ACT and working with Problem Gamblers

Transcription

1 ACT and working with Problem Gamblers WILEY D. HARWELL, D.MIN., LPC, NCGC-II 320 W. MAIN, STE. 102 NORMAN, OK

2 ACT Model of Psychopathology

3 Experiential Avoidance 1. Experiential Avoidance is also known as: (Experiential control).the attempt to control or alter the form, frequency, or situational sensitivity of internal experience (i.e., thoughts, feelings, sensations, or memories). P. 11 As with all defense mechanisms this ultimately will be unhelpful and selfamplifying over the long term and will become a chronic habit. Even in the short term the process will seem effective but upon review the client is able to see that it really doesn t work. We all create a mental language that expands the external world into an internal experience.

4 Cognitive Fusion 2. Cognitive fusion is the tendency for the human mind to get caught in the content or narrative that dominates other sources or possible behavior or choices we could make. No matter what happens, we tend to see events or circumstances through the lenses of our perspective and interpret the situation/event to match or view of reality. Fusion means to pour we pour our world view over life events and they tend to come out in a predictable self determined manner or conclusion. ACT the problem is not so much what we think but how we relate to what we think. We tend to identify with our thoughts and feelings.

5 Cognitive Fusion Cognitive Fusion continued When the mind fuses with it s own content we lose touch with the present moment and then focus on the past or worry about the future. When a client or we, fuse with the content of the mind and it s language, this process will dominate our behavior, limit our resources, and exclude other resources and possibilities. Perception is our personal reality. We can all explain or understand how we came to our conclusions. We assume perception is reality. Our culture assumes that private experiences can be dangerous and they need to be controlled.

6 Dominance of the conceptualized Past and Future; limited Self- Knowledge 3. When we identify with the content of the mind, we are not fully aware of the content. We may be more interested in arresting the thoughts or seeking to avoid our attachment to the content. This prevents us from experiencing the present moment. When we fuse with the content of the mind, we tend to lose awareness of our neoconceptual, direct, and current experience. p. 15 The conceptualized past or future dominates over the present. A client may ruminate about past wrongs or fearful futures. p. 15

7 Attachment to the Conceptualized Self 4. As we grow up, we learn about who we are by how we are treated, how we are spoken to, and what is said about who we are. This is a personal narrative that we have bought. Inwardly and privately we use this mind to see and interpret the world but may also struggle against it and try to have a different experience. This is like trying to solve problems with the mind that created the problems in the first place. Even if all of the events that shape a person s life are 100% true, we have to buy into the conclusions we draw about how we let those events create our reality.

8 Lack of Values Clarity/Contact 5. Values Values are chosen qualities of life that are represented by ongoing patterns of behavior. p. 16 Values are the compass heading that will guide our lives. Values are also a type of language we use in our minds and they become a standard by which we will judge other things. Valuing is a partially verbal process, not a logical or rational one; it involves choosing, assuming, creating, and postulating. Goal setting is an arbitrary attempt to make changes or accomplish mile stones but it is our chosen values that will truly determine our behavior.

9 Inaction, Impulsivity, or Avoidant Persistence Because of fusion, avoidance, the conceptualized self, loss of the present moment, we develop the inability to behave effectively in regard to chosen values. We seem to do the things or live in such a way that defies the values we say we have chosen. This is likely to manifest in impulsivity or rigid persistence. The preferred stance to life should be flexibility and actions that lead to long-term goals. Immediate gratification or even short term goals will not lead to satisfying life and will only confirm the invalidity of the conceptualized self.

10 Six Core Therapeutic Processes of ACT

11 Acceptance 1. Acceptance the alternative to experiential avoidance or fusion with the private events of the mind. Example psychological symptoms like anxiety are assumed to be a feeling state and there is little to no defense to it s presence. Acceptance in ACT is not an end in itself. Rather, acceptance is fostered as a method of increasing values-based action. Acceptance is the ability to see and experience what is happening in the mind without identifying with the content as reality and without judging the content which will lead to avoidance or trying to change the experience.

12 Radical Acceptance The concept of radical acceptance is to be able to develop the observer self / True Self, in order to see the thoughts/perceptions that are happening in our mind. This gives us flexibility and choices in how we will respond (if at all). Acceptance from the neutral stance enables one to recall their stance or chosen values and then to act accordingly. Too many times we react according to our preconceived self and/or the emotional states that we generate.

13 Cognitive Defusion 2. Cognitive defusion instead of identifying with mental states/emotions, we seek to see it clearly, realize it is historically established, but then understand that the situation that currently is happening is not exactly the same as all other events that have risen in the past. thoughts are historical; often automatic; and in clinical areas at least, generally well established. p. 18 A little different from traditional CBT the content of thought does not need to be changed in order to change the function of the thoughts. we can watch what the mind says, rather than be a slave to it. p. 18 We seek to loosen the relationship to the content of our thoughts and emotions, creating flexibility.

14 Cognitive Defusion For example, a negative thought can be watched dispassionately, repeated out loud until only its sound remains, or it can be treated as an externally observed event by giving it a shape, size, color, speed, or form. P. 19 The point is to have a more mindful perspective on thoughts, which increases behavioral flexibility linked to chosen values. Thoughts/emotions can be looked at instead of being looked from.

15 Being Present 3. Being Present establishing a sense of self as boundary-less locus. Now versus then, and here versus there, and I versus you. Without adequate contact with the present moment, behavior tends to be more dominated by fusion, avoidance, and reason giving, resulting in more of the same behavior that occurred in the past. There are no new possibilities. ACT sees the Self as process being present is to be able to observe one s thoughts and feelings as a familiar process of self identity. Mindfulness is the learned and practiced discipline that reorients the self to the present moment and not summations/conclusions of the self.

16 Self as Context 4. Self as Context - I in some meaningful sense if the location that is left when all the content differences are subtracted. P. 19 ACT helps us contact this sense of self as context a continuous and secure I from which events are experienced, but that is also distinct from those events. This helps us disentangle from the fused sense of self that is caught in the interpretation of the events and is often left with an inadequate sense of self in the situation. We seek to be the observers and experiencers of the event by being fully present.

17 Self as Context We are transcending the thoughts that are interpreting the events and just experiencing the moment. This is not a state of detachment but it s opposite. This always means that we can be in the moment without Judgement of what we are thinking A sense of detachment from self thoughts but not from the flow of events that are happening. In this regard we can experience and make decisions based on our values and not immediate reactions. This means that empathy, compassion, and other real values can be a guiding force for present and future behavior.

18 Defining Valued Directions 5. Values - are chosen actions that can never be obtained as an object, but can be instantiated moment to moment. p. 21 Values are choices What would you choose your life to be about? Values are the path you choose for your life. Values should empower us to life rich, meaningful lives. The value driven life is directed instead of reaction to the situation. Clients have to set and choose their values no matter how strongly we feel about our personal values or beliefs we hold dearly.

19 Committed Action Actions Based on the ability to operate from the observed self to be present Is guided by chosen values Actions may need to be learned by developing skills, constant work on observing and letting go of the conditioned self, and has to come from a sense of calm in the present moment. The ultimate goal of ACT is to change behavior Applies mindfulness and acceptance as primary tools Asks for commitment based on chosen values as a tool to guide the behavior

20 Developing Willingness/Acceptance Life is Difficult/Suffering. The source of suffering is the mind that self identifies with the content that was formed in the developmental phases of life. If we can recognize the source of our suffering then we can develop an inner self that can be at peace. We cannot undo what has already happened. However, our greater problem is that we identify with all of the negative conclusions we drew about our self. One option is to try to change the inner self talk, another is to try to find solace or happiness in the external world. There is never enough.

21 Developing Willingness/Acceptance 1. Part of the solution is the acceptance that life is painful. Life isn t fair. 2. if we don t understand the actual source of the problem, we are destined to an unhappy life and/or the external search for happiness. 3. The nature of the human mind is to accept negative information and negative self evaluation as a matter of fact. 4. The mind is Teflon for the positive and Velcro for the negative.

22 Willingness/Acceptance Willingness is defined as being open to one s whole experience3 while also actively and intentionally choosing to move in a valued life direction. p. 24 This can only happen in the present tense moment by observing what the mind is doing/thinking without judgement and then rely on our choice of values to guide our behavior. Willingness and Acceptance are considered to be interchangeable. Neither concept is a sense of resignation. We are practicing a sense of surrender to that which we can t change and to learn to not identify with the mind that is largely negative by nature.

23 Willingness/Acceptance Willingness/Acceptance has to be learned and then practiced. Acceptance is an aspect of Mindfulness. The goal of Mindfulness is to open to our own experiences in a nonjudgmental fashion. ACT differentiates between dirty pain and clean pain. Dirty pain the pain caused while trying not to have pain Clean pain is the natural and automatic result of living.

24 Willingness/Acceptance The connection between willingness and defusion We tend to verbally conceptualize our inner thoughts with literal language. However, we can also have an experience of the world that is directly experienced. Fusion the expectation that culturally supported messages, negative thoughts and emotions are bad and should be eliminated. We are taught to believe that if there is something we don t like we can figure out how to get rid of it and then do so.

25 Undermining Control Our efforts to control the negative mind or the symptoms that develop is our attempt to change the situation but analysis proves it only makes the matter worse. The first step is to loosen the attachment we have to need to control. We want to help the client list all of the ways we have tried to change our life or things we have tried to control the way we feel. We are actually helping the client to confront the system they are using in the effort to create homeostasis. Gambling is one thing that helps the client escape the mental anguish.

26 Undermining Control Step I Help the client understand what they are trying to control. Step 2 Draw out the strategies the client is or has used in an effort to solve the presenting problem. Step 3 Identify the function of a client s attempts at solutions. i.e., how oversleeping or overeating can be a way to fight depression.

27 How is it working? 1. Over the long term, what is the workability of the client s efforts to help the problem. 2. Help the client see the ways they have limited the search or limited his/her efforts to deal with the problem. Often clients will use the same solution but just try harder. 3. What would you be doing if you were not busy managing your (feelings, thoughts, sensations, images, or memories). 4. Then the client is ready to see that meaning and purpose comes from a life that is based on values that gives a sense of direction.

28 The client s experience ACT seeks to examine all of the ways the client has tried to resolve or change their presenting issue/problem. This is called creative hopelessness It is not that people don t try, it that what they are trying will likely never resolve the problem. As therapists we want to validate the client s experience and their efforts to make changes. The hope is to build a new possibility - not to get frustrated or feel stupid because nothing was going to work. The goal is to abandon what will not work.

29 The client s experience The important role the therapist plays is to let the client s past experiences be the final voice of what hasn t worked. Usually all of the past efforts have been some element of control. The last point for the client is that control of the problem or symptoms is the problem.

30 The client s experience Remedies 1. to teach willingness we teach the client to witness their thoughts with a minute to minute process of awareness. Once we can observe the thoughts and emotions without grabbing a hold of them or identifying with them, we begin to find some distance from them. The thoughts and emotions will still occur but we slowly learn to acknowledge them with complete awareness. After awareness, the client can practice acceptance instead of trying to control the thoughts/emotions or change them. Before full acceptance of our inner state we learn to be aware of the content without placing a judgement on them.

31 Practicing the present moment Life is always lived right here and right now: there is nothing else that can be directly experienced but the present moment. Everything else we do, besides living in the present, is a sketch, a mental picture, a memory. We only learn something new in the present moment. We can only truly experience our environment in the present moment. However, our clients struggle with difficult personal histories, memories, feelings, thoughts, and sensations. The present moment is an opportunity to step out of this world and into an entirely new reality.

32 Practice of Mindfulness Step 1 we begin by learning to focus: observing or noticing what arises in our awareness moment-tomoment Step 2 - we can add to this by observing or noticing what is happening in our body moment to moment Step 3 - observe what we are feeling from moment to moment

33 Practice of Mindfulness Mindfulness seems like the most simple process there could be. Fusion with our thinking not only makes life full of suffering but it also creates a sense of familiarity to the point we don t even realize we are stuck in our thoughts. When we first try to practice mindfulness, it is uncomfortable to be conscious of our thinking instead of just letting our thoughts run their own course. Being present or in the here and now will also diminish the tendency to practice avoidance and struggle. When we are not in the present moment we automatically go back to judgement and evaluations, avoidance or efforts to control.

34 Mindfulness with our Emotional states We know through experience that any difficult emotion that may be present in the moment can be felt and is not destructive. It is when we fight against a feeling, wishing it were not so, that harm can occur. p. 93 We want to teach the client to have this experience: I am having this experience now. When we experience the emotion with awareness we are not controlled by our own pain and history. When we spend our time in the present, experiencing whatever is happening - helps us realize that we can live by and from our values in spite of whatever we are thinking or feeling.

35 Common struggles 1. We seem out of touch with what we are thinking or feeling (dissociated) 2. Cannot describe what is happening in the inner self 3. Is in a state of avoidance fusion - seeking to change or control 4. Speaks only from the head and never from the heart 5. Can t track the issues that are present in the therapy session 6. Is immersed in well-practiced patterns of behavior operating from the conceptualized self. 7. Fails to notice opportunities or choices for valued living in the present moment.

36 Practices and Methods Techniques Examples 1. After some progressive relaxation have client become aware of thoughts and while looking at the blue sky, see the thoughts pass by like the clouds moving across the field of vision. What comes next? When we begin wondering what will come next, we create a space in the thought process. 2. After some progressive relaxation have client listen to all of the sounds that come to their senses. Near, far, internal. Move to thoughts, then emotions, then physical sensations. Notice that we are constantly experiencing something. We are a constant flow of consciousness and sensations.

37 Practices and Methods The purpose of Mindfulness exercises is to learn how to be aware on demand in the moment. The extended purpose is to learn how to practice mindfulness so it can become a method to apply to each moment. Many times when we are busy, there is no need to practice mindfulness because we are already practicing mindfulness by being in the moment of our activity or awareness.

38 Self as Context Being in the present moment helps us to develop a sense of self that is more than our past experiences or our conceptualized self. Life is fluid, with a sense of movement but all while being present in the moment.

39 Defining our Values Values - defined as verbally constructed, global, desired, and chosen life directions. Another way of saying that we choose to be intentional in all of our actions and thoughts. P. 133 Values are directly associated and tied to our behaviors. They have to be predetermined and then practiced as a way of directing our behavior and accepting our thoughts. One great way of doing this is to observe some thing that we don t like or an act by someone that seems harmful. Then to say to our self, just like me that person is suffering.

40 Defining our Values Values must be a person s free choice. Not what they think they should value. Values I hold this to be important Values are the key to moment to moment awareness. Being present without values, or ethics, is just living in neutral. Therefore; values are linked to choice Values speak to the truth we choose Values provide a sense of guidance in difficult times/situations

41 Defining our Values The therapist s job is to draw out the client s hopes and dreams, and to help the client detect the life directions he or she would choose freely, not select in order to avoid guilt, anxiety, shame, or the negative opinions of others. p. 134 Values usually extend into the future but they are about the immediate situation; the present moment. Part of this work will be to gently help the client see how closely their life and actions line up with their chosen values. This will correspond to the old conceptualized self and how it takes over and takes one to the path of control instead of being present.

42 Defining our Values compared to goals The main purpose of teaching clients to distinguish between values and goals is to help them become more focused on the process of living and less attached to the outcomes of their actions. p. 144 Values and living them as a principle, always leaves us in the present moment. Values are about living in the here and now, and observing our behavior. There is nowhere we need to go before we can value, and nothing for which we need to wait to begin valuing. p. 144

43 Building Committed Action Committed action - a step-by-step process of acting to create a whole life, including integrity, and a dedication to living according to one s values. This means learning to be completely responsible. By this, it also means to be able to respond to live and it s demands. The opposite of responding to life is a constant reaction to what is happening from the preconceived sense of self.

44 Building Committed Action This section is built on the previous work Awareness of what is happening as it happens on purpose Awareness without judgement or avoidance The practice of mindfulness The claim and commitment to live by chosen values Commitment depends on willingness/acceptance Committed action, however, allows clients to experience that thoughts, feelings, and sensations cannot literally harm them, but only harmful if allowed control over how the clients act in their lives. p. 159

45 Building Committed Action Steps to Committed Action 1. Action goals must be specific and measurable. 2. They must be practical and within the client s ability to accomplish 3. Avoid dead ends. Saying I will do something less that I am currently do it is not a goal. 4. Make a public commitment 5. Goals and action must be on target and linked to client s values 6. Goals need to be linked to the evidence and functional needs of the client. Is it psychologically helpful; is it functional; does it help change past behavior.

46 Building Committed Action Committed action is not just about reaching goals. Committed action is more about creating a process of living a meaningful life based on values.

47 Building Committed Action The process of building committed action can follow these steps. 1. Recognition 2. Acceptance 3. Letting go in order to be fully present 4. Anonymity - repeatedly coming back to the present moment to a mindful moment where one finds themselves centered. 5. Love and Compassion - continuing to live a life based on values. This is the evidence that we are working the process.

48 Building Committed Action Barriers to remember Internal barriers Difficult emotions Traumatic memories Fear of failure The need to be right Usually requires calls for acceptance, mindfulness, and defusion. Barriers to remember External barriers Difficult people or situations May include skills building Behavioral modification Experimentation and practice Homework

49 Treatment Planning 1. Confront the system of thinking (self talk) and the client s creative hopelessness 2. Develop knowledge and direct experience with emotional control as the problem, build and practice willingness 3. Develop and practice cognitive defusion 4. Generating experiences of self as context (being present) no matter what one is feeling or thinking 5. Making and sustaining contact with the present moment. 6. Exploring and then claiming values

50 Treatment Planning 7. Engaging in committed action based on chosen values. 8. Constantly reevaluate the process.