Creative Hopelessness Experienced by the client when she notices that there is an unworkable change agenda. 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 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. Creative hopelessness creates a space for something new to happen.

Hopelessness (non-creative kind!) Nothing has helped Nothing has helped You are my 6 th (10 th, 37 th ) therapist… You are my 6 th (10 th, 37 th ) therapist… Meds, CBT, EMDR, acupuncture, prayer, etc. weren’t helpful, and I am hoping that ACT might help. 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’ve relapsed at least a dozen times I don’t expect this to help, and I’m here because I promised my wife... I don’t expect this to help, and I’m here because I promised my wife...

The solution is part of the problem Doing more of the same Doing more of the same Using control in contexts where it is unhelpful, difficult, or impossible 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 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 short run

So what is the alternative? Willingness Willingness

Willingness Willing Vs wanting Willing Vs wanting

diagnosis diagnosis DSM Vs functional diagnoses 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

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

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

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

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

A useful rule of thumb is that when a behavior has negative consequences AND it is not clear why a person is engaging in that behavior, then look for avoidance. A useful rule of thumb is that when a behavior has negative consequences AND it is not clear why a person is engaging in that behavior, then look for avoidance. This is because in avoidance – when it is effective – the person is reinforced by what did NOT happen. This is because in avoidance – when it is effective – the person is reinforced by what did NOT happen. We cannot easily identify the relevant negative reinforcer unless we have a very thorough history of the presenting complaint or the client is insightful/psychologically minded. We cannot easily identify the relevant negative reinforcer unless we have a very thorough history of the presenting complaint or the client is insightful/psychologically minded.

Avoidant behavior in the therapy session Does the client frequently change the subject, ‘zone out’, lose eye contact? 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 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 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” 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 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. actively contacting psychological experiences – directly, fully, and without needless defense – while behaving effectively.

That thing you do…

Remain curious. Hold assumptions of EA lightly. Remain curious. Hold assumptions of EA lightly. Don’t get caught up in content. Don’t get caught up in content. Sit with uncertainty and confusion. Sit with uncertainty and confusion. Watch for picking up the shovel. Watch for picking up the shovel. Remain on equal ground. Remain on equal ground. Creative Hopelessness How To

Acceptance of Where You Start 10 minutes in role – yourself or a client, do not say which 10 minutes in role – yourself or a client, do not say which Try to help the person walk into the struggle with thoughts, feelings, memories, urges, or sensations Try to help the person walk into the struggle with thoughts, feelings, memories, urges, or sensations Examine the workability Examine the workability Try to help the client clear the field experientially of unworkable “solutions” – but do not judge from outside. Instead ally from within. Try to help the client clear the field experientially of unworkable “solutions” – but do not judge from outside. Instead ally from within. Notice the pull to rescue or change but do neither Notice the pull to rescue or change but do neither

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

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

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? What is it like to sit in the room with the client? The relationship The relationship Are you fully present with the client? Are you fully present with the client? Is thinking about therapy interfering with doing therapy? Is thinking about therapy interfering with doing therapy? Counter-transference (in the generic sense) Counter-transference (in the generic sense) Your feelings are data Your feelings are data Irreverence Irreverence Well timed process comments 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 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? Are you willing to be present with whatever thoughts and feelings show up in you during treatment sessions?

Cognitive fusion Inflexible behavior influenced more by verbal networks than by recently experienced environmental consequences 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 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’ i.e., the person ‘living in his head’

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

Defusion Looking at thoughts rather than from thoughts Looking at thoughts rather than from thoughts Seeing thoughts as what they are, not as what they say they are. Seeing thoughts as what they are, not as what they say they are. In contact with direct experience rather than thoughts about experience In contact with direct experience rather than thoughts about experience

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

Defusion exercises Bad cup Bad cup Physicalizing Physicalizing “I’m having the thought that…” “I’m having the thought that…” Taking your mind for a walk 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? 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 Fusion is also related to attachment to the conceptualized self

Fusion and attachment to the conceptualized self in therapy

I’m a fraud I’m a fraud I’m not ready I’m not ready I’m incompetent I’m incompetent I can’t do this I can’t do this What if I screw up? What if I screw up? Her problem is too difficult Her problem is too difficult I have no idea what to do I have no idea what to do I’ll never be able to relate to this client I’ll never be able to relate to this client I don’t like 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 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? Are you willing to be present with whatever thoughts and feelings show up in you during treatment sessions?

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 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 Words pull us into the past and future –Rumination about the past or feared future –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 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. 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.

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

Mindlessness in therapy

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

Self as context and Senses of Self Self as content Self as content Self as process Self as process Self as context (self as perspective) 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 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 They are three senses of self that pertain to self-knowledge

Self as content A conceptualized self is useful A conceptualized self is useful It allows us to participate in a verbal social community and answer questions such as: 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 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: During case conceptualization look for statements such as: I am too… I am too… If only I did…(or didn’t…) then I would If only I did…(or didn’t…) then I would My problem is that I… My problem is that I… I am a (failure, loser, wimp, druggie, etc.) I am a (failure, loser, wimp, druggie, etc.) I am not (smart, pretty, strong) enough I am not (smart, pretty, strong) enough I can’t… 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 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 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 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-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 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. 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 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 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 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 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’ 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 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. 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 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 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 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 Aimlessness, inertia, lack of vitality

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

The observing self Guided exercise Guided exercise

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

Values Chosen life directions; values give lives meaning 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 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

Lack of values clarity The client may describe a general lack of vitality and be vague about values and goals 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) 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” “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. Tracking is useful. Imagine learning traffic rules or trying to get from Memphis to Nashville through contingency shaping rather than rule governed behavior… Imagine learning traffic rules or trying to get from Memphis to Nashville 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 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” “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” Notice that “pliance” is the root word of “compliance” A single instance of pliance is called a “ply” A single instance of pliance is called a “ply”

Pliance vs Tracking Recall the child who put on his mittens because it will keep his hands warm Recall the child who put on his mittens because it will keep his hands warm Now imagine his mother instead says “put on your mittens because Mommy says so”; this is a ply Now imagine his mother instead says “put on your mittens because Mommy says so”; this is a ply He might put them on to avoid getting in trouble, or because he has a history of doing what Mommy says, and his behavior with respect to mittens is under the control of ‘doing what Mommy says’ rather than under the control of the weather He might put them on to avoid getting in trouble, or because he has a history of doing what Mommy says, and his behavior with respect to mittens is under the control of ‘doing what Mommy says’ rather than under the control of the weather

Pliance vs Tracking Now imagine another child tells him,“take off your mittens or everyone will think you’re a baby” Now imagine another child tells him,“take off your mittens or everyone will think you’re a baby” This is also a ply, and he may take off his mittens so others will not think he is a baby even though hands will be cold This is also a ply, and he may take off his mittens so others will not think he is a baby even though hands will be cold

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 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 excessive = sometimes pliance is useful… And note that it is problematic when excessive = sometimes pliance is useful…

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

Dominance of pliance and avoidant tracking… I always/never I always/never Life is (unfair, painful, perfect right now…) Life is (unfair, painful, perfect right now…) Yes, but… Yes, but… If I do (an important behavior), then I will feel… If I do (an important behavior), then I will feel… If I do (an important behavior), then others will think… If I do (an important behavior), then others will think… What if… What if…

Values clarification exercise Values worksheets Values worksheets bullseye bullseye

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

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

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

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 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: 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 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 in the service of experiential avoidance? What is the client doing that gets in the way of valued living? What is the client doing that gets in the way of valued living? What does the client want to do, learn, experience? What does the client want to do, learn, experience?

That thing you do III Barriers to valued living Barriers to valued living

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

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

Committed action What actions will help you reach your clinical training goals? What actions will help you reach your clinical training goals? What are the barriers to committed action? What are the barriers to committed action? “Be yourself: everyone else is already taken” – Oscar Wilde “Be yourself: everyone else is already taken” – Oscar Wilde

Lack of values clarity and committed actions

What’s that in the service of? Or, why are you doing that intervention? What’s that in the service of? Or, why are you doing that intervention? Whose values are we talking about? Whose values are we talking about? What does the client want his/her life to be about? What does the client want his/her life to be about?

Commitment What’s your commitment? What’s your commitment?

The outcome: Psychological Flexibility! Vitality, competence Vitality, competence

Questions? Questions?

Useful references Bach & Moran (2008). ACT in Practice: Case Conceptualization in Acceptance and Commitment Therapy. New Harbinger Bach & Moran (2008). ACT in Practice: Case Conceptualization in Acceptance and Commitment Therapy. New Harbinger