Presentation on theme: "Introduction to Acceptance and Commitment Therapy"— Presentation transcript:
1Introduction to Acceptance and Commitment Therapy Patricia Bach, PhDUniversity of Central Florida
2Get Out of Your Mind and Into Your Life…and Into Your Therapy Sessions
3Agenda Introduction An overview of the ACT Model Does ACT work, and how is it related to other evidence-based practices?ACT techniques, some useful no matter what your theoretical orientationACT processes for clinicians
4Informed 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 chooseConfidentialityNo judging the level of risk taking of others: go for it or not, it is up to you4
5Why now?ACT and other mindfulness based treatments are growing in popularity.The 21st century is prime time for the emergence of mindfulness and acceptance based treatments…
8“The single most remarkable fact about human existence is how hard it is for humans to be happy.” (Hayes, Strosahl, & Wilson, 1999)8
9The Ubiquity of Human Suffering High lifetime incidence of major DSM disordersHigh rates of divorce, sexual concerns, abuse, obesity, violence, prejudice, lonelinessSome extremely destructive behaviors are both common and non-syndromal, e.g., suicide, self-injury9
10The Ubiquity of Human Suffering People don’t just suffer when things are badWe suffer when things may be badWhat is the consequence of withdrawing from suffering?10
11Question:If that’s true, why don’t we all struggle with anxiety, depressed moods, insecurities, fears, etc….?
14Destructive Normality Normal psychological processes often are destructiveWe need to understand these processes and work within them to promote healthOne cause: human language and cognition – human verbal behavior14
15Language is a Blessing and a Curse EvaluationProblem solvingAvoidance15
16Experiential Avoidance Experiential avoidance is built into human language and then amplified by the cultureExperiential 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 harm4/13/201716
17Higher Avoidance Scores Are …. Associated with:Higher anxietyMore depressionMore overall pathologyPoorer work performanceInability to learnSubstance abuseLower quality of lifeHistory of sexual abuseHigh risk sexual behaviorBPD symptomatology and depressionThought suppressionAlexithymiaAnxiety sensitivityLong term disabilityNormal as dirt.4/13/2017Sources: Hayes et al (2004); Polusny (1997); Toarmino (1998); Pistorello (1997); Batten, Follette, & Aban (1998); Stewart, Zvolensky, & Eifert (1998);17
18Central Clinical Insights Trying to get rid of thoughts and feelings can make difficult ones more important, andNarrows behavioral RepertoiresBut we can bring the functions of mind under better contextual controlWe do that by learning to relate to the mind in a different wayThat is one of the larger messages of mindfulness methods -Hayes18
19What is ACT? A form of CBT A form of clinical behavior analysis A mindfulness-based treatmentFunctional contextual therapyBehavior is situationally boundBehavior is functional
20Acceptance 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)
21ACT 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 themGet in contact with your goals and valuesDo what is there to be done (Hayes, 2006)
22The ACT model Psychological Flexibility Contact with the Present MomentAcceptanceValuesPsychologicalFlexibilityCommitted ActionDefusionSelf-as-Perspective22
24The ACT model Psychological Flexibility Contact with the Present MomentAcceptanceValuesPsychologicalFlexibilityCommitted ActionDefusionSelf-as-Perspective24
25Psychological 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
26How do you know you’ve got ‘psychological flexibility’?
28Assumptions of ACT Pain in life is inevitable Normal verbal processes contribute to psychopathologyControl 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)
32Experiential Avoidance Deliberate attempts to avoid, control, suppress, escape, or get rid of negatively evaluated or unwanted thoughts, feelings and body sensations
33AcceptanceWillingness to experience uncomfortable or unwanted thoughts, feelings, and body sensations in the service of response flexibility.“Control is the problem, not the solution”“If you’re not willing to have it, then you’ve got it”Especially when control of thoughts and feelings is limited or reduces quality of life
34Cognitive FusionThoughts dominate behavior – “being pushed around by thoughts” (Harris, 2009)Entanglement with judgments – thoughts are taken literallyReduces the impact of direct experience
35Cognitive Defusion Also known as cognitive distancing Observing thoughts without automatically taking them literally“I’m having the thought that…”No need to change thought contentChanging ones relationship to thoughts
36Dominance of the conceptualized past and feared future Loss of contact with the here and nowOut of touch with thoughts and feelings – lack of self knowledgeRumination and worry
37Dominance of the Conceptualized Past/Future “A mind is a wonderful tool for detecting and evaluating external dangers and developing plans for adapting to these demands, but we cannot avoid applying these same processes to the content of our private world. When we do so, we both see and produce negativity.”…Steven Hayes
38Contact with the Present Moment “Mindfulness means paying attention in a particular way: on purpose, in the present moment and non-judgmentally.” (Kabat-Zinn)Openness to experience, engagement, flexibility, awareness, attention, process vs outcomeMindfulness promotes and requires acceptance and defusion.Vitality is only experienced in the present moment.38
39Attachment to the conceptualized self Buys into self-evaluations – “I am too…” or “I am not…”I am my thoughts and feelingsLimiting – we are more than we can ever say about ourselves
40Self as Perspective Thinking self Vs observing self You are not your thoughts and feelingsTranscendent sense of self: thoughts, feelings and experiences change, and the YOU who notices these events doesn’t change“Notice who’s having that feeling/thought/sensation”
41Lack of values clarity What do you want your life to be about? avoidant valuesPeople pleasing
42Values & values clarification Chosen life directionsDifferent from goalsThough values are verbally construed, they are actions: you value with your feet“Outcome is the process through which process becomes the outcome” (Hayes, Strosahl, & Wilson, 1999)
43Barriers to values What is getting in the way of valued living? Look for avoidance, impulsivity, inaction.Often the presenting complaint or most obvious ‘problem behavior’
44Committed Action Behavior in the service of values EBP’s, skill’s training, doing more or less of something, joining a support group, homework, etc.Value’s clarification builds motivation for committed action.“what’s that in the service of?”
45Psychological Flexibility Contact with the Present Moment Acceptance (2) are you willing to have that stuff, fully and without defense(6) at this time, in this situation?AcceptanceValues(5) of your chosen valuesIf the answer is “yes,” that is what builds...PsychologicalFlexibilityCommitted ActionDefusion3) as it is, and not as what it says it is,(4) AND do what takes you in the directionSelf-as-Perspective(1) Given a distinction between you and the stuff you are struggling with and trying to change45
46We can try to control the uncontrollable by looking for security and predictability, always hoping to be comfortable and safe. But the truth is that we can never avoid uncertainty and fear. So the central question is not how we avoid uncertainty and fear but how we relate to discomfort.-Pema Chodron
47Does ACT work? Meta-analytic studies support effectiveness of ACT Hayes et al., 2006; Powers et al., 2009; Ost 2008RCTs for treatment of many different problemsAnxiety disorders, chronic pain, psychosis, trichotillomainia, substance abuse, depression, eating disorders, management of medical problems, obesity, epilepsy, impulse control disorder, etc.
48Psychological Flexibility The primary measure of PF is the Acceptance and Action QuestionnaireDifferentiates patients from healthy controlsIs correlated with variables largely consistent with predictionsShows treatment sensitivityExplains unique variancemediates and moderates as predictedBond et al., 2011; Gloster et al., 2011
49Is ACT an Evidence-Based Practice? National Registry of Evidence-based Programs and Practices (NREPP)APA Division 12chronic paindepressionmixed anxietyObsessive compulsive disorderpsychosisVeterans Administration
50One major difference between ACT and many 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.
51Can you mix ACT with other treatment approaches? Mindfulness is widely applicable (just be sure to apply it mindfully!)Values clarification can build tx motivationMost problematic is mixing acceptance and cognitive defusion with cognitive restructuring
52Can you mix ACT with other treatment approaches? The ‘Committed Action’ process often includes other EBP’sERPHabit reversalBehavior activationskills training
54Hopelessness 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 timesI don’t expect this to help, and I’m here because I promised my wife...
55Creative Hopelessness Experienced by the client when she notices that there is an unworkable change agenda.the client has tried to make things better for herself by using control strategies in contexts where they don’t workCreative hopelessness creates a space for something new to happen.55
56The solution is part of the problem Doing more of the sameUsing control in contexts where it is unhelpful, difficult, or impossibleWhen control is usefulWhen it isn’tPain Vs suffering
57Acceptance of the Unworkability of Control Why we stick with itIt works elsewhereIt seems to work for othersYou are told it should work for youIt even SEEMS to work in the short run57
60diagnosis DSM Vs functional diagnoses What brings you here? Why NOW? How would you know that you are better?What would you be doing if things were going better for you?Tell me about a time when your life was going better for you
61The ACT model Psychological Flexibility Contact with the Present MomentAcceptanceValuesPsychologicalFlexibilityCommitted ActionDefusionSelf-as-Perspective61
65Experiential avoidance What behaviors might suggest that experiential avoidance is an issue for your client?
66Presenting complaints Behaviors with clear negative consequences and obvious negative reinforcementSubstance abuseEscape from feared stimuli (e.g., phobias, OCD, agoraphobia)
67And then there are behaviors where it is less obvious what is being avoided. Anger problemsUnderachievementLack of intimacy
68Avoidant behavior in the therapy session Does the client frequently change the subject, ‘zone out’, lose eye contact?Does the client often say “I don’t know” when you ask an emotion laden or interpersonally important question?Does the client have difficultly with process work regarding his/her relationship with you?Does the client often provide vague answers to questions, e.g., “I guess I like my job and stuff ”; “It was no big deal”
69Avoidant behavior in the therapy session Watch for pseudo-acceptanceIf I accept it, then will it go away?
70Acceptanceactively contacting psychological experiences – directly, fully, and without needless defense – while behaving effectively.70
71Acceptance Control is the problem/Two scales metaphor Feeding a baby tigerTug of war with a monsterChinese handcuffs/monkey trapIf you’re not willing to have it/lose it…Polygraph exerciseClean Vs dirty discomfort
73Cognitive fusionInflexible behavior influenced more by verbal networks than by recently experienced environmental consequences
74Cognitive fusionVerbally related antecedents and consequences such as thoughts, feelings, judgments and memories have more influence over responding than direct experience with the worldi.e., the person ‘living in his head’
75Cognitive fusionLook for instances where responding is guided by evaluations and inflexible rulesThis may look similar to ‘irrational beliefs’
76Defusion 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 experience76
77Defusion metaphors and demos The automaticity of languageMary had a little…Lemon, lemon, lemonsunglasses
78Defusion exercises Bad cup Physicalizing “I’m having the thought that…”Taking your mind for a walk
79Notice 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
81Dominating 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 momentWords pull us into the past and futureRumination about the past or feared futureJudgments about the self or othersProcrastinationAnticipatory anxiety and avoidance
82Contact with the Present Moment “Mindfulness means paying attention in a particular way: on purpose, in the present moment and non-judgmentally.” Kabat-ZinnMindfulness 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.82
83Contact with the present moment Meditation/mindfulnessLeaves on a stream/soldiers in a paradeJust noticingTin can monsterOne minute mindfulnessCounting to 10
87Self as context and Senses of Self Self as contentSelf as processSelf as context (self as perspective)These are not to be construed as three different selves, or as the only three possible senses of selfThey are three senses of self that pertain to self-knowledge
88Self 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
89Attachment 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
90Attachment to the conceptualized self During case conceptualization look for statements such as:I am too…If only I did…(or didn’t…) then I wouldMy problem is that I…I am a (failure, loser, wimp, druggie, etc.)I am not (smart, pretty, strong) enoughI can’t…
91Weak self-knowledge and self as content Not usually problematic in most clinical setting – clients are more likely to be too attached to/fused with contentMay 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 contentMay be problematic in lower functioning clients who have others care for them and limited opportunity to build up a sense of self
92Self-as-processSelf-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-awarenessThe client with poor ongoing self-awareness doesn’t know what he is thinking or feeling.
93Self as processIt is experienced when we notice our own private or public experience in the present momentI feel sad (or hungry, tired, anxious, happy)I am thinking about what to have for dinnerI am walking to the coffee shopI am typing an message to my bossI am having the thought “I don’t want to go”I am having a panic attackI am obsessing about germs
94Weak self-knowledge and self as process Alexithymia – the inability to describe ones feelingsClients 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
95Self as contextSometimes 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 wordsThe 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
96Weak self-knowledge and Self as Perspective May be problematic when ability to contact self as perspective has not been learned or is immatureEvidence for weak self-knowledge in this domain might be a client who is at a loss to describe values and life goalsAimlessness, inertia, lack of vitality
97Self-as-contextAs you can see, self-as-context is difficult to describe in words.Best contacted experientially
101Values 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 values101
102Lack of values clarityThe client may describe a general lack of vitality and be vague about values and goals
103Dominance of pliance and avoidant tracking Rule governed behavior (RGB)TrackingPlianceAugmenting
104Tracking“Rule governed behavior under the control of the apparent correspondence between the rule and the way the world is arranged”Reading a map to get somewhereFollowing a recipePutting on mittens after being told “it is cold, and mittens will keep your hands warm”Noticing that meeting new people makes you anxious and staying away from parties to avoid anxiety
105Avoidant tracking Tracking is useful. Imagine learning traffic rules or trying to get from Orlando to Tampa Bay through contingency shaping rather than rule governed behavior…Avoidant tracking is behavior under the control of emotional avoidance. The rules tracked pertain to thoughts and feelings to be avoided rather than to other available contingencies
106Pliance“Rule governed behavior under the control of apparent socially mediated correspondence between the rule and relevant behavior”Notice that “pliance” is the root word of “compliance”
107Excessive plianceExcessive pliance is problematic when behavior is under the control of pleasing others or avoiding upsetting others rather than under the control of other consequencesAnd note that it is problematic when it is excessive; sometimes pliance is effective and values-based baehavior…
108Examples of excessive pliance Staying in an unfulfilling relationship because of what Mom & Dad will think or so the other will not be upsetChoosing a car or career or partner solely to impress othersSuccumbing to peer pressureExcessive advice-seeking (which might also be avoidance of ‘being wrong’)
109Dominance of pliance and avoidant tracking… I always/neverLife is (unfair, painful, perfect right now…)Yes, but…If I do (an important behavior), then I will feel…If I do (an important behavior), then others will think…What if…
111Outcome Vs processOutcome is the process through which process becomes the outcome…
112Values exercises Defining values Values narrative Skiing metaphor Green pen.argyle socksEpitaph/lifetime achievementDeciding vs choosingOutcome is the process through which process becomes the outcome
114Committed ActionOvert behavior in the service of values/moving in a valued direction114
115Persistent 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
116Persistent 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?
120What’s that in the service of? Or, why are you doing that intervention? Whose values are we talking about?What does the client want his/her life to be about?
121Get out of your mind and into your therapy session
122ACT and the practitioner In ACT the core processes are regarded as being relevant for all human beings, not only for therapy clientsAs such, ACT processes can be implicitly or explicitly applied to the clinician as well as the client
124Therapist avoidance strategies Assigning LOTS of homeworkBeing a “good listener”Choosing not to interveneKeeping it light – coffee talkChanging the subjectChasing understandingProviding consolationNot being preparedBeing really, really, really preparedBeing bigBeing smallBeing an expertBeing cleverAlways bringing a clip-board
127Attention to therapy process What is it like to sit in the room with the client?The relationshipAre you fully present with the client?Is thinking about therapy interfering with doing therapy?Counter-transference (in the generic sense)Your feelings are dataIrreverenceWell timed process commentsAvoidance especially common around process issues
129Are you willing to be present with your client and whatever thoughts, feelings, sensation show up for him/her?Are you willing to be present with whatever thoughts and feelings show up in you during treatment sessions?
130Fusion and attachment to the conceptualized self in therapy
131I’m a fraudI’m not readyI’m incompetentI can’t do thisWhat if I screw up?Her problem is too difficultI have no idea what to doI’ll never be able to relate to this clientI don’t like this client
133Are you willing to be present with your client and whatever thoughts, feelings, sensation show up for him/her?Are you willing to be present with whatever thoughts and feelings show up in you during treatment sessions?
134Values What values bring you to this work? What do you want your professional practice to be about?
135Committed actionWhat actions will help you reach your clinical training goals?What are the barriers to committed action?“Be yourself: everyone else is already taken” – Oscar Wilde