Introduction to Acceptance and Commitment Therapy Patricia Bach, PhD University of Central Florida

Get Out of Your Mind and Into Your Life…and Into Your Therapy Sessions

Agenda 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 orientation ACT processes for clinicians

Informed 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 choose Confidentiality No judging the level of risk taking of others: go for it or not, it is up to you 4

Why 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…

Mindlessness

Judgment: You’re not good enough

“The single most remarkable fact about human existence is how hard it is for humans to be happy.” (Hayes, Strosahl, & Wilson, 1999) 8

The Ubiquity of Human Suffering High lifetime incidence of major DSM disorders High rates of divorce, sexual concerns, abuse, obesity, violence, prejudice, loneliness Some extremely destructive behaviors are both common and non-syndromal, e.g., suicide, self-injury 9

The Ubiquity of Human Suffering People don’t just suffer when things are bad We suffer when things may be bad What is the consequence of withdrawing from suffering? 10

Question: If that’s true, why don’t we all struggle with anxiety, depressed moods, insecurities, fears, etc….?

Answer: Oh, wait…we DO!

That thing you do…

Destructive Normality Normal psychological processes often are destructive We need to understand these processes and work within them to promote health One cause: human language and cognition – human verbal behavior 14

Language is a Blessing and a Curse Evaluation Problem solving Avoidance 15

Experiential Avoidance Experiential avoidance is built into human language and then amplified by the culture Experiential 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 harm 4/13/2017 16

Higher Avoidance Scores Are …. Associated with: Higher anxiety More depression More overall pathology Poorer work performance Inability to learn Substance abuse Lower quality of life History of sexual abuse High risk sexual behavior BPD symptomatology and depression Thought suppression Alexithymia Anxiety sensitivity Long term disability Normal as dirt. 4/13/2017 Sources: Hayes et al (2004); Polusny (1997); Toarmino (1998); Pistorello (1997); Batten, Follette, & Aban (1998); Stewart, Zvolensky, & Eifert (1998); 17

Central Clinical Insights Trying to get rid of thoughts and feelings can make difficult ones more important, and Narrows behavioral Repertoires But we can bring the functions of mind under better contextual control We do that by learning to relate to the mind in a different way That is one of the larger messages of mindfulness methods -Hayes 18

What is ACT? A form of CBT A form of clinical behavior analysis A mindfulness-based treatment Functional contextual therapy Behavior is situationally bound Behavior is functional

Acceptance 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)

ACT 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 them Get in contact with your goals and values Do what is there to be done (Hayes, 2006)

The ACT model Psychological Flexibility Contact with the Present Moment Acceptance Values Psychological Flexibility Committed Action Defusion Self-as-Perspective 22

A trip around the hexaflex

The ACT model Psychological Flexibility Contact with the Present Moment Acceptance Values Psychological Flexibility Committed Action Defusion Self-as-Perspective 24

Psychological 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

How do you know you’ve got ‘psychological flexibility’?

Vitality!

Assumptions of ACT Pain in life is inevitable Normal verbal processes contribute to psychopathology Control 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)

Show up for your own life

What gets in the way of vitality?

The ACT ‘inflexahex’ 31

Experiential Avoidance Deliberate attempts to avoid, control, suppress, escape, or get rid of negatively evaluated or unwanted thoughts, feelings and body sensations

Acceptance Willingness 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

Cognitive Fusion Thoughts dominate behavior – “being pushed around by thoughts” (Harris, 2009) Entanglement with judgments – thoughts are taken literally Reduces the impact of direct experience

Cognitive Defusion Also known as cognitive distancing Observing thoughts without automatically taking them literally “I’m having the thought that…” No need to change thought content Changing ones relationship to thoughts

Dominance of the conceptualized past and feared future Loss of contact with the here and now Out of touch with thoughts and feelings – lack of self knowledge Rumination and worry

Dominance 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

Contact 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 outcome Mindfulness promotes and requires acceptance and defusion. Vitality is only experienced in the present moment. 38

Attachment to the conceptualized self Buys into self-evaluations – “I am too…” or “I am not…” I am my thoughts and feelings Limiting – we are more than we can ever say about ourselves

Self as Perspective Thinking self Vs observing self You are not your thoughts and feelings Transcendent 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”

Lack of values clarity What do you want your life to be about? avoidant values People pleasing

Values & values clarification Chosen life directions Different from goals Though 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)

Barriers 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’

Committed 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?”

Psychological 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? Acceptance Values (5) of your chosen values If the answer is “yes,” that is what builds... Psychological Flexibility Committed Action Defusion 3) as it is, and not as what it says it is, (4) AND do what takes you in the direction Self-as-Perspective (1) Given a distinction between you and the stuff you are struggling with and trying to change 45

We 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

Does ACT work? Meta-analytic studies support effectiveness of ACT Hayes et al., 2006; Powers et al., 2009; Ost 2008 RCTs for treatment of many different problems Anxiety disorders, chronic pain, psychosis, trichotillomainia, substance abuse, depression, eating disorders, management of medical problems, obesity, epilepsy, impulse control disorder, etc.

Psychological Flexibility The primary measure of PF is the Acceptance and Action Questionnaire Differentiates patients from healthy controls Is correlated with variables largely consistent with predictions Shows treatment sensitivity Explains unique variance mediates and moderates as predicted Bond et al., 2011; Gloster et al., 2011

Is ACT an Evidence-Based Practice? National Registry of Evidence-based Programs and Practices (NREPP) APA Division 12 chronic pain depression mixed anxiety Obsessive compulsive disorder psychosis Veterans Administration

One 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.

Can you mix ACT with other treatment approaches? Mindfulness is widely applicable (just be sure to apply it mindfully!) Values clarification can build tx motivation Most problematic is mixing acceptance and cognitive defusion with cognitive restructuring

Can you mix ACT with other treatment approaches? The ‘Committed Action’ process often includes other EBP’s ERP Habit reversal Behavior activation skills training

ACT in practice…

Hopelessness 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 times I don’t expect this to help, and I’m here because I promised my wife...

Creative 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 work Creative hopelessness creates a space for something new to happen. 55

The solution is part of the problem Doing more of the same Using control in contexts where it is unhelpful, difficult, or impossible When control is useful When it isn’t Pain Vs suffering

Acceptance of the Unworkability of Control Why we stick with it It works elsewhere It seems to work for others You are told it should work for you It even SEEMS to work in the short run 57

So what is the alternative? Willingness

Willingness Willing Vs wanting

diagnosis 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

The ACT model Psychological Flexibility Contact with the Present Moment Acceptance Values Psychological Flexibility Committed Action Defusion Self-as-Perspective 61

Experiential Avoidance Avoiding unwanted thoughts…

Increases their intensity

And their frequency

Experiential avoidance What behaviors might suggest that experiential avoidance is an issue for your client?

Presenting complaints Behaviors with clear negative consequences and obvious negative reinforcement Substance abuse Escape from feared stimuli (e.g., phobias, OCD, agoraphobia)

And then there are behaviors where it is less obvious what is being avoided. Anger problems Underachievement Lack of intimacy

Avoidant 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”

Avoidant behavior in the therapy session Watch for pseudo-acceptance If I accept it, then will it go away?

Acceptance actively contacting psychological experiences – directly, fully, and without needless defense – while behaving effectively. 70

Acceptance Control is the problem/Two scales metaphor Feeding a baby tiger Tug of war with a monster Chinese handcuffs/monkey trap If you’re not willing to have it/lose it… Polygraph exercise Clean Vs dirty discomfort

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Cognitive fusion Inflexible behavior influenced more by verbal networks than by recently experienced environmental consequences

Cognitive fusion Verbally related antecedents and consequences such as thoughts, feelings, judgments and memories have more influence over responding than direct experience with the world i.e., the person ‘living in his head’

Cognitive fusion Look for instances where responding is guided by evaluations and inflexible rules This may look similar to ‘irrational beliefs’

Defusion 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 experience 76

Defusion metaphors and demos The automaticity of language Mary had a little… Lemon, lemon, lemon sunglasses

Defusion exercises Bad cup Physicalizing “I’m having the thought that…” Taking your mind for a walk

Notice 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

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Dominating 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 moment Words pull us into the past and future Rumination about the past or feared future Judgments about the self or others Procrastination Anticipatory anxiety and avoidance

Contact with the Present Moment “Mindfulness means paying attention in a particular way: on purpose, in the present moment and non-judgmentally.” Kabat-Zinn Mindfulness 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

Contact with the present moment Meditation/mindfulness Leaves on a stream/soldiers in a parade Just noticing Tin can monster One minute mindfulness Counting to 10

Mindlessness in therapy

Mindfulness Mindfulness takes practice Do not invite your client to try any mindfulness technique you have not first practiced yourself!

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Self as context and Senses of Self Self as content Self as process Self as context (self as perspective) These are not to be construed as three different selves, or as the only three possible senses of self They are three senses of self that pertain to self-knowledge

Self 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

Attachment 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

Attachment to the conceptualized self During case conceptualization look for statements such as: I am too… If only I did…(or didn’t…) then I would My problem is that I… I am a (failure, loser, wimp, druggie, etc.) I am not (smart, pretty, strong) enough I can’t…

Weak self-knowledge and self as content Not usually problematic in most clinical setting – clients are more likely to be too attached to/fused with content May 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 content May be problematic in lower functioning clients who have others care for them and limited opportunity to build up a sense of self

Self-as-process Self-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-awareness The client with poor ongoing self-awareness doesn’t know what he is thinking or feeling.

Self as process It is experienced when we notice our own private or public experience in the present moment I feel sad (or hungry, tired, anxious, happy) I am thinking about what to have for dinner I am walking to the coffee shop I am typing an email message to my boss I am having the thought “I don’t want to go” I am having a panic attack I am obsessing about germs

Weak self-knowledge and self as process Alexithymia – the inability to describe ones feelings Clients 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

Self as context Sometimes 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 words The 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

Weak self-knowledge and Self as Perspective May be problematic when ability to contact self as perspective has not been learned or is immature Evidence for weak self-knowledge in this domain might be a client who is at a loss to describe values and life goals Aimlessness, inertia, lack of vitality

Self-as-context As you can see, self-as-context is difficult to describe in words. Best contacted experientially

The observing self Guided exercise

Self as context exercises Chessboard metaphor Three senses of self discussion/link with defusion work Observing self exercise Mental polarity

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Values 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 values 101

Lack of values clarity The client may describe a general lack of vitality and be vague about values and goals

Dominance of pliance and avoidant tracking Rule governed behavior (RGB) Tracking Pliance Augmenting

Tracking “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 somewhere Following a recipe Putting 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

Avoidant 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

Pliance “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”

Excessive pliance Excessive pliance is problematic when behavior is under the control of pleasing others or avoiding upsetting others rather than under the control of other consequences And note that it is problematic when it is excessive; sometimes pliance is effective and values-based baehavior…

Examples of excessive pliance Staying in an unfulfilling relationship because of what Mom & Dad will think or so the other will not be upset Choosing a car or career or partner solely to impress others Succumbing to peer pressure Excessive advice-seeking (which might also be avoidance of ‘being wrong’)

Dominance of pliance and avoidant tracking… I always/never Life 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…

Values clarification exercise Values worksheets bullseye

Outcome Vs process Outcome is the process through which process becomes the outcome…

Values exercises Defining values Values narrative Skiing metaphor Green pen.argyle socks Epitaph/lifetime achievement Deciding vs choosing Outcome is the process through which process becomes the outcome

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Committed Action Overt behavior in the service of values/moving in a valued direction 114

Persistent 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

Persistent 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?

Barriers to valued living

Committed Action and barriers to committed action Eyes on Exposure Ball and chain Jump Garden metaphor Joe the bum Take your keys

Lack of values clarity and committed actions

What’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?

Get out of your mind and into your therapy session

ACT and the practitioner In ACT the core processes are regarded as being relevant for all human beings, not only for therapy clients As such, ACT processes can be implicitly or explicitly applied to the clinician as well as the client

Avoidance in the therapy room

Therapist avoidance strategies Assigning LOTS of homework Being a “good listener” Choosing not to intervene Keeping it light – coffee talk Changing the subject Chasing understanding Providing consolation Not being prepared Being really, really, really prepared Being big Being small Being an expert Being clever Always bringing a clip-board

Lack of vitality in the therapy room

Therapy process & experiential work

Attention to therapy process What is it like to sit in the room with the client? The relationship Are you fully present with the client? Is thinking about therapy interfering with doing therapy? Counter-transference (in the generic sense) Your feelings are data Irreverence Well timed process comments Avoidance especially common around process issues

Acceptance and defusion

Are 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?

Fusion and attachment to the conceptualized self in therapy

I’m a fraud I’m not ready I’m incompetent I can’t do this What if I screw up? Her problem is too difficult I have no idea what to do I’ll never be able to relate to this client I don’t like this client

Acceptance and defusion

Are 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?

Values What values bring you to this work? What do you want your professional practice to be about?

Committed action What 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

Commitment What’s your commitment?

The outcome: Psychological Flexibility! Vitality, competence

Questions?

Useful references Patricia.bach@ucf.edu contextualpsychology.org www.newharbinger.com Bach & Moran (2008). ACT in Practice: Case Conceptualization in Acceptance and Commitment Therapy. New Harbinger