Program Profile: Acceptance and Commitment Therapy (ACT) for Partner Aggression

This was an emotional- and behavioral-skills enhancement program targeted at adults who engaged in aggressive behavior with their partners. This group-format program aimed to promote psychological flexibility and thereby decrease aggression in participants. The program is rated Effective. Participants reported less physical and psychological aggression at post-treatment and at the 6-month follow up. These findings were statistically significant.

An Effective rating implies that implementing the program is likely to result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program Goals

Acceptance and Commitment Therapy (ACT) aims to increase psychological flexibility and to decrease experiential avoidance. Psychological flexibility is the ability to do what is important, even if psychological barriers (such as anger, fear, or shame) are present. Experiential avoidances is defined as the attempt to change the form, frequency, or situational sensitivity of unwanted thoughts, feelings, and physiological sensations (Hayes et al. 1996). Experiential avoidance occurs when a person is unwilling or unable to deal with certain internal experiences (such as emotions, thoughts, or urges), and instead engages in behavior to alter the form or frequency of those internal experiences, even when doing so may cause harm, including to others. Experiential avoidance is a known risk factor for partner violence, therefore targeting it may be a useful strategy to reduce partner aggression (Zarling and Beta 2017). The program aims to encourage adaptability of participants who may be acting aggressively in an attempt to cope with negative thoughts or feelings. The following six core processes are applied to reach this goal: 1) present moment awareness, 2) acceptance of difficult emotions or thoughts, 3) decrease in believability of (or attachment to) thoughts, 4) perspective-taking, 5) identification of values, and 6) committed action in service of values.

The ACT model was adapted to focus on individuals who engage in partner aggression. ACT for Partner Aggression was a group-format, emotional- and behavioral-skills enhancement program targeted at adults who engaged in aggressive behavior with their partners. The program aimed to promote psychological flexibility and thereby decrease aggression in participants. The ACT model targeted many of the problematic characteristics of partner aggressors, including a low tolerance for emotional distress, low empathy (particularly for an abused partner), and an inability to notice or identify emotions (Zarling and Beta 2017). 

Target Population/Eligibility

Program participants were referred to treatment by mental health professionals at clinics, community mental health centers, and private practices. The participants were seeking treatment for problems that may have included anxiety, depression, substance abuse, and life stressors (e.g., unemployment), as well as more pervasive interpersonal difficulties (e.g., borderline personality disorder). 

Program Components

The program consisted of 12 weekly, 2-hour group sessions that emphasized emotional- and behavioral-skills enhancement techniques to decrease experiential avoidance. The modules focused on the development of each skill in a group context, skills generalization outside the group, and homework assignments. Throughout the treatment, clients completed daily monitoring forms on the emotional and relational consequences of their use of problematic interpersonal behaviors such as aggression. Participants also worked to identify emotional avoidance versus emotional acceptance and the consequences of each. Each session and accompanying description are as follows:  

• Session1: Introduction and values. This session included introductions and an opportunity for clients and facilitators to become acquainted as well as an explanation of the group format and group protocol. Facilitators began to lay the foundation for future sessions by assisting clients in identifying and clarifying the kind of relationships they would like to have, and what behaviors were getting in the way of establishing or maintaining those relationships.
• Session 2: Mindfulness. This session introduced mindfulness and included exercises to promote ongoing nonjudgmental contact with psychological and environmental events as they occurred. This was accomplished by using language more as a tool to note and describe events, and not simply to predict and judge them.
• Sessions 3–4: Emotional intelligence. These sessions focused on increasing emotional awareness and clarity. During these weeks, clients were assisted in improving their ability to identify and differentiate between emotional states and their responses to emotions. An emphasis was placed on the functionality of primary emotional responses, and clients were encouraged to identify both the information being provided by their primary emotions, as well as adaptive ways of acting on this information.
• Sessions 5–6: Acceptance. These sessions focused on the development of emotional acceptance, emphasizing the experiential benefits and emotion-regulating consequences of emotional acceptance, and the long-term consequences of emotional avoidance. In addition to receiving psycho-education on the long-term consequences of these approaches, clients were encouraged to actively monitor and assess the different experiential consequences of emotional willingness (i.e., an active process of being open to emotional experiences as they arise) versus emotional unwillingness.
• Sessions 7–8: Defusion. These sessions focused on understanding the mind and the pros and cons of human language and cognition. In-session exercises and other strategies were used to promote defusion experientially. The goal was to reduce participants’ entanglement with verbal processes and to change the way they interacted with or related to their thoughts.
• Sessions 9–10: Behavioral change/commitment. These sessions emphasized behavioral change, focusing on further values clarification and identifying barriers to adaptive behavioral change. Group work involved a focus on commitment and engaging in actions consistent with valued directions, with an emphasis placed on moment-to-moment choices in everyday living and process rather than outcome.
• Sessions 11–12: Practice, review, and closing. These sessions included a) continued practice of new skills, including interpersonal skills; b) a review of previous group material; and c) a debriefing and discussion of the overall group experience.

Study

Zarling, Lawrence, and Marchman (2015) conducted a randomized controlled trial to evaluate the effectiveness of the Acceptance and Commitment Therapy (ACT) for aggressive behavior on measures of physical and psychological aggression. To be eligible for treatment, individuals were required to acknowledge engaging in at least two physically aggressive behaviors toward a current or former partner in the past 6 months. There were 101 participants who were randomly assigned to receive ACT (n=50) or a support-and-discussion control condition (n=51). Both interventions consisted of 12 weekly, 2-hour sessions. Assessments at pretreatment, during treatment, posttreatment, and 3 and 6 months posttreatment measured psychological aggression (Multidimensional Measure Emotional Abuse Scale [MMEA]), physical aggression (Conflict Tactics Scales [CTS-2]), experiential avoidance (Avoidance and Action Questionnaire [AAQ]), and emotion dysregulation (Difficulties in Emotion Regulation Scale [DERS]).

The mean age of participants was 31.5 years, with ages ranging from 19 to 67 years. The majority of participants were white (82 percent). Sixty-eight percent of participants were female, and in general, the sample was educated; most participants (86.3 percent) had completed some or all of college. Almost all of the participants were in self-identified heterosexual romantic relationships (89 percent). Based on the pretreatment evaluations, the participants met criteria for a range of disorders, including any mood disorder (85 percent), substance use disorder (19 percent), social phobia (46 percent), generalized anxiety disorder (64 percent), borderline personality disorder (71 percent), and antisocial personality disorder (2 percent). Members of the treatment group and the control group were equivalent regarding their baseline characteristics.

Both the treatment and control groups had between 8 and 10 members and two facilitators. One active treatment group and one attention-placebo control group were conducted simultaneously over the course of 1 year for a total of four ACT groups and four control groups. Participants were not asked to stop any individual mental health treatment, and it was assumed that they continued their individual mental health treatment as usual, including the use of psychotropic medications. The treatment condition participated in the ACT group-therapy sessions while the control condition used a strictly support-and- discussion format and provided no instruction on ways to implement behavioral change.

All analyses were conducted with growth curve analytic techniques (Raudenbush and Bryk 2001). Levels and changes in aggressive behaviors and other outcome variables over time were examined at the group level. No subgroup analyses were conducted.  

Three female master’s-level clinical psychology doctoral students, who completed training prior to the beginning of the study, were group therapists. Qualifications for group leaders included more than 2 years of experience conducting therapy under the supervision of psychologists, experience conducting group therapy, training in ACT, and experience conducting ACT in individual treatment. Additionally, facilitators were required to participate in each group as a member before serving as a co-facilitator (Zarling, Lawrence, and Marchman 2015). All group sessions were audio-recorded and reviewed for protocol adherence and continued competence in study protocols. Adherence checklists were developed specifically for this study to provide guidelines for group leaders and to detail the content that ideally would be covered in each session. The checklist included criteria rated on a scale ranging from 1 (non-adhering) to 5 (excellent adherence). Therapists were rated as adherent on 92 percent of the ACT tapes and 94 percent of the control tapes. Overall, this pattern of results shows that the ACT and control conditions were distinct and implemented in accord with their respective treatment protocols (Zarling, Lawrence, and Marchman 2015).  

These sources were used in the development of the program profile:

These sources were used in the development of the program profile: