Introduction to ACT. Introduction to ACT 5/29/2015. Third wave vs. CBT Emphasis on acceptance-willingness to have Approach to cognition

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1 Dr. Jennifer Patterson MidAmerican Psychological Institute, P.C. Introduction to ACT Third wave vs. CBT Emphasis on acceptance-willingness to have Approach to cognition Not disputing negative thoughts Not trying to change thoughts (though change sometimes happens) Introduction to ACT Similarities with: Dialectical Behavior Therapy (DBT), Linehan Mindfulness-Based Stress Reduction (MBSR), Kabat-Zinn Mindfulness-Based Cognitive Therapy (MBCT), Segal, Williams, Teasdale Gestalt Therapy Existential Therapy 1

2 Introduction to ACT Very experiential Use of metaphors Perception of both therapist and client as people struggling with what life offers ACT focuses on the individual s behavior and the context in which it occurs. Treatment success is successful working of individual s behavior according to that person s values and desired outcomes. Philosophical and Theoretical Foundations The Dilemma of Human Suffering Humans as a species are suffering creatures. The assumption of destructive normality is basic to many of our cultural traditions (religious), but is much less dominant in psychology. Philosophical and Theoretical Foundations Positive and negative of human language. Human misery can be understood in the context of human achievement, because the most important source of each is the same: human symbolic activity. Language is both the reason for our ascendance as a species and a primary cause of our suffering. 2

3 Philosophical and Theoretical Foundations Why language creates suffering if your paint is peeling scrape it off and repaint if there is dirt on the floor sweep it up if you are sad or angry or fearful? Terms we use to deal with the physical world can be used inappropriately to the internal world Philosophical and Theoretical Foundations no "symptom" is a problem in and of itself symptoms become problems when they get in the way of living a life worth living example: social phobia why confront your fears if you don't value relationships or feeling connected? Philosophical and Theoretical Foundations psychological pain is normal cannot get rid of it pain is different from suffering accepting your pain reduces suffering (Hayes and Smith, 2005) 3

4 Acceptance and Commitment Therapy is built on empirically based principles aimed to increase psychological flexibility using a mindfulness-based approach with behavior change strategies built on empirically based principles Severe substance abuse Depression Obsessive-compulsive disorder Panic disorder Generalized anxiety disorder Post-traumatic stress disorder Trichotillomania Social phobia Smoking Chronic pain Medical problems Psychosis Workplace stress and more... aimed at increasing psychological flexibility Psychological flexibility is: contacting 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 4

5 using a mindfulness-based approach Mindfulness: is much easier learned by experience involves: paying attention ti in a particular way; on purpose, in the present moment, and nonjudgmentally -Jon Kabat-Zinn with behavior change strategies Behavior change strategies include: Applied Behavior Analysis strategies Contingency management Level systems Traditional Behavior Therapy strategies Flooding Exposure & ritual prevention Social skills training Behavior activation Brief Acceptance and Commitment Therapy 1. Narrowed Self-Definition - Understanding Sense of Self 2. Lack of Awareness Mindful Decision Making 3. Experiential Avoidance Acceptance 4. Cognitive Fusion Thought/Action defusion 5. Persistent Inaction Committed Action 6. Unclear Values Values Clarification 5

6 Brief ACT can help with: Grief Parenting and interpersonal relationship problems, Stress Work/life balance Workplace conflicts and other psychosocial problems Brief Acceptance and Commitment Therapy Each session is structured Between 6-12 sessions Clinician and client are in a partnership A high level of importance is placed on the work a client does outside of the sessions homework is given at the end of each session. 6

7 Brief Acceptance and Commitment Therapy Seeks to build awareness Seeks to resolve ambivalence Focuses on achieving specific, measurable, short-term term goals directed at resolving current problems, skills building, and eliminating hazardous, harmful and/or debilitating behaviors Stance of the Clinician Acceptance of clients values Avoid pushing the client toward our own values Acceptance of ongoing self awareness process Avoiding or trying to control thoughts and feelings in the therapy session (yours or the client s!) Willingness to self-disclose

8 Commitment Plan Worksheet Commitment Plan Worksheet I am here now accepting the way I feel and noticing my thoughts while doing what I care about Addressing Internal World Issues I am Notice if you are being influenced by any unhelpful selfdescriptions. Let go of any problematic beliefs that you are having about yourself. here now Center your situational awareness on what you are doing. Notice what is happening here and now, and rather than getting wrapped up in events not in your present control, let go of these distracting events. Focus on what is relevant to your actions. accepting my emotions Allow yourself to acknowledge any emotions you are having without trying to control the emotions. Be willing to simply have those emotions while moving forward with productive actions. noticing my thoughts Prepare to simply notice thoughts that arise while moving forward with your valued actions. Let them go if they are not helpful. Treat distracting thoughts as disconnected dfrom action while hl choosing to act in a productive manner. doing To Do List Wear PPE Communicate hazards immediately Use tool guards Perform lockout/ tagout procedures what I care about Values Based Motivation Personal Values: For my children For my spouse To continue making money to contribute to charity Behavior Change Contract Describe incentives and behavior criteria. If 80% of the observations meet safety criteria by end of the month, everyone on the shift earns the Friday Fish Fry for lunch Narrowed Self-Definition vs Understanding Sense-of-Self Narrowed Self-Definition We all have stories to tell about what we ve done and about what we like, about our problems, and how we differ from others. All of these stories have some truth to them When this becomes problematic for people it is when they become attached or fused to the content of their story. 8

9 Narrowed Self-Definition A narrowed self-definition refers to a limited understanding of one's identity, character, abilities, and attitudes by oneself. Narrowed Self-Definition Examples I am a mess and a failure I am sick I am unlovable I am not normal I am a bad. Understanding Sense of Self The sense-of-self that is a a consistent perspective from which to observe and accept all changing experiences. 9

10 Can you notice that you are not your: thoughts - emotions - sensations and roles? These are experiences you simply have Goals for Clinicians To increase understanding sense of self Use of metaphors Experiential exercises Defusion exercises I am having the thought, I m a failure as opposed to I m a failure Looking at thoughts as just thoughts Commitment Plan Worksheet I am here now accepting the way I feel and noticing my thoughts while doing what I care about Addressing Internal World Issues I am Notice if you are being influenced by any unhelpful selfdescriptions. Let go of any problematic beliefs that you are having about yourself. here now Notice what is happening here and now, and rather than getting wrapped up in events not in your present control, let go of these distracting events. Focus on what is relevant to your actions. accepting my emotions Allow yourself to acknowledge any emotions you are having without trying to control the emotions. Be willing to simply have those emotions while moving forward with productive actions. noticing my thoughts Prepare to simply notice thoughts that arise while moving forward with your valued actions. Let them go if they are not helpful. Treat distracting thoughts as disconnected from action while choosing to act in a productive manner. doing To Do List Wear PPE Communicate hazards immediately Use tool guards Perform lockout/ tagout procedures what I care about Values Based Motivation Personal Values: For my children For my spouse To continue making money to contribute to charity Behavior Change Contract Describe incentives and behavior criteria. If 80% of the observations meet safety criteria by end of the month, everyone on the shift earns the Friday Fish Fry for lunch 10

11 Lack of Awareness vs Mindfulness Lack of Awareness Words pull us into the past and future Rumination about the past or feared future Procrastination Anticipatory anxiety and avoidance When we are preoccupied with thoughts of the past and future we are not in contact with the present moment. The only time you can do The only time you can do is right now 11

12 What is Mindfulness? Mindfulness: is much easier learned by experience involves: paying attention ti in a particular way; on purpose, in the present moment, and nonjudgmentally -Jon Kabat-Zinn Goals of Mindfulness To come into contact with the present moment willingly, in the services of greater vitality and psychological flexibility To establish observation and awareness skills To continue practicing theses skills so they are honed To help contact the present moment in the presence of an aversive experience that constricts behavior How Do We Teach Clients To be Mindful? As clinicians we need to encourage clients to observe and notice what is present in their environment and in their private experience. Clinicians should encourage their clients to label and describe what is present, without excessive judgment or evaluation. 12

13 Observe and notice + label l and describe = Mindfulness Commitment Plan Worksheet I am here now accepting the way I feel and noticing my thoughts while doing what I care about Addressing Internal World Issues I am Notice if you are being influenced by any unhelpful selfdescriptions. Let go of any problematic beliefs that you are having about yourself. here now Notice what is happening here and now, and rather than getting wrapped up in events not in your present control, let go of these distracting events. Focus on what is relevant to your actions. accepting my emotions Allow yourself to acknowledge any emotions you are having without trying to control the emotions. Be willing to simply have those emotions while moving forward with productive actions. noticing my thoughts Prepare to simply notice thoughts that arise while moving forward with your valued actions. Let them go if they are not helpful. Treat distracting thoughts as disconnected from action while choosing to act in a productive manner. doing To Do List Wear PPE Communicate hazards immediately Use tool guards Perform lockout/ tagout procedures what I care about Values Based Motivation Personal Values: For my children For my spouse To continue making money to contribute to charity Behavior Change Contract Describe incentives and behavior criteria. If 80% of the observations meet safety criteria by end of the month, everyone on the shift earns the Friday Fish Fry for lunch It is an active process of moment to moment awareness of your: Surroundings I am hear in this room listening to Jennifer talk about Mindfulness AND Private Events I am bored, I feel tired, I need more coffee 13

14 Goals for Clinicians To weave mindfulness into the fabric of the sessions in an ongoing manner so that clients can learn an essential skill for increasing acceptance, learning defusion, and fostering values. Mindfulness exercises are not so much about developing mindfulness during the periods of exercise themselves but to raise present moment to moment awareness that can be applied more generally. Obstacles in Trying to Teach Mindfulness? Clients and clinicians can misunderstand the goal of mindfulness Mindfulness is NOT a technique to diminish an undesirable feeling such as anxiety MINDFULNESS and RELAXATION are not synonymous. They are separate techniques with separate goals. Clinical Strategies Use Structured Mindfulness exercises during office sessions Use Unstructured Mindfulness exercises at home 14

15 Avoidance vs Acceptance Experiential Avoidance What happens when you are unwilling to experience the things that show up in your life? Also known as "experiential control The attempt to control or alter the form, frequency, or situational sensitivity of internal experiences -- thoughts, feelings, sensations, or memories -- even when doing so causes harm. Presenting complaints What behaviors might suggest that experiential avoidance is an issue for your client? Behaviors with clear negative consequences and obvious negative reinforcement. Substance abuse Escape from feared stimuli (e.g., phobias, OCD, agoraphobia) 15

16 Experiential Avoidant Behaviors in Sessions 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 Creative Hopelessness - engendering a posture of giving up strategies when giving up is what is called for in the service of larger goals. We help clients understand that the alternative to control is willingness. Are you willing to have what shows up? Creative Hopelessness Metaphors Quick Sand Tug or war with a monster Finger Trap 16

17 Clean Pain vs. Dirty Pain Example: Lost job due to economy = sadness, frustration, and irritability How am I going to feed my family (clean) Negative evaluation of the clean pain I m Im a loser I ll never find a job I can t handle this = Dirty Pain and leads to Avoidant behavior (e.g., Drinking excessively) Which can then lead to further problems = Driving while intoxicated DUI (More dirty pain) Actively contacting psychological experiences directly, fully, and without needless defense while behaving effectively Hayes, Wilson, Gifford, Follette, & Strosahl, 1996, p Acceptance is An active and aware embrace of what's going on inside without trying to change things, especially if attempting to change causes psychological harm 17

18 Goals for Clinicians Help clients let go of the agenda of experiential avoidance as applied to internal and external experiences. Help clients see experiential willingness as an alternative to experiential avoidance. Help clients come into contact with willingness as a choice, not a desire. Help clients to understand willingness as a process, not an outcome. Clinical Strategies Help client to increase willingness to accept by Acceptance exercises Commitment Plan Worksheet I am here now accepting the way I feel and noticing my thoughts while doing what I care about Addressing Internal World Issues I am Notice if you are being influenced by any unhelpful selfdescriptions. Let go of any problematic beliefs that you are having about yourself. here now Notice what is happening here and now, and rather than getting wrapped up in events not in your present control, let go of these distracting events. Focus on what is relevant to your actions. accepting my emotions Allow yourself to acknowledge any emotions you are having without trying to control the emotions. Be willing to simply have those emotions while moving forward with productive actions. noticing my thoughts Prepare to simply notice thoughts that arise while moving forward with your valued actions. Let them go if they are not helpful. Treat distracting thoughts as disconnected from action while choosing to act in a productive manner. doing To Do List Wear PPE Communicate hazards immediately Use tool guards Perform lockout/ tagout procedures what I care about Values Based Motivation Personal Values: For my children For my spouse To continue making money to contribute to charity Behavior Change Contract Describe incentives and behavior criteria. If 80% of the observations meet safety criteria by end of the month, everyone on the shift earns the Friday Fish Fry for lunch 18

19 Cognitive Fusion vs. Thought/Action defusion Cognitive Fusion Inflexible behavior influenced more by verbal networks than by recently experienced environmental consequences. Verbally related antecedents and consequences such as thoughts, feelings, judgments and memories have more influence over responding than direct experience with the world. Cognitive Fusion Look for instances where responding is guided by evaluations and inflexible rules This will look similar to irrational beliefs in CBT 19

20 Defusion is Learning to notice thoughts as just thoughts and not to change their content rather, change their context and function. How to help clients Use defusion exercises such as: Physicallizing And deliteralizing language Focus on functionality- - And what is that story in the service of? - Is this helpful or is this what your mind does to you? - What does your experience tell you? - Metaphors/analogies (pop up ads, leaves on a stream clouds in the sky) How to help clients I am having the thought, I m a bad person as opposed to I m a bad person Looking at thoughts as just thoughts Metaphors Good Cup Bad Cup House Bus driver 20

21 Commitment Plan Worksheet I am here now accepting the way I feel and noticing my thoughts while doing what I care about Addressing Internal World Issues I am Notice if you are being influenced by any unhelpful selfdescriptions. Let go of any problematic beliefs that you are having about yourself. here now Notice what is happening here and now, and rather than getting wrapped up in events not in your present control, let go of these distracting events. Focus on what is relevant to your actions. accepting my emotions Allow yourself to acknowledge any emotions you are having without trying to control the emotions. Be willing to simply have those emotions while moving forward with productive actions. noticing my thoughts Prepare to simply notice thoughts that arise while moving forward with your valued actions. Let them go if they are not helpful. Treat distracting thoughts as disconnected from action while choosing to act in a productive manner. doing To Do List Wear PPE Communicate hazards immediately Use tool guards Perform lockout/ tagout procedures what I care about Values Based Motivation Personal Values For my children For my spouse To continue making money to contribute to charity Behavior Change Contract Describe incentives and behavior criteria. If 80% of the observations meet safety criteria by end of the month, everyone on the shift earns the Friday Fish Fry for lunch Persistent Inaction vs Committed Action Persistent Inaction 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. 21

22 Persistent Inaction The clinical question in this domain is: What is the client doing too much of, too little of, or doing in inappropriate contexts? Put another way, what is the client doing in the service of experiential avoidance? What can change? What can they do different? Will they commit to:,, and. Example: Saying I LOVE YOU more, continuing to work instead of calling off, spending more time with loved ones Barriers to Committed Action I always/never statements 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 22

23 Commitment Plan Worksheet I am here now accepting the way I feel and noticing my thoughts while doing what I care about Addressing Internal World Issues I am Notice if you are being influenced by any unhelpful selfdescriptions. Let go of any problematic beliefs that you are having about yourself. here now Notice what is happening here and now, and rather than getting wrapped up in events not in your present control, let go of these distracting events. Focus on what is relevant to your actions. accepting my emotions Allow yourself to acknowledge any emotions you are having without trying to control the emotions. Be willing to simply have those emotions while moving forward with productive actions. noticing my thoughts Prepare to simply notice thoughts that arise while moving forward with your valued actions. Let them go if they are not helpful. Treat distracting thoughts as disconnected from action while choosing to act in a productive manner. doing To Do List what I care about Values Based Motivation Personal Values: For my children For my spouse To continue making money to contribute to charity Behavior Change Contract Describe incentives and behavior criteria. If 80% of the observations meet safety criteria by end of the month, everyone on the shift earns the Friday Fish Fry for lunch Unclear Values vs Values Clarification Verbally construed global outcomes or chosen life directions (Hayes et al., 1999). 23

24 Unclear Values The client may describe a general lack of vitality and be vague about values and goals Scores on Quality of Life measures are low Help Individuals to Clarify Their Values Values Clarification Exercises Commitment to behavioral change is strengthened by personal relevance. Motivation is increased when we care about the process and the outcomes. D.J. Moran If you won a Lifetime Achievement Award, what personal qualities would you like to be recognized for during the award speech? 24

25 Commitment Plan Worksheet I am here now accepting the way I feel and noticing my thoughts while doing what I care about Addressing Internal World Issues I am Notice if you are being influenced by any unhelpful selfdescriptions. Let go of any problematic beliefs that you are having about yourself. here now Notice what is happening here and now, and rather than getting wrapped up in events not in your present control, let go of these distracting events. Focus on what is relevant to your actions. accepting my emotions Allow yourself to acknowledge any emotions you are having without trying to control the emotions. Be willing to simply have those emotions while moving forward with productive actions. noticing my thoughts Prepare to simply notice thoughts that arise while moving forward with your valued actions. Let them go if they are not helpful. Treat distracting thoughts as disconnected from action while choosing to act in a productive manner. doing To Do List Wear PPE Communicate hazards immediately Use tool guards Perform lockout/ tagout procedures what I care about Values Based Motivation Personal Values: For my children For my spouse To continue making money to contribute to charity Behavior Change Contract Describe incentives and behavior criteria. If 80% of the observations meet safety criteria by end of the month, everyone on the shift earns the Friday Fish Fry for lunch 25

26 Mindful Behavior Mindful Behavior I am here now, accepting the way I feel, and noticing my thoughts, while doing what I care about 26

27 The Outcome of ACT is Psychological flexibility Contacting 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. Leads to a life full of vitality and meaning! Questions? Useful references Patterson-jennifer@comcast.net Bach & Moran (2008). ACT in Practice: Case Conceptualization in Acceptance and Commitment Therapy. New Harbinger 27