Koke Saavedra, Psy.D. & Katherine Plambeck , M.A.

KOKE SAAVEDRA, PSY.D. & KATHERINE PLAMBECK, M.A.

ACBS WORLD CONFERENCE XII MINNEAPOLIS, JUNE 2014

KOKE SAAVEDRA, PSY.D. & KATHERINE PLAMBECK, M.A.

ACBS WORLD CONFERENCE XII MINNEAPOLIS, JUNE 2014

A Group-Based ACT Training for Problematic Anger:

A New Functional-Contextual Solution to Anger-Related Problems

A Group-Based ACT Training for Problematic Anger:

A New Functional-Contextual Solution to Anger-Related Problems

Hi there!

ACBS XII Minneapolis - June 2014Koke Saavedra & Katherine Plambeck 2

Presenters…

Would you say hi?

Today’s Workshop Overview


I.) ACT Model/Context – Anger Functionally SpeakingSome data on ACT for problematic anger

II.) ACT Group for Problematic Anger Values & Anger: What Do I Want to Do?

o Group-Based ExerciseAction & Anger: Waking Up to What I Actually Do

o Group-Based Creative HopefulnessMindfulness

o Promoting Willingness, Undermining Controlo Self-as-Context & Defusion

A Focus on Committed Action

I.) ACT Model/Context – Anger Functionally SpeakingSome data on ACT for problematic anger

II.) ACT Group for Problematic Anger Values & Anger: What Do I Want to Do?

o Group-Based ExerciseAction & Anger: Waking Up to What I Actually Do

o Group-Based Creative HopefulnessMindfulness

o Promoting Willingness, Undermining Controlo Self-as-Context & Defusion

A Focus on Committed Action

Context: A Ubiquitous Human Experience

ACBS XII Minneapolis - June 2014Koke Saavedra & Katherine Plambeck

4

Social Context: Stress in America - APA 2013 Survey I


Stress you have experienced over last month 67% report emotional, 72% physical stress

Specific stress experience reported: 1st – Irritability or anger – 41% consistently

#1 2nd - No interest, energy – 39% 3rd - Nervous or anxious – 37% 3rd - Feeling overwhelmed – 37% 3rd - Fatigue or tired – 37% 6th - Depressed or sad – 36%

Social Context: Stress in America - APA 2013 Survey II


Stress you have experienced over last month 46% of adults report they lost patience or

yelled at their spouse, partner or children

Among teens specific stress reported: 1st – Irritability or anger – 40% #1 2nd – Nervous or anxious – 36% 3rd - Fatigue or tired – 36% 4th - Feeling overwhelmed – 31%

Anger… A Functional-Contextual Perspective


Basic ACT metaphor: The ongoing act in context Action (response) is inseparable from

context (stimuli)

No truth to be revealed (a-ontological) Pragmatic analysis – purpose is to meet

chosen ends (help)



Acting/behaving is what a person does -- Context (stimuli) is anything in the psych. environment that influences what a person does, the stream of action Change in behavior (response) follows change in

context (stimuli) Action changes through changes in context – so

ACT aims to influence a person’s here/now living by changing context



‘Anger’ is complex psychological context (stimuli) to a person’s stream of here/now actions (responses) ANS arousal narrows our responses to functional control

Anger is a psychological context that intensely compels a person to act at the service of controlling the environment – experiential avoidance Function of anger: control or moving away from what is Anger is confusing: Its form/topography is a ‘moving towards’

objects in the environment to change them

ACT focus: Does it work in your broader life context?

‘Problematic-Anger’ & the Topography of Anger


Stress/ANS arousal – promotes functional control

Problematic-anger is an anger context that controls unworkable behavior patterns in the broader context of the acting person’s life, given valued ends

The form of behaviors controlled by anger includes what we call aggression, rumination, avoidance, cruelty, etc. Forms are myriad, their function one and the same.

ACT targets context so as to change the function of a person’s actions from control to valued living

Subtle Anger Topography: Primary & Secondary Anger


Primary Anger: Visceral, immediate physical reaction to physical context, often suppressed by other classically conditioned emotion/cognition

Secondary Anger: Anger mediated by behavior & cognition (e.g., angry rumination, parent hitting child because he is wrong, anger towards past or self-concept, etc.) and (classically) associated to other emotion/experience (fear, low energy, sadness)

Source: Emotion-Focused Therapy & Buddhist Psychology

Not-so-Subtle Anger Topography: From ‘Hot’ to ‘Cold’ Aggression


‘Hot-blooded’ or ‘reactive’ aggression (e.g., tantrum, hit, yell, ruminate, suppress) occurs in context of ANS stress point to behavior under control of aversive antecedent stimuli (Experiential Avoidance & Fusion ), & ST conseq.

‘Cold-blooded’ or ‘proactive’ aggression (bullying, kidnap, torture, theft, cruelty) may not be assoc. with antecedent stress point to behavior under control of whole hexaflex – pervasive psych. inflexibility ‘Cold’ aggression is associated with a violence/trauma

learning hx, incl. intense violence, fear, anger/rumination

The Actual Problem with Anger: Loss of Vitality/Quality of Life


Problematic anger: Incongruity between inflexible action controlled by anger & what the person deeply cares for.

Anger typically directly undermines the main source of value and vitality for most people: personal relationships

An overwhelming share of the targets of problematic anger are fellow human beings (and 75% are very important relationships)*

Contact with and sharing of our psychological vulnerabilities is a requirement for intimacy & its suppression (e.g., in a controlling anger context) betrays valued relationships

* (Deffenbacher, 1993; Deffenbacher, Oetting, Thwaites, et * (Deffenbacher, 1993; Deffenbacher, Oetting, Thwaites, et al., 1996).al., 1996).

.

Problematic Anger: Or How Does the Anger Context Controls Action that Undermines

Living?


.

Living Well with Anger: What Can We Do to Undermine the Control the Anger Context

Exerts Over Action?

ACBS XII Minneapolis - June 2014Koke Saavedra & Katherine Plambeck15Self as

Context

Contact with the Present Moment

Defusion

Acceptance

Committed Action

Values

Psychological Psychological FlexibilityFlexibility

I. What We Can Do About Anger: Functional-Contextual Analysis of ‘Problematic Anger’ & ACT

Intervention


ACT changes the controlling functions of the contextual variables affecting a person’s action

Problematic action is under aversive antecedent control & thus promoted by ineffective suppression/avoidance Problematic action is negatively reinforced by reductions of antecedent stress

Mindfulness/flexible present moment attention direct contact with aversive antecedents & other context variables, promoting actual physical context to control effective action

Acceptance dissolves the controlling function of antecedent anger & associated emotion/physical context

II. What We Can Do About Anger: Functional-Contextual Analysis of ‘Problematic Anger’ & ACT Intervention



Problematic action is positively reinforced by desired, instrumental consequences control over environment, especially change in others’ behavior (child doesn’t cry)Problem. action is reinforced by ‘being right’: consistency of action w/rules reinforced by verbal community/pliance

Defusion deliteralizes anger cognition and so undermines the control a literal thinking context exerts over action

Values clarity changes controlling conseq. from emotion control, ‘being right’, unworkable rewards to valued action

The Problem with Being Right


Stuck Chicken

III. What We Can Do About Anger: Functional-Contextual Analysis of ‘Problematic Anger’ & ACT Intervention



Problematic anger is maintained by skills deficits & difficulty engaging in flexible, workable action poor behavioral repertoires and mindfulness/perspective-taking skills; values disorientation; social skills/empathy deficits

Committed Action & Skills training expands action repertoire to behaviors that allow for changes in contextual variables to occur as well as action at the service of chosen values

IV. What We Can Do About Anger: Changing Subtle Anger Context


Primary Anger: Visceral, immediate physical reaction to physical context, often suppressed by other classically conditioned emotion/cognition Experience it directly & respond consciously to actualize

chosen values

Secondary Anger: Anger mediated by behavior & cognition (e.g., rumination, parent hitting child to educate, anger toward past/self-concept) & assoc. w/other emotion/exper. (fear, low energy, sad Mindfulness/acceptance of primary emotion, defusion at

the service of actualizing chose values


The ABC’s of the Hexaflex: The ABC’s of the Hexaflex: ACT Assessment & CF of Problematic ACT Assessment & CF of Problematic

AngerAngerA –

ANTECEDENTS What I experience(Mental & Physical

Environment)

B – BEHAVIORSMy responding or how am I relating (functionally) to A &

C(VNS – Action functional)

C – CONSEQUENCES

What I get when I do B in the context of A:

-Immediately (ST) -Over time (LT)

MIND:- Cognition (verbal content?)- Memories/images? (Trauma?)

BODY:- Emotion? Sensation?- Senses?- Breathing

OTHER CONTEXT:- Valued context- Physical & human environment

MINDFULNESS- Self-as-context perspective or conceptualized self controls B?- Is attention flexible/inflex.?- Willing? Accepting of experience or control struggles? - Mindfulness of cognition or fused? (Angry rumination?)

VALUES ORIENTATION:- Values Oriented/Disoriented?

COMMITTED ACTION :-Effective action at the service of chosen values?-Social skills?

ST Consequences:- Negative reinforcement?- Positive reinforcement?-Valued living/costs?-’Being right’/pliance?

LT Consequences: - Valued living? - Chronic anger & other psych. struggles?- Relationships & life costs ?

.

Living at the service of:•Being right & enforcing socially learned arbitrary verbal rules on

self and others (Fu & Concept. Self)•Automatically regulating unwanted emotion, stress, memory (Exp. Av.)•Controlling other human beings’ behaviors to fit my conditioned

desires & interests (Autopilot Act.)

Some of the costs I pay:• Chronic anger and stress • Health & wellbeing costs

• Hurt family, friends & other significant relationships

• Alienate myself from community, fellow humans, and from self

• Other life constriction

1. Freely Set My Valued Directions in Significant

Life/Relationship Contexts: Partner/spouse; family (parents, children, siblings, etc.); friends;

community; education; fun; work/creativity; spirituality; health.

2. Take Freely Chosen Valued Actions in Those Contexts: Is

doing that working for you? Is it moving you in the direction of who you want to

be and what you want to offer the world?

3. Work with the Barriers in those Contexts: Are you willing to contact your experience undefendedly as it is and not as it says it is for the purpose of living a chosen, effective

valued life?

The The actuaactua

l l choicchoic

e e

To ‘ACT’ Consciously: The Antidote to Problematic Anger


Aware: of your present moment experience as it is, not as it says it is

Choosing: in contact with your freely chosen valued directions

Taking Action: that effectively actualizes what matters to you in that life or relational context

The End of ACT: Psychological Flexibility


The ability to live and relate to other humans/world to actualize chosen valued ends, irrespective of the presence or absence of psychological barriers (such as, an anger context of difficult thoughts & memories, emotional & physical discomfort, strong control impulses, etc.)

PSYCHOLOGICAL FLEXIBILITY promotes vitality & a sense of control over my quality of life, but not over experience or others

Exciting ACT for Anger Data


Ongoing ACT for Anger Group for Incarcerated Men - Preliminary Data


ACT group goal: to reduce problematic anger behaviors for incarcerated men at a California

jail8 weekly 90-min. group sessions (group size: 8 to 13)Non-controlled ACT pilot - males over 18 years oldPre, post, and 1 month follow-up questionnaires looking at psych. flexibility (AAQ-II) and frequency of problematic anger behaviors (ACQ).Study progress to date:

41 men completed pre-treatment questionnaires 10 participants have completed treatment & post questionnaires 27 participants are currently in ongoing ACT groups

Katherine Plambeck, Dissertation Research

.V

-20%-20%

-40%-40%

-60%-60%

+20%+20%

% Change inProblem Behaviors

% Change inPsych. Inflexibility

35

15

40

17

59

25

6

26

Ongoing ACT for Anger Ongoing ACT for Anger Group for Incarcerated Group for Incarcerated Men (Preliminary Data)Men (Preliminary Data)Katherine Plambeck, M.A.Katherine Plambeck, M.A.

Ongoing ACT for Anger Ongoing ACT for Anger Group for Incarcerated Group for Incarcerated Men (Preliminary Data)Men (Preliminary Data)Katherine Plambeck, M.A.Katherine Plambeck, M.A.

Quotes from Participants Who Completed the ACT Group – Acceptance & Valued Action Focus


““I’ve learned how to have compassion for myself. This has I’ve learned how to have compassion for myself. This has produced in me the ability to love others more and have produced in me the ability to love others more and have compassion for them, which is huge! A heavy weight has been compassion for them, which is huge! A heavy weight has been lifted!”lifted!”

“…“…the focus on self-awareness enhanced my ability to express the focus on self-awareness enhanced my ability to express myself, and understand my thought-to-action process.”myself, and understand my thought-to-action process.”

““Before your class I never really thought much about what I Before your class I never really thought much about what I am thinking about. …I have very little, if any, control over my am thinking about. …I have very little, if any, control over my crazy-ass mind. However, I have complete control over my crazy-ass mind. However, I have complete control over my actions. After all, I am not my thoughts. Right? That’s a damn actions. After all, I am not my thoughts. Right? That’s a damn good thing! …the monsters that reside in my head are NOT in good thing! …the monsters that reside in my head are NOT in the driver’s seat.”the driver’s seat.”

Randomized Controlled Trial: ACT for Anger for Minority Adults in Recovery


29

Koke Saavedra (2006)

29


Process of Change: ACT for Anger Process of Change: ACT for Anger Change in acceptance but not in propensity to experience Change in acceptance but not in propensity to experience

angeranger

Change in Freq. of Change in Change in

Problematic Behaviors Trait Anger Acceptance

(ACQ-B) (STAXI-2) (AAQ-16)

-16.7

-1.7

-6.9

-3.3-2.4

2.4

-20

-10

0

10

Measure

Ave

rag

Par

tici

pan

t C

han

ge:

Pos

ttre

atm

ent

min

us

pre

trea

tmen

t sc

ore

ACT Treatment Group

Wait List Control Group(50.2%) *

(15%)

(7.7%)

*Significant: p < 0.05%

(12%)

(9.9%) *

(3.7%)

Negative sign represents

reduction in exp. avoidance

Cool findings! Consistent with Mindfulness model, not with CBT


Promising new model: Cohen d = .76 .8 is large

Findings consistent ACT model: Gains NOT mediated by changes in “trait anger”

(STAXI-2); No cognitive restructuring ACT & CBT work through different mechanisms Acceptance improved for treatments only Some limitations of the study: very small sample

(but results consistent with other ACT trials); mediation analysis of acceptance failed (sample too small); no F/U (ACT tends to show further gains).


ACT impact by frequency of ACT impact by frequency of anger-related problematic behaviors anger-related problematic behaviors

ACT for Anger ACT for Anger Group TrainingGroup Training

ACT for Anger Group Training Overview


Values Work & Valued Action Focuso Setting Valued Ends Against Which to Measure Actiono Beginning with a Focus on Chosen Valued Action

Creative Hopefulnesso Observing Action Patterns & their Consequences

Mindfulnesso Promoting Willingness, Undermining Controlo Self-as-Context & Defusion

Maintaining & Expanding Committed Action

Values Work & Valued Action Focuso Setting Valued Ends Against Which to Measure Actiono Beginning with a Focus on Chosen Valued Action

Creative Hopefulnesso Observing Action Patterns & their Consequences

Mindfulnesso Promoting Willingness, Undermining Controlo Self-as-Context & Defusion

Maintaining & Expanding Committed Action

Safety & Free Choice during Experiential Exercises


Experiential exercises may or may not put you in contact with difficult or uncomfortable experience

Freely choose if you participate or not, as well as your level of risk/involvement/disclosure

The expectation is not that you will participate, but that you will make your own free choices – also that we will all keep an open heart to fully allow others to show up as they choose to

Values Work IWhat do you really want to

be about?


Values Orient Our Actions: Chosen verbal descriptions of

intrinsically valued action patterns

Values make contacting unwanted, painful events desirable & dignified

Our values, like a lighthouse, they guide us through the storms…

Values Orient Our Actions: Chosen verbal descriptions of

intrinsically valued action patterns

Values make contacting unwanted, painful events desirable & dignified

Our values, like a lighthouse, they guide us through the storms…

Drawing: Joseph Ciarrochi & David Mercer

Values Work IIWhat do you really want to be about?


Some Key Discriminations:

Values are not goals “Going west…”

Values are not feelings You are what you do, not

what you think/feelValues point to the process

of living, not to its outcomes Playing to play vs. playing to win Going for a Hike

Some Key Discriminations:

Values are not goals “Going west…”

Values are not feelings You are what you do, not

what you think/feelValues point to the process

of living, not to its outcomes Playing to play vs. playing to win Going for a Hike

The Problem with Goals…


“When you reach the top of the ladder and realize it was leaning against the wrong wall.”

~ Joseph Campbell

Midlife crisis

Photo: http://goulddesigninc.wordpress.com/2013/05/30/5-keys-to-knowing-if-you-are-on-the-ladder-of-opportunity/

What do you Want Your Life to be About?


Write Your Own Epitaph

“Here lies Anne who successfully avoided intimacy with her mother because she couldn’t forgive her”

“Here lies Tom who yelled and screamed at his wife and kids because his work was so stressful”

“Here lies Alicia who never enjoyed a stroll in the park, because there were too many inconsiderate people”

.

Values Exercise: What really matters to you?

Values are not goals or things you can have, or feelings, they are your chosen life directions, the compass tat guides your actions nowBull’s Eye is a creation of Tobias Lundgren & Joanne Dahl

Relationship/life domain ___________

Values _____________Actions ____________


41

Group-Based Creative Hopefulness:

Undermining ineffective action by bringing awareness to what one is doing & its consequences


Demonstration

What do you want? What are you doing? What are you getting? And over time? Is this this consistent with your

values?What does your mind say? What does your experience show?Which one do you trust?

Person in the Hole Metaphor


Isn’t acting on anger a bit like digging in a hole? We just keep

acting it out because it feels so right, but it

actually over time we are just sinking

deeper?

What if Control is the Problem?


Digging in a HoleFeeding the TigerHolding the Door ShutQuicksand metaphor

So, which one do you choose…

being right or being effective?

Mindfulness: Undermining Barriers to Valued Action in the Context of Anger


Mindfulness is willingness

Mindfulness/Present moment practice Body scan & deep breathing for awareness

Self-as-Context & Defusion Where do your thoughts come from?

-Don’t think & instead watch-Who are you? Watch you hand, watch your mind

Chessboard & letting the river flow Blue sky: Watching vs. struggling with weather

Fusion Controls Problematic AngerFusion Controls Problematic Anger


Functional Control: Verbal Topography of Secondary Emotion (Fusion)

‘‘Me’ is Me’ is conceptualizeconceptualized as…d as…

Other/word is Other/word is conceptualized conceptualized as…as…

Future/past is Future/past is conceptualizeconceptualized as…d as…

Anger – an energy to change the context

Being wronged & being right (how could

them…, I’ll show them…)

Wrong, wronging me (‘blame game’)

& in need to change, be righted

(control focus)

Full of frustrations, a

struggle to right or against

wrongs (unjust, stupid, etc.)

Depression – an energy to remain inactive in the context

Worthless or lacking value (incompetent,

a failure, etc.)

Not valuing me(not caring about me, unavailable, rejecting,

judging me, etc.)

A story of failure to create value.

(Hopeless future and worthless, failed past)

Anxiety – an energy to avoid the context

Vulnerable (fragile, weak or unable to cope, helpless); in need to be vigilant,

in control.

An unpredictable

source of dangers.

Full of dangers,

lurking catastrophes.

Putting your thoughts on clouds

Thank you mind for those Thank you mind for those thoughtsthoughts


“Wise Exiting”: Action at the Service of Value


The anger context is very powerful…

Often (and in particular when a person is beginning to work with anger) new behaviors are difficult to access in the presence of the physical and mental experience of anger

We wisely choose to exit the context that is eliciting our anger… to practice new helpful responses in the anger context

Lots of practice in the therapy room too!

Anger Rumination & Suppression of Thought/Experience


The power of mind – it’s magical Imagine your favorite food Imagine you are in a dungeon…

Having a conversation with the TV in the living room?

Take your mind for a walk…

Undermining suppression: Don’t think of an angry lion

Undermining Blind Faith On Mind

...but I thought I totally understood how to swim… …glug, glug…


Targeting Subtle Action: Primary & Secondary Anger


Primary Anger: Visceral, immediate physical reaction to physical context, often suppressed by other emotion/cognition learn to experience it directly & respond consciously (e.g., express it effectively)

Secondary Anger: Anger mediated by cognition (e.g., angry rumination, parent hitting a child to educate him, anger towards past, self-concepts, politics) and (classically) associated to other emotion/experience (fear, low energy, sad) mindfulness of primary emotion, acceptance of primary emotion, defusion.


Mindfulness Exercise


EXERCISE: Contacting a difficult interpersonal

experience… for valued ends

Committed Action


“Your steps tell you where you have been, not where you are going.”

Establishing patterns of freely chosen

committed action is the purpose of ACT

54

How to Elicit Committed Action?


Help client connect with freely chosen values in a life or relationship domain

Have client identify actions that he wants to engage in to support that value in that domain

Set goals and practice, practice, practice…

Use mindfulness (self-as-context, PM attention, acceptance & defusion) to undermine control by anger context

Promoting Interpersonal Committed Action:

Some Helpful Metaphors for Anger


Being Right vs. Being Effective – (Choose a fist) Which one you choose if you must pay w/one for the other?

Being Right vs. Being the person you deeply want to be

The Monks and the Arrogant Ladies Why do we forgive? For us, for them

Fishhook metaphor

What matters to you vs. what matters to your mind?

Living with anger buttons all over our mind

Learning how to jump…

ACT Helps Us Live Rich Lives with Psychological Obstacles


o Willingness Question- Are you willing to have this experience so

you can move in the direction of … (your chosen value)?

o Effectiveness Question- Is what you are doing moving you closer or

further away from the life you want?


58

Thanks!That’s all

folks!

Thanks!That’s all

folks!

. ACBS XII Minneapolis - June 2014Koke Saavedra & Katherine Plambeck

BIBLIOGRAPHYHayes, Strosahl, & Wilson (2012). Acceptance & Commitment Therapy: The Process & Practice of Mindful Change. Gilford.Dahl & Tobias (2004). Living Beyond Your Pain. New Harbinger.Wilson & DuFrene (2009). Mindfulness For Two. New Harbing.APA (February 7, 2013), Stress in America. Retrieved from www.apa.org/news/press/releases/stress/2012/full-report.pdfGreenberg (2002). Emotion-Focused Therapy. DC: APA Press. Eifert, Forsyth & McKay (2006). ACT on Life, Not on Anger. New HarbingerSaavedra (2008). Toward a New ACT Treatment of Problematic Anger for Low Income Minorities in Substance Abuse Recovery. Dissertation & Theses Full Text Database (Publication No. AAT3306472).Rhodes (1999). Why They Kill? New York: Knopf.

59

Koke Saavedra, Psy.D. & Katherine Plambeck , M.A.

Documents

Transcript of Koke Saavedra, Psy.D. & Katherine Plambeck , M.A.