Acceptance and Commitment Therapy: Advanced Workshop Julian McNally

Program Outline Review Of ACT Model Getting Stuck Into ‘Getting Stuck’ 7 Frequent Problems And How To Respond Sweet Spot And Client Descending Matrix For Case Formulation Developing Mastery In ACT For Sweet Spot & Client Descending, add a template for “How to develop these kinds of exercises”

“Hexaflex” Contact with the Present Moment Values, Purpose & Meaning Acceptance & Willingness Psychological Flexibility Defusion Committed Actions Transcendent Sense of Self/ Self As Context “Hexaflex” ACT Model of Effective Living

“InFlexaHex” Dominance of Conceptualised Past or Feared Future Lack of Values Clarity or Contact Experiential Avoidance Inaction or Disorganised Activity Fusion Attachment to “Storied” or Conceptualised Self “InFlexaHex” ACT Model of Psychopathology

Mindfulness & Acceptance Processes Behaviour Change Processes Contact with the Present Moment Acceptance & Willingness Values, Purpose & Meaning Defusion Committed Actions Transcendent Sense of Self/ Self As Context “Hexaflex” ACT Model of Effective Living

Pair up - one is “A” the other is “B” Your turn! Pair up - one is “A” the other is “B” Decide who will be client first Brief your partner on presenting problem, but not what’s ‘tricky’ about this client Counsellor: Notice yourself getting stuck. Observe thoughts and feelings Client: observe and resist urge to be agreeable or make it easy for counsellor If 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

Getting 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 Person Rogers 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 again The expertise literature (more to come about that in the afternoon) says you learn by exposing your mistakes to correction Bike-riding metaphor. How do you keep your balance when you’re riding a bike? Trick question – you don’t!

Bennet and Cari Notice your reactions and make peace with them Provide an ACT-consistent response Where 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 thoughts Provide a response that acknowledges the client's position and provides a bridge to one of the Hexaflex points What ACT process is going on with the client (that warrants your attention)? What ACT process is going on with you?

7 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?

What do I do if I get stuck? General principles: Slow down! Be willing and accepting Hold your formulation and treatment trajectory lightly Stick closely to principles and loosely to techniques Listen to client’s experience before yours Listen to experience before models and ideas Invite a change in action rather than in understanding or feeling Demonstrate with a volunteer if there is time – or offer to come back to this.

Do 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.

What if they say “it didn’t work”? Is there a control agenda in place? Try another part of the model Try a different technique from the same part Invite 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 stuck DIFFERENT 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?

What 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 problems Detect values in the present How 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?

What do I do with clients who are sceptical/concrete/psychotic? “Trust your experience, not my words or your thoughts” Workability of scepticism Sideline “beliefs” and “being right” for a while You don’t have to do “mindfulness” – just pay attention Psychosis – ACT is not an EST – other treatments Metaphor-imperviousness? Present-moment defusion and willingness with Self-As-Context ALL 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 symptoms Emphasise small steps and relational shifts: to the symptoms and ‘small steps’ = behavioral change Metaphor 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?

What 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 – pairs If time, Conversational demo - "Who is noticing that? Who is saying that? Who answered that question?"

Indicators Of Increased Capacity For Self-As-Context Detecting and defusing from rules and stories Increased perspective taking and noticing Noticing own processes of fusion and unwillingness Naming or joking about own scripts and stories Able to dispassionately examine value-contradictory behaviours and thoughts Recognising current choices and history as separate phenomena Relating 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

What if they are fused with their beliefs or a ‘sick’ or ‘victim’ role? Try Self-As-Context Be curious and empathic Appeal to workability Curious 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.

Template for Experiential Exercises Recognise your mind will interfere, so slow down and accept Contact with present moment – sounds and touch Locate the moment of choice or ‘stuckness’ Immerse in the moment (file cabinet or movie screen) Open eyes and express it Hold the moment silently and appreciate Recognise your mind will interfere, so slow down and accept Contact with present moment – sounds and touch Locate 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 CLIENT Hold the moment silently and appreciate TRAIN THE CLIENT TO DEFUSE DURING THIS

Sensory 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 suffering If 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              value Have 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 Experience The Grid - Kevin Polk Even Simpler Model of ACT Processes

I 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 unbearable I notice those thoughts are there again 3 Step defusion of troublesome thoughts 1. I think that this suffering is unbearable 2. 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.]

Recontextualising the Problem The Life I’m left with Depressed Unmotivated Unemployed Indecisive Overweight Unloveable Need therapy! What I want my life to stand for Depressed Unmotivated Unemployed Indecisive Overweight Unloveable Need therapy!