The U.S. correctional system faces an increasingly daunting challenge: providing mental health care to an inmate population disproportionately affected by serious mental illness. Literature shows nearly two-thirds of inmates in state and federal prisons have a mental health problem, with rates of major depressive disorder and psychotic disorders exceeding those found in the general population (Bronson & Berzofsky, 2017). Psychiatrists and other mental health professionals use many tools to help mitigate this crisis. Acceptance and Commitment Therapy (ACT) has emerged as a potentially transformative therapeutic model.
What is Acceptance and Commitment Therapy?
Developed by psychologist Steven C. Hayes and his colleagues, ACT is a form of cognitive-behavioral therapy emphasizing mindfulness, values-based action, and psychological acceptance (Hayes et al., 2011). Unlike traditional CBT, which seeks to change the content of distressing thoughts, ACT aims to shift one’s relationship with these thoughts – encouraging awareness of the present moment and a willingness to experience painful cognitions without avoidance or struggle. ACT teaches us the skills to accept discomfort.
Several factors make ACT particularly well-suited to the corrections environment:
- Focus on values and committed action: ACT’s emphasis on identifying core values and taking action towards them can empower a sense of purpose and meaning, potentially countering the sense of hopelessness prevalent among inmates. By identifying one’s true values and connecting actions to those values, individuals can find motivation for positive behavioral change, even in the face of challenging circumstances.
- Mindfulness and acceptance as resilience skills: ACT teaches inmates to observe their thoughts and emotions with acceptance and understanding rather than becoming entangled in the anxiety of them. These skills can enhance resilience, helping individuals cope with the stresses of incarceration and potentially reducing the risk of self-harm, aggression, and maladaptive behaviors.
- Group format and efficiency: ACT can be delivered individually in a facilitated text. The therapist gives handouts or modules on ACT to the patient, and then they work through them at the next meeting. ACT also works in a group format, making it a more resource-efficient option compared to other individual therapies. This group option addresses the logistical challenges and staffing limitations common in correctional settings.
- Adaptability: ACT’s focus on processes (e.g., mindfulness, cognitive defusion) over specific topics allows it to be tailored to the unique needs and concerns of inmates, such as addressing trauma, substance use, depressed mood, grief, or anger management.
Emerging Research and Future Directions
ACT is already established as an evidence-based therapeutic model, with consistent success in the general population. The research base for ACT in corrections is still developing, but early studies offer encouraging findings. A pilot study of ACT for inmates with opioid addiction found significant reductions in substance craving and depression symptoms, as well as increases in mindfulness skills (Vilardaga et al., 2011). Another study of an ACT program for incarcerated veterans with PTSD showed promise in reducing symptoms of trauma and improving quality of life (Walser et al., 2013).
The corrections system continues to seek innovative solutions for addressing mental health, and ACT warrants further investigation. Larger, randomized controlled trials are needed to establish its efficacy compared to other therapeutic approaches. Additionally, research should explore the optimal methods for ACT delivery in corrections (e.g., length of program, facilitation by trained vs. peer facilitators).
Acceptance and Commitment Therapy offers a unique set of tools and principles that may enhance mental health care within the corrections system. By promoting psychological flexibility, values-based action, and a willingness to experience discomfort and even pain in the pursuit of meaning, ACT has the potential to foster resilience and support rehabilitation among inmates. As mental health professionals, we must remain open to innovative approaches and committed to providing compassionate, effective care to this underserved population.
Dr. C.J. Rush D.O., M.S.(MedEd), CCHP
Chief Psychiatric Officer
References:
Bronson, J., & Berzofsky, M. (2017). Indicators of mental health problems reported by prison and jail inmates, 2011-2012. Bureau of Justice Statistics.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2011). Acceptance and commitment therapy: The process and practice of mindful change. Guilford Press.
Vilardaga, R., Waltz, J., Levin, M. E., Fisher, A., & Hayes, S. C. (2011). From coping to radicals: Acceptance and commitment therapy for opioid addiction. Journal of opioid management, 7(6), 415-428.
Walser, R. D., Karlin, B. E., Trockel, M., Mazina, B., & Barr Taylor, C. (2013). Training in and implementation of acceptance and commitment therapy for depression, anxiety, posttraumatic stress disorder, and traumatic brain injury: VA interprofessional practice committee recommendations. Journal of Clinical Psychology, 69(9), 940-952.
