Advancing Skills in Acceptance and Commitment Therapy (ACT ...
Transcript of Advancing Skills in Acceptance and Commitment Therapy (ACT ...
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Advancing Skills in Acceptance and Commitment Therapy (ACT): A 2-Day Intermediate Workshop
Presented by: Rhonda M. Merwin, PhD Assistant Professor of Psychiatry and Behavioral Sciences Director, ACT at Duke Duke University Medical Center Peer-Reviewed ACT Trainer, ACBS UNC School of Social Work, April 7-8, 2016 (**some slides courtesy of the generous ACT community)
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Other Resources � www.contextualscience.org � http://www.actmindfully.com.au � You Tube – Steve Hayes, Kelly Wilson, Kevin
Polk, Russ Harris � ACT 2nd ed. (Hayes, Strosahl, Wilson) � ACT Made Simple (Harris) � Learning ACT (Luoma) or Get Out of Your
Mind and Into Your Life (Hayes) � Mindfulness for Two (Wilson) � A Practical Guide to ACT (Hayes, edited)
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Set an Intention
� What are you going to be about over the next 2 days? How much of yourself will you bring? How much willingness and for what?
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� Contextual Behavioral Science
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Leave Relief
Negative Reinforcement
Anxiety
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� Impact of aversives on behavioral variability (it narrows us, flexibility is the goal)
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� Language (or symbolic
behavior) and a culture of control.
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� Responding not just to the world, but also our verbal formulations of the world.
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� “Push the button slowly to win points…”
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� As we become more verbal, we begin to live more in the verbal construction of the world and less in the actual world
� We listen to our minds, rather than to our experience
� The solution is to
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� Not only do we start living in a dream, but language also creates unique suffering in human beings.
� It’s like this: We are reinforced for treating words like the events that they represent
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“Apple”
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“Where’s the Apple?”
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� Words “stand in” � Some of the psychological functions of
events are present in the words about them (ex. Car) � Highly adaptive on the savannah
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You are not enough.
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� … means we can “experience” things Anytime. Anywhere. � Right now � Trauma
� We can’t control pain by controlling the environment, so we try to control our thoughts and feelings.
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Amplified by our culture that teaches us
� The natural state of the human is not only the absence of pain (including painful thoughts and feelings), but also the presence of positive feelings.
� Humans are meant to be happy and we should strive for happiness.
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� Control works well sometimes. � It also fails miserably.
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� Working to control our feelings, we lose control over our lives.
� We invest needless energy that would be better spent elsewhere.
� We avoid things we care about because of the potential for painful feelings.
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� In what area of life are you on an emotional avoidance detour?
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� Thoughts and feelings themselves are not pathogenic.
� Our culture of control is the cancer.
� What if bad feelings are not themselves problems to be solved? What if we are not problems to be solved?
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Pain
Struggle
Life will turn on the pain switch.
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� Consider diagnostic syndromes � It is emotion + struggle
with emotion = MDD, Anxiety disorders, etc.
Sadness
Struggling With
Sadness (e.g., withdrawal to avoid a world that
feels painful)
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� The way out is in.. Into willingness � Finger traps and quicksand
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� ACT changes how we relate to thoughts and feelings, rather than changing the thoughts and feelings themselves
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“I am Unloveable.”
Avoid Intimacy
Fusion/literality
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� What it sounds like � Sample
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Sad/Lonely Cut. Binge.
Use Substances.
Emotional Control
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� What it sounds like � Sample
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“I have no idea what I am doing.”
Work harder Give up
Fear Knot in
stomach
Urge to withdraw
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� So that behavior can be flexible and effective -- The goal is flexibility in the presence of difficult or compelling thoughts and feelings
� Stay present, sensitive and connected to values � Not just or must
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definitions � ACT targets cognitive fusion (i.e.,
overattachment to the content of mental activity) and experiential avoidance (i.e., attempts to avoid, suppress, attenuate unwanted internal experiences when doing so causes psychological harm)
� that interferes with individuals behaving in ways that are effective for the situation and consistent with deeply held, personal values.
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Or psychological inflexibility.
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Psychological flexibility � The ability to contact the present moment, fully
and without defense, and cease or persist in behavior based on our values and what would be most effective in the situation
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Engaging 6 Core Processes � With defusion (decreasing attachment to the
content of mental activity) � With acceptance (increasing willingness to
experience unwanted thoughts/feelings) � With contact with the present moment (practicing
flexible attention to events as they occur) � With self-as context (strengthening the observer self
perspective) � With values (articulating what is most meaningful) � With committed action (aligning activity with those
values)
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Case formulation/Treatment planning � Start with functional assessment (timelines,
diary cards, chain analyses, CRBs etc.) � Use diagnosis as starting point for
avoidant repertoire
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This is also intervention. � Avoidance/control has deep roots. � Tilling the soil to prepare for something
new. � Guided exploration of the workability of
actions: “and how has that gone…” � “So, let me see if I am hearing this right,
the situation is something like this…”
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Self as Context
Contact with the Present Moment
Defusion
Acceptance
Committed Action
Values
psychological inflexibility
Dominance of the conceptualizedfeared future & regretted past
Lack of values clarity;Dominance of pliance andavoidant tracking; valuesavoidance; values as burden
Inaction, impulsivity, oravoidant persistence
Attachment to conceptualizedself; Impoverished sense of self
Cognitivefusion
Experiential avoidance
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Accept
Move Values
Defuse (in the
moment, not in your head)
Fusion
Self-as-context
Contact with the Present Moment
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Accept
Move Values
Defuse (in the
moment, not in your head)
Values
Fusion
Self-as-context
Contact with the Present Moment
Experiential Avoidance
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Accept
Move Values
Defuse (in the
moment, not in your head)
Values
Committed Action
Fusion
Self-as-context
Contact with the Present Moment
Experiential Avoidance
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� Move from listening to thoughts to listening to experience (WORKABILITY)
� Move from fighting with feelings to embracing feelings (WILLINGNESS)
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Be Present
Psychological Flexibility
Open Up Do What Ma:ers
Values Acceptance
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Nonacceptance � Ignoring, suppressing
or denying feelings � Resignation, giving in
or giving up, secretly hoping for change
� Organizing life to avoid feelings
Acceptance � Openness to feelings
as they arise � An active choice to
embrace feelings � Approaching
situations that may be uncomfortable
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Fusion � Being entangled (or lost
in) in one’s thoughts � Fighting with one’s
thoughts � Trying to decide if (or
convince that) thoughts are true or not true
� Listening or buying into thoughts despite unworkability
Defusion � Watching thoughts � Holding thoughts lightly as
one feature of an internal landscape
� Appreciating other aspects of experience, not just what the mind says
� Behaving in ways that are contrary to thoughts sometimes
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� Really exists on a continuum. � Can track between and across sessions.
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� Values are distinguished from goals � Values are offered as an alternative to
“listening to thoughts” or “running from feelings”
� Provide direction when we feel “lost” � like a compass or lighthouse, leading the way
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� Values also dignify the pain inherent in living (recontextualize pain) � What if there is something important in
that? � Mule in the well
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Identifying Valued Directions (a “What for”) � Many people will be clear about what
they have lost in the struggle
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� And if you know what is painful, you probably know what they care about � What is your worst fear? What is most
important to you? Are they related?
� Sweet spot � What if X was gone?
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EXPOSURE DEFUSION ACCEPTANCE MINDFULNESS
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Self asContext
Contact with the Present Moment
Defusion
Acceptance
Committed Action
Values
Acceptance & Mindfulness
Processes
Commitment & Behavior
Change Processes
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Detecting “Mind” � Old, familiar, lifeless � Full of comparison and evaluation � Busy, complex � Buts and shoulds � Strong past or future orientation � Lots of warnings � Disruptions in behavioral variability and
sensitivity to the environment
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Detecting Openness � New, fresh, clear � Me, here and now � A sense of choice, decisiveness � Focus on being effective � Feels vital, meaningful � Might be expansive � Behavior is appropriately variable and sensitive to
feedback
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Parallel Process It applies to us too.
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� ACT is a model of human functioning and adaptability, not a model of psychopathology.
� It applies to us too. (mountain climbing)
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Accept
Move Values
Defuse (in the
moment, not in your head)
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Evidence Based Practice
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v APA Division 12 / Society of Clinical Psychology (http://www.div12.org/psychological-treatments/) lists ACT as a research supported treatment for:
v Chronic Pain v Depression v Mixed Anxiety v Psychosis
v SAMHSA’S National Registry of Evidenced Based Programs and Practices (NREEP) http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=191 lists ACT as an evidence based practice treatment for:
v OCD v Depression Symptoms v Rehospitalization v General Mental Health
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1" 2" 3" 4" 5" 9"13"19"
24"28"36"
45"60"
81"
102"
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20"
40"
60"
80"
100"
1985" 1990" 1995" 2000" 2005" 2010" 2014"
August&2014:&104&ACT&RCTs&N="8,636"(avg:"84,7)""
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Pain 16 Depression 13 Stress 11 Anxiety 8 Various 7 Weight Loss 6 Substance Abuse 5 Smoking 5 Cancer 4 Eating Disorders 4 Social Anxiety 4 Psychosis 3 Epilepsy 2 Borderline Personality Disorder 2 Diabetes 2 Tinnitus 2 Parenting 2 Stigma 2 Trichotillomania 1 OCD 1 Prevention 1
ACT RCTs as of August 2014
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Extra 6 Process Slides (some content overlaps)
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Acceptance Active embrace of internal experience (difficult thoughts, feelings, body sensations, urges, memories)
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Acceptance/Willingness
� Opening up to uncomfortable thoughts, feelings, body sensations, urges, memories etc.
� Letting go of the struggle so that we can live more freely and consistently with our values
� You don’t have to like it, want it, approve of it, in order to accept it
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v Acceptance is not resignation v It is not “giving in” or “giving up” v It is also not “gritting your teeth & bearing
it” v It is ACTIVE not PASSIVE v It is a CHOICE to stop fighting feelings
v to be willing to let them come or go as they will v to be willing to go into hard spaces b/c there
might be something important about that
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� Deep roots
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Building acceptance or willingness
� If you aren’t willing to have it, you got it � White bear, polygraph
� You can keep it away for a while, but it takes effort � Closet full of stuff, pushing against something,
tug-of-war with a monster, throwing balls/cards, uninvited guest
� Costs accumulate (pain of absence) � Card file exercise
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A counter-intuitive solution � The way out is in
� Chinese finger trap, quicksand � Notice the freedom in that
� We don’t have control over the pain switch, only the struggle switch
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� Goal: Create a context of emotional willingness/disrupt the context of emotional control, build out a broad and flexible repertoire of relating
� Anything other than avoidance is good J
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� Recontextualizing with values � Mule in the well � I could take away pain, but then you
lose X � Metaphor that pulls for kindness/
compassion/gentleness � Baby, gift, precious gem
� Competing repertoire � Scientist, witness � Object (curiosity, you have objects,
they don’t have you)
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� Unexpected reactions � Using an object to observe how the client
is relating to a thought/feeling, and practice relating differently (e.g., cards)
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� Experiential exercise
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Defusion Decreasing overattachment to the content of mental activity
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� Recognize when listening to our mind is and is not helpful
� Workability is the metric � What happens if you take the advice that
thought would give? � Does it get you where you want to go? � (sidestep truth, logic etc., it’s irrelevant)
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� Metaphors that highlight the nature of “mind” and its limits � Sensitive car alarm, bad news radio, worlds
greatest story teller, a masterful salesman � Instruct nonverbal or sensory based experience
� Active language that separate the client and mind (and highlight client as response-able) � Thank your mind, who’s talking here…. � Pushed around, buying, hooked, listening
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� Metaphors that pull for an observer stance (observing the dynamic process of thinking) � Parade, passing cars, leaves on a stream,
ticker tape, baggage claim
� Experiential observation
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� Changing the auditory cue � Sing it, say it fast or slow, etc.
� Metaphors that label fusion � Story, chapter, book, familiar script
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Present Moment The future and past are true illusions. The only thing that exists is this moment.
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Virabhadrasana II (Warrior II)
Here there is nothing to fight Except willfulness. Some lean too far
Into the past. Others stretch way out
Into the future. The true warrior
Stays in the moment, Burning deeper
Into whatever comes, Or sometimes with
Even more difficulty, What doesn’t.
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� Strong past or future orientation � Fixed or inattention
� Experiential exercise � You have arrived.
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Self-as-Context The observer self
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Self-as-Context/Observer Self (Distinguished from Self-as-Content or the Conceptualized self) � Our language encourages fusion
between ourselves and our thoughts, feelings, roles, content, etc. � I am ____ � Hard to deviate from self-story, threatened
by the presence or absence of content
� Need variation but not overattachment – might build out content, but all held lightly
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� Metaphors of “bigger than” � Sea floor, chessboard, sky with clouds, house
with furniture � Experiencing that you are the observer of so
you mustn’t be those experiences � Observer self exercise � Noticing � Stage show
� Meditations � Kabat Zinn – Mountain Meditation
� All defusion has SAC
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Values
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If you are not going to be guided by momentary thoughts and
feelings, what are you going to be about?
What will guide you?
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� Metaphors that highlight values as showing the way when we are lost (in thoughts or feeling) � Compass, lighthouse
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� What do you want your life to stand for? � Tombstone, epitaph, eulogy, 80th bday � What if no one knew?
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� Enter through vulnerability � What is your worst fear?
� There must be a pony.
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� Enter through memory � Recall a sweet moment, a moment where you
felt most connected, where there was a sense of vitality (not necessarily joy or happiness but vitality)
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� Imagine if/Magic wand � If I could take ___ away, the what? � Imagine ___ is no longer and issue, what
would you want to be doing? What would you want to be about?
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� Structure a conversation � Values Inventories
� Family � Parenting � Intimate/Marriage/Partnership � Friendships � Citizenship/Community/Environment � Spirituality � Health � Personal Growth � Leisure
� I want to be a person who… � Rate importance, consistency
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� Tools to look at consistency in behavior � Recording cards � Bulls eye exercise � Cups and beans/time allocation
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Process, not outcome � It’s the process of behaving consistently
with values, not the outcome � Example of holding the door open � Skiing metaphor
� You might do with reasons, but not for reasons.
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Not about believing or feeling, but behaving � You can think and feel other ways and still
chose value consistent action � Chosen qualities of purposeful action
� Love vs. behaving lovingly � Argyle socks
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Coming back � Not about being perfect – it’s about
taking a stand � Noticing when we are sideways, coming
back, and recommitting � In what area of your life are most
consistent? Least? What is showing up that is pulling you off course?
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Values and WILLINGNESS � What do you want to be about? Reasons, beliefs,
avoiding pain… THE CHOICE
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Rejection Intimacy
You can toss one, but not without getting rid of the other.