Acceptance and Commitment Therapy for Psychosis: A Valuable Contribution Despite Major Flaws


The core of Acceptance and Commitment Therapy, or ACT, is the idea of simply accepting, rather than trying to get rid of, disturbing or unwanted inner experiences like anxiety or voices, and then refocusing on a commitment to take action toward personally chosen values regardless of whether that seems to make the unwanted experiences increase or decrease.

The process of applying ACT to “psychotic” experiences is well described in the book Acceptance and Commitment Therapy and Mindfulness for Psychosis, which I recently finished reading.  I found a lot to like in the book and generally in the concept of applying ACT to psychotic experiences, but I also noticed some major limitations, which I will get to below.

There is, I think, great value in the notion of shifting attention away from attempts to eliminate experiences that might be labeled “psychotic” and focusing instead on increasing a person’s ability and willingness to move toward his or her values.  This idea is consistent with the emphasis in the recovery movement of finding a way to live a valued life despite any ongoing problems; but ACT has value because of the unique and effective strategies it offers to help people make this shift.

It is also a virtue of ACT that it is “transdiagnostic.” That is, it is not an approach designed for specific “mental disorders” but rather an approach designed to address problems in living which are understood to be universal for human beings, including for the professionals themselves.  ACT appreciates that life is tricky and that we can get caught up in strategies that are unhelpful to us like focusing too much on trying to get rid of unwanted experiences and/or getting too taken over by – or “fused” – with them; but it also appreciates that we all retain the ability to turn toward more constructive, value-driven approaches.

ACT is also often fun.  Inspired by the book, I recently led a group mindfulness exercise, with my co-facilitator playing the role of a voice that interrupted that exercise, saying things designed to provoke and distract the group members.  Meanwhile, I was guiding people in disengaging from his remarks, and having them notice they could gently bring their attention back to their breath.  People ended up laughing a lot during the exercise but also noticing they did have the option of just disengaging from whatever was said, no matter how provocative, and attending instead to a particular chosen goal such as, in this case, paying attention to the breath.  (You can download a detailed guide to using ACT in groups for people with “psychotic” experiences here.)

However, as noted by one group member who has made progress in understanding the parts of herself that lie behind her “voices,” such an approach of treating the voice-hearing experience as simply something to accept and make nothing of is best seen as a strategy to do only some of the time.  At other times, people may be better off trying to understand what is behind their voices.

That’s where I see problems with ACT:  it tends to suggest that disruptive experiences, whether they be emotions, impulses, thoughts, or voices, are just static to be disengaged from and then basically ignored as one moves toward values.  It neglects the way such experiences, when attended to and understood, can actually contribute to the development of a more integrated sense of values and self.

A commonly used metaphor in ACT is called “passengers on the bus.”  The idea is to imagine yourself as a bus driver, and imagining that you have a lot of rowdy, scary looking passengers.  They start telling you where to go, with the threat being that if you don’t obey they will come up front of the bus where they will be very hard to ignore.  So sometimes you do what they say to keep from having to notice them, and sometimes you stop the bus and try to throw them off (but they are too strong to throw off, plus you have to stop the bus to engage with them that way). The idea the ACT practitioner would be wanting you to become aware of is that in trying to get control over the passengers and over how noticeable they are to you, you have actually ended up with less control over the direction of the bus.  The ACT practitioner would suggest you try instead focusing on where you want the bus to go, without trying to get rid of the passengers or worrying about whether they come up to the front of the bus and yell at you.

I believe the problem with always trying to live by this ACT metaphor is that while it may lead to being able to carry out intentional behavior toward values identified by the conscious part of the psyche, it tends to suggest there is no way of reconciling with the angry, scary, noisy parts of the psyche which may be objecting to those actions.  For a different point of view, consider the perspective of Eleanor Longden, a woman who once was seen as a “hopeless schizophrenic” but who recovered using methods promoted by the hearing voices network, which she summarizes in the following analogy:

  “….I want you to imagine a group of people coming into a room.  Some are angry, some are hugely distressed, and some are goading and malicious.  They are not easy to be around, and we can choose one of two options for dealing with them.  The first is to sit down and try to understand them, to comfort them, to set helpful and safe boundaries on their behavior, to ask them what has happened to make them feel this way, and to seek possible solutions.  The second option is to lock them in another room and wait for them to calm down.  And perhaps they will.  But what if they don’t?  What if, instead, they begin to claw and pound at the door, to shout louder to get our attention, to grow even more frustrated and distressed?  And what if we, in turn, grow more afraid and mistrustful of them and become even less inclined to open the door and begin to negotiate peace and resolution?  For years I had chosen the second option as the way to deal with the voices.  The first option, quite simply, was what made my recovery possible – out of the dark room and into the light.”  From Learning from the Voices in My Head.

I suspect a wise “bus driver” would alternate between at times being firm and taking some actions despite “passengers” yelling and complaining, but also at times being flexible and seeking to understand strongly expressed complaints and to come up with reasonable solutions that resolve difficulties and make peace with the passengers.  So I think that even while ACT strategies are helpful for people with difficult or psychotic experiences to know and practice at times, ACT would do better to be more aware of the limitations of those strategies, and to consider alternating them with more self-exploratory strategies such as those suggested by Eleanor, who also wrote that:

 “…possibly one of the greatest revelations on the journey occurred when I realized that the most hostile, aggressive voices actually represented the parts of me that had been hurt the most profoundly – and as such, it was these voices that need to be shown the greatest compassion and care.  In turn, this meant sending a loving message of compassion, acceptance, and respect toward myself.  My voices seemed like the problem; they were actually the solution, an inextricable part of the healing process.”

I believe, like Eleanor, that every bit of our psyche and of our experience has value if and when we put it in the right perspective.  I hope to see future versions of ACT which acknowledge this and which help people find value in, rather than just tolerate, the experiences they once felt compelled to avoid at all costs.


Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.


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  1. Ron

    I really appreciate you writing this review and agree with the thrust of your critique. I also appreciate the fact that you provided more quotes from Eleanor Longden’s new book which only deepens our understanding of her TED talk on voice hearing.

    I have worked over 20 years helping people with addictions in a community mental health setting. In a somewhat different area of work with “voices” I focus some attention on helping people confront their “addiction voice.” (for those interested you can read part three of my past blog at MIA titled “Confronting the Addiction Voice on the Road to Recovery”).

    Similar to the point you are making about ACT’s approach, there are some times, especially in an early and very vulnerable stage of recovery, where it is necessary to just “thought block” when your “addiction voice”(a voice that every addict is familiar with) is tempting you with engaging in the addictive behavior. This tactic can be necessary and successful in the short run, but in the long run merely using “thought blocking” as a strategy for abstinence will not sustain itself and people will often relapse.

    Eventually people will be forced to engage with their “addiction voice” because it can be unrelenting and pervasive as it is so often triggered by multiple associations related to the addictive behavior in one’s surrounding environment.

    So in order for people to break the addictive pattern, they will need to learn more about the specific content of “excuses” and “justifications” that their “addiction voice” uses to convince them to continue the dysfunctional behavior. And most importantly, they will need to learn to talk back to their “addiction voice” and consistently and permanently defeat it in on going internal arguments.

    As people gain more time and confidence in their recovery, especially by strengthening overall coping mechanisms, the “addiction voice” will be heard much less frequently and will be more easily put in its place when encountered. Through this process people will eventually lose their fear of the “addiction voice” and learn to accept its occasional presence in their life experience.

    So with addictions, just ignoring or distracting oneself from the “addiction voice,” may not be a successful strategy of achieving recovery and defeating addictive behaviors. And while this may be somewhat different than other forms of voice hearing, I believe there are some parallels in viewing this issue relative to your critique of ACT.


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    • Thanks Richard, for drawing out those parallels! I agree that there are similar dynamics present whether the voice is “heard” as though physically present, or is just a more metaphorical “voice” that speaks in favor of a particular direction, such as participating in an addiction.

      In regards to the addiction voice, you spoke about a need to “consistently and permanently defeat it in on going internal arguments.” While I agree with you that there may be a need to consistently and permanently defeat the idea of relapsing into destructive drug use, just as people may need to consistently and permanently defeat the idea of making suicide attempts, I think there are problems with seeing this as a need to defeat the voice itself.

      Another way of looking at this is that when part of the psyche proposes use of destructive drugs, or self harm or suicide, it is attempting to meet some kind of need. So if we look to really understand a voice or part of the psyche, we can find that unmet need and then actually find a way to ally with the part of the psyche that had previously been trying to get that need met in the “dysfunctional” way. In other words, set healthy limits with the “addiction voice” – such as absolutely no use of a drug one can’t handle well – but then get to know the deeper concerns of the voice and find healthy ways of addressing those concerns.

      Of course, many people will heal fully without ever noticing themselves finding anything positive behind their “addiction voice.” The reason that can happen is that they only recognize part of their psyche as an “addiction voice” when it is asking for the drug: if the person becomes able to learn about and meet the underlying needs in the healthy way, then it will seem that the addiction voice has just faded away even though it may in some sense still be present but is now proposing different solutions to meet its needs.

      So I think the deeper levels of peacemaking with voices is most important to know about when the voices themselves are more differentiated, because it is then we are most likely to get into trouble if we simply focus on defeating the voice rather than understanding it and taking its needs seriously.

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  2. Dear Ron

    Very late comment but “it tends to suggest there is no way of reconciling with the angry, scary, noisy parts of the psyche which may be objecting to those actions. For a different point of view, consider the perspective of Eleanor Longden”… Is a common misunderstanding of ACT. Your suggestion of “a wise “bus driver” would alternate between at times being firm and taking some actions despite “passengers” yelling and complaining, but also at times being flexible and seeking to understand strongly expressed complaints and to come up with reasonable solutions that resolve difficulties and make peace with the passengers” sounds exceedingly workable, very important potentially in a certain individual and certain circumstances, and certainly something that would be embraced by a psychological flexibility point of view. ACT in no way dismisses personal experience, as ACT practitioners do not dismiss our evolutionary history, and we simply seek to notice when entanglement with figuring out not moving us to where we want to go – and sometimes it can be exceedingly helpful in understanding the nature of our difficulties – see Steve Hayes recent TED talk in which he talks about his early life experiences contributions to his difficulties (I’m aware this came out after your posting)

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    • I’ve been told by some others, after I wrote this article, that ACT does go further than I suggested, and could involve reflecting on some truth that may be within disturbing feelings etc. I don’t doubt that they are correct. But I would point out that common ACT metaphors are presented in a much more black and white way, as when people are just instructed to essentially ignore the behavior of the “passengers on the bus” while thinking about where to drive the bus.

      I would contrast that with the way people in the hearing voices network tend to talk about as a preferred way of handling voices. There the emphasis is more explicitly on having a dual method: there’s a time both for listening to the voices and a time for not listening (and when they are listened to, they don’t need to be taken literally – just as one may listen to a child, and “hear” that the child needs a nap, which wasn’t what the child literally said.

      So what I’m thinking is that if ACT would be more explicit up front about how both strategies are needed at different times – and if it would provide examples of how trouble can also be caused by getting too carried away with NOT listening to disturbing thoughts or feelings – then I would find it a more complete model.

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