1. ACT WITH CLIENTS WHO STRUGGLE WITH DEPRESSION Rob Zettle, Ph.D. Sarah Staats, M.A. Wichita State University June 22, 2014

2. ACT – like swimming - is best learned by doing it, rather than reading and talking about it. Structure of workshop: Didactic presentations Experiential exercises All are invited and encouraged to participate. None are required to do so. May opt to discontinue at any time. Helpful to have writing materials. Please ask questions Please switch cell phones, other e-devices to off or vibrate. Scan/sign in for Continuing Education GROUND RULES

3. At the end of the session, you will be able to: 1.Summarize the perspective of ACT in responding to unmotivated clients. 2.Identify client values by following sorrow and other means. 3.Identify barriers to value-consistent behavioral activation and ways to minimize them. WORKSHOP OBJECTIVES

4. INITIAL ORIENTING EXERCISE

5. Included in the National Registry of Evidence-Based Programs and Practices of the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA). Recognized as having “modest research support” for depression by Society of Clinical Psychology (Forman et al., 2007; Hayes et al., 2004; Zettle & Rains, 1989; Zettle & Hayes, 1986). Outcome compares favorably to CT, but appears to operate through different processes (Forman et al., 2012; Hayes et al., 2006; Zettle et al., 2011). EMPIRICAL STATUS OF ACT

6. For our clients: 1. What do you want your life to be about? 2. What’s standing in your way? For us as therapists: 1. What do I want my work with my clients to be about? 2. What’s standing in my way? TWO MAJOR QUESTIONS IN ACT

9. Depression = Both overt behavior and private events (thinking and feeling) Both behavioral deficits (social withdrawal) and excesses (suicidality) Struggle with feeling the right way to feel Secondary, reactive emotion Dirty pain of unsuccessful efforts to control clean pain of dysphoria, sorrow, guilt, and bereavement Stands in the way of what clients want their lives to be about (valuing) ACT MODEL OF DEPRESSION

10. Not getting what you want – “You can’t always get what you want” And/or getting what you don’t want -- “You don’t always want what you get” THREE TYPES OF SORROW: 1.Actual Loss of What Once Had 2.Projected Loss of What Have Now 3.Imagined Loss of What Could Have Had DEALING WITH SORROW

11. Comparison of Now to a Preloss Past Role of rumination: Living in a Regretted Past Role of worrying: Living in a Barren Future “Poster child” of complicated bereavement Grief = Bereavement (clean pain) Grief + Rumination (EA) = Complicated Bereavement (dirty pain) “Why do the birds go on singing? Why do the stars shine above? Don’t they know it’s the end of the world? It ended when I lost your love.” – Skeeter Davis (1962) Related exercise 1. ACTUAL LOSS OF WHAT ONCE HAD

12. Comparison of Now to a Bereft Future Role of worrying: Living in a Dreaded (Fused) Future “When I get older, losing my hair many years from now, will you still be sending me a Valentine, birthday greetings, bottle of wine?”... “Will you still need me, will you still feed me, when I’m 64?” – The Beatles (1967) Related exercise 2. PROJECTED LOSS OF WHAT HAVE NOW

13. Comparison of Actual Now to What Now Might Have Been Living in a Unfulfilled Present “You can lose what you never had.” – Muddy Waters (1964) “I held your love on the tips of my fingers, but I let it slip right through my hands.” – Bill Anderson (1963) “I coulda had class. I coulda been a contender. I coulda been somebody instead of a bum, which is what I am.” -- Terry Malloy (Marlon Brando) in On the Waterfront Related exercise 3. CONSTRUCTED LOSS OF WHAT COULD HAVE HAD

14. Why are they challenging? Interfere with larger goals of therapy Therapists get pulled in unproductive directions Behavioral Deficits: Unmotivated, apathetic, inactive, “I don’t care” client Behavioral Excesses: Suicidality CHALLENGING CLIENT BEHAVIORS

15. Own reactions: What shows up for you when... ? Clients are apathetic, indifferent, unmotivated, “not caring” You have felt apathetic, indifferent, and/or unmotivated EXPLORING BEING UNMOTIVATED

16. Be mindful of own reactions, urges, thoughts, feelings, values, etc. What is the client’s behavior telling you? Conduct a functional assessment: EA? Experiential in-session exercise “Unpack” being unmotivated Pervasiveness and history With whom and where/when FAP: Is it a CRB? RESPONDING TO THE UNMOTIVATED CLIENT

17. Return to two Major ACT Questions: Values Barriers to valued, committed action: Fusion and EA Emphasize workability throughout Focus on behavioral activation: If necessary, do so in-session Reframe current behavior RESPONDING TO THE UNMOTIVATED CLIENT

18. Framed as an obstacle to larger goals in therapy, rather than as a rich and integral part of it. Barrier lies not in the client’s behavior, but in our reaction to it. Not useful to frame “not caring” as an emotional/affective state that has to be changed. More usefully framed as itself a way of caring and a behavioral choice. OK to “get stuck,” not OK to “stay stuck.” FRAMING THE UNMOTIVATED CLIENT

20. Opt for indirect over direct means of doing so (e.g., PVQ & VLQ) Follow the types of sorrow Through goal-setting Sweet Spot Exercise Through self-monitoring homework Revisit childhood wishes Whose Life Do You Admire? What Do You Want Your Life to Stand For? Epitaph Exercise Others? IDENTIFYING VALUES

21. Values = Verbally construed global desired life consequences Process, not an outcome Distinguishable from goals Questions to ask? 1. IDENTIFYING AND CLARIFYING VALUES

22. Related Questions: What types of sorrow has the client experienced? What caring lies behind your sorrow? What have you lost in life? Why was that so important to you? If you no longer struggled with depression how would your life be different? What was your life like when you didn’t struggle with depression? What has prevented your struggles with depression from getting even bigger? FOLLOW THE SORROW

23. Ala Kelly Wilson (2008) ask client to imagine a time, place, activity during which all was “right with the world”: What would it be like to have more moments like that in your life? Is it important enough to you that you would want our work to be about seeing if that could be possible? Serves as motivative augmental: Butterfly garden metaphor SWEET SPOT EXERCISE

24. Identify values after actions are performed ala Hank Robb: Ask clients to record answers in a notebook at the end of each day: “Did I do anything today that, looking back on it, was worth my time?” “If ‘yes’, what was it?” “What might I try tomorrow to see if it might be worth my time?” SELF-MONITORING HOMEWORK

25. Search for past hopes, dreams, and aspirations: When you were a child what did you want to do when you grew up? What was it about that excited you and appealed to you? Is there something, however small it might be, that you could still do today that would serve the same purpose? REVISIT CHILDHOOD WISHES

26. Identify either real or factitious heroes/heroines: Whom do you look up to? Why? If it were possible for your life to be like that of anyone else you know, who would that be? Why? What was their life about? What do you admire about their life? WHOSE LIFE DO YOU ADMIRE?

27. Experiential exercise in which clients are asked to imagine what they would most want their spouse, family members, best friend, co- workers, etc. to say about them upon their: Retirement 70 th Birthday Party 50 th Wedding Anniversary Memorial service WHAT DO YOU WANT YOUR LIFE TO STAND FOR?

28. Experiential exercise that can accompany “What Do You Want Your Life to Stand For?” Clients imagine what they would most like to have carved on their tombstone (e.g., “Loving wife, devoted mother, beloved daughter”, etc.) vs. what they are most fearful of showing up if they remain stuck (e.g., “Life ended before she could figure out what she wanted hers to be about”). EPITAPH EXERCISE

29. Related Questions: What are you hoping to accomplish in therapy? If therapy worked out for you, how would your life be different? What are your goals? What are those goals in the service of? What would attaining those goals do for you? Why are they important to you? GOAL-SETTING

30. Specific: “Exactly what actions will be taken?” Meaningful: “What value(s) are the actions in the service of?” Adaptive: “How will the actions make your life better?” Realistic: “Are the necessary resources for undertaking the actions available?” Time-Framed: “When, where, with whom and for how long will the actions occur?” SETTING “SMART” GOALS

31. Can occur at multiple levels: Single thoughts: “milk, milk, milk”, “I have the thought that..” Reason-giving: Exhaust good vs. bad reasons Life story: Deconstruct and rewrite it ADDRESS BARRIERS TO VALUED ACTION: DEFUSION

32. Take 5-10 minutes to deconstruct at least part of your life story with depression by following the instructions on the appropriate handout. DECONSTRUCTING YOUR LIFE STORY WITH DEPRESSION

33. Take 5-10 minutes and rewrite at least part of your life story with depression by following the instructions on the appropriate handout. REWRITING YOUR LIFE STORY WITH DEPRESSION

34. Don’t oversell it. Validate the past, focus on the present and future. Emphasize costs Story of your past could become the story of your future What are the costs of not trying? Emphasize choice What story would you like to write for yourself? Would you rather be right or do what works? Emphasize benefits Which “take home message” is more useful? DEFUSING FROM THE LIFE STORY

35. How will you carry your sorrow? exercise. ADDRESS BARRIERS TO VALUED ACTION: ACCEPTANCE

36. Demonstration? Role-Play Form groups of 3: Unmotivated client Therapist Consultant/observer Switch roles every 5 min. with 2-3 min debriefing between episodes. WALKING THE TALK

37. WORKING FROM A PLACE OF SORROW

38. Forman, E, M., Chapman, J. E., Herbert, J. D., Goetter, E. M., Yuen, E. K., & Moitra, E. (2012). Using session-by-session measurement to compare mechanisms of action for acceptance and commitment therapy and cognitive therapy. Behavior Therapy, 43, 341-354. Forman, E. M., Herbert, J. D., Moitra, E., Yeomans, P. D., & Geller, P. A. (2007). A randomized controlled effectiveness trial of acceptance and commitment therapy and cognitive therapy for anxiety and depression. Behavior Modification, 31, 722- 799. Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcome. Behaviour Research and Therapy, 44, 1-25. REFERENCES

39. Hayes, S. C., Masuda, A., Bissett, R., Luoma, J., & Guerrero, L. F. (2004). DBT, FAP, and ACT: How empirically-oriented are the new behavior therapy technologies? Behavior Therapy, 35, 35-54. Kohlenberg, R. J., & Tsai, M. (1991). Functional analytic psychotherapy: Creating intense and curative therapeutic relationships. New York: Plenum. Strosahl, K. D., & Robinson, P. J. (2008). The mindfulness and acceptance workbook for depression: Using acceptance and commitment therapy to move through depression and create a life worth living. Oakland, CA: New Harbinger. Wilson, K. G. (2008). Mindfulness for two: An acceptance and commitment therapy approach to mindfulness in psychotherapy. Oakland, CA: New Harbinger.

40. Zettle, R. D. (2007). ACT for depression: A clinician’s guide to using acceptance and commitment therapy in treating depression. Oakland, CA: New Harbinger. Zettle, R. D., & Hayes, S. C. (1986). Dysfunctional control by client verbal behavior: The context of reason giving. Analysis of Verbal Behavior, 4, 30-38. Zettle, R. D., & Rains, J. C. (1989). Group cognitive and contextual therapies in treatment of depression. Journal of Clinical Psychology, 45, 436-445. Zettle, R. D., Rains, J. C., & Hayes, S. C. (2011). Processes of change in acceptance and commitment therapy and cognitive therapy for depression: A mediation reanalysis of Zettle and Rains. Behavior Modification, 35, 263-283.

41. THANK YOU! Scan/sign out reminder. “Happy trails to you, until we meet again. Happy trails to you, keep smilin’ until then. Who cares about the clouds when we’re together? Just sing a song and bring the sunny weather. Happy trails to you, ‘til we meet again.” -- Roy Rogers & Dale Evans (1952)