MINI REVIEW

published: 11 January 2018

doi: 10.3389/fpsyg.2017.02350

Acceptance and Commitment

Therapy for Health Behavior Change:
A Contextually-Driven Approach
Chun-Qing Zhang 1* , Emily Leeming 2 , Patrick Smith 2 , Pak-Kwong Chung 1* ,
Martin S. Hagger 3,4 and Steven C. Hayes 2
1
Department of Physical Education, Hong Kong Baptist University, Kowloon, Hong Kong, 2 Department of Psychology,
University of Nevada, Reno, Reno, NV, United States, 3 School of Psychology and Speech Pathology, Faculty of Health
Sciences, Curtin University, Bentley, WA, Australia, 4 Department of Sport Sciences, University of Jyväskylä, Jyväskylä,
Finland

Promoting health behavior change presents an important challenge to theory and

research in the field of health psychology. In this paper, we introduce a context-
driven approach, the Acceptance and Commitment Therapy (ACT) model which
is built on Relational Frame Theory. The ACT-based intervention aims to promote
individuals’ new health behavior patterns through the improvement of the key construct
Edited by: of psychological flexibility, which is defined as the ability to contact the present
Gian Mauro Manzoni,
Università degli Studi eCampus, Italy moment more fully with acceptance and mindfulness as a conscious human being.
Reviewed by: Building on the psychological flexibility model, implemented through the six core ACT
Roberto Cattivelli, processes, individuals improve maintenance of long term health behavior change
Istituto Auxologico Italiano (IRCCS),
through committed acts in service of chosen values while acknowledging and accepting
Italy
Raffaella Calati, the existence of contrary thoughts, rules, and emotions as part of themselves but not
Centre Hospitalier Universitaire determinant of their behaviors. Taking advantage of this context-driven approach of
de Montpellier, France
health behavior change, we recommend researchers and practitioners to design their
*Correspondence:
Chun-Qing Zhang health behavior change intervention programs based on ACT.
[email protected]
Keywords: ACT, behavior change, behavior maintenance, psychological flexibility, relational frame theory
Pak-Kwong Chung
[email protected]

Specialty section: INTRODUCTION

This article was submitted to
Clinical and Health Psychology, The pragmatic utility of psychological interventions on health behavior changes are judged by
a section of the journal their effectiveness in promoting sustained and desired behavior change over an extended period
Frontiers in Psychology of time. For example, effective interventions are not only those that get people to increase their
Received: 06 October 2017 steps per day or to eat a healthy meal, but also are those that maintain such gains months or
Accepted: 22 December 2017 years beyond the initial intervention. Mainstream health behavior change approaches have focused
Published: 11 January 2018 primarily on the content of cognitive and emotional variables that are thought to support long-term
Citation: behavior change. Traditionally, health behavior change interventions target the social cognitive
Zhang C-Q, Leeming E, Smith P, and belief-based variables to increase individuals’ intention (i.e., a person’s motivation toward the
Chung P-K, Hagger MS and target behavior in terms of direction and intensity) and self-efficacy (i.e., one’s confidence in being
Hayes SC (2018) Acceptance
capable of performing a novel behavior) in the hopes of maintaining the health behavior change
and Commitment Therapy for Health
Behavior Change:
(Schwarzer, 2008). While these approaches can be helpful to a degree, the magnitude of health
A Contextually-Driven Approach. problems and the maintenance of health behavior change suggests that alternatives are needed
Front. Psychol. 8:2350. (Kwasnicka et al., 2016). One important approach that gains more and more momentum is to apply
doi: 10.3389/fpsyg.2017.02350 the context-driven approach to understand and predict health behavior change (Hayes, 2004). In

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Zhang et al. ACT and Health Behavior Change

the current mini review, the authors aim to introduce the context- experiencing psychological events thus reducing psychological
driven approach of Acceptance and Commitment Therapy (ACT; barriers to behavior change, and (c) by improved awareness of
Hayes et al., 1999) along with the description of how and one’s internal and external environment through mindfulness
why Relational Frame Theory (RFT; Hayes et al., 2001) and processes that allow behavioral choices to be better fitted to the
psychological flexibility provide coherent theoretical foundations contextual situation (Butryn et al., 2011). Functionally speaking,
and validated measures for ACT-based health behavior change. these processes are assessed empirically, in part, by examining
This should not be viewed as a detailed guidance and/or a whether psychological flexibility serves as the change mechanism
systematic and comprehensive review, but more of a brief for maintenance of adaptive and healthy behaviors (Ciarrochi
explanation and introduction focused on illustrating the links et al., 2010).
between the basic principles of ACT and related health behavior Acceptance and Commitment Therapy is a behavior change
change. method based on RFT and is explicitly oriented toward the
As compared to the content-driven approach, in which development of greater psychological flexibility (Hayes et al.,
behavior change is based on thought content unique to each 1999). Although much of the early ACT work targeted mental
particular behavior (Ellis, 1962; Beck, 1976), a context-driven health, from the beginning there was also a focus on health
approach examines the social, psychological, and situational behavior change (of the first three studies done on ACT in
context that regulates the behavioral impact of thought and the 1980s one was on diet, and another on dealing with
emotion (Hayes et al., 1999). For health behavior change, tolerance of physical pain) and that interest has only grown
instead of trying to directly change difficult thoughts or feelings, in recent years (e.g., Butryn et al., 2011; Manlick et al., 2013;
acceptance and mindfulness-based skills can be cultivated to Bricker et al., 2014, 2017; Moffitt and Mohr, 2015). ACT
foster greater behavioral regulation. Perhaps the most studied set offers an alternative to traditional attempts to control unwanted
of contextual processes of this kind is psychological flexibility, psychological experiences. Rather than trying to control the
which is “the ability to contact the present moment more content of thinking and emotions, ACT aims to help individuals
fully as a conscious human being and to change, or persist change their relationship to these events (Hayes, 2004). In ACT,
in, behavior when doing so serves valued ends” (Biglan et al., the goals of the health behavior change interventions are not
2008). Psychological flexibility is contextual in the sense that explicit replacement of previous unhealthy psychological events
it refers to individuals changing their relationships with private with new and healthy events, but the concurrent cultivation of
events (i.e., thoughts, memories, feelings, and bodily sensations), acceptance toward of the occurrence of unhealthy psychological
not the events themselves. For example, psychological flexibility events, defusion from strict adherence to those events (i.e.,
may focus on teaching a dieter to be mindful and observe an observe the events for what they are as just thoughts of our mind,
urge to eat a chocolate cake without necessarily attempting get rather than becoming entangled and fused with them), and the
rid of that urge. The content surrounding a temptation to eat committed action of behaviors that support living in ways that
something delicious may include such things as judgments about serve predetermined healthy values. In this way, habits for the
whether this urge is good or bad; psychological flexibility suggests new healthy behaviors may be established with greater resiliency
that the focus should be on how the individual interacts with to psychological barriers.
these thoughts, rather than their form or frequency. Accordingly, Preliminary evidence of ACT on direct and initial behavior
the ultimate goal for individuals, initiating and maintaining the change as well as promotion of behavioral maintenance
health behavior change, is to make said change(s) consistent with has been established. ACT has been investigated in several
their chosen values (e.g., having a healthy lifestyle) even in the health related domains, with positive long-term results. For
face of difficult thoughts or emotions. example, the effectiveness of a randomized brief physical-activity-
Health behavior change is a dynamic process. Psychological focused ACT-based intervention produced significant increases
flexibility has much to offer in the context of health behavior in individuals’ levels of physical activity. The skills taught in
change as a theoretical guide for cultivating long-term this intervention were mindfulness, values clarification, and
improvements in behavior. According to Kashdan and willingness to experience distress via face-to-face intervention
Rottenberg (2010), four aspects of psychological flexibility can (Butryn et al., 2011) or via DVD (Moffitt and Mohr, 2015).
be viewed as fundamental to health, including: (a) recognizing In smoking cessation treatment, the effectiveness of ACT as
and adapting to various situational demands, (b) shifting compared to other interventions (e.g., nicotine replacement
mindsets or perspective when personal or social functioning treatment, functional analytic psychotherapy, and cognitive
are compromised, (c) balancing competing desires, needs, and behavioral therapy) has been demonstrated in a series of
life domains, and (d) being aware of, open, and committed to RCTs (e.g., Gifford et al., 2004, 2011; Hernández-López et al.,
behaviors that are congruent with deeply held values. These four 2009; Bricker et al., 2014, 2017). ACT has been recommended
aspects of psychological flexibility are well positioned to explain as an acceptance-based self-regulation framework for weight
successful behavioral maintenance toward healthy living in a management (Lillis and Kendra, 2014), with awareness of
real-life context (Kwasnicka et al., 2016). decision-making thoughts and commitment to chosen values
In principle, psychological flexibility can facilitate lasting viewed as two key components (Forman and Butryn, 2015). For
change in three ways: (a) by increasing commitment to, example, a 1-day mindfulness and acceptance-based workshop
and improved maintenance of, value-driven behaviors, (b) targeting obesity-related stigma and psychological distress is
by strengthening a willing, open, and accepting method of effective on weight loss and weight-specific acceptance coping;

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Zhang et al. ACT and Health Behavior Change

the intervention effects on weight loss was also found mediated times cause the inverse effect and why even individuals who
by psychological flexibility (Lillis et al., 2009). choose to change their eating behavior, from an unhealthy to a
healthy diet, may struggle to maintain this new lifestyle choice
despite reporting high motivation.
RELATIONAL FRAME THEORY AND To overcome the problem of this paradoxical effect, RFT
HEALTH BEHAVIOR CHANGE provides a theoretical explanation for the importance of using
ACT-based interventions to develop psychological flexibility
As the underlying foundation of the ACT, RFT is a contemporary toward the verbal/cognitive networks that establish relations
behavioral account of language and human cognition. RFT among stimuli, rules, and behaviors. People may need to learn
claims that language is not based on learned associations or how to strengthen or weaken the behavioral impact of rules
direct contingencies of a typical variety but is rather based on rather than attempt to relate their presence or absence to success
learned relational responses – patterns of responding to one or failure. This breath of application is one reason ACT has
event in terms of another (Hayes et al., 2001). Taking in to the been used to promote individuals’ psychological flexibility across
context of health behavior change, RFT provides advantages in a wide domain of health-related behaviors (e.g., Lillis et al.,
the degree of precision made possible when analyzing verbal 2009; Butryn et al., 2011). For example, a diabetic person who
contributions to complex human behavior. When applied to can strengthen a values-linked rule such as “if I carry too
the topic of health related behaviors, it provides a preliminary much excessive weight I may not see my children grow up”
behavioral account for how specific verbal rules come to exert may successfully reduce excessive eating throughout the day.
control over responding (Barnes and Keenan, 1993; Carpentier Conversely, learning to weaken the impact of shame-linked
et al., 2002). For example, the sound of the word “cigarette” rules like “I am a fat failure” through mindfulness and defusion
is placed in a “frame of coordination” or “sameness” with a methods described below fosters that same behavioral end.
thin cylinder of finely cut tobacco rolled in paper. From an Very recently, implicit methods of cognitive assessment,
RFT perspective, this relational response is not dependent on derived from RFT, have been used to predict the motivational
the sound of the name because it is under arbitrary contextual impact of verbal descriptions on the relation between
control, not the form of the related events or even direct contact athletic activity and its outcomes, altering exercise levels
with them (Hayes, 1994; Barnes-Holmes and Barnes-Holmes, and persistence through motivational operations (Jackson et al.,
2000; Hayes et al., 2001). The word “is” in the sentence “this 2016). Accordingly, the effects of the sensory, or perceptual,
is a cigarette” regulates the relational response of sameness consequences of eating can be altered based on how an
between the name and object. These mutual relations then individual frames those consequences verbally, and by how the
combine into networks of relations and the effects of related person relates to their own verbal processes. A similar effect has
events are transformed. If you were told that a particular brand been empirically shown in the physical activity of people who
of cigarettes is laced with poison, you might be afraid to avoid pain (e.g., Vowles et al., 2007). Therefore, more research
touch a cigarette of that brand even though you had no direct should be conducted in the fields of health, behavior, and clinical
experience of bad things happening. From an RFT point of view, psychology to further clarify the processes underlying RFT
health behavioral change maintenance depends on not only one principles, ACT processes, and health behavior change.
triggering factor like the intention of doing the behaviors but
strengthening or weakening existing relational responses and
learning new relational responses in the context of the target ACT FOR HEALTH BEHAVIOR CHANGE:
behavior(s). THE PSYCHOLOGICAL FLEXIBILITY
Relational Frame Theory also provides grounds for MODEL
considering contextual forms of ACT-based interventions
versus content-based forms. If cognitive relations are learned, Psychological flexibility model is a behavior change model
it is not fully possible to remove the historically established based on RFT and its applied extensions that is used for
psychological relations between environmental cues and past understanding how rule-following behavior can affect behavior
unhealthy behaviors because there is no psychological process (Hayes et al., 1999; Gross and Fox, 2009) based on how
called “unlearning” (Hayes, 2004). Furthermore, if relating can be people interact with their own language processes (Bond et al.,
based on arbitrary cues it is hard to imagine how to deliberately 2006). According to the psychological flexibility model, which
alter ones cognitive networks without unexpected effects. This underpins ACT, psychological flexibility consists of six primary
makes lasting change difficult. For example, telling yourself not components: defusion, acceptance, self as context, contact with
to think of eating unhealthy food (say “don’t think about potato the present moment, values, and committed action. Psychological
chips”) may paradoxically increase the likelihood that you are inflexibility is the opposite: fusion, experiential avoidance, the
thinking about unhealthy food, since the rule contains the very conceptualized self, rigid attention to the past or future, unclear
verbal stimuli (the words “potato chips”) that are related to values, and inaction, impulsivity, or persistence avoidance.
the unhealthy food, and every time you check to see if you are Psychological flexibility promotes behavior that aligns with the
following the rule, you are very close to violating it (Wegner, individual’s values rather than allowing thoughts about events to
1994). This paradox of emotional or cognitive control may help dominate regardless of their usefulness. To date, ACT is the most
explain why attempting to control unhealthy behaviors may at researched intervention model targeting psychological flexibility.

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Zhang et al. ACT and Health Behavior Change

Psychological flexibility is described as the ability to contact the merely the “what if ” contexts reflective of rumination over past
present moment more fully as a conscious human being, and to experiences and anxious anticipation of future ones (Bond et al.,
change or persist in behavior such that one continues to behave in 2006). When individuals attend flexibly, fluidly, and voluntarily
a way that is consistent with their pre-established and identified to the immediately relevant internal and external environment,
values (Hayes et al., 1996). The following will briefly describe performance demands can be better adjusted to what is presently
these six flexibility processes and relate them to health behavior. occurring.

Defusion Self-as-Context
A defining concept of psychological flexibility is defusion. In The concept of self-as-context refers to the perspective skills
situations where fusion occurs, individuals respond to the needed for an individual to report on their own behavior
content of their language as if those descriptions are literally from a consistent perspective or point of view. RFT research
occurring (Hayes et al., 1999). For example, an individual shows three key deictic relational frames are involved: I/YOU,
attempting to quit smoking may experiencing physiological HERE/THERE, and NOW/THEN (Hayes et al., 2006). When
distress and may engage in verbal behavior that describes the “I/HERE/NOW” comes together, it yields a sense of self as
context as “this is too difficult, I can’t quit.” When this verbal an observer. An individual, who can see and recognize their
behavior is seen as a literal description of ability, the individual own verbal descriptions of themselves as distinct from the
may return to smoking as a function of the description of the “I/HERE/NOW” perspective, may feel less threatened by negative
event and not as function of what they are physically capable statements about the self. For example, someone engaging in
of achieving. Defusion is the use of function-altering cues and addictive behavior stating “I’m a no good drunk” might more
strategies to reduce the transformation of stimulus functions in readily recognize that statement merely as a thought that does not
such cases, thus changing the impact of verbal events on other summarize themselves as a totality. By changing the statement to
behavioral processes. Said in a more commonsense way, defusion “I am having the thought that I am a no good drunk” they may
it looking at thoughts with an attitude of dispassionate curiosity. thus reorient toward better quality of life behaviors.
Defusion methods, such as repeating the name of a feared object This first four flexibility processes provide a working
until it loses meaning, may reduce the impact of such thoughts definition of mindfulness in a psychological flexibility model.
(Blackledge, 2015). The processes of adopting chosen values and commitment to
the action of health behaviors relates to both initiation and
Acceptance maintenance of health behavior change.
Acceptance occurs when an individual willingly experiences
automatic, and sometimes unwanted, emotions or sensations
without attempting to control the form, frequency, or situational Values
sensitivity of these experiences (Bond et al., 2006). The Values are defined as chosen immediate qualities of ongoing
psychological flexibility model contends it is not the content of patterns of action that are verbally established as reinforcers
emotions that become problematic to a quality life but rather (Hayes et al., 1999). For example, an individual may value
problems arise when individuals interact with these events in “investing in family life.” Such a statement is differentiated from
an avoidant way (Bond et al., 2006). An example of behavior a goal in that a value is not a tangible outcome such as “Friday
that is not indicative of acceptance is when an obese individual, family movie night” but is instead a quality of action. Values
who experiences anxiety around exercise and the gym, avoids are known to increase task persistence across multiple health
these situations where anxiety occurs. Conversely, an individual related behavior (e.g., Chase et al., 2013; Jackson et al., 2016).
experiencing anxiety around exercise and engaging in acceptance An individual who values investing in family life will engage
responses would instead acknowledge the anxiety with a sense of in multiple behaviors that contribute to that stated value, i.e.,
dispassionate curiosity and allow themselves to experience these helping children with homework, attending soccer and dance
emotions and situations where they occur. Scores of studies have lesions, date nights, open communication, dressing up for date
shown that such strategies increase task persistence (Levin et al., nights, exercising to model and pattern healthy life behaviors and
2012). so on. Values based living then, is living in such a way that values
provide direction like a compass.
Flexible Attention to the Present Moment
Human beings are uniquely adept at problem solving and Committed Action
planning. While these behaviors are often beneficial, they can In clinical settings, committed action looks much like
sometimes be maladaptive, especially when language patterns traditional behavioral approaches (Bond et al., 2006). As
become fused with temporal and evaluative statements. Problem part of psychological flexibility, committed action takes the
solving always requires examination of the past and future (e.g., role of expanding an individual’s valued responses into larger
“How did I get here?” “Where am I going?”), but can overwhelm and larger patterns of activity. Larger patterns can be built by
flexible attention to the present environment, both external and obtainable intermediary goals that comport with pre-established
internal. Working in coordination with acceptance and defusion, values. For example, an individual who experiences exercise
contact with the present moment helps individuals respond anxiety and has historically pulled out or stopped exercising,
while in touch with current environmental demands rather than may now set the goal of walking for an hour, three times a

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Zhang et al. ACT and Health Behavior Change

week in alignment with their value of “living a healthy lifestyle efficacy and resilience/durability of ACT interventions on
through exercise.” health behavioral change is urgently needed (e.g., randomized
controlled trials).
CONCLUSION
Although ACT was originally developed in the field of AUTHOR CONTRIBUTIONS
clinical psychology (Hayes, 2004), it has shown promise in
facilitating individuals’ health behavior change with greater C-QZ, EL, PS, P-KC, MH, and SH contributed to the conception
efficacy and fulfillment in individuals’ real-life contexts. The and writing of the content for the review.
authors call for the further application of ACT and its
underlying psychological flexibility model into the promotion
of health behavior change. In particular, the health behavior FUNDING
change of individuals with clinical conditions such as chronic
pain in order to increase beneficial physical activity (e.g., The open access publication fee was supported by RAE
VanBuskirk et al., 2014). Finally, we emphasize that empirical Professional Development Grant (Ref. 0032017) awarded to P-KC
evidence, gathered through robust research designs, on the by the Faculty of Social Sciences, Hong Kong Baptist University.

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Manlick, C. F., Cochran, S. V., and Koon, J. (2013). Acceptance and commitment Conflict of Interest Statement: The authors declare that the research was
therapy for eating disorders: rationale and literature review. J. Contemp. conducted in the absence of any commercial or financial relationships that could
Psychother. 43, 115–122. doi: 10.1007/s10879-012-9223-7 be construed as a potential conflict of interest.
Moffitt, R., and Mohr, P. (2015). The efficacy of a self-managed Acceptance and
Commitment Therapy intervention DVD for physical activity initiation. Br. J. Copyright © 2018 Zhang, Leeming, Smith, Chung, Hagger and Hayes. This is an
Health Psychol. 20, 115–129. doi: 10.1111/bjhp.12098 open-access article distributed under the terms of the Creative Commons Attribution
Schwarzer, R. (2008). Modeling health behavior change: how to predict and modify License (CC BY). The use, distribution or reproduction in other forums is permitted,
the adoption and maintenance of health behaviors. Appl. Psychol. 57, 1–29. provided the original author(s) or licensor are credited and that the original
doi: 10.1111/j.1464-0597.2007.00325.x publication in this journal is cited, in accordance with accepted academic practice.
VanBuskirk, K., Roesch, S., Afari, N., and Wetherell, J. L. (2014). Physical activity No use, distribution or reproduction is permitted which does not comply with these
of patients with chronic pain receiving acceptance and commitment therapy terms.

Frontiers in Psychology | www.frontiersin.org 6 January 2018 | Volume 8 | Article 2350