1. Robyn D. Walser, Ph.D. Robyn.walser@sbcglobal.net
Acceptance and Commitment Therapy: Using Mindfulness and Values to Make Powerful Life Enhancing Choices
Robyn D. Walser, Ph.D.
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2. Welcome and Housekeeping
Lunch, breaks, restrooms
Put cell phones vibrate/silent
Please refrain from texting during the workshop
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3. Additional Goals To train you in ACT
To help you to engage with and work more effectively with your clients
To give you new ways to make a difference in the lives of your clients
To reduce burnout and bring more vitality to your work
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4. Training Support… Resources Books: New Harbinger
Supervision/Consultation: Contexutalscience.org
Trainings
ACBS
Videos
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5. Training Workshop Day 1 Day 2
Mission of ACT-D Training and Implementation
Theory of treatment
Begin to work through application of ACT
Day 2
Application of ACT
Case Conceptualization
ACT and the therapeutic relationship
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6. Informed Consent: Workshop
This training is experiential in nature:
Designed this way to increase understanding of the theory and to help clinicians contact the core of the work
May stir a few things up
What might that look like….
Your privacy will never be violated, but you will be invited to take risks.
For that reason we must agree to confidentiality
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7. A Request Intend for these three days to make a difference
My commitment:
To stay present
To step forward
To serve you in this joint effort
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8. Introductions In less than a minute: Your name About you
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9. Research on ACT Short summary: See ACT/RFT Reader’s Update (website)
Principle based intervention and is used to treat a variety of disorders and cultural problems
Over 65 RCT’s showing ACT as good as or better than tx as usual (more studies under review or under investigation)
Targeted processes addressed in ACT (experiential avoidance/acceptance mediate outcomes in most studies)
See ACT/RFT Reader’s Update (website)
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10. Research…
The United States Substance Abuse and Mental Health Services Administration (SAMHSA) has now listed ACT as an empirically supported method as part of its National Registry of Evidence-based Programs and Practices (NREPP):
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11. Research….
APA Division 12 approves ACT as EBP for several disorders
Articles reviewing the literature/ACT/RFT Readers Update
Contextualscience.org
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12. ACT Core Competency Subscales
Therapist Outcomes
ACT Core Competency Subscales
Core Competency
Subscale Mean
Early Phase
Mean (SD)
Middle Phase
Late Phase
Basic ACT Therapeutic Stance
3.1 (0.8)
3.6 (0.7)
4.0 (0.6)
Developing Acceptance & Willingness, Undermining Control
2.8 (0.7)
3.4 (0.6)
3.8 (0.6)
Undermining Cognitive Fusion
2.5 (0.7)
3.1 (0.6)
3.5(0.6)
Getting in Contact Present Moment
2.6 (0.7)
3.2 (0.7)
3.7 (0.6)
Distinguishing the Conceptualized Self & Self-as-Context
2.2 (0.8)
3.0 (0.7)
3.5 (0.7)
Defining Valued Directions
2.4 (0.8)
3.7 (0.7)
Build Patterns Committed Action
2.1 (0.9)
3.0 (0.8)
Total Score
75.6 (19.1)
96.3 (17.7)
111.1 (16.4)
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13. Introduction and Theory
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14. Depression Human cost is much greater Vitality, viability
Strain on personal, familial and professional relationships
Suicide
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15. Anxiety: Same Story Human cost is much greater
Among the most prevalent,
Accounted for 31% of total costs of mental health care
Annual estimated cost at $45 billion
VA: PTSD, Panic, Generalized anxiety, phobias, worry
Human cost is much greater
Vitality, viability
Strain on personal, familial and professional relationships
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16. “The single most remarkable fact of human existence is how hard it is for human beings to be happy.”
- Steven C. Hayes
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17. The Situation Most humans are hurting
It is hard for humans to be happy – we have shelter, warmth, food, yet we have misery, suicide, alcohol, etc.
Every day of every year – suicide/alcohol/checking
It is easy to sink into a psychological struggle
Suffering is pervasive
This is not happening in non-humans
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18. The Issue
To sensitize you to the role that language plays in human suffering
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19. The Target
To make experiential contact with previously avoided private events without excessive verbal involvement and control – and to make powerful life enhancing choices.
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20. The Assumption of Healthy Normality
Underlying assumptions of psychological mainstream
Follow the medical model
Psychological health is the natural homeostatic state
This state is disturbed by illness or distress
Example of suicide
By dividing the world into normal and healthy versus abnormal and disturbed – we have failed to see that most humans suffer
We have narrow measures of psychological health and effective living
It is difficult to create fundamental change
Up to 60% have suicidal ideation/verbalization or serious ideation (Chiles and Strosahl)
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21. What if? Normal to be abnormal The answer lies in the ordinary
Psychological health is a goal, not an automatic possession.
We have to earn it.
Why psychological health is not automatic
We aren’t built that way
Would we want to be?
The answer lies in the ordinary
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22. Verbal Knowledge: Language
We have knowledge:
Relational Frame Theory
Theory of human language and cognition
What we are doing with our minds: describing categorizing, relating, evaluating, talking about, writing, reading, thinking
Based on principles of learning
Generalized operant
Relating as a class of behavior
(RFT)
Briefly explore the Yvonne Barnes-Holmes info from the Metaphor Video
*Regarding this video…explaining how the metaphors, used at the proper moment in therapy, permit clinicians to make use of RFT--WHETHER THEY GET RFT OR NOT—may be helpful here. E.g., using cognitive disputation re: specific cognitive distortions permits cognitive therapists to intervene in a manner that is consistent with the cognitive model. This is true regardless of whether that clinician could articulate the cognitive model. The idea that ACT is not REALLY based on RFT because many therapists don’t get it just is not sound; it’s the same issue with most schools of therapy.
Regarding the Metaphors/Barnes-Holmes piece: I also imagine that you may need to do this toward the end, reflecting on the training, rather than in the midst of it. It may be over their heads at this point (?).
The major source of the problem is language. Two sides to the force – we deal with the dark side.
Why not automatic and normal?
Human language has only existed for a short period of time- 450 generations ago – cave drawings; 200 generations – written language; 60 – 100 generations – inventing and science. Hard to modify within this time frame
Verbal behavior pays off biologically. Although it can create misery, it has not put us at a competitive disadvantage – we produce and reproduce easily.
Human misery is learned: people aren’t broken
Verbal behavior pays off culturally. Symbolic activity enormously increases the ability to pass cultural practices on. + Carries great advantages biologically even if suffering –written language and knowledge.
Practices can propagate at the level of group – even if destructive to individual.
Suicide
Unpleasant work environment
*Questions becomes: Can we have the cultural and biological advantages of human language and avoid its psychological cost? ---We cannot go back to the Garden of Eden. ***Said another way: we cannot un-bite the apple.
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23. RFT We live in a world of relations:
One thing comes before or after another
One object is bigger or smaller
Something is hotter or colder
This is the same as that
This object is below that object and the other above
This thing is over here, that thing is over there
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24. RFT
Operant behavior is controlled by relations between certain behavior and its consequences
Through language we find a “work-a-round”
We free ourselves from direct stimulus functions and transform these functions by putting things in relation in a particular way
A monkey can react to relations like…choosing the longest stick….this is an actual relation
Humans can react to relations that are arbitrary and can be established by the social context
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25. We learn to react to one stimulus in terms of another
RFT
@ is 2 times as much as # (arbitrary relationship)
Let’s assume that # is 10 dollars
@ now acquires a new function – one that would influence what you would do if you were asked to pick
@ or #
But what if # is a hard punch in the face?
Are you still wanting to
We learn to react to one stimulus in terms of another
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26. What is the natural relationship between these two things?
= C A R
C A R = GRAP
Now what do we also know about graps?
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27. RFT
In addition to making these relations with cars, we also do it to ourselves and others
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28. Verbal knowledge is our blessing and our burden
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29. Good…… Language is useful: Communicate Predict and plan
Solve complex problems
Develop rules to regulate behavior
Learn from people and cultures that no longer exist
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30. …….and Bad Only species aware of our own death
Create an idealized future
Evaluation
Form negative opinions about ourselves and others
Construct hateful and prejudice beliefs
Obsess or relive traumatic events
Develop rules for acting that are harmful and ineffective
Excessive use of language makes it difficult to maintain contact with the present moment
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31. Our “Minds” Do Not Always Know What is Good for Us
As noted, we can verbally construct needs, dangers, and futures and take action based on these constructions
We struggle for no reason and hold on when we should let go
We live in a derived, verbally regulated reality rather than to experience the world as it unfolds in the here and now
Language is overemphasized as a means to achieving well-being
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32. Our Relationship With Private Events
People become identified with the content of their mental life to a large extent:
Example: Vietnam Era Veteran
Disentangling people from their “minds” is one of the main goals of ACT
Helping people get back in contact with another way of knowing the world
Verbal knowledge vs. experiential knowledge
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33. Fusion, Evaluation, Avoidance, & Reason-giving
How are we entangled?
F.E.A.R.
Fusion, Evaluation, Avoidance, & Reason-giving
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34. Fusion:
Literality: cognitive fusion occurs when a person holds their thoughts to be literally true.
Exercise: Lemon
ACT aims to alter the context in which thoughts occur so as to decrease the impact and importance of difficult private events
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35. Evaluation: We hold it as if it exists in the object
Under this circumstance it seems that it must be given into, argued with, undone, put out of one’s mind
“Good” cup, “Bad” cup
Exercise: 3 Volunteers
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36. Avoidance: Social training of cognitive and emotional control
Avoid that which should be avoided - nonhappiness
“Just forget about X”
“Get on with it”
“I can’t control my depression”
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37. Reason-Giving
Believing one’s stories: refers to verbal explanations and justifications that clients give for their actions.
Behavior is caused
Reasons are causes
Thoughts and feelings are good reasons
Thoughts and feelings become accepted as legitimate causes for dysfunctional actions
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38. Reason-Giving Why this might not be so
We don’t have access to all variables
We can’t formulate it even if we did
Even if true, too small a part of the real picture
This is not the function of reasons
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39. …..Are thoughts and feelings are good reasons….
There is evidence that people believe this
It is in lay talk
It receives support from the verbal community
Creates a problem: if these reasons are causes, what caused them?
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40. The Conclusion:
If you want to change the outcome, change the thoughts and feelings.
We are deep into this conclusion
We hold a repair model of human happiness
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41. The usual agenda for therapy: FEEL GOOD
MORE, BETTER, DIFFERENT
If a client comes to us they have generally not found the right way to fix their problem:
They say, “Why am I failing?”
“I am failing because I need more _______”
Will power, emotional control, confidence
Or “less _________”
Anxiety, depression, stress, worry, urges
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42. Problem with these “feel good” change efforts:
Even if it works it can give an undesirable meta-message
Encourages people to live some other history than what they have
Seems to support oppressive cultural practices: BE GOOD
Creates needless trauma
Possibly increases our failure rates
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43. Is there another way?
In the place of literal meaning, there are multiple meanings (your thinking, what is present, context, history, feelings)
In the place of evaluations – own your evaluations and do what works
In the place of reason-giving – honest ignorance and commitment to a course
In the place of emotional control – emotional acceptance
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44. Accept and Commit
The Acceptance and Commitment Therapy (ACT) approach assumes the position that clients can learn to accept their own emotions and deliteralize their own thoughts such that they do not have a significant negative psychological impact, even if these emotions and thoughts continue to occur.
Rather than change the form or frequency of the thought/feeling– ACT seeks to change the function.
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45. Six Core Processes Open, Aware, Active
Foster acceptance and willingness while undermining the dominance of emotional control and avoidance (Acceptance).
Undermine the language-based processes that promote fusion, needless reason-giving, and unhelpful evaluation (these can cause private experiences to function as psychological barriers to life promoting activities) (Defusion).
Live more in the present moment, contacting more fully the ongoing flow of experience as it occurs (Present Moment).
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46. Core Processes Continued
Make experiential contact with the distinction between self-as-context versus the conceptualized self to provide a position from which acceptance of private events is less threatening (Self-as-Context).
Identify valued outcomes in living that will legitimize confronting previously avoided psychological barriers (Values).
Build larger and larger patterns of committed action that are consistent with valued life ends (Committed Action).
Open, Aware, Active
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47. OR….
Using a unique set of experiential and mindfulness exercises that promote acceptance of self and others, while working to define personal values and also to support efforts at making and keeping commitments related to those values.
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48. The Model
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49. Living in the past; worrying about future; Limited self knowledge
Attachment to the
conceptualized self
Living in the past; worrying about future;
Limited self knowledge
Cognitive
fusion
Experiential
avoidance
Inaction, Impulsivity, or
Avoidance
Lack of values
clarity/contact
Psychological
In-flexibility
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50. Instead of running away from your emotions --- Acceptance
Contact with the Present Moment
Values
Defusion
Committed Action
Self-as-context
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51. Instead of arguing with your mind--- mindfulness. We call it defusion.
Contact with the Present Moment
Values
Acceptance
Instead of arguing with your mind--- mindfulness. We call it defusion.
Committed Action
Self-as-context
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52. Instead of living in the past or worrying about the future -- Contact the present moment, slow down and show up
Values
Acceptance
Defusion
Committed Action
Self-as-context
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53. Instead of attachment to the conceptualized self –
Contact with the Present Moment
Values
Acceptance
Defusion
Committed Action
Instead of attachment to the conceptualized self –
Self as context; Consciousness;
experiencer, not the experienced.
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54. Instead of a life focused on emotion, thought and symptom elimination –A values guided life; What do you want to stand for?
Contact with the Present Moment
Acceptance
Defusion
Committed Action
Self-as-context
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55. Contact with the Present Moment
Values
Acceptance
Instead of inaction and remaining stuck –Commitment; getting your feet moving in the direction of what matters to you?
Defusion
Self-as-context
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56. Acceptance and Commitment Therapy
Psychological
Flexibility
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57. Psychological Flexibility
Psychological flexibility is contacting the present moment fully as a conscious human being, experiencing what is there to be experienced and working to change behavior such that it is in the service of chosen values.
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58. Tools of the Trade
Difficulty with giving verbal rules to instruct experiential material
Use of metaphors, stories, and experiential exercises
Distinction between mind and experience
Functional analysis of behavior
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59. Functional Analysis of Behavior
A single ACT of behavior can have multiple functions
Mr. Brown waves to his neighbor:
To be friendly
To avoid hurting his neighbors feelings
To avoid feeling awkward
To please his wife
Many behaviors can have the same function
Mr. Brown waves to his neighbor
Discreet bow
Raising of arm high in the air
Lifting his hat
Saying “hi there.”
Function not form
Too often we pay attention to the topographical aspects of behavior rather than the functions
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60. Ask: What is the context in which the behavior occurs
Ask: What is the context in which the behavior occurs? And what is the behavior’s purpose?
What came before, what did you do? What happened?
Consequence
Decreases sadness temporarily
Antecedent
War reminder
Behavior
Avoid the setting
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61. Centered Open Engaged Acceptance Values defusion Committed Action
Present Moment
Acceptance
Values
defusion
Committed
Action
Self-as-Context
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62. Application of ACT Several ACT protocols Things to think about
12 sessions-ish
Longer term
Things to think about
Brief introduction/summary
Informed consent
Assessment
Other materials: client handouts/homework
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63. Informed Consent General discussion of operating principles
What happens in ACT is contained in it’s name
ACT is an experiential therapy
Much of the learning occurs in the doing
Explanations cannot sufficiently depict this experience
Discuss areas of ambiguity
Commit to a course of treatment
Agree not to measure progress impulsively
Hang out long enough to see if it is working
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64. The Application and Technique Part
Six Main Goals of ACT:
Creative hopelessness
Control of private events as the problem
Willingness/Letting go of the struggle
Self as context rather than content
Values
Commitment and behavior change
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65. - Chinua Achebe, from Arrow of God (1967, p. 84)
“When suffering knocks at your door and you say there is no seat for him, he tells you not to worry because he has brought his own stool.”
- Chinua Achebe, from Arrow of God (1967, p. 84)
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66. Creative Hopelessness
Bring individual into experiential contact with the fact that what they have done so far has not worked
Exercise: Struggles?
What have you done to make these go away?
How did it work?
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67. Creative Hopelessness
Tried, but problem remains
The problem is not one of motivation
The problem is not one of specific tactics
The problem is not like other areas of life
The problem: More, Better, Different
Here we are talking about control of internal experiences, not control of the individual’s life. We want client’s to be in control of their lives.
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68. Creative Hopelessness
Attempts to do something different with respect to difficult emotional content may fail if control agenda remains present
Person in the hole
Chinese Finger-trap
Quicksand
Exercise: Tug of war
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69. Sticking Points: The client:
Feeling validated, or feeling angry, confused
Argue that control does work - my experience tells me it does
Where and how long?
Use control when control works
In the “where and how long” section, could be useful to keep the example of diets in mind. Many diets help individuals lose wt over weeks to months. Over a year or two, however, something like 95% fail. Whether we conclude that a move “works” depends on our time scale. Our minds like the immediate, short-term. In this therapy, however, we want to set the bar higher. We don’t want to win the inning or the period, we want to win the game.
Metaphor
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70. Sticking Points: The therapist: Getting caught in content Convincing
Not letting clients feel what they feel
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71. Summary: Creative Hopelessness
The culture instructs (rules) the client that:
Psychological problems can be defined as the presence of unpleasant feelings, thoughts, etc.
These undesirable experiences are viewed as “signals” that something is wrong; something has to change
Healthy living cannot occur until these experiences are eliminated
The client needs to get rid of them by correcting the deficits that are causing them (lack of confidence, being a “bad” person, not worthy)
This is best achieved by modifying the adverse factors that cause the difficulty (e.g. low self-esteem resulting from critical parents)
Perhaps this change agenda is not very workable -
It is important to remember what kind of change we are talking about. We want people to change their lives….let go of needing to change internal experience to get there
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72. “I used to think that the brain was the most wonderful organ in my body. Then I realized who was telling me this.”
- Emo Philips
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73. Control is the Problem Giving a name to the unworkable agenda
Validation of efforts to try to control painful experiences
Works outside of the skin
Taught that it should work
Appears to work for others
Sometimes works
Should work if we work hard enough
Exercises:
Perfect anxiety detection machine
Ice cream
What are the numbers?
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74. Sticking Points The Client Wishing to feel good at a fundamental level
Responsibility versus blame
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75. Sticking Points The therapist: Control language
Personal use of excessive control
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76. Summary: Control As the Problem
The client’s change efforts are really efforts at controlling private events
The culture, through language, engrains control strategies
Manifestations of control are emotional avoidance and escape
The more control is applied, the more negative experiences escalate and take control of life
Alternative: Willingness
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77. ACT: Willingness as the alternative
Change the context in which culturally conditioned rule systems operate (loosening rule governed behavior)
Aim is to disrupt unworkable rules and lay the groundwork for more workable ones
As client makes direct contact with unworkability of control strategies, he or she becomes more susceptible to direct contingencies
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78. Day 2
Opening mindfulness exercise
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79. “We have only begun to imagine the fullness of life.”
- Denise Levertov
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80. Willingness
Experience the avoided thoughts, feelings, bodily sensations, etc.
“Feel the edges” of painful events in an effort to experience avoided stimuli – with a purpose
Pain Circle: natural pain versus suffering
Exercise: Willingness scales
After all these years, I still do not like the “clean” and “dirty” language! I wish we could find a better way of saying this.
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81. Willingness Willingness is not wanting Willingness is not a concession
Willingness is not liking
It is a stance/an action
How do we get there?
Exercises:
Take your mind for a walk
Eyes on
Swamp metaphor
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82. Establishing Willingness: Defusion
Reason-giving
“Does that description help you move ahead?”
“Is this helpful or is this what your mind does?”
“You are 100% correct, now what?”
Separate thought and thinker, emotion from feeler
“I am having the thought that…”
“I am having the feeling of….”
Out with the “but’s”
I often find that people balk a bit at my first intro at the “I am having the through that….” It sounds so much like what non-psych folks expect psychologists to say! I would encourage you to do a brief experiential exercise with this. Have them “try on” a sharp thought like “I am a loser” vs. “I am having the thought…” Can dispel the resistance to this simple but powerful idea.
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83. Establishing Willingness: Defusion
Humans “fuse” with the content of their mind’s
The distinction between the process of the language versus the product of language is very hard to detect without special effort
Looking from rather than looking at
Evaluation is not in the object
The arrogance of words
Exercises:
Finding a place to sit
Saliva
Leaves on stream
Describe a chair; ask can you sit in it?
Mindfulness: leaves on stream
Name badges exercise:
Write a negative self evaluation you are ready to let go of on the nametag
Don’t go beyond your willingness and don’t expect others to do your work
Feel the pull to explain or avoid
Do look at others, but no talking about them or explaining them until later
*”Name badges” is a pretty strong exercise. Any chance this is more than some attendees will have bargained for?
*”content of their mind’s” should be “…minds.”
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84. Sticking Points The client: Eyes on Discomfort
Confusing willingness with being okay with what happened
Confusing acceptance with forgiveness/right
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85. Sticking Points Personal unwillingness The therapist:
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86. Summary: Willingness Language versus “languaging” Undermine evaluation
Teach healthy distancing
Teach non-judgmental awareness
Continue to establish willingness:
Self-as-Context
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87. “I’ve been here all along.”
- patient, following observer exercise
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88. Establishing Willingness Through Self-as-Context
Distinguishing the Self from Experiential Phenomena
What is “Programming?”
Two computers
Exercise: “What are the numbers?”
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89. Distinguishing the Self from Experiential Phenomena
Our histories are not controllable
Self as Context vs. Content
Chessboard metaphor
Exercises:
Continuous You
Label Parade
Increased awareness of the self lessons the perceived danger of one’s emotional reactions
Liberates action
A bit gimmicky, but an add-on to the chessboard I have done with some clients recently (easily adaptable to attendees): have a jar of small chess pieces, from which they can take a piece. Have them place it in their pockets or on their work areas. Instruct them, whenever seeing it, to stop for a moment and ask whether they are at “piece level” or “board level” at that moment (stole this from cue-controlled relaxation). The chess piece becomes their mindfulness bell, in a sense.
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90. Sticking Points The client: Finding the self
Holding too tightly to identity
Missing ongoing experience: present moment
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91. Sticking Points The therapist: Buying your own identity and thoughts
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92. Summary: Self-As-Context
The client is not defined by private experience; rather the client is a conscious vessel that contains private experience
Observing self is beyond evaluation, does not change and has no mechanical qualities
Observing self is found in experience not logic
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93. “If we don’t decide where we’re going, we’re bound to end up where we’re headed.”
- Chinese Saying
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94. Values What would it say on your tombstone?
Exercise: Funeral/Retirement Party
Exercise: Two Coins
Exercise (Small Groups):
What stands between you and living life a values based life?
What do you value?
What are specific goals related to those values?
What are the barriers (thoughts, feelings, other experiences) to living out those goals?
Two sides of the coin
2 emotions that you struggle with in your life, one per card
What situations bring these emotions up
Flip over the card, what does the emotion tell you about what you want in life? e.g. (pain of betrayal)
Which one of these cards do you …..
Coin exercise
This is why avoidance is so costly
Inside the push you have to give something away
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95. vitality Values and Choice Choice Valuing as an activity
Skiing
Moment by moment choosing
Coke and 7-Up
Brings
“It is not our abilities that show what we truly are. It is our choices.”
- Professor Dumbledore to Harry Potter (Chamber of Secrets)
vitality
If you find that your audience resonates with harry potter: the Ridiculoso spell used on Boggarts (sp?) is a great illustration of cognitive defusion!
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96. Sticking Points The client: Finding meaning
Missing the point of process (happiness)
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97. Sticking Points The therapist:
Getting caught in the idea of thinking “right” – a right way to do values
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98. Summary: Values
Learn how values create a sense of life meaning and direction
Define how values suggest specific life goals
Define actions to achieve goals
Defined by behavior, not by private content
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99. “Try not. Do, or do not. There is no try.” - Yoda
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100. Commitment And do what takes you in the direction…. ACT
Passengers on the bus
Try versus do
ACT
Accept
Choose
Take a direction
“And do what takes YOU in the direction…”
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101. Commitment Taking Action Not a promise, not a prediction
A stand; a game selected
Values / goals / actions / barriers
Fyi: There are some great Frankl quotes regarding “taking a stand” with regard to our suffering.
People familiar with 12 step traditions will often bring up the “this is just like ‘fake it til you make it’ from AA.” While some may find this confluence consoling, someone else in your audience is likely to see this similarity to the AA slogan in a negative light: this step feels inauthentic. In some ways, I think the jist of the ACT idea here is different than the AA idea, as it is commonly cited. When doing valued action, even with all of our unpleasant private reactions, the step taken is not “faked” in any meaningful way –it is values-consistent or not taken at all. How is anxious avoiding more authentic than a step taken in accord with what matters? Etc.
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102. Sticking Points The client: Jumps off of paper and buildings
Forgiveness
Right and wrong
Clinging to the conceptualized self
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103. Sticking Points The therapist: Fear of “activating” client
“Faking” stand and commit
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104. Summary: Commitment
Willingness is a primary condition of committed action
No such thing as partly willing
Tolerating
White knuckling
Committed action inevitably invites unwanted experience
Barriers can be identified with F.E.A.R.
Commitment is funded by ongoing process of valuing
Goal: building larger and larger patters of behavior that are values consistent
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105. The Question?
Out of the place from which there is a distinction between you and the things you have been struggling with and trying to change, are you willing to experience those things, fully and without defense, as they are and not as what they say they are, AND do what works for you in this situation according to what you value?
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106. If the answer is “yes,” that is what builds...
ACT Question
(6) at this time, in this situation?
(2) are you willing to have that stuff, fully and without defense
(5) of your chosen values
Psychological
& Behavioral
Flexibility
If the answer is “yes,” that is what builds...
(4) AND do what takes you in the direction
(3) as it is, and not as what it says it is,
(1) Given a distinction between you and the stuff you are struggling with and trying to change
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107. Accept and Commit
The enemy of health is rigidity; the proponent of health is flexibility.
Exercise:
Compassion/child
Stand and commit
Annoying Aunt Ida
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108. ACT Case Conceptualization
Broadly speaking:
Context for case formulation: the goal of ACT is to help clients consistently choose to act effectively and according to their values
Assessment
Self-report measures (AAQII, KIMS, Values Assessment & Assessment Packet)
What private experiences is the client attempting to avoid (e.g. sadness, anxiety, thoughts of worthlessness)? What life values are not happening?
Consider
Contextual circumstances (current life issues and living conditions, etc)
General behavioral themes and patterns
In-session behavior
Refine complaints and concerns into ACT conceptualization (e.g. eliminate depression so can have relationship)
You could also mention using the ACT Question as assessment….either for the clinician (I do this all the time) or even WITH the client at some later point in therapy. Once they have gotten some of the core ideas and experienced their utility, many clients can walk through the question and clearly state: “Yeh, I still get stuck with x and y and need to work on z.” Can be very helpful in clarifying direction and having the client clearly on board.
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109. ACT Targets: Overt behavioral avoidance
ASK: What parts of your life have you dropped out of?
External and internal emotional control strategies
ASK: What external strategies (drinking, drug taking, smoking, self-mutilation, etc.) do you use to avoid your emotions?
ASK: What internal strategies (distraction, self monitoring, etc.) do you use to avoid your emotions?
In-session avoidance or emotional control behaviors (e.g., topic changes, aggressiveness, resistance, dropout risk)
Observe
While in-session barriers may not be apparent from the beginning of therapy, it may be
possible to predict what could show up later and take proactive steps to address these barriers. For example,
you may find out that the client has a tendency to flee relationships when they begin to feel threatened by
intimacy. Thus, you might have a conversation at the start of therapy about what the client could do, rather
than leave therapy, in the case that they feel they are getting too close to the therapist.
*Lillis & Luoma, (For further information see Bach & Moran, 2007)
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110. Consider Factors Related to Motivation to Change
Cost of avoidance: decreased interaction and connection, loss of important goals, addiction, etc.
Experience of unworkability of current efforts to control
Clarity of values
Importance of therapeutic relationship
Beliefs about consequences of facing feared events
“I wouldn’t be able to stand it”
“It would never end”
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111. Environmental Barriers to Change
Non-supportive home/family environment
Financial circumstances
Costs of change:
Loss of friends
Loss of disability
Loss of special status
Risks
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112. Factors Contributing to Psychological Inflexibility
Non-acceptance of thought, emotion, memories, sensations
Fusion
Entangled with evaluative thoughts
Overly attached to beliefs, expectations, right and wrong
Overuse of insight and understanding
Fused with self-as-content; identity/conceptualized self
Entangled with life story
Particular content
What are the specific functions of avoidance and control:
Feared consequences of experiencing avoided private events (“I will be destroyed”, “I wouldn’t be able to stand it.” “It is too painful.”
Thoughts are causes: fused the story (I am broken because of my family history)
feared consequences of defusing from literally held thoughts or rules
What other behavioral domains with these same functions?
4. Are there other, more direct, functions that are also involved (e.g., social support, financial consequences)
5. Given the functions that are identified, what are the relative potential contributions of:
a. generating creative hopelessness (client still resistant to unworkable nature of change agenda)
b. understanding that excessive attempts at control are the problem (client does not understand experientially the paradoxical effects of control)
c. experiential contact with the non-toxic nature of private events through acceptance and exposure (client is unable to separate self from reactions, memories, unpleasant thoughts)
d. developing willingness (client is afraid to change behavior because of beliefs about the consequences of facing feared events)
e. engaging in committed action based in values (client has no substantial life plan and needs help to rediscover a value based way of living)
C. Consider the factors that may be perpetuating the use of unworkable change strategies and their treatment implications
1. Client’s history of rule following and being right
(if this is an issue, consider confronting reason giving through defusion strategies; pit being right versus cost to vitality; consider need for self-as-context and mindfulness work to reduce attachment to a conceptualized self)
2. Level of conviction in the ultimate workability of such strategies
(if this is an issue, consider the need to undermine the improperly targeted change agenda, i.e., creative hopelessness)
3. Belief that change is not possible
(if this is an issue, consider defusion strategies; revisit cost of not trying; arrange behavioral experiments)
4. Fear of the consequence of change
(if this is an issue, consider acceptance, exposure, defusion)
5. Short term effect of ultimately unworkable change strategies is positive
(if this is an issue, consider values work)
D. Consider general client strengths and weaknesses, and current client context
1. Social, financial, and vocational resources available to mobilize in treatment
2. Life skills (if this is an issue, consider those that may need to be addressed through first order change efforts such as relaxation, social skills, time management, personal problem solving)
E. Consider motivation to change and factors that might negatively impact it
1. The “cost” of target behaviors in terms of daily functioning (if this is low or not properly contacted, consider paradox, exposure, evocative exercises before work that assume significant personal motivation)
2. Experience in the unworkability of improperly focused change efforts (if this is low, move directly to diary assessment of the workability of struggle, to experiments designed to test that, or if this does not work, to referral)
3. Clarity and importance of valued ends that are not being achieved due to functional target behavior, and their place in the client’s larger set of values (if this is low, as it often is, consider values clarification. If it is necessary to the process of treatment itself, consider putting values clarification earlier in the treatment).
4. Strength and importance of therapeutic relationship (if not positive, attempt to develop, e.g., through use of self disclosure; if positive, consider integrating ACT change steps with direct support and feedback in session)
F. Consider positive behavior change factors
1. Level of insight and recognition (if insight is facilitative, move through or over early stages to more experiential stages; if it is not facilitative, consider confronting reason giving through defusion strategies; pit being right versus cost to vitality; consider need for self-as-context and mindfulness work to reduce attachment to a conceptualized self)
2. Past experience in solving similar problems (if they are positive and safe from an ACT perspective, consider moving directly to change efforts that are overtly modeled after previous successes)
3. Previous exposure to mindfulness/spirituality concepts (if they are positive and safe from an ACT perspective, consider linking these experiences to change efforts; if they are weak or unsafe – such as confusing spirituality with dogma – consider building self-as-context and mindfulness skills)
III. Building interventions into life change and transformation strategy
A. Set specific goals in accord with general values
B. Take actions and contact barriers
C. Dissolve barriers through acceptance and defusion
D. Repeat and generalize in various domains
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113. Factors Contributing to Psychological Inflexibility
Out of contact with the present moment
Preoccupied with past or future
Unable to see the flow of experience
Out of contact with values; lack of values clarity
Inability to build patterns of committed action
Procrastination
Compulsive behaviors
Self-defeating actions
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114. Factors Contributing to Psychological Flexibility: Strengths
Positive experience with mindfulness
Episodes when “letting go” worked
Times of intense presence to the moment
Times in past where patient took course of action that, although painful, consistent with values
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115. Given Assessment: What Parts of ACT May Need to Be Emphasized?
Generating creative hopelessness
Understanding that emotional control is the problem
Developing willingness
Experiential exposure to the non-toxic nature of private events through acceptance and defusion
Generate experiences of self-as-context to facilitate experiencing of feared events in the present moment
Make contact with the present moment/mindfulness
Values exploration
Engage in committed action based on chosen values
Lillis & Luoma (2005); Bach & Moran (2007)
Generating creative hopelessness
Understanding that emotional control is the problem (client does not understand experientially the paradoxical
effects of control)
Developing willingness (client is afraid to change behavior because of beliefs about the consequences of facing
feared events)
4. Experiential exposure to the non-toxic nature of private events through acceptance and defusion (client is afraid to
change behavior because of beliefs about the consequences of facing feared events)
5. Generate experiences of self-as-context to facilitate experiencing of feared events in the present moment (client is
unable to separate self from reactions, memories, unpleasant thoughts; client needs safe place from which to
engage in exposure)
6. Make contact with the present moment/mindfulness (client lives in conceptualized future, e.g., worry; client is not
contacting reinforcements already present in the environment)
7. Values exploration (client does not have a substantial set of stated values or is out of contact with their values)
8. Engage in committed action based on chosen values (client needs help to rediscover a value based way of living;
client’s behavior is not generally productive or well-directed and client could use help in maintaining consistency
of life direction; client has little motivation to engage in exposure)
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116. “To listen well is as powerful a means of influence as to talk well, and is as essential to all true conversation.”          Chinese Proverb
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117. ACT Core Competencies: Therapists Luoma, Hayes, Walser (2007)
The ACT therapist speaks to the client from an equal, vulnerable, compassionate, genuine, and sharing point of view and respects the client’s inherent ability to move from unworkable to workable responses.
The therapist is willing to self disclose about personal issues when it serves the interest of the client.
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118. Core Competencies
The therapist avoids the use of “canned” ACT interventions, instead fitting interventions to the particular needs of particular clients. The therapist is ready to change course to fit those needs at any moment.
The therapist tailors interventions and develops new metaphors, experiential exercises, and behavioral tasks to fit the client’s experience, language practices, and the social, ethnic, and cultural context.
Fyi: One of the best examples of this 1st point that I have seen was Kirk Strosahl doing a brief ACT intervention (on video) during one of his talks: he hits most, perhaps all 6, of the ACT Core Processes in ~10-15 min intervention; very organically performed. Time permitting (probably won’t be!), that would be a great illustration of this point.
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119. Core Competencies
The therapist models both acceptance of challenging content (e.g., what emerges during treatment) while also being willing to hold client’s contradictory or difficult ideas, feelings, and memories without any need to “resolve” them.
The therapist always brings the issue back to what the client’s experience is showing, and does not substitute his or her opinions for that genuine experience.
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120. Core Competencies
The therapist introduces experiential exercises, paradoxes, and/or metaphors as appropriate and deemphasizes literal “sense-making” of the same.
The therapist does not argue with, lecture, coerce or attempt to convince the client.
ACT relevant processes are recognized in the moment and where appropriate are directly supported in the context of the therapeutic relationship.
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121. The Relationship
The therapist detects instances of psychological flexibility and inflexibility in their clients, and uses psychologically flexible responses to establish a therapeutic relationship that models, instigates, and reinforces client psychological flexibility.
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123. Books
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125.
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126. “There is no baser folly than the infatuation that looks upon the transient as if it were everlasting.”
- Tiru Valluvar
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