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= Acceptance and Commitment Therapy (ACT) for Trauma =

Overview of ACT
Acceptance and Commitment Therapy (ACT; said as the word "act") for Posttraumatic Stress Disorder (PTSD) and Trauma-Related Problems is a treatment for people who have not been able to recover from traumatic experiences in a long-term way, even if their symptoms do not meet full criteria for PTSD diagnosis. Based in Relational Frame Theory, ACT treatment takes the perspective that human suffering is prolonged by the ways verbal language interacts with lived experience. ACT suggests that there are ways in which verbal language is helpful and effective in solving everyday problems, but that in other contexts, it contributes to inflexible thinking and gets in the way of people's values and related life goals. ACT frequently targets a person's avoidance behavior and attachment to thoughts that maintain inflexible behavior. Trauma-related avoidance and attributions of meaning are theorized to be key components of PTSD symptom maintenance. As such, ACT is in the early stages of empirical exploration to determine its value as a treatment for PTSD and trauma-related problems. A clinician manual for use of ACT to treat PTSD and trauma-related problems was published in 2007.

The ACT "Hexaflex" describes six interrelated constructs that influence psychological flexibility, with each construct occurring along a spectrum of flexibility. ACT for Trauma seeks to address each inflexible process and increase psychological flexibility through a range of experiential and behavioral practices. Mindfulness practice is one of the predominant strategies used to increase flexibility. The desired flexible constructs (and inflexible counterparts) include Acceptance (Experiential Avoidance), Defusion (Fusion), Self-as-Context (Self-as-Content), Present Moment Awareness (Dominance of Conceptualized Past/Future), Committed Action (Inaction), and Values (Lack of Direction).

PTSD Symptoms Overview
People who have undergone trauma may experience an array of symptoms that may or may not meet full diagnostic criteria for PTSD. Following is a brief overview of major symptom clusters of PTSD as defined by the Diagnostic Statistical Manual of Mental Disorders-5th Edition. Intrusion symptoms may include dreams of the traumatic event, feeling distressed when reminded of the event, feeling as if one were re-living the event, and upsetting and intrusive memories of the event. Avoidance symptoms may include efforts to avoid internal reminders of the trauma, such as thoughts or feelings, as well as external reminders of the trauma, such as places or people that one associates with the event. Other symptoms are related to reactivity and arousal, such as insomnia, irritation, and being easily startled. Symptoms may also include those related to negative mood and thoughts, such as not being able to experience positive emotions, feeling detached from others, not feeling interested in important activities, blaming oneself for the trauma, and not remembering important parts of the traumatic event.

Cognitive Theory of PTSD
The Cognitive Theory of PTSD posits that, in general, people have assumptions about the safety and fairness of life, and have beliefs about life narratives related to logic and control. However, the experience of trauma forces a person to confront the unpredictable nature of life and thereby disrupts or confirms the trauma survivor’s previously held assumptions. Cognitive Theory of PTSD suggests that people may maintain their original assumptions in the face of trauma by ignoring contradictory evidence or by making up stories about why their expectations were challenged. They may find ways to incorporate their trauma experience into their existing belief system, which allows them to maintain a sense of control. An example of this type of reaction is blaming oneself for certain actions taken or not taken. Other times, trauma survivors may change their assumptions to be consistent with the trauma, but ignore their previous non-traumatic experiences. The trauma survivor may no longer assume that the world is a place of order and safety, despite having experienced safety for the majority of their life. Cognitive Theory of PTSD implicates important treatment targets of ACT for Trauma, namely, that people desire control over their experience and work to maintain that their thoughts and self-descriptions are stable and right, even when it does not benefit them. This Cognitive Theory of PTSD also supports the theoretical basis for PTSD treatments other than ACT, such as Cognitive Processing Therapy.

The ACT Approach
Traditional cognitive behavioral-based treatments, such as Cognitive Processing Therapy, have garnered strong research support and are widely used in the treatment of PTSD. These traditional CBT-based treatments often work to challenge the problematic trauma-related beliefs and to replace them with new, more adaptive thoughts. Where ACT differs from these treatments is its response to the disrupted assumptions of control often caused by trauma. ACT for PTSD suggests that it is not necessary to change the problematic beliefs in order to reduce suffering. ACT proposes that the majority of distress from PTSD symptoms is the result of efforts to control and get rid of thoughts and feelings associated with the trauma. It asserts that one’s relationship to the existing thoughts can be changed in ways that reduce suffering.

ACT for PTSD is generally not focused on reducing specific psychiatric symptoms, though symptom reduction may occur; ACT theory suggests that symptom reduction is not necessary for one to engage in ACT’s intended goal of increasing psychological flexibility. One exception in the case of PTSD is related to avoidance symptoms. In ACT, experiential avoidance describes a person’s unwillingness to stay present with and attempts to escape experiences such as unwanted emotional states and sensations, memories of trauma, and negative beliefs. Experiential avoidance often includes repeated attempts to escape those experiences, even when they cause further damage or negative consequences to one’s life. ACT suggests that all PTSD symptoms, not just those in the “avoidance” cluster, can be related to experiential avoidance. For example, insomnia is considered a reactivity/arousal symptom, while nightmares are considered an intrusion symptom. ACT may explore whether a trauma survivor’s insomnia can be explained by avoidance of going to sleep in order to avoid nightmares. ACT theorizes that the costs of experiential avoidance inhibit recovery from trauma by interfering with a person’s ability to live a life directed by meaningful values.

ACT theory, as it relates to trauma, highlights the impact of verbal language on prolonging PTSD symptoms. In speaking about a past trauma, someone may re-experience emotions and thoughts as if the trauma were currently happening, even though the person may not be in any present danger. ACT uses the term “fusion” to describe this blending of the actual experience with thoughts about the experience. ACT proposes one's ability to flexibly recognize that thoughts about trauma are separate from the actual traumatic event ("de-fusion") allows a person to stay in the present moment and increases a person’s ability to act consistently with their values and move toward their goals. Defusion is thought to be one mechanism that supports ACT’s primary goal of increasing psychological flexibility.

Overall, ACT for Trauma is situated in the following expectation: successful treatment will allow trauma survivors "to recognize that they can carry the burden of their traumatic experiences without being overwhelmed or defined by it, and that they can live the lives they want to despite their trauma histories." (p. 34)

Practicing ACT
ACT treatment for PTSD and trauma attempts to move a patient away from avoiding their experiences to a stance of willingness to be fully present with their experiences. The patient is encouraged to stay in contact with unpleasant thoughts and feelings without trying to change them. They are taught mindfulness strategies for maintaining a nonjudgmental stance toward their experiences. These techniques attempt to undermine thoughts that trauma reminders are intolerable and that action must always be taken to avoid or change a negative experience. The patient is then free to choose a valued action rather than acting from avoidance. However, avoidance is not viewed as unquestioningly maladaptive, so treatment is focused on avoidant behaviors that negatively impact the person's valued life goals. In ACT, the term "behavior" is inclusive of internal events, such as thoughts. Practitioners of ACT rely heavily on the use of metaphor and behavioral exercises to help patients concretely experience abstract concepts. Common metaphorical exercises include "Tug-of-War with a Monster," "Passengers on a Bus," and "Person-in-a-Hole."

Larger Treatment Structure of ACT for PTSD and Trauma-Related Problems

 * 1) Introducing ACT: Practitioners describe ACT to the client, including that it is not the intent of treatment to eliminate trauma memories or related feelings.
 * 2) Creative Hopelessness: Practitioner explores client's avoidance and control strategies in ways that highlight their problematic nature.
 * 3) Exploring an Alternative: Practitioner introduces and engages client in non-avoidant responding, including mindfulness practice and methods of undermining cognitive fusion and evaluative judgments of self or behavior.
 * 4) Moving toward Values: Practitioner supports client in accessing and choosing actions that support the client's identified values.

Session Structure of ACT for PTSD and Trauma-Related Problems
ACT for PTSD may be delivered in either individual or group formats. The therapy as structured by Walster's and Westrup's treatment manual, ACT for PTSD and Trauma-Related Problems, includes eight to sixteen hour-long individual sessions or 90-minute group sessions. Each session consists of the following elements:


 * 1) Beginning with a mindfulness-based exercise
 * 2) Homework assignments and the most recent session are reviewed
 * 3) A main topic (typically one of the flexibility constructs) is introduced and the client engages in related experiential and behavioral exercises
 * 4) Homework is assigned for the following week.

Meta-Analytic and review findings
Current evidence examining the specific effectiveness of ACT for PTSD and trauma-related problems is limited. A few uncontrolled studies (e.g. case studies) have demonstrated precursory evidence that ACT may be efficacious for reducing trauma-related distress. Studies with reliable controls and larger samples will need to provide evidence of consistent improvement in trauma-related distress following ACT in order to formally establish ACT for PTSD as an evidence-based treatment. More generally, mindfulness and acceptance-based strategies may serve as resilience factors in protecting against maladaptive trauma responses.