Acceptance and Commitment Therapy (ACT) an Important Evidenced Based Practice for Social Work Practice

Social work practitioners must utilize evidenced-based practices to assist their clients with various mental health, substance use, and other phases of life issues.“During the past 10 to 15 years, there has been an increased focus in the behavioral health community on delivering what is known as Evidence-Based Practice (EBP)”(Surface, 2009, para. 1). While there is no one size fit all evidenced based practice that will help all clients, most social workers are looking for an effective evidenced-based practice that will allow them to assist a large number of clients with various life experiences and concerns. This paper will discuss the benefits and effectiveness of utilizing Acceptance and Commitment Therapy (ACT) in social work practice.


Introduction
As social work practitioners, it is essential always to recognize that there is no one size fits all approach when it comes to providing clinical services to our clients. Social workers like other mental health and substance abuse providers are encouraged to utilize the most effective evidence-based practices when educating and intervening with clients. According to Surface (2009), "During the past 10 to 15 years, there has been an increased focus in the behavioral health community on delivering what is known as Practice (EBP) is a process in which the practitioner combines well-researched interventions with clinical experience and ethics, and client preferences and culture to guide and inform the delivery of treatments and services" (para. 1). The practitioner, researcher, and client must work together to identify what works, for whom and under what conditions. This approach ensures that the treatments and services when used as intended will have the most effective outcomes as demonstrated by the research. It will also ensure that programs with proven success will be more widely disseminated and will benefit a more significant number of people.
Social workers learn about various effective evidenced-based practices as social work students, employees, professionals, professors, and practitioners. To identify the best evidence-based practice for a client, a social worker may communicate with their supervisors, professors, colleagues, or interdisciplinary team members to determine the most effective evidenced informed interventions.
Other social workers may attend conferences or continuing education training to learn about accessible and useful evidenced-based practices with the most valuable outcomes. Moreover, others may perform research and utilize the Substance Abuse and Mental Health Services Administration (SAMHSA), National Registry of Evidence-Based Practices, Cochrane Collaboration, Campbell Collaboration, or Google Scholar to use articles and research to identify an evidenced-based practice that will benefit a significant number of people. No matter the search method most social workers are looking for an active evidenced-based practice that will allow them to reach a large number of clients with various life experiences and concerns.

Method
Searches for journal articles and dissertations were conducted using PsychINfo, PubMed, Science Direct, ProQuest, and Google Scholar databases. Due to the lack of research on the topic Google, Social Work Today, The New Social Worker, and SWHelper were also utilized. The search terms included: Acceptance and Commitment Therapy, ACT, evidenced-based practice, EBP, social work.
Resources and articles had to be written in English and published in a peer-reviewed journal to meet the criteria for being part of this review. Dissertations written in English are included. A review of titles, abstracts, and keywords determined inclusion. Collectively, more than 773,000 articles were produced.
Any materials lacking information on social work and acceptance and commitment therapy were excluded. Articles appearing on multiple databases were also eliminated. Three articles initially met inclusion criteria and were selected for this literature review.

Results
The literature review will discuss the use of Acceptance and Commitment Therapy (ACT), using ACT in the field of social work, and culture and ACT.

Acceptance and Commitment Therapy (ACT)
An evidenced-based practice that can benefit a significant number of clients as well as customizable to meet the client where they are and assess and address their needs is Acceptance and Commitment Therapy (ACT). Hayes and Hofmann (2017) suggested that ACT is a "third wave" method of Cognitive Behavioral Therapy (CBT). Third wave methods "emphasize aspects of mindfulness, emotions, acceptance, the relationship, values, goals, and meta-cognition" (Hayes & Hofmann, 2017, p. 22). ACT is considered a third wave method because it includes all of the noted characteristics of a "third wave".
ACT is an effective transdiagnostic evidenced-based practice that can treat clients with various mental health and substance use symptoms. Dewane (2008), found that ACT would be appropriate for clients with symptoms of substance use, mood, trauma, phobia, obsessive-compulsive, post-traumatic stress, psychotic, and various other disorders. In addition, ACT has also been found to be effective in working with adolescents, young adults, adults, college students, families, and couples (Dewane, 2008). ACT meets the Social Work Policy (2010), Institute criterion to be "widely disseminated and benefit a great number of people" (para. 1).
The social worker must work directly with the client to utilize ACT and identify what is useful. ACT assists clients in gaining psychological flexibility through its six core processes of acceptance, cognitive defusion, being present, self as context, values, and committed action (ACT, 2013).
Researchers discussed the effectiveness of the six core processes of ACT through a meta-analysis. The "acceptance core process increased the client's openness to their life experiences as well as raised the client's committed action" (Hayes, Pistorello, & Levin, 2012, p. 976). "Cognitive defusion attempts to defuse a client from their negative thoughts" (Hayes, Pistorello, & Levin, 2012, p. 977). "Cognitive defusion can assist clients that struggle with negative thoughts and allowed them to recognize that while the thoughts cause discomfort, it is acceptable to have these uncomfortable thoughts, acknowledge the thoughts are present and move forward" (Hayes, Pistorello, & Levin, 2012, p. 978).
While ACT encourages clients to defuse from their thoughts and accept things that happen this does not mean that a client must accept detrimental things such as abuse. Mattaini (as cited in Dwane, 2008) "explained that ACT does not mean we ask clients to accept every situation (e.g., abusive relationships), but that some circumstances should ultimately be accepted (i.e., physical reality or historical events), should be accepted for now, should be accepted with expectation of eventual change, or should be changed now" (p. 37). Being present is a part of the mindfulness aspects of ACT and clients learned mindfulness techniques to be in and stay in the present moment. "Mindfulness is an effective tool when working with clients who become inflexible during their therapeutic sessions" (Hayes, Pistorello, & Levin, 2012, p. 976 important and created the framework for committed action" (Hayes, Pistorello, & Levin, 2012, p. 976).
If the client is aware of what they value the social worker can assist the client in coming up with a treatment plan based on those values. Research has shown the clients are more likely to be compliant with a treatment plan where they have given their input, and that is based on their value system.
"Noticing self is the client being exposed to their thoughts, emotions, and fears with the recognition that this exposure will not or does not need to threaten their well-being" (Hayes, Pistorello, & Levin, 2012). The committed action of ACT provides clients "with the skills needed to set goals that will assist in behavioral changes" (Hayes, Pistorello, & Levin, 2012). Committed actions are "self-selected, and self-monitored, and the failure to meet them is viewed with curiosity and nonjudgmental by the therapist, as a valuable source of information about barriers to value-based action" (Hayes, Pistorello, & Levin, 2012, p. 988). Social workers can work with their client to identify the best core process to work towards psychological flexibility. ACT is an evidenced-based practice that is utilized in the way that makes sure that the treatments and services are used in the most effective way for both the client and the social worker and has proven effective outcomes as demonstrated by the research.

Social Work and ACT
ACT appears to be a very effective evidenced based practice utilized in the field of social work. The

Culture and ACT
There is no one size fits all person; therefore, social workers must understand there is no one size fits all evidenced based practice that will work for every single client. However, it is imperative that creators of evidenced-based practices take into account culture, race, ethnicity, socioeconomic class, religion, nationality, sexual orientation, and intersectionality when creating evidenced-based practices that work with diverse clientele. Hayes (n.d.) found "the ACT literature is just now getting large enough to consider whether its impact is differential based on SES, ethnicity, gender, nationality, and the like". Research shows that ACT uses culture to guide and inform treatment delivery. Hayes (as cited in Gregg, Callaghan, Hayes, & Glenn-Lawson, 2007) found showing that a six-hour ACT workshop with patient education works significantly better than a six-hour patient education workshop alone in producing changes in diabetes self-management and blood glucose (at three-month follow-up)". The reports in the study Hayes (n.d.) reports "the study was done at a public health clinic in a lower socioeconomic area that was a largely Latino and Asian section of East Palo Alto". However, ACT has also been used not just locally with clients of ethnically and racially diverse backgrounds, but it has to be utilized globally.
ACT has been used in South African with clients with medical conditions. According to Hayes (n.d.), "Lundgren and Dahl performed RCT in South Africa which showed that a nine-hour ACT protocol reduced seizures in [individuals] with epilepsy by 96% (90% were seizure free at a one year follow up), while an attention placebo had no effect". Hayes (n.d.) reported the participants were South African Black, a part of the lower socioeconomic class, and living in a residential center. Showing ACT can be effective with globally based on both race and socioeconomic status.
ACT has been used to study racial differences in a higher education setting. According to Hayes (as cited in Lillis & Hayes, 2007), study of undergraduates enrolled in two separate classes on racial differences were exposed to acceptance and commitment therapy, and an educational lecture drawn from a textbook on the psychology of racial differences in a counterbalanced order. The results indicated that "only the ACT intervention was effective in increasing positive behavioral intentions at termination, and a one-week follow-up and these changes were associated with other self-reported changes that fit with the ACT model" (Hayes,n.d.,para. 8). The research shows that ACT has been used with various populations and dealing with matters outside of mental health but also matters addressing racial differences which can spur inquiry into social justice.
Hayes reports that ACT is also useful in working with members of all genders. Hayes (n.d.), states "as for gender, in all of the studies so far ACT works as well for women as men, except for one analog pain study in which it worked better for women" (para. 7). The literature has not discussed ACT and the transgender population.
The research has shown that ACT works well with various diverse groups. As more research is collected on the effectiveness of ACT overall, we will also learn more about the efficacy of ACT with multiple groups. This research will make sure that ACT is continuously informed by culture making it an evidenced-based practice that will help the greatness number of people and not a one size fits all method.

Discussion
Despite the effectiveness, efficiency, and flexibility of this evidence-based practice, research, teaching/training, and utilization of ACT in the field of social work continues to be limited. According to Dewane (2008), "For social workers dealing with the broad range of behavioral problems that demand short and empirically-based intervention, ACT has a place" (para. 30). It is vital that social workers research, study, practice, and utilize acceptance and commitment therapy to improve the health of our clients and benefit a more significant number of people. Social workers should also contribute to the research on the effectiveness of ACT. Social work educators, practitioners in medical and community health settings, social service and human service agencies, colleges and universities, non-profit agencies, private practices, organizations, communities, and other systems that provides mental health, substance abuse, and social work services should train their social workers in this useful, ethical, and informative transdiagnostic evidenced-based practice.