Presentation on theme: "Acceptance and Commitment Therapy: Advanced Workshop"— Presentation transcript:
1Acceptance and Commitment Therapy: Advanced Workshop Julian McNally
2Program Outline Review Of ACT Model Getting Stuck Into ‘Getting Stuck’ 7 Frequent Problems And How To RespondSweet Spot And Client DescendingMatrix For Case FormulationDeveloping Mastery In ACTFor Sweet Spot & Client Descending, add a template for “How to develop these kinds of exercises”
3“Hexaflex” Contact with the Present Moment Values, Purpose & Meaning Acceptance & WillingnessPsychologicalFlexibilityDefusionCommitted ActionsTranscendent Sense of Self/ Self As Context“Hexaflex”ACT Model of Effective Living
4“InFlexaHex” Dominance of Conceptualised Past or Feared Future Lack of Values Clarity or ContactExperiential AvoidanceInaction or Disorganised ActivityFusionAttachment to “Storied” or Conceptualised Self“InFlexaHex”ACT Model of Psychopathology
5Mindfulness & Acceptance Processes Behaviour Change Processes Contact with the Present MomentAcceptance & WillingnessValues, Purpose & MeaningDefusionCommitted ActionsTranscendent Sense of Self/ Self As Context“Hexaflex”ACT Model of Effective Living
6Pair up - one is “A” the other is “B” Your turn!Pair up - one is “A” the other is “B”Decide who will be client firstBrief your partner on presenting problem, but not what’s ‘tricky’ about this clientCounsellor: Notice yourself getting stuck. Observe thoughts and feelingsClient: observe and resist urge to be agreeable or make it easy for counsellorIf counsellor is not getting stuck, brief “client” on what the actual client does that’s ‘tricky’ and try again. Switch.Can use GUIDE FOR AN INITIAL ACT SESSION If this helps you get started
7Getting Stuck Into “Getting Stuck” My experience is not authoritative because it is infallible. It is the basis of authority because it can always be checked in new primary ways. In this way its frequent error or fallibility is always open to correction. Carl Rogers, On Becoming a PersonRogers quote: Nothing to do with getting stuck.Value of getting stuck: Committed action is not about not falling down on the climb up the mountain, it’s about continually getting up againThe expertise literature (more to come about that in the afternoon) says you learn by exposing your mistakes to correctionBike-riding metaphor. How do you keep your balance when you’re riding a bike? Trick question – you don’t!
8Bennet and Cari Notice your reactions and make peace with them Provide an ACT-consistent responseWhere is the client on the Hexaflex?Where are you on the Hexaflex?Notice your own cognitive and emotional response to what the client says. Take a moment to accept and make peace with these feelings and to observe these thoughtsProvide a response that acknowledges the client's position and provides a bridge to one of the Hexaflex pointsWhat ACT process is going on with the client (that warrants your attention)?What ACT process is going on with you?
97 Frequent Problems What do I do if I get stuck? Do I need to cover all 6 processes?What if they say “it didn’t work”?What if they don’t know/can’t say what their values are or don’t have any?What do I do with clients who are sceptical/concrete/psychotic?What if they (or I!) don’t “get” Self-As-Context?What do I do with clients who are fused with their beliefs or a ‘sick’ or ‘victim’ role?
10What do I do if I get stuck? General principles:Slow down!Be willing and acceptingHold your formulation and treatment trajectory lightlyStick closely to principles and loosely to techniquesListen to client’s experience before yoursListen to experience before models and ideasInvite a change in action rather than in understanding or feelingDemonstrate with a volunteer if there is time – or offer to come back to this.
11Do I need to cover all 6 processes? No!Respect the context in which you are working and the client’s treatment goals. To some extent the latter are negotiable anyway – who doesn’t want a richer, more vital and meaningful life? Clients are only stuck in how they’re trying to achieve that (get fixed first and the EA agenda). From the research lit on ACT it seems as though the approach is robust enough that leaving bits of the Hexaflex out doesn’t prevent good outcomes.
12What if they say “it didn’t work”? Is there a control agenda in place?Try another part of the modelTry a different technique from the same partInvite participants to give examples. “Who has had clients say this? What did they say? What were your therapeutic goals?”CONTROL AGENDA: You or the client are trying to change or avoid an experience/feeling?ANOTHER PART: Sometimes what your formulation is off and they will respond to a different part of the model better. The main thing is to keep things flowing, not get stuckDIFFERENT TECHNIQUE: Some people just don’t respond to certain exercises. Or maybe the exercise doesn’t suit you.IF YOU SAY IT DIDN’T WORK: What was your agenda? And why aren’t you just moving on?
13What if they don’t know/can’t say what their values are or don’t have any? How do they know they don’t know?When was the earliest (last) time they remember having values?Make the therapy about discovering/creating values?Check for semantic problemsDetect values in the presentHow do they know they don’t know? Where do they go to determine the answer to this problem? Check that it’s not into their feelings or comparisons with others/idealised self/ rules etc.Semantic problems? E.g. they think of values as something given by society, parents, scripture, or other rule source. i.e. they’re not the author and chooser of them.Detect values in the present: What purpose do they have in being in therapy here with you today? There is so much else you could be doing, why this? What matters? Who will be positively affected if they change?
14What do I do with clients who are sceptical/concrete/psychotic? “Trust your experience, not my words or your thoughts”Workability of scepticismSideline “beliefs” and “being right” for a whileYou don’t have to do “mindfulness” – just pay attentionPsychosis – ACT is not an EST – other treatmentsMetaphor-imperviousness? Present-moment defusion and willingness with Self-As-ContextALL of this with an invitational attitude.Workability of scepticism: What is it costing you? How is life working when you follow the rules of a sceptic?Psychosis: What ACT does have to offer – increasing client’s capacity to tolerate the distress occasioned by the symptomsEmphasise small steps and relational shifts: to the symptoms and ‘small steps’ = behavioral changeMetaphor problems? Perspective-taking challenges from ABI/ developmental difficulties/ psychosis – but present moment is always there, so what can client practise willingness in the presence of?
15What if they (or I!) don’t “get” Self-As-Context? Let’s practise!Don't get Self-As-Context"I'm not that" exercise - whole group"Observer Self" exercise - demo with s.o. who doesn't get it"Who are you?" exercise – pairsIf time, Conversational demo - "Who is noticing that? Who is saying that? Who answered that question?"
16Indicators Of Increased Capacity For Self-As-Context Detecting and defusing from rules and storiesIncreased perspective taking and noticingNoticing own processes of fusion and unwillingnessNaming or joking about own scripts and storiesAble to dispassionately examine value-contradictory behaviours and thoughtsRecognising current choices and history as separate phenomenaRelating to multiple conceptualisations of self as determined by context and values-in-the-moment• The ability to see rules and stories about one's life as just verbal formulations, not as determinative of one's choices• Increased ability to take or notice the perspective of others• Increased ability to notice the appearance of old rules or the process of being 'hooked' by one's own thoughts* Naming and joking about scripts and stories• Able to examine patterns of thinking and behaviour that have been contrary to one's values• Recognising that while one's history may bring difficulties, it doesn’t define one or one's choices and that valued choices are always possible• Relating flexibly to multiple conceptualisations of self depending on context and on values being lived
17What if they are fused with their beliefs or a ‘sick’ or ‘victim’ role? Try Self-As-ContextBe curious and empathicAppeal to workabilityCurious and empathic: Help me understand. Can we just dwell in the space of this conflict or choice without rushing to either conclusion? Demonstrate if a volunteer and there is time.Workability: How is it going with the belief and getting a life that you love? "Gee, that all sounds reasonable, and yet there's this difficulty you keep encountering...”And if there’s time do “Demonstrate with a volunteer if there is time – or offer to come back to this” from Slide 10 – How do you get stuck and what do you do?Promise that after lunch you’ll get to experience staying with being stuck.
18Template for Experiential Exercises Recognise your mind will interfere, so slow down and acceptContact with present moment – sounds and touchLocate the moment of choice or ‘stuckness’Immerse in the moment (file cabinet or movie screen)Open eyes and express itHold the moment silently and appreciateRecognise your mind will interfere, so slow down and acceptContact with present moment – sounds and touchLocate the moment of choice or ‘stuckness’Immerse in the moment (file cabinet or movie screen)Open eyes and express it. SLOW RIGHT DOWN – YOU FIRST AND THEN THE CLIENTHold the moment silently and appreciate TRAIN THE CLIENT TO DEFUSE DURING THIS
19Sensory Experience SwS Valued Living Mental Experience Healthy living = Acceptance of and response to sensory experience, with actions guided by values.Pathology = Fusion and overinvolvement with Mental Experience and actions directed into struggling with sufferingIf time - do this:Simply draw The Grid for your client and explain that to the right are behaviors or actions toward values, important things like health, relationships, etc. To the left are behaviors away from unwanted mental experiences like anxiety and depression. Explain that all humans do both kinds of behaviors. Above the left line write the following:I ________ for ___________. I ________ for _________. action suffering action valueHave the person fill in the action blanks with the same action, but the suffering and value blanks are filled with an unwanted mental experience (suffering) and value. For example, one might sleep for depression or sleep for health. One might walk for anxiety or walk for health. One might talk for anger or one might talk for friendship. Once the person has filled in the blanks ask, "Is there a difference between doing that action to move away from suffering and doing that action to move toward a value?" Most people will immediately notice the difference between moving toward and moving away. If not, keep training until the difference is noticed.Mental ExperienceThe Grid - Kevin PolkEven Simpler Model of ACT Processes
20I notice those thoughts are there again “I think that...”“I’m having the thought that...”“I notice I’m having the thought that...”This is unbearableI notice those thoughts are there again3 Step defusion of troublesome thoughts1. I think that this suffering is unbearable2. You could say though, that i’m having the thought that this suffering is unbearable.3. You could also NOTICE that you are there having the thought.4. It looks like the thought appears out of nowhere. Just like when you open your eyes, there is the world.5. As soon as that “unbearable” thought appears, so does everything else associated with it. [RFs]6. But there is a mind there having the thoughts. In a sense you contain them, so you are not them...7. ...and can observe your mind having them. [Then go on to choose value-consistent actions in their presence.]
21Recontextualising the Problem The Life I’m left withDepressedUnmotivatedUnemployedIndecisiveOverweightUnloveableNeed therapy!What I want my life to stand forDepressedUnmotivatedUnemployedIndecisiveOverweightUnloveableNeed therapy!