Acceptance and Commitment Therapy for Teens

Cognitive behavioral therapy (CBT) is the most common form of psychotherapy used in the U.S. today, but there’s another evidence-based approach gaining steam among clinicians who work with teens and parents. It’s called acceptance and commitment therapy, or ACT.

ACT is a treatment approach in which teenagers learn to do two things. First, they accept that negative thoughts and feelings are appropriate human responses to certain situations and don’t need to be avoided. Second, they commit to taking concrete steps to making meaningful changes in their lives despite negative thoughts and feelings. Taken together, they enable teens to acknowledge the painful feelings that come with anxiety or depression and move past them, explains Morgan Eldridge, PhD, a clinical psychologist in the Mood Disorders Center at the Child Mind Institute.

Developed in the 1980s by psychologist Steven C. Hayes, ACT is only about 20 years newer than CBT, the therapy from which ACT was derived. Both have plenty of research behind them. But there are some significant differences in methodology between CBT and ACT.

“CBT is about recognizing negative thoughts and then changing them,” says Sandra L. Whitehouse, PhD, senior director of the Anxiety Disorders Center at the Child Mind Institute. “ACT involves observing negative thoughts and acknowledging them as being valid so you can then work past them.”

For example, think about a child experiencing anxiety about having to make a presentation at school. With CBT, the child might be coached to avoid negative thinking patterns by imagining a stop sign any time negative thoughts about their presentation come to mind and replace them with positive thoughts or affirmations. For example, they might say to themselves, “I will rock this presentation today.” The idea here is that positive self-talk will have the effect of making the child feel more confident and empowered, which will result in them performing better.

On the other hand, with ACT, the child would be encouraged to acknowledge and reflect on their negative thoughts, and then focus on their goals to get through the presentation.

“The strategy there would be for the child to say, ‘Of course I’m anxious. Public speaking is super stressful and being anxious is a perfectly normal response to this situation. But I still should do it, because I want to do well in school,’” Dr. Whitehouse says.

With ACT, teens learn to acknowledge that negative emotions are a natural part of the human experience and don’t need to be “fixed.” Instead, acknowledging them can help someone get past them.

“I once had a client explain it this way,” Dr. Whitehouse says. “He said, ‘I just imagine I’m in a raft, floating down a river, and the thoughts that are coming at me are like people at the side of the river, waving at me trying to get my attention. They want me to pull off the river, but I’m just going to notice they’re there and I’m going to keep on drifting forward past them.’ And I just thought that was such a beautiful description of mindfulness, which underlies the skills needed to engage in ACT.” From there, it’s possible to observe, accept, and defuse emotions.

ACT was developed for adults and has since been adapted for use with teens. It is not recommended for use with younger children because it requires more abstract thinking. As with CBT, ACT can be used to treat a variety of mental health challenges, including:

• Anxiety
• Depression
• Obsessive-compulsive disorder
• Disordered eating
• Substance abuse

Still, CBT remains the first-line treatment for these conditions, particularly in the beginning stages when the disorders are more easily treated. ACT is usually reserved for the treatment of more moderate to severe conditions in teenagers who are more experienced with therapy and are already well-versed in CBT.

“I find that for individuals who haven’t had a lot of exposure to therapy, CBT is a bit more simplified and tends to be a good jumping off point,” Dr. Eldridge says. “Then, I might add in ACT down the road.”

Rather than labeling negative thoughts as “thinking errors” and trying to change them into positive thoughts, the theory behind ACT is that all thoughts and emotions, both positive and negative, are essential to the human experience. Thus, it’s unnecessary and even counterproductive to try to suppress negative thoughts and emotions. So instead of a teenager trying to convince themselves they’re not nervous about baseball tryouts coming up and telling themselves they’re going to do great, they would acknowledge, “You know, I am nervous about tryouts, and that’s perfectly normal. But I’m not going to let it get to me; I’m going to keep working out and preparing.”

ACT promotes what it calls “psychological flexibility,” which is the ability to navigate a wide range of thoughts and emotions while continuing to focus on larger-picture needs and desires. It’s based on six principles:

• Acceptance of a full range of thoughts and emotions
• Cognitive defusion, which involves acknowledging negative thoughts and emotions but not allowing yourself to get caught up in them
• Being present and taking note of your emotions without judgment
• Perspective-taking sense of self, which involves acknowledging you are more than your thoughts and emotions
• Identification of values and taking action to live within those values
• Commitment to action to make decisions that align with your values

A large part of ACT is centered on identifying a patient’s values and helping them decide if their actions are getting them closer to or farther from those values.

“For instance, I’ll first help my client identify their values in different areas, such as social relationships, education and work, leisure activities, and health and well-being,” Dr. Eldridge says. “Next I’ll have them do a bullseye exercise in which they imagine their values being at the center of a target. Then they analyze how their actions are getting them closer to or farther away from their values.”

If your child’s therapist is using ACT, it can be helpful to familiarize yourself with the method so you can reinforce the principles outside of the clinician’s office. Dr. Whitehouse recommends reading Break Free: Acceptance and Commitment Therapy in 3 Steps, by Tanya J. Peterson.

“What I like about this book is it’s super easy to understand and really accessible for patients and parents,” she says.

Talking to your child’s therapist can be helpful, too.

“Parent involvement is important,” Dr. Eldridge says. “Not necessarily knowing all the ins and outs of your child’s sessions, but showing interest and touching base with the therapist about how you can get some education on the skills being built in the office can be quite helpful.”

Continuing the conversation at home about what your child values is another way you can get involved.

“Parents can engage in values-based discussions, too,” Dr. Eldridge says. “You can help your child identify their values and help them understand how their actions and behaviors get them closer to or farther away from their values. Ask questions, such as, ‘What’s important to you?’ and ‘What do you care about in life?’”

You can do the values exercise right along with your teen. It might even be a good idea to seek out psychotherapy for yourself.

“Often, when we see teens or kids with anxious symptoms, their parents also have anxious symptoms,” Dr. Eldridge says. “So it can be a good idea for parents to touch base with a therapist to help them build skills to help not only their child but themselves as well.”