Transcript Acceptance & Commitment Therapy

Acceptance & Commitment
Therapy
Patty Bach
University of Central Florida
Agenda
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Introductions
An overview of the ACT model
The core processes
Experiential work on the core processes
Case conceptualization
ACT and the clinician
First, a few housekeeping items…
Informed Consent
• At times this workshop will be
experiential
• Your privacy will never be violated, but
you will be invited to take a few risks if
you choose
• Confidentiality
• No judging the level of risk taking of
others: go for it or not, it is up to you
Introductions
• Your name, your work setting
• What do you hope to get out of these two days?
What is ACT?
• A form of CBT
• A form of clinical behavior
analysis
• A mindfulness-based
treatment
• Functional contextual
therapy
– Behavior is situationally
bound
– Behavior is functional
Acceptance and Commitment Therapy
• A contextually focused form of cognitive
behavioral therapy that uses mindfulness and
behavioral activation to increase clients’
psychological flexibility – their ability to
engage in values-based behaviors even while
experiencing difficult or unwanted thoughts,
feelings, and sensations. (http://nrepp.samhsa.gov, 2011)
Does ACT work?
• Meta-analytic studies support effectiveness of ACT
Hayes et al., 2006; Powers et al., 2009; Ost 2008
• RCTs for treatment of many different problems
Anxiety disorders, chronic pain, psychosis, trichotillomainia,
substance abuse, depression, eating disorders,
management of medical problems, obesity, epilepsy,
impulse control disorder, etc.
Psychological Flexibility
• The primary measure of PF is the Acceptance
and Action Questionnaire
– Differentiates patients from healthy controls
– Is correlated with variables largely consistent with
predictions
– Shows treatment sensitivity
– Explains unique variance
– mediates and moderates as predicted
Bond et al., 2011; Gloster et al., 2011
Is ACT an Evidence-Based Practice?
• National Registry of Evidence-based Programs
and Practices (NREPP)
• APA Division 12
– ACT for chronic pain
– ACT for depression
• Veterans Administration
One difference between ACT and some
other treatment approaches
• There is no attempt to reduce symptoms in
ACT.
• Symptom reduction often occurs, and it is a
byproduct of treatment rather than an explicit
goal of treatment.
Can you mix ACT with other treatment
approaches?
• Mindfulness is widely applicable (just be sure
to apply it mindfully!)
• Values clarification can build tx motivation
• Most problematic is mixing acceptance and
cognitive defusion with cognitive restructuring
Can you mix ACT with other treatment
approaches?
• The ‘Committed Action’ process often includes
other EBP’s
– ERP
– Habit reversal
– Behavior activation
– skills training
ACT Therapeutic Stance
• Universality - The struggles we have are not fundamentally
different from other human beings. We communicate this to
the client.
• ACT is an experiential therapy in which the therapist is
personally invested in the client, but is radically respectful of
the client’s struggles and values.
• To do ACT competently, you need to deal with your own
anxieties in the same way you are asking your clients to deal
with their anxieties.
– Open up to them
– Get in contact with your goals and values
– Do what is there to be done (Hayes, 2006)
Contact with
the Present
Moment
Acceptance
The ACT model
Values
Psychological
Flexibility
Committed
Action
Defusion
Self-asPerspective
• A trip around the hexaflex
Contact with
the Present
Moment
Acceptance
The ACT model
Values
Psychological
Flexibility
Committed
Action
Defusion
Self-asPerspective
The outcome of ACT is
psychological flexibility
• The ability to contact the present moment
fully as a conscious historical human being
and, based on what the situation affords,
changing or persisting in behavior in the
service of chosen values
-Hayes
How do you know you’ve got ‘psychological
flexibility’?
Vitality!
Assumptions of ACT
• Pain in life is inevitable
• Normal verbal processes contribute to
psychopathology
• Control is best applied where it works - to
overt behavior rather than to thoughts,
feelings, and sensations
• “The aim of ACT is to create a rich, full,
meaningful life while accepting the pain that
inevitably goes with it.” (Harris, 2009)
Show up for your own life
What gets in the way of vitality?
The ACT ‘inflexahex’
“The single most
remarkable fact about
human existence is how
hard it is for humans to be
happy.”
(Hayes, Strosahl, & Wilson, 1999)
Myths that perpetuate unworkability
1. Happiness is the natural state for all human
beings.
2. If you’re not happy, you’re defective
3. To create a better life, we must get rid of
negative feelings.
4. You should be able to control what you think
and feel.
The Assumption of
Healthy Normality
• By their nature humans are psychologically
healthy
• Abnormality is a disease or syndrome
driven by unusual pathological processes
• We need to understand these processes
and change them
The Major Reason to
Suspect this is False
• The ubiquity of human suffering
The Ubiquity of
Human Suffering
• High lifetime incidence of major DSM
disorders
• High rates of substance abuse, divorce, sexual
concerns, abuse, obesity, violence, prejudice,
loneliness
• Some extremely destructive behaviors are
both common and non-syndromal, e.g.,
suicide, self-injury
The Ubiquity of
Human Suffering
• People don’t just suffer when things are bad
• We suffer when things may be bad
• What is the consequence of withdrawing from
suffering?
Alternative Assumption:
Destructive Normality
• Normal psychological processes often are
destructive
• We need to understand these processes
and work within them to promote health
• One cause: human language and cognition
– human verbal behavior
Language is a Blessing and a Curse
• Evaluation
• Problem solving
• Avoidance
Your mind is not your friend
• It’s not your enemy either, and one thing
minds are very good at is evaluating
Evaluation Judgment
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You’re not wrong, just stupid…
Only an idiot would say that
I hope people like you die next
I don’t know what to believe anymore
Learn how to spell moron
#$@!^&(!
Why are you reading this article if you ‘don’t care’??!
Censored
People like you are the problem with this country
You’re not good enough
Problem solving
• Problem = something
we don’t want
• Problem solving =
Finding a way to change it,
avoid it, or get rid of it
The Problem with problem solving
• Problem solving works
great in the world of
things, and not so well
when we apply it to
private events
Acceptance of the
Unworkability of Control
• Why we stick with it
– It works elsewhere
– It seems to work for others
– You are told it should work for you
– It even SEEMS to work short run
Experiential Avoidance
• Experiential avoidance is built into
human language and then
amplified by the culture
– Experiential avoidance is the
tendency to attempt to alter
the form, frequency, or
situational sensitivity of
historically produced negative
private experience (emotions,
thoughts, bodily sensations)
even when attempts to do so
cause psychological and
behavioral harm
Experiential Avoidance
• Avoiding
unwanted
thoughts and
feelings…
• Increases
their
intensity
• And their
frequency
Avoidance
• “A person often meets
his destiny on the road
he took to avoid it”
-Jean de la Fontaine
Higher Avoidance Scores Are ….
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Higher anxiety
More depression
More overall pathology
Poorer work
performance
– Inability to learn
– Substance abuse
– Lower quality of life
7/17/2015
– History of sexual abuse
– High risk sexual behavior
– BPD symptomatology
and depression
– Thought suppression
– Alexithymia
– Anxiety sensitivity
– Long term disability
Sources: Hayes et al (2004); Polusny (1997); Toarmino (1998); Pistorello (1997); Batten, Follette, &
Aban (1998); Stewart, Zvolensky, & Eifert (1998);
The Tree of Knowledge is Useful,
Necessary, and Toxic
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Draws us into the future or past
Produces cognitive entanglement
Supports experiential avoidance
And even claims to BE us
And yet it is needed and it is virtually unstoppable.
What shall we do when nothing we do will do?
Hayes
Central Clinical Insights
• Trying to get rid of thoughts and feelings can
makes difficult ones more important, and
• Narrows behavioral repertoires
• But we can bring the functions of mind under
better contextual control
• We do that by learning to relate to the mind in a
different way
• That is one of the larger messages of mindfulness
methods -Hayes
If you’re not willing to have it, then
you’ve got it
• A few examples.
• And a corollary: If you’re not willing to lose it,
then you’ll lose it
The alternative is acceptance
Creative Hopelessness
• Experienced by the client when she notices
that there is an unworkable change agenda.
• The client is NOT hopeless…the change
agenda is hopeless
• the client has tried to make things better for
herself by using control strategies in contexts
where they don’t work
• Creative hopelessness creates a space for
something new to happen.
Hopelessness
(non-creative kind!)
• Nothing has helped
• You are my 6th (10th, 37th) therapist…
• Meds, CBT, EMDR, acupuncture, prayer, etc.
weren’t helpful, and I am hoping that ACT
might help.
• I’ve relapsed at least a dozen times
• I don’t expect this to help, and I’m here
because I promised my wife...
The solution is part of the problem
• Doing more of the same
• Using control in contexts where it is unhelpful,
difficult, or impossible
– When control is useful
– When it isn’t
– Pain Vs suffering
That thing you do…
Creative Hopelessness How To
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Remain curious. Hold assumptions of EA lightly.
Don’t get caught up in content.
Sit with uncertainty and confusion.
Watch for it in session.
Remain on equal ground.
Acceptance of Where You Start
• 10 minutes in role – yourself or a client, do not say
which
• Try to help the person walk into the struggle with
thoughts, feelings, memories, urges, or sensations
• Examine the workability
• Try to help the client clear the field experientially of
unworkable “solutions” – but do not judge from
outside. Instead ally from within.
• Notice the pull to rescue or change but do neither
Acceptance
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Control is the problem/Two scales metaphor
Feeding a baby tiger
Tug of war with a monster
Chinese handcuffs/monkey trap
If you’re not willing to have it/lose it…
Polygraph exercise
Clean Vs dirty discomfort
Cognitive fusion
• Inflexible behavior
influenced more by
verbal networks than by
recently experienced
environmental
consequences
Cognitive fusion
• Verbally related antecedents and
consequences such as thoughts, feelings,
judgments and memories have more influence
over responding than direct experience with
the world
• i.e., the person ‘living in his head’
Cognitive fusion
• Look for instances where responding is guided
by evaluations and inflexible rules
• This may look similar to ‘irrational beliefs’
Get out of your mind and into your life
Identifying Hooks
• Hooks look tasty, and
instead of moving us
forward they often keep
us stuck
That thing you do II
• Where are you fused?
• Name tag exercise
Defusion
• Looking at thoughts rather than from thoughts
• Seeing thoughts as what they are, not as what
they say they are.
• In contact with direct experience rather than
thoughts about experience
Defusion metaphors and demos
• The automaticity of
language
• Mary had a little…
• Lemon, lemon, lemon
• sunglasses
Defusion exercises
• Bad cup
• Physicalizing
• “I’m having the thought
that…”
• And versus But
• Taking your mind for a
walk
• Notice that these exercises are not just
defusion exercises, but also entail acceptance,
i.e., are you willing to have what shows up
without trying to change it?
• Fusion is also related to attachment to the
conceptualized self
Fusion and the therapist
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I’m a fraud
I’m not ready
I’m incompetent
I can’t do this
What if I screw up?
Her problem is too
difficult
• I have no idea what to do
• I’ll never be able to relate
to this client
• I don’t like this client
Dominating concept of the evaluated past
and/or feared future
• Fusion with the verbally constructed past or
future means that one is not in contact with
the present moment
• Words pull us into the past and future
– Rumination about the past or feared future
– Procrastination
– Anticipatory anxiety and avoidance
Contact with the Present Moment
• “Mindfulness means paying attention in a particular
way: on purpose, in the present moment and nonjudgmentally.” Kabat-Zinn
• Mindfulness practice is based on the premise that
only in the experience of the present moment can
one accurately perceive what is really happening,
when life is fully appreciated without the need to
judge it, and when effective action can be taken.
Contact with the present moment
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Meditation/mindfulness
Leaves on a stream/soldiers in a parade
Just noticing
Tin can monster
One minute mindfulness
Counting to 10
Mindlessness in therapy
Mindfulness
• Mindfulness takes practice
• Do not invite your client to try any mindfulness technique you have not
first practiced yourself!
Self as context and Senses of Self
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Self as content
Self as process
Self as context (self as perspective)
These are not to be construed as three
different selves, or as the only three possible
senses of self
• They are three senses of self that pertain to
self-knowledge
Self as content
• A conceptualized self is useful
• It allows us to participate in a verbal social
community and answer questions such as:
– What is your name?
– What do you do for a living?
– Where do you live?
– Is that your son?
– How old are you?
– Tell me about your hobbies
Attachment to the conceptualized self
• The conceptualized self
is the same thing as
self-as-content and
attachment to the
conceptualized self is
usually related to fusion
with content
Attachment to the conceptualized self
• During case conceptualization look for
statements such as:
• I am too…
• If only I did…(or didn’t…) then I would
• My problem is that I…
• I am a (failure, loser, wimp, druggie, etc.)
• I am not (smart, pretty, strong) enough
• I can’t…
Once upon a time…
• We each have stories
about our lives, our
selves. How much of
that the story is fused
content? How flexible is
the story?
Tell me another
A short story about authenticity…
Now it’s your turn!
Weak self-knowledge
and self as content
• Not usually problematic in most clinical setting –
clients are more likely to be too attached to/fused
with content
• May be problematic when one small piece of the
conceptualized self dominates, e.g., being defined by
“I got fired from a job” “I flunked mathematics” “I
was abused”, while ignoring most other content
• May be problematic in lower functioning clients who
have others care for them and limited opportunity to
build up a sense of self
Self-as-process
• Self-as-content refers to how one might
describe the self.
• Self-as process is noticing what one is
experiencing in the present moment, e.g.,
ongoing self-awareness
• The client with poor ongoing self-awareness
doesn’t know what he is thinking or feeling.
Self as process
• It is experienced when we notice our own private or
public experience in the present moment
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I feel sad (or hungry, tired, anxious, happy)
I am thinking about what to have for dinner
I am walking to the coffee shop
I am typing an email message to my boss
I am having the thought “I don’t want to go”
I am having a panic attack
I am obsessing about germs
Weak self-knowledge and
self as process
• Alexithymia – the inability to describe ones
feelings
• Clients who show excessive pliance are often
out of touch with their own thoughts and
feelings and may answer “I don’t know” or
“what do you think?” or “what do you want to
do?”, when asked to share an opinion or
desire
Self as context
• Sometimes described as ‘the observing self’ or as
‘pure consciousness’ or ‘the self that is aware but
does not think’
• Purely experiential so difficult to put into words
• The sense of self we get a glimpse of when we notice
that we experience from a perspective or locus;
often experienced during mindfulness practice.
• While our thoughts and feelings change and events
change over time they are experienced from a
unique perspective – YOU as the perspective from
which your life unfolds
Weak self-knowledge and
Self as Perspective
• May be problematic when ability to contact
self as perspective has not been learned or is
immature
• Evidence for weak self-knowledge in this
domain might be a client who is at a loss to
describe values and life goals
• Aimlessness, inertia, lack of vitality
Self-as-context
• As you can see, self-as-context is difficult to
describe in words.
• Best contacted experientially
The observing self
• Guided exercise
Self as context exercises
• Chessboard metaphor
• Three senses of self discussion/link with
defusion work
• Observing self exercise
• Mental polarity
Values
• Chosen life directions; values give lives
meaning
• In values work, distinguish choices from
reasoned actions; to understand the
distinction between a value and a goal; to help
clients choose and declare their values and to
set behavioral tasks linked to these values
Choice and reason giving
• Are you making a choice
or do you “have to”?
• Reason giving
• Doing things ‘with
reasons’ rather than ‘for
reasons’
Lack of values clarity
• The client may describe a general lack of
vitality and be vague about values and goals
Values clarification exercise
• Values worksheets
• bullseye
Outcome Vs process
• Outcome is the process through which process
becomes the outcome…
Values exercises
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Defining values
Values narrative
Skiing metaphor
Green pen.argyle socks
Epitaph/lifetime achievement
Deciding vs choosing
Outcome is the process through which process
becomes the outcome
Committed Action
• Overt behavior in the service of
values/moving in a valued direction
Persistent inaction, impulsivity, or
avoidance
• This is often the domain that is most obvious
to clients (and significant others and
therapists!) and often is what influences them
to seek help
Persistent inaction, impulsivity, or
avoidance
• The clinical question in this domain is:
• What is the client doing too much of, too little
of, or doing in inappropriate contexts?
• What is the client doing in the service of
experiential avoidance?
• What is the client doing that gets in the way of
valued living?
• What does the client want to do, learn,
experience?
That thing you do III
• Barriers to valued living
Committed Action
and barriers to committed action
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Eyes on
Exposure
Ball and chain
Jump
Garden metaphor
Joe the bum
Take your keys
Values
• What values bring you to this work?
• What do you want your professional practice to be
about?
Committed action
• What actions will help you reach goals in the
service of your values?
• What are the barriers to committed action?
• “Be yourself: everyone else is already taken” –
Oscar Wilde
Lack of values clarity and committed
actions
• What’s that in the service of?
• Whose values are we talking about?
• What do you want your life to be about?
Commitment
• What’s your commitment?
The outcome:
Psychological Flexibility!
• Vitality, competence
• Questions?
Useful references
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[email protected]
contextualscience.org (ACBS official site)
www.newharbinger.com
Hayes, Strosahl & Wilson (2012). Acceptance and
Commitment Therapy. Guilford
• Bach & Moran (2008). ACT in Practice: Case
Conceptualization in Acceptance and
Commitment Therapy. New Harbinger
• Harris (2009). ACT Made Simple. New Harbinger.