Is there a role for Acceptance and Commitment Therapy (ACT) in mental health Occupational Therapy?

I have recently started to learn about the role of Acceptance and Commitment Therapy (ACT) (Harris, 2011) in supporting individuals with severe and enduring mental health needs, through an occupational lens. This therapy teaches that people should focus on what they can control and make actions towards values, to create a more meaningful life.

ACT is a mindfulness-based behavioural therapy, that encourages clients to expand their lives, alongside the existence of inevitable pain and suffering (Harris, 2011). Harris' renowned self-help book, The Happiness Trap (2011, b), prioritises acceptance and personal development over symptom reduction. You can access his YouTube channel, for videos/podcasts to support learning.

If one is focused on improving the present moment, there is recognition of the world of opportunities outside our own self-critical thoughts and current difficulties. We are more than the sum of our past experiences, thoughts and feelings
 (Harris, 2011).

The 21st century is full of complexity and stress (e.g. work, politics and healthcare). This can negatively impact mental health and well-being if we do not embrace contentment and meaning in everyday life (Harris, 2011). If we solely focus on solving problems, we will never achieve happiness. Through an occupational therapy lens, engagement in occupation facilitates mindful awareness of the present moment; supporting one to achieve a sense of flow, skill development and pleasurable feelings (Reid, 2011). This approach focused on developing life experiences, in response to psycho-social stress that creates negative symptomology and poor health outcomes.

In a similar way to ACT, behavioural activation helps alleviate depression, through planning pleasurable activities, based on what we are motivated to change (Lovell & Richards 2008). This evidence-based intervention teaches us that we are able to control our mood through our activity management (Ekers et al, 2014). This approach is often used by occupational therapists to create change, based on the occupations that we both want and need to do in order to live a fulfilling life. To maintain health and well-being, Occupational Therapy helps people to develop a sense of being, becoming and belonging, through engagement in everyday life (Wilcock, 1998). It is through engaging in valued actions that one develops a sense of mastery, in order to promote positive emotions (Reid, 2011). Goal setting by planning activities is a core OT tool, which helps to enhance skill development to promote improvements in health (Park, 2011).

Occupational performance has been categorised in relation to self-care, productivity and leisure activities (Law et al, 1990). While these terms are criticised for their simplicity, low evidence-base and cultural limitations (Hamell, 2009), they are frequently utilised by occupational therapists to facilitate treatment plans.

The process of behavioural activation supports people to relearn the benefits of activity for motivation, mood and mental health. Those with Major Depressive Disorders experience dopamine dysregulation (APA, 2013) and can often lack the dopamine rewards experienced by most through participation in activity. It is through repetitive engagement in meaningful occupations that one relearns the benefits of activity on mood (Lovell and Richards, 2008). Occupational Therapists can support washing, dressing and eating, through planning daily self-care activities. A weekly plan - based on routine (eg. washing), necessary (eg. bills) and personally satisfying occupations - is used to promote improvement in mood (Lovell and Richards, 2008).

It is through occupational engagement that people gain confidence in their ability to achieve actions, developing personal causation and a sense of control over one’s environment and health needs (Kielhofner and Burke, 1980). Occupational categories could be related to work, volunteering or vocational activities. It is through an ACT perspective that practitioners can promote the development of productivity skills, alongside experiences of emotional pain and symptoms of poor health. Research suggests that this third wave approach is most helpful for clients with severe and enduring mental health needs (Kahl et al, 2012), as supported by structured physical activity programmes for those with chronic mental health needs (Hodgson et al, 2011).

Occupational Therapists help people to expand their activities, interests and hobbies, through exploration, competency and achievement of leisure occupations (Pepin et al, 2008). They can help develop a sense of achievement, social connection and personal gratification via valued occupations. Practitioners use tools such as the Activity Checklist to help clients explore past, present and future occupations of interest (Taylor, 2017). Categories are not limited to, but include: physical, outdoor, home-based, creative and vocational. Through behavioural activation, leisure pursuits are scheduled in order to facilitate a balance of self-care, productivity and leisure occupations. Through activity analysis, we can grade and adapt occupations (Thomas, 2012) to meet individual needs. This approach can be used to create realistic and achievable goals, within a context of negative symptomology (e.g. tiredness, fatigue or chronic low mood). This can help to create a valued and meaningful life, whilst living with the negative indicators of poor mental health.

The information gathered suggests that ACT and Occupational Therapy appear to hold a common focus, in identifying action aligned with personal values. It could be argued that, as Occupational Therapist, we are already following a values-based approach, given that 'client-centredness' prioritises what is important to the client (Townsend et al, 1990).

It is through expanding our occupations of interest (self-care, leisure and productivity) that we can maintain our mental health and well-being (CAOT, 2002).

However, given that occupational therapy prioritises action over thinking, it may be helpful to use ACT to enhance understanding of the impact of behavioural change on mood. Occupational therapy is based on holistic practice, which uses a range of frameworks and tools to promote health, wellness and well-being across population needs (Scaffa et al, 2010). Arguably it is our role, as Occupational Therapy practitioners, to continue to expand our knowledge and apply behavioural frameworks from a bio-psycho-social perspective (Carson, 2020), to meet individual needs.