological inflexibility indirectly and directly increased psychological distress through avoidant coping styles. Further mediation analyses found similar results where well-being was significantly reduced by psychological inflexibility through avoidant coping. This study has important implications for how we conceptualize psychological flexibility, especially within the context of COVID-19. The authors argue that while psychological flexibility directly impacts on psychological distress and is related to coping strategies, psychological flexibility is not necessarily a coping strategy but might determine the type of coping strategy an individual employs. As such, the way an individual navigates the negative impacts of COVID-19 will be determined by their level of psychological flexibility and their selection of appropriate coping strategies. In terms of therapeutic intervention, consideration should be given to identifying a person’s psychological flexibility as well as their current coping strategies.

Psychological flexibility is an important factor to consider when identifying the effects of COVID-19 on the psychological well-being of individuals. Psychological inflexibility should be considered a risk factor given its association with higher levels of distress and a tendency to choose maladaptive coping strategies. Therapeutic interventions such as acceptance and commitment therapy which typically target psychological flexibility may be useful during the COVID-19 pandemic (Frinking et al., 2019; Kashdan & Rottenberg, 2010, Kashdan et al., 2006; Kroska et al., 2020)—especially given that individuals are unable to change the current circumstance.

Psychological flexibility and functional coherence

Psychological flexibility is the ability to respond to stimuli in a manner that is functional given a particular context, and that is congruent with personal values (Kashdan & Rottenberg, 2010). It has been solidly linked to both positive health outcomes and, in its negative form (i.e., psychological inflexibility), to psychopathology. [For reviews see Kashdan and Rottenberg (2010) and Whiting, Deane, Simpson, McLeod, and Ciarrochi(2017)]. Low psychological flexibility has been associated with greater posttraumatic stress symptom severity in multiple studies (e.g., Boykin, Anyanwu, Calvin, & Orcutt, 2019; Bryan, Ray-Sannerud, & Heron, 2015; Meyer et al., 2019). Psychological flexibility has also been negatively linked to distress and positively linked to quality of life in cancer patients, as well as to moderate the effect of their physical symptoms (McAteer & Gillanders, 2019).

While there is some overlap between psychological flexibility and processes that have been described to promote it, and different aspects of positive psychology, there are some considerable and important differences. Where positive psychology has traditionally focused on the presence of “positive” emotions and experiences, psychological flexibility research is based in the functional contextualist paradigm that emphasized that there are more or less functional behaviors and responses to situations and sensations. Functional, here, refers to how well it serves to increase behavior in line with long-term, valued goals. For example, behaviors such as avoidance can be highly effective in terms of reducing immediate distress, but if they end up creating further unwanted consequences they would not be considered functional. Similarly, the efforts to restore cohesion following stressful events can be successful without being very functional. For example, a survivor of childhood sexual abuse can conclude that she was entirely to blame for the abuse which may decrease discrepancy between global and situational meaning and thus decrease distress short-term, but this conclusion is likely to be detrimental to her sense of self and emotional health long-term.

When applied to processes of making sense of the world, the term functional coherence has been used to describe a flexible approach to meaning-making. Functional coherence focuses on what works in a particular context; by increasing attention to and tracking of actual experience, coherence is formed predominantly on the basis of conditional relational frames and responses can be chosen and engaged in more effectively with individual goals in mind (Villatte et al., 2015). Statements that indicate functional coherence often include conjunctions such as “if,” or “when” and seemingly contradictory aspects can be held in mind. A statement exemplifying functional coherence might be “although I really value independence, I can accept help from others when tasks are too physically demanding.” In this case, the act of accepting help serves the function of increasing independence long-term by refraining from activities in the short-term that negatively impact health.

In contrast, essential coherence refers to seeking a kind of absolute truth with symbolic equivalency and consistency to reduce discomforts of cognitive dissonance and incoherence. To achieve essential coherence, it is suggested that we must often ignore important aspects of our experiences in favor of defending simplified conceptualizations and descriptions. For example, people who see themselves as “healthy” might ignore early signs of heart disease, as they believe that this could not apply to them. Similarly, social coherence refers to an abandonment of personal experience in favor of rigid rules and conceptualizations that are socially reinforced (Villatte et al., 2015). An example of social coherence for a person who prefers not to work out might be “I should exercise because the doctor told me to.” Although this might seem like a good enough reason to exercise, this is unlikely to be motivating in the moment as the potential reinforcer (doctor) is not in close proximity of the actual activity. Furthermore, any failure to do so might lead to avoidance of going to the doctor.

Applied Model: ACT Processes of Change

Within the families of CBT models, the ACT model is characteristic in suggesting that it is the context surrounding verbal/cognitive activity, rather than the content of verbal/cognitive activity itself, that is key in producing or in reducing human suffering. The core target of ACT is “psychological flexibility”, contacting the present moment as a conscious human being, fully and without needless defense—as it is and not as what it says it is—and persisting with or changing a behavior in the service of chosen behaviors (i.e., increasing psychological flexibility; Hayes et al., 2012, p. 96). The repertoire narrowing and self-amplifying processes of experiential avoidance, thought suppression, or other forms of cognitive entanglement are reduced by attempting to alter the functions of thoughts and feelings via acceptance, mindfulness, flexible attention to the now, and cognitive defusion. Theoretically, the aim is to bring the functions of verbal and cognitive events under more precise and voluntary contextual control, to broaden behavioral repertoires in the direction of chosen values.

According to the ACT model, six core processes produce psychological flexibility: enhancing client acceptance of distressing experiential content, utilizing cognitive defusion techniques to mitigate the deleterious effects of cognitions, increasing client ability to attend to the present moment, enhancing a self-as-context perspective within the client, identifying core values meaningful to the client, and supporting committed, effective action toward reaching those valued ends. These core processes are commonly diagramed as a hexagon (the tongue in cheek name for the diagram is the “hexaflex”) (see Fig. 7.1), with the four processes on the left considered to be mindfulness and acceptance processes, whereas the four on the right are taken to be commitment and behavior change processes. Note that flexible attention to the present moment and self-as-context are invoked in both groups of processes. The hexaflex illustrates all processes as connected to one another—in practice, movement in one ACT process almost always results in changes in one or more other processes (Hayes et al., 2012).

Before psychological flexibility processes are directly targeted, steps are taken to increase motivation and to establish an agenda for change. Most clients seeking treatment have struggled with, worked around, and fought through their problems for some time. Often, clients have attempted many different solutions, to little success. Almost universally, clients believe that their failure to reduce their emotional distress is due to an inability to find the “correct” way to fix the problem. However, the ACT model proposes a second alternative: that trying directly to reduce or eliminate distress can itself become a problem. Such a message may initially seem counterintuitive to clients, who live in the context of a culture that promotes the control and elimination of painful memories, feelings, thoughts and sensations. Thus, the first step in ACT is often to aid the client in considering alternative, culturally incongruent methods of dealing with the problem. Typically, clients are asked such questions as:

What does a “better” life look like?

What strategies have you tried so far?

How have those strategies worked?

What has been the cost of following those strategies?

If they had worked what would you then have hoped for?

What does your experience tell you: are these outcomes closer or farther away?

The goal of this line of questioning is to utilize the client’s direct experience to highlight the problems with an experiential control strategy and to encourage the client to give up such a strategy, only knowing that the next step is to try something different.

Acceptance. Etymologically, acceptance refers to the act of “taking what is offered.” In ACT, acceptance refers to the active, voluntary embracing of moment-to-moment experience. Unfortunately, clients sometimes mistake this posture with a passive stance of “grinning and bearing.” Such confusion should be clarified as soon as it is recognized, as the latter form of acceptance is not associated with positive health outcomes, regardless of the cultural or ethnic group (Cook & Hayes, 2010; see also Monestès et al., 2016). Rather, the client should be guided to adopt a willful experiencing of feelings as feelings, thoughts as thoughts, sensations as sensations, and so forth. Notably, an exposure paradigm is invoked via acceptance, with an important distinction: in ACT, exposure is not utilized as a vehicle for emotional regulation (Farmer & Chapman, 2008), but rather done in service of building out a heightened awareness of the contingencies, both positive and negative, that act as a context for behavior.

Defusion. From an RFT perspective, the functions of language processes are contextual, rather than mechanical: the specific stimulus properties of words depend on their context (e.g., picture an apple). Due to the transformation of stimulus functions, verbal/cognitive events can at times dominate over other sources of behavioral regulation. This process is termed “cognitive fusion.” For example, a thought like “I am worthless” can seem to mean that the individual having the thought actually is worthless. To remedy this, ACT utilizes cognitive defusion techniques, deliberately altering the context of language to alter it automatic functions. An example of a way that ACT therapists might facilitate defusion is the “Leaves on a Stream” metaphor, in which clients are asked to imagine their thoughts as leaves floating by on a stream (e.g., Hayes & Smith, 2005).

Present moment focus exercises are designed to increase flexible attention to internal and external events in the here and now. Empirical research supports the association between rigid, nonpresent attention and psychological dysfunction (e.g., Davis & Nolen-Hoeksema, 2000), as well as a positive relationship between present-moment awareness and psychological well-being (Bowlin & Baer, 2012). Skills-building in this domain allows the client to create a space from which to experience both positive and negative psychological content without it encompassing the entirety of attention and behavior.

Self-as-context. Clients often enter therapy heavily fused with stories of themselves and others, and as a result are less able to react flexibly from moment to moment. This inflexibility is not strictly associated with negative thoughts—clients may be fused to the thought, “I am a caring person,” and thus be unwilling to discuss the ways in which they are hurtful to others. Perspective taking allows clients to loosen the attachment to rigid self-stories. The “I” invoked by a sense of perspective is a locus from which experience occurs. In one sense it holds or contains all of experience, and in another sense there is a separation between self-as-awareness and self as the content of psychological events. These qualities of inclusion and distinction arguably foster more flexible behavioral patterns.

These first four flexibility processes are a kind of operational definition of mindfulness. The overlaps with Kabat-Zinn’s (1990) well-known definition of mindfulness, “Paying attention in a particular way: on purpose, in the present moment, nonjudgmentally” (p. 4).

Values. Values in ACT are chosen qualities of being and doing. Engaging in values-based actions has advantages in establishing adaptive behavioral repertoires: The reinforcing effects of a quality of action exist in the present moment of behavioral engagement rather than external outcomes that may or may not follow. Values construction exercises are used in ACT to orient the client toward overt behaviors and away from private events. A critical component of the ACT values formulation is the emphasis on choosing values, rather than deciding upon values. Decisions are based on a verbal problem-solving strategy, whereby an individual weighs the costs and benefits associated with an array of options and selects the most attractive based on relative merits. Conversely, though values choices are often made within a context of reasons for and against, they are not made for those reasons. Choice is the natural state of affairs for nonverbal organisms. When defusion skills are applied to reason-giving itself, something approximating choice is afforded. The distinction between decision and choice is crucial in ACT because it aids the client in transitioning from a control-based agenda to a willingness-based agenda by allowing the client to engage in values even if there is a constant flow of reason-giving linked to a problem-solving, control-based agenda.

Committed action. The final component of the psychological flexibility model is committed action, the active, behavioral expression of personal values identified by the client and their construction into larger and broader patterns of flexible, effective, values-consistent habits of living. Commitments, from an ACT perspective, are not promises about actions to be made in the future. Rather, a commitment is a moment-to-moment decision to build patterns of meaningful action. Slips in committed action are not construed as therapeutic failures, but as opportunities to take responsibility for the lapse and to recommit to values-based action. A common misunderstanding regarding committed action is to confuse the distinction between values and goals. Clients may believe that the road to happiness and life satisfaction lies in goal attainment. Functionally, this mantra is intrinsically connected to a state of deprivation, as equating goal achievement to happiness constructs a context in which what is important is constantly missing. Concrete goals can be useful as a kind of values-compass, so long as emphasis is placed on living within a process of committed action. The primary outcome of interest is in the act of living: the habits of action embodying chosen qualities.

ACT Model of Psychological Flexibility

The overarching goal of ACT is to increase psychological flexibility. Psychological flexibility is the ability to stay in contact with the present moment regardless of unpleasant thoughts, feelings, and bodily sensations, while choosing one's behaviors based on the situation and personal values. Studies show that psychological flexibility is associated with quality of life and mental well-being and may mediate symptom reduction (Eilenberg, Hoffmann, Jensen, & Frostholm, 2017; Forman et al., 2012; Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Wicksell, Olsson, & Hayes, 2011). It is worth noticing that psychological flexibility is not a state of happiness or ease but an ability to flexibly navigate through changing demands of life, also when difficult thoughts and feelings arise. Thus, the metric from which psychological health is evaluated is broadened from symptom reduction to include how the individual as a whole functions with respect to valued life domains as stated by Kashdan and Rottenberg (2010): “after all, a healthy person is someone who can manage themselves in the uncertain, unpredictable world around them, where novelty and change are the norm rather than the exception” (p. 875) (Kashdan & Rottenberg, 2010).

ACT targets unhelpful control and avoidance behaviors while empowering psychological flexibility through six interrelated core processes. Theoretically, these six core processes are defined separately, but in practice, they are always intertwined. Further, they can be unified in three pillars (see Fig. 1).

The three pillars that constitute the overarching process of psychological flexibility are as follows: (1) open up with acceptance and defusion, (2) be present with contact to the present moment and self-as-context, and (3) do what matters with value clarity and committed action (Harris, 2009). They are based on the following six core processes:

Acceptance originally means an “action of taking or receiving what is offered.” It is often misunderstood as passive tolerance or resignation. Instead, acceptance refers to actions entailing a choice and thus willingness.

Defusion is the opposite of fusion. Fusion is when a person identifies oneself with the content of thoughts, feelings, and memories; for example, “I am sick.” Defusion identifies the content of inner experiences as such and not as the truth; for example, “I have the thought that I am sick” or “I notice that I have the thought that I am sick.” This promotes a greater distance to the thought.

Contact with the present moment is a nonjudgmental awareness of inner and outer experiences in the present moment. This does not imply that the present moment is necessarily comfortable; it may be unpleasant. It means that the person does not resist what is present but trains an attitude toward every moment that “this is it.”

Self-as-context is opposite to self-as-content. Instead of identifying oneself with the changing content of one's thoughts, feelings, and bodily sensations, self-as-context is the experience that you are not the content of your thoughts, but the one experiencing it. Therefore, it is more a constant sense of self-containing the flux of thoughts, feelings, and sensations.

Values clarify what is most important for a person and creates a direction in life. Therefore, values guide and motivate actions but are superior to concrete goals, because values cannot be reached like a goal. A value is more like a direction on a compass and not the destination. Lacking clarity of one's values may entail more rule-governed or avoidance behaviors.

Committed action is a concrete step or action toward a goal guided by the values. Committed action underlines the willingness to carry through even though there may be unpleasant experiences such as anxiety, thoughts, feelings, and bodily sensations. The opposite may be actions determined by control and avoidance.

According to an ACT conceptualization, the cause of psychological distress is psychological inflexibility (see Fig. 2). This pertains to both clients with health anxiety and people with other mental health problems. The pathological processes involved are presented in Figure 2 specifically exemplified in relation to health anxiety.

These pathological processes will naturally be the focus for treatment with ACT. Clinically, the triflex can be used for case conceptualization to identify both skills and limitations within one or more processes, which can guide the further treatment planning. For example, our case person Peter may be aware of his personal values and live a meaningful life with his family but still feel disconnected because he constantly thinks about illness and death. From the outside, everything looks fine, but on the inside, he is not present and misses out on his life. In treatment, he would typically be encouraged to train present-moment awareness and defusion from thoughts and images. How to work with the different core processes will be described in more detail in the next section.

6.03.2.1 Acceptance/Experiential Avoidance

Acceptance is a largely adaptive process within the psychological flexibility model and is paired with experiential avoidance as a largely maladaptive process. These processes are “largely” adaptive or maladaptive because like the small dot in each color of a “ying-yang” symbol, there are special contexts in which these adaptive functions can switch and experiential avoidance can become helpful and acceptance can become hurtful. Experiential avoidance is characterized by an individual's unwillingness to experience private events, such as emotions, thoughts, urges, memories, or sensations, and takes action to diminish their form, frequency, or situational sensitivity, even when that creates psychological difficulties. Acceptance is characterized by a willingness to come into contact with psychological events and to observe, describe, or note them so are to extract their social or behavioral value without avoiding them or grasping on to them.

In general, experiential avoidance is focused on “negative” thoughts or feelings, but over time a more generalized pattern of avoidance may occur in which even “positive” experiences are avoided for fear they will go away (Kashdan et al., 2008). A wide variety of actions can be deployed in service of experiential avoidance, such as substance use, unhealthy forms of distraction, emotional numbing, alexithymia, and so on (Forsyth et al., 2003). These habits of avoidance tend to reduce the precision of self-awareness. For example, experientially avoidant participants shown a film-clip designed to elicit a “low-mood” described the clip in less concrete language than those who were not experientially avoidant (Cribb et al., 2006).

Experiential avoidance tends to foster unwelcome forms of generalization. The functions of painful events such as the memory of a relative's passing can come to be related to initially innocuous everyday items or verbal utterances, creating patterns of symbolic generalization. This happens through our uniquely human ability to relate literally any stimulus to any other stimulus.

Acceptance processes allows therapists to identify the functions that stimuli carry for clients. For example, the transformation of stimulus function described in RFT, feeling trapped in a relationship can be a generalization focus of a person who was trapped in a car accident, even though the connection is purely symbolic, not based on formal similarity. Identifying and coming into closer contact with our affective responses to stimuli can help clients and therapists identify the stimuli whose functions may need to be influenced in order to create a better life.

The acceptance process is central to the psychological flexibility model because oftentimes the things that we value the most are also places where human vulnerability leads to avoidance. For example, a loving daughter caring for an elderly parent with ailing health may be unable to enjoy the time that they have left because the sight of their parent is too difficult for them to endure. The key to moving toward one's values cannot lie in simply feeling all of the difficult emotions that come up, which is why this process has to work in tandem with the other processes to allow a person to move in a valued direction with feelings of depression, anxiety, or even chronic pain when and if they emerge (Forman et al., 2007; Johnston et al., 2010). Examples of acceptance methods include graded emotional exposure, social sharing of feelings, or deliberate deepening of emotional experience.

Psychological Flexibility

Related to the concept of resilience is the notion of psychological flexibility. The definition of psychological flexibility reflects a multifactorial process of how a person deals with stress, situations, and people. According to a comprehensive review of this topic in the context of health (Kashdan & Rottenberg, 2010), the concept reflects multiple aspects of how persons contextualize their psychological responses, including (1) flexible accommodation of fluctuating situational demands, (2) reconfiguration of psychological resources, (3) modification of perspective, and (4) balancing competing desires, needs, and life domains. In the domain of chronic pain management, several factors are considered critical in psychological flexibility: acceptance, mindfulness, value-based processes, and cognitive defusion.

Acceptance may often be confused with resignation to having pain. Acceptance of pain is not the same thing as giving up on life because of pain. Instead, it requires a mental framework to feel pain with realistic expectation but without avoiding it and without judgmental disapproval (McCracken & Eccleston, 2003). What seems important is balance between acceptance and control. The serenity prayer attributed to Reinhold Niebuhr (2014) captures the need to strike a balance between accepting what we cannot change and striving to change what we can and asking for the wisdom to know the difference. Thus, acceptance not only encompasses “taking what it is” but also extends it to identifying what can be changed and committing oneself to the change. Acceptance of pain seems to be positively related to psychological well-being in chronic pain patients (Viane et al., 2003). Longitudinally, high acceptance early on predicts low depression at later times in chronic pain (McCracken & Eccleston, 2005).

A value-based process refers to the ability to identify valued life domains (activities, relationships, self-image) that can be used to build a set of goals for an individual to strive to achieve. It is fundamentally an individualized “wants” list that directs a person's commitment and priority. In chronic pain, positive emotional well-being is reported when a person perceives that he or she lives in accordance with his or her valued commitments (McCracken & Yang, 2006). Their subsequent prospective study (McCracken & Vowles, 2008) showed that acceptance and value-based processes, after controlling for pain severity, predicted 27% of the variance in depression at later times.

Cognitive fusion refers to the maladaptive thought process in which a person is constrained in his or her own thought process in experiencing emotion and directing behaviors. McCracken, DaSilva, Skillicorn, and Doherty (2014) describe it as “similar to the more familiar concept of believing a thought versus having a thought and not believing it” (pp. 894). For example, when a pain flare occurs, one may have the thought “I will never get better” (fusion) or place the thought in the context of “I am having a thought that I will never get better” (defusion). The ability to defuse such thoughts may be protective; indeed, the level of defusion in chronic pain patients is significantly related to depression after controlling for age, education, and pain level (McCracken, et al., 2014).

The concept of psychological flexibility is relatively new. However, the evidence seems to strongly point to it as an important, clinically relevant factor that may help us understand how people adapt or fail to adapt in a context of stress associated with chronic pain.

c Infants Learn to Gauge Balance Control in Real Time

A third important finding illustrated in Figure 9 is that the decrease in errors points to immense psychological flexibility. The naturally occurring changes in infants’ bodies and skills cause corresponding changes in the size of their region of permissible postural sway. Nevertheless, infants were able to make adaptive decisions about whether to descend slopes despite weekly changes in their bodies and locomotor skill levels.

Additional evidence for flexibility comes from a cross-sectional study with relatively experienced 14-month-old walking infants (Adolph & Avolio, 2000). We experimentally manipulated the size of infants’ sway region by loading them with shoulderpacks that varied in weight from trial to trial (120 g and 25% of infants’ body weight). With the heavy shoulderpacks, the region of permissible postural sway was reduced by 30% and infants’ slope thresholds showed a corresponding reduction of 4°–12°. Despite constant switching between trials of their shoulderpacks, infants could accurately gauge threats to balance as they walked down steep and shallow slopes. They treated the same absolute degree of slope as safe while wearing their light shoulderpacks but as risky while wearing their heavy shoulderpacks. On the sway model, both naturally occurring and experimentally induced changes in the sway region would require continual updating about infants’ locomotor abilities relative to the degree of slant. Coping with moment-to-moment changes in the size of the sway region means that infants must learn to gauge threats to balance control in real time, in the context of their current abilities, goals, and the particular constraints of the task.

A related point about flexibility concerns the breadth of infants’ generalization. Apparently, learning resulted from uneventful everyday experience maintaining balance in crawling and walking postures at home, not from experience descending slopes. None of the infants had experiences on slopes outside the laboratory. Moreover, the control infants (represented by the open symbols in Figure 9) who had no weekly experience descending laboratory slopes showed nearly identical decisions after comparable experience crawling and walking as the babies in the experimental group.

A final point about flexibility concerns the consistency of infants’ responses within sessions. At each test session, infants’ attempt ratios were scaled to their slope thresholds. They were most likely to attempt risky slopes closest to their thresholds and least likely to attempt risky slopes most remote from their thresholds. In 89% of the 219 individual session protocols, infants’ responses were entirely consistent on risky slopes, where attempt ratios were constant or steadily decreasing from the threshold slope to the steepest increment. Over weeks of crawling and walking experience, infants’ attempt ratios decreased on slopes closer to their thresholds, until, finally, attempt ratios closely matched the conditional probability of success. Thus, learning reflected a process of “gearing in” to the limits of infants’ abilities, a process of gradually differentiating the slopes which presented threats to balance from those that did not.

Acceptance and Commitment Therapy

ACT described their theoretical basis for understanding psychopathology, and their model for psychological treatment is embedded in what is called Relational Frame Theory (RFT). The details of RFT go beyond the scope of this article, so just a very short version of the theory is given here. From a RFT perspective, psychopathology develops mainly because individuals have problems in separating the process of thinking from the products of thinking. This cognitive fusion between the process and products of thinking leads to an excessive or improper regulation of behavior by verbal processes. The behaviors of individuals will then be guided more by their inflexible verbal networks than by contingencies of reinforcement in their environment. The process of cognitive fusion leads to other processes in developing psychopathology. As individuals have problems in separating the content of thoughts from the process of thinking (thinking the thought), many people start to fear and avoid their own thoughts, feelings, and bodily sensations as a way to cope with and regulate their negative emotions. This process of escaping thoughts and emotions is destructive, because it leads to what is called ‘experiential avoidance.’ It will trigger people to think that certain emotions, thoughts, and bodily sensations are dangerous to experience and therefore must be avoided. All in all, these psychological processes will cause people to miss out of their experiences of their present moment. They will disappear in what Stephen Hayes describes as “a cacophony of human thinking and its reasons, explanations and justifications for behavior.” In accordance with RFT, it would therefore be of importance to downregulate these negative processes so that people could start clarifying their personal values and goals and let them guide their behavior instead.

In ACT, psychological suffering is seen as being caused by experiential avoidance and cognitive fusion. This would result in psychological inflexibility that leads to a failure in taking the needed behavioral steps into acting according to a person's core values of life. If people's actions are directed by their personal values, it would bring more vitality and meaning into their lives. Making people clarify their values and act according to these goals would increase their psychological flexibility and make them less vulnerable to psychological problems.

ACTs principles of treatment is focused around six core treatment principles, where all of them are aimed at helping the client to develop an increased psychological flexibility, making the client experience the present moment more fully, and trying to let the clients’ behavior be guided by their personal values and goals. A short description of these six treatment processes in ACT is given in the following paragraphs.

Cognitive defusion: Cognitive defusion techniques try to make the client to change the way one interacts with or relates to one's thoughts. Instead of trying to alter the form of the thoughts and their frequency, the client is taught to perceive thoughts and emotions as they are, not as what they appear to be.

Acceptance: Acceptance of the thoughts and emotions is taught as an alternative to experiential avoidance. Instead of trying to avoid specific thoughts and emotions, the client is taught to allow emotions and thoughts to come and go, without struggling to suppress and avoid them.

Contact with the present moment: ACT tries to increase the client's skill of having a nonjudgmental contact with his or her private events and events in the environment as they occur. In order to make this happen, the client is trained in developing skills to develop a better awareness of the ‘here and now.’ If the experience of the ‘here and now’ is guided by interest and openness instead of an experiential avoidance, it would increase psychological flexibility in the individual.

Observing the self: Since human language leads to a sense of self as a locus of perspective, the self cannot be contacted consciously since it is at the core of consciousness itself. It is therefore essential that the client gets access to his or her transcendent sense of the self. A transcendent sense of the self instead of having a picture of the self as a fixed entity, would help the client to experience his or her thoughts and feelings as ideas of themselves, instead of permanent and predetermined characteristics.

Values: Early in treatment, the client is asked to list values in different life domains, in order to make them discover what is important to oneself and life. When the client chooses directions in life which are based on their personal values instead of choices based on avoidance or cognitive fusion, it could help the client to develop a more vital and meaningful life.

Committed action: While personal values never really can be fully achieved, committed actions involving these values must be broken down to make concrete short- and long-term goals. Based on these goals, committed actions to achieve their values are carried out by clients.

These core treatment processes in ACT are overlapping and interrelated, and could be chunked into two groups of interventions according to ACT. Mindfulness and acceptance processes involve acceptance and cognitive defusion which will result in a better contact with the present moment, and the development of the client’s ability to see their personal self in a context. The processes of commitment and behavior change involve contact with the present moment, where the clients could see themselves in a context, and make their values explicit and committed actions in accordance with these values. All of these treatment processes use different exercises, homework, and metaphors in order to work and change the client's psychological problems.

There are a substantial number of controlled trials investigating the efficacy of ACT on a diversity of psychiatric disorders. A meta-analysis by Öst done in 2008 showed that ACT compared to waiting list conditions reported a large effect size both at treatment and follow-up. Powers followed up with a new meta-analysis in 2009 where further new ACT studies were included. The meta-analysis from Powers showed that ACT outperformed control conditions as waiting list, treatment as usual (TAU), and psychological placebo both at posttreatment and follow-up with a medium effect size. However, when ACT was compared to established active treatments as for example CBT, ACT showed no distinct advantage over these treatments.

8.19.1.10.6 Acceptance and Commitment Therapy (ACT)

ACT is a form of third wave psychological therapy that does not seek to reframe or change difficult thoughts and feelings. Instead, it aims to increase psychological flexibility and focusses more on the values that matter to patients and taking committed action steps toward life that fits with someone's values (Hegarty et al., 2020). The use of ACT in a rheumatology population is built on evidence suggesting that increased psychological flexibility is associated with improved wellbeing and a greater quality of life (Maher-Edwards et al., 2020). There are 6 major principles that ACT proposes contribute to increased psychological flexibility. These are: acceptance, cognitive defusion, awareness of the present moment, ability to see oneself in context, values, and committed action (Hayes et al., 1999; cited in Hegarty et al., 2020).

ACT delivered with a purpose of managing the impact of long-term conditions such as rheumatic conditions could focus on dealing with difficult emotions, feeling more able to live with them and being able to live a life that is structured around valued action rather than controlled and in battle with physical and psychological symptoms. It could include gaining distance and perspective from difficult thoughts and feelings around unhelpful thoughts people are fused or attached to and recognizing thoughts as thoughts, including taking time to identify thoughts and perspectives individuals hold about themselves in a wider context. Identifying patients' values for living meaningfully and setting goals based on these values contributes to ACT sessions and meditation-based exercises help to increase patients' awareness of the present moment.

ACT has been incorporated into psychological support for patients with chronic pain with positive results and given the overlap in psychosocial difficulties between patients with chronic pain and patients living with rheumatic conditions, there is clear rationale for the delivery of ACT-based interventions within rheumatology. A systematic review investigating the existing evidence around ACT interventions with rheumatology patients identified that compared to control groups, patients who have received ACT interventions experienced better physical function, higher quality of life, lower pain and increased emotional wellbeing (Hegarty et al., 2020). Of these interventions, most were group-based face-to-face sessions over 8 or 12 weeks, two were individual 8 session interventions (one online and one face-to-face) and two were self-guided internet-based interventions.

1.02.3 A Meta-framework for Understanding Change Processes

There are many therapeutic orientations, all with their own constructs and ways of describing key processes. Psychodynamic therapy often focuses on transference and unconscious conflict, CBT on automatic negative thoughts and dysfunctional beliefs, ACT on psychological flexibility, and humanistic psychotherapy on need satisfaction and self-actualization. If we were to describe a process-based approach from within one of these orientations, we would see pushback from the other orientations. The key then is to pick a framework that is not nested within any therapeutic orientation and that has widespread acceptance across orientations.

One framework that is sufficiently well developed and broadly applicable is an extended evolutionary synthesis (Hayes and Hofmann (2020a,b; 2019)). The Extended-Evolutionary Meta- Model (EEMM) is based on that idea (Hayes et al., 2020a,b). It is “extended” because it seeks to apply evolutionary principles beyond the narrow confines of genetics to all aspects of human development. It is a “meta-model” because it seeks to provide a common language and framework for understanding all psychological models of intervention.

Evolution is a theory about how change comes about, and is accepted by almost all life scientists. While the early focus of evolution was on genetic change, much research has now shown that genes are not destiny. For example, large scale genetic research has failed to show that specific genes cause psychological disorders (Border et al., 2019; Cross-Disorder Group of the Psychiatric Genomics Consortium, 2013). Genes are important but only in the context of a multi-level system that includes epigenetic regulation, environment, behavior, physiological processes, and social context (Hayes et al., 2020a,b).

Jablonka and Lamb (2006) have shown how evolutionary principles can be extended to epigenetic, behavioral, and symbolic change. Importantly, these change processes do not have to be left to random variation and chance survival; the change can be intentional (Wilson et al., 2017).

Practitioners can directly influence behavior, epigenes, and symbolic activity, and thereby indirectly influence genetic expressions. Thus all of the major evolutionary strands are available to psychotherapists. Let's consider now how the EEMM might provide a unifying framework for intervention science.

We began with the three key evolutionary principles: Variation, selection, and retention. We can use these principles intentionally to promote change. Variation starts the wheels of evolution moving. If dog breeders want to create a dog with a flat nose (e.g., a pug), they can start with a population of dogs that have different sized noses. Without that variation, they would be unable to select the dogs with the flattest noses and breed them so that the genes that support flat noses are more likely to be passed down to the next generation of dogs. Similarly, if clinicians want to help clients alter a behavior, they will need to support the client to do something new. For example, imagine that a client's usual response to distress is to engage in excessive drinking. The first step of the practitioner is to help the client vary or change their behavior (See middle column, Table 2).

Table 2. Clinically-relevant questions to explore Extended Evolutionary Meta-Model

Notably, “behavior”, in this case, does not refer only to overt behavior, but includes everything a client does, including feeling, thinking, being motivated, self-esteeming, and attending. All these behaviors, types, or “dimensions'', could be the target of change.

Interventions seek to promote four types of variation, or new behavior. First, they often seek to alter the form or frequency of the behavior. For example, we might help clients who suffer from alcoholism to reduce the intensity and frequency of the distress that triggers the drinking. In the EEMM, we would be targeting the affective dimension at the individual level. We might also alter the situational specificity of the distress, so, for example, we might target processes that facilitate the client feeling less angry when their boss unfairly attacks them. Finally, we may seek to create new patterns of behavior. Clients could be encouraged to respond in new ways to the distress, say with acceptance, mindfulness and non-reactivity.

Once clients are engaging in new behavior, we can help them to select which behavior works best for them. One client may find that relaxation helps reduce distress and thereby reduces alcohol consumption. Another client may struggle to manage distress through relaxation, but is able to learn to engage in some alternative, non-alcoholic behavior in response to the stress, say exercising.

Furthermore, for any client, the adaptive alternative behavior is likely to differ across environmental context and time, thus a core goal is flexibility in having alternative behaviors available for the client to utilize. This example highlights how the EEMM focuses on the function of the process in the context of a specific client at a specific time. Once a value-consistent behavioral pattern has been identified, the practitioner would encourage the client to retain it, through practice (e.g., regular mindfulness training), stimulus control (e.g., by removing alcohol from the house), social support, and other interventions.

Returning to Table 2, variation, selection, and retention are bound by context, the existing historical and situational features that predict whether variants will be selected and retained. Any intervention delivered in a fashion that does not consider context could be harmful. For example, helping an abused woman in a dangerous and violent relationship to be more assertive might fail until she is supported through escaping from the abusive situation.

Finally practitioners can target multiple-levels of the client's life, including biology (e.g., get more sleep; eat less junk), psychological factors (practice mindfulness) and social factors (increase social support). Because the processes of change in the EEMM are known to be functionally important to outcomes, they can be used to select treatment processes that are highly tailored to the needs of the individual.

Table 2 provides one example of how the EEMM can help the practitioner clarify which interventions to try, which dimensions to target, and the outcomes the practitioner and client are hoping to achieve. Most practitioners are familiar with their procedures and outcomes, but are less familiar with the processes that lead to change, that is, which sequences of events are likely to lead to important outcomes. To explore this issue in more detail, we now consider how research has sought to identify the critical mediators, or processes, of therapeutic change. Once we have addressed this as a scientific issue, we will return to a pragmatic discussion of therapeutic change processes and provide empirical examples of processes for each dimension and level of the EEMM. But first, let's consider how we might decide if something is a process in the first place.