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Robyn D. Walser, Ph.D. RDW-ACT Training Workshop 1.

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1 Robyn D. Walser, Ph.D. RDW-ACT Training Workshop 1

2 Welcome and Housekeeping Lunch, breaks, restrooms Put cell phones vibrate/silent Please refrain from texting during the workshop RDW-ACT Training Workshop 2

3 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

4 Training Support… Resources Books: New Harbinger Supervision/Consultation: Trainings ACBS Videos RDW-ACT Training Workshop 4

5 Training Workshop Day 1 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 RDW-ACT Training Workshop 5

6 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

7 RDW-ACT Training Workshop 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

8 RDW-ACT Training Workshop 8 Introductions In less than a minute:  Your name  About you

9 RDW-ACT Training Workshop 9 Research on ACT Short summary: 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)

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): 1 1 RDW-ACT Training Workshop 10

11 RDW-ACT Training Workshop 11 Research…. APA Division 12 approves ACT as EBP for several disorders s/treatments.html Articles reviewing the literature/ACT/RFT Readers Update

12 RDW-ACT Training Workshop 12 ACT Core Competency Subscales Core Competency Subscale Mean Early Phase Mean (SD) Middle Phase Mean (SD) Late Phase Mean (SD) Basic ACT Therapeutic Stance3.1 (0.8)3.6 (0.7)4.0 (0.6) Developing Acceptance & Willingness, Undermining Control2.8 (0.7)3.4 (0.6)3.8 (0.6) Undermining Cognitive Fusion2.5 (0.7)3.1 (0.6)3.5(0.6) Getting in Contact Present Moment2.6 (0.7)3.2 (0.7)3.7 (0.6) Distinguishing the Conceptualized Self & Self-as-Context2.2 (0.8)3.0 (0.7)3.5 (0.7) Defining Valued Directions2.4 (0.8)3.1 (0.8)3.7 (0.7) Build Patterns Committed Action2.1 (0.9)3.0 (0.8)3.6 (0.7) Total Score75.6 (19.1)96.3 (17.7)111.1 (16.4) Therapist Outcomes

13 RDW-ACT Training Workshop 13 Introduction and Theory

14 RDW-ACT Training Workshop 14 Depression Human cost is much greater Vitality, viability Strain on personal, familial and professional relationships Suicide

15 RDW-ACT Training Workshop 15 Anxiety: Same Story 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

16 RDW-ACT Training Workshop 16 “The single most remarkable fact of human existence is how hard it is for human beings to be happy.” - Steven C. Hayes

17 RDW-ACT Training Workshop 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

18 RDW-ACT Training Workshop 18 The Issue  To sensitize you to the role that language plays in human suffering

19 RDW-ACT Training Workshop 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.

20 RDW-ACT Training Workshop 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

21 RDW-ACT Training Workshop 21 What if?  Normal to be abnormal 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

22 RDW-ACT Training Workshop 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)

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 23 RDW-ACT Training Workshop

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 24 RDW-ACT Training Workshop

25 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 pick @ We learn to react to one stimulus in terms of another 25 RDW-ACT Training Workshop

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? 26 RDW-ACT Training Workshop

27 RFT In addition to making these relations with cars, we also do it to ourselves and others 27 RDW-ACT Training Workshop

28 Verbal knowledge is our blessing and our burden 28 RDW-ACT Training Workshop

29 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

30 RDW-ACT Training Workshop 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

31 RDW-ACT Training Workshop 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

32 RDW-ACT Training Workshop 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

33 RDW-ACT Training Workshop 33 How are we entangled? F.E.A.R. Fusion, Evaluation, Avoidance, & Reason-giving

34 RDW-ACT Training Workshop 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

35 RDW-ACT Training Workshop 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

36 RDW-ACT Training Workshop 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”

37 RDW-ACT Training Workshop 37  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 Reason-Giving

38 RDW-ACT Training Workshop 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

39 RDW-ACT Training Workshop 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?

40 RDW-ACT Training Workshop 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

41 RDW-ACT Training Workshop 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

42 RDW-ACT Training Workshop 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

43 RDW-ACT Training Workshop 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

44 RDW-ACT Training Workshop 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.

45 RDW-ACT Training Workshop 45 1. Foster acceptance and willingness while undermining the dominance of emotional control and avoidance (Acceptance). 2. 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). 3. Live more in the present moment, contacting more fully the ongoing flow of experience as it occurs (Present Moment). Six Core Processes

46 RDW-ACT Training Workshop 46 Core Processes Continued 4. 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). 5. Identify valued outcomes in living that will legitimize confronting previously avoided psychological barriers (Values). 6. Build larger and larger patterns of committed action that are consistent with valued life ends (Committed Action).

47 RDW-ACT Training Workshop 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.

48 RDW-ACT Training Workshop 48 The Model

49 49 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 RDW-ACT Training Workshop

50 50 Instead of running away from your emotions --- Acceptance Defusion Self-as-context Committed Action Contact with the Present Moment Values RDW-ACT Training Workshop

51 51 Acceptance Instead of arguing with your mind--- mindfulness. We call it defusion. Self-as-context Committed Action Contact with the Present Moment Values RDW-ACT Training Workshop

52 52 Acceptance Defusion Self-as-context Committed Action Instead of living in the past or worrying about the future -- Contact the present moment, slow down and show up Values RDW-ACT Training Workshop

53 53 Acceptance DefusionCommitted Action Contact with the Present Moment Values Instead of attachment to the conceptualized self – Self as context; Consciousness; experiencer, not the experienced. RDW-ACT Training Workshop

54 54 Acceptance Defusion Self-as-context Committed Action Contact with the Present Moment Instead of a life focused on emotion, thought and symptom elimination –A values guided life; What do you want to stand for? RDW-ACT Training Workshop

55 55 Acceptance Defusion Self-as-context Instead of inaction and remaining stuck – Commitment; getting your feet moving in the direction of what matters to you? Contact with the Present Moment Values RDW-ACT Training Workshop

56 56 Psychological Flexibility Acceptance and Commitment Therapy RDW-ACT Training Workshop

57 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.

58 RDW-ACT Training Workshop 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

59 Functional Analysis of Behavior A single ACT of behavior can have multiple functions Mr. Brown waves to his neighbor: 1. To be friendly 2. To avoid hurting his neighbors feelings 3. To avoid feeling awkward 4. To please his wife Many behaviors can have the same function Mr. Brown waves to his neighbor 1. Discreet bow 2. Raising of arm high in the air 3. Lifting his hat 4. Saying “hi there.” 59 RDW-ACT Training Workshop

60 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? A ntecedent War reminder B ehavior Avoid the setting C onsequence Decreases sadness temporarily 60 RDW-ACT Training Workshop

61 Acceptance Committed Action Values defusion Self-as-Context Present Moment 61 RDW-ACT Training Workshop

62 62 Application of ACT Several ACT protocols 12 sessions-ish Longer term Things to think about Brief introduction/summary Informed consent Assessment Other materials: client handouts/homework

63 RDW-ACT Training Workshop 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

64 RDW-ACT Training Workshop 64 The Application and Technique Part Six Main Goals of ACT: 1.Creative hopelessness 2.Control of private events as the problem 3.Willingness/Letting go of the struggle 4.Self as context rather than content 5.Values 6.Commitment and behavior change

65 RDW-ACT Training Workshop 65 “ 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)

66 RDW-ACT Training Workshop 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?

67 RDW-ACT Training Workshop 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

68 RDW-ACT Training Workshop 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

69 RDW-ACT Training Workshop 69 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 Sticking Points: Metaphor

70 The therapist: Getting caught in content Convincing Not letting clients feel what they feel RDW-ACT Training Workshop 70 Sticking Points:

71 RDW-ACT Training Workshop 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 -

72 RDW-ACT Training Workshop 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

73 RDW-ACT Training Workshop 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?

74 RDW-ACT Training Workshop 74 The Client Wishing to feel good at a fundamental level Responsibility versus blame Sticking Points

75 The therapist: Control language Personal use of excessive control RDW-ACT Training Workshop 75 Sticking Points

76 RDW-ACT Training Workshop 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

77 RDW-ACT Training Workshop 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

78 RDW-ACT Training Workshop 78 Day 2 Opening mindfulness exercise

79 RDW-ACT Training Workshop 79 “We have only begun to imagine the fullness of life.” - Denise Levertov

80 RDW-ACT Training Workshop 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

81 RDW-ACT Training Workshop 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

82 RDW-ACT Training Workshop 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”

83 RDW-ACT Training Workshop 83 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 Establishing Willingness: Defusion

84 RDW-ACT Training Workshop 84 The client:  Eyes on  Discomfort  Confusing willingness with being okay with what happened  Confusing acceptance with forgiveness/right Sticking Points

85 The therapist:  Personal unwillingness RDW-ACT Training Workshop 85

86 RDW-ACT Training Workshop 86 Language versus “languaging” Undermine evaluation Teach healthy distancing Teach non-judgmental awareness Continue to establish willingness: Self-as-Context Summary: Willingness

87 RDW-ACT Training Workshop 87 “I’ve been here all along.” - patient, following observer exercise

88 RDW-ACT Training Workshop 88 Establishing Willingness Through Self-as-Context  Distinguishing the Self from Experiential Phenomena  What is “Programming?”  Two computers  Exercise: “What are the numbers?”

89 RDW-ACT Training Workshop 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

90 RDW-ACT Training Workshop 90 Sticking Points The client:  Finding the self  Holding too tightly to identity  Missing ongoing experience: present moment

91 Sticking Points The therapist:  Buying your own identity and thoughts RDW-ACT Training Workshop 91

92 RDW-ACT Training Workshop 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

93 RDW-ACT Training Workshop 93 “If we don’t decide where we’re going, we’re bound to end up where we’re headed.” - Chinese Saying

94 RDW-ACT Training Workshop 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?

95 RDW-ACT Training Workshop 95 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)

96 RDW-ACT Training Workshop 96 Sticking Points The client:  Finding meaning  Missing the point of process (happiness)

97 Sticking Points The therapist:  Getting caught in the idea of thinking “right” – a right way to do values RDW-ACT Training Workshop 97

98 RDW-ACT Training Workshop 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

99 RDW-ACT Training Workshop 99 “Try not. Do, or do not. There is no try.” - Yoda

100 RDW-ACT Training Workshop 100 Commitment  And do what takes you in the direction….  Passengers on the bus  Try versus do  ACT  Accept  Choose  Take a direction

101 RDW-ACT Training Workshop 101 Commitment Taking Action Not a promise, not a prediction A stand; a game selected Values / goals / actions / barriers

102 RDW-ACT Training Workshop 102 Sticking Points The client:  Jumps off of paper and buildings  Forgiveness  Right and wrong  Clinging to the conceptualized self

103 Sticking Points The therapist:  Fear of “activating” client  “Faking” stand and commit RDW-ACT Training Workshop 103

104 RDW-ACT Training Workshop 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

105 RDW-ACT Training Workshop 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 ?

106 106 Psychological & Behavioral Flexibility (1) Given a distinction between you and the stuff you are struggling with and trying to change (2) are you willing to have that stuff, fully and without defense (3) as it is, and not as what it says it is, (4) AND do what takes you in the direction (5) of your chosen values (6) at this time, in this situation? ACT Question If the answer is “yes,” that is what builds... RDW-ACT Training Workshop

107 107 Accept and Commit The enemy of health is rigidity; the proponent of health is flexibility. Exercise: Compassion/child Stand and commit Annoying Aunt Ida

108 RDW-ACT Training Workshop 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)

109 RDW-ACT Training Workshop 109 ACT Targets: 1. Overt behavioral avoidance  ASK: What parts of your life have you dropped out of? 2. 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? 3. In-session avoidance or emotional control behaviors (e.g., topic changes, aggressiveness, resistance, dropout risk)  Observe *Lillis & Luoma, 2005 (For further information see Bach & Moran, 2007)

110 RDW-ACT Training Workshop 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”

111 RDW-ACT Training Workshop 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

112 RDW-ACT Training Workshop 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

113 RDW-ACT Training Workshop 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

114 RDW-ACT Training Workshop 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

115 RDW-ACT Training Workshop 115 Given Assessment: What Parts of ACT May Need to Be Emphasized? 1. Generating creative hopelessness 2. Understanding that emotional control is the problem 3. Developing willingness 4. Experiential exposure to the non-toxic nature of private events through acceptance and defusion 5. Generate experiences of self-as-context to facilitate experiencing of feared events in the present moment 6. Make contact with the present moment/mindfulness 7. Values exploration 8. Engage in committed action based on chosen values Lillis & Luoma (2005); Bach & Moran (2007)

116 RDW-ACT Training Workshop 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

117 RDW-ACT Training Workshop 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.

118 RDW-ACT Training Workshop 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.

119 RDW-ACT Training Workshop 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.

120 RDW-ACT Training Workshop 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.

121 RDW-ACT Training Workshop 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.

122 122 RDW-ACT Training Workshop

123 123 Books

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125 RDW-ACT Training Workshop 125

126 RDW-ACT Training Workshop 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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