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Acceptance and Commitment Therapy An Experiential Approach

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Acceptance and Commitment Therapy An Experiential Approach to Behavior Change Kirk D. Strosahl PhD Email: mountainconsult_at_msn.com Choose Mindfully-Mindless Choosing ... – PowerPoint PPT presentation

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Title: Acceptance and Commitment Therapy An Experiential Approach


1
Acceptance and Commitment Therapy
  • An Experiential Approach to Behavior Change

Kirk D. Strosahl PhD Email mountainconsult_at_msn.co
m
2
Workshop Objectives
  • An introduction to ACT for those who are new to
    it
  • Appreciate the core assumptions about human
    suffering that underpin the ACT model
  • Appreciate the change agenda that clients bring
    into therapy and why it is bound to fail
  • Understand the six core processes of ACT and the
    role they play in promoting psychological
    flexibility
  • Demonstrate various ACT interventions that
    support work in each of the six core process
    areas
  • We will titrate this based upon how much you
    already know about ACT

3
Basic Assumptions
  • Philosophical basis in functional contextualism
  • Emphasis on pragmatic truth constructfunctionally
    workable relationship are truth
  • What works for one might not work for another
  • In the case of humans, there are three contextual
    fields covert behavior (thoughts, feelings,
    memories, sensations), overt behavior
    controlling environmental influences
  • All contextual fields must be taken into account
    if you are going to establish workability

4
Basic Assumptions
  • Basic Science Underpinning in Relational Frame
    Theory (RFT)
  • Language is based on arbitrary learned relations
    that are controlled within relational frames
    (rule governed behaviors ,bi-directional
    relations, transformation of functions)
  • Provides an evolutionary advantage, but also
    expands the ability to feel, predict, categorize
    evaluate makes behavioral avoidance possible
    and cognitive dominance likely (stimulus
    equivalence and equivalence class)
  • Experiential avoidance and cognitive fusion are
    built into language and amplified by the culture
    they are implicated in psychopathology (pliance,
    tracking augmentals)

5
Basic Assumptions
  • Basic human condition is we cant live without
    language . . . And we cant live with it
  • Eliminating verbal relations is impossible
    because they are historically acquired and
    automatically conditioned
  • All forms of human experience, both real and
    imagined, can enter into relational frames and
    govern behavior
  • Rule governed relations are insensitive to
    direct environmental contingencies
  • All verbal relations function behind the eyes
    and therefore operate directly in the moment they
    exert behavioral control (i.e., they are not
    transparent)
  • It is possible to exert control over the
    FUNCTIONS but not the FORM of verbal relations

6
The Bottom Line
  • When this powerful computer is focused inward,
    the very properties that moved us to the top of
    the feeding chain can become toxic
  • The two central culprits from a ACT point of
    view are. . .
  • Cognitive fusion Mistaking private events as
    reality
  • Emotional avoidance Unwillingness to make
    contact with undesirable, unwanted private mental
    events, leading to ever widening patterns of
    behavioral constriction

7
The ACT Model of Human Suffering and
Psychopathology
  • Human pain (physical and psychological) is
    ubiquitous, normal and self restorative
  • Unwillingness to have pain leads to reliance on
    avoidance and control based strategies
  • Excessive use of control avoidance leads to a
    loss of contact with committed actions vital
    purposeful living
  • It is not physical/mental pain per se that is the
    enemy but our attempts to avoid or control it
    lead to disorder and suffering
  • This cycle of suffering is strongly supported in
    the culture through language acquisition and
    socialization

8
The Principle of Destructive Normalcy
  • Health is defined as the absence of distressing
    private content
  • When you have distressing private content, that
    is a sign you are not healthy and abnormal
  • The goal therefore is to eliminate the
    distressing content in the service of being
    normal (the culture of feel goodism)
  • In the event distressing content cannot be
    readily controlled or eliminated, the human is
    required to come up with a justification for why
    that is so (reasons)
  • Reasons are culturally taught to be good causes
  • The goal therefore is to eliminate and/or control
    the identified reasons in the service of
    achieving health

9
FEAR A Formula for Human Suffering
  • Fusion Attaching to unwanted private experiences
    (thoughts, feeling, memories, sensations) and
    their rule governed functions
  • Evaluation Imbuing events/experiences with
    evaluative properties that become functionally
    associated as primary properties
  • Avoidance Using behavioral or psychological
    strategies designed to eliminate or constrict
    exposure to distressing private content
  • Reason Giving Providing a socially supportable
    justification for dysfunctional and unworkable
    behaviors

10
Definition of ACT
  • ACT uses acceptance and mindfulness processes,
    and commitment and behavior change processes, to
    produce greater psychological flexibility.

11
Psychological Flexibility
  • is contacting the present moment fully as a
    conscious human being, and based on what the
    situation affords changing or persisting in
    behavior in the service of chosen values.

12
The Six Core Processes of ACT
  • Defusion Establishing new functions for
    thoughts, feelings, memories, sensations
  • Acceptance Non-judgmental awareness
  • Getting in the present moment Showing up
  • Self as context Contacting the transcendental
    sense of self in which all experience is safe
  • Valuing A process that instantiates goal
    directed behavior
  • Committed action Engaging in behaviors that are
    consistent with personal values

13
(No Transcript)
14
Acceptance and Mindfulness Processes
You can chunk them into two larger groups
15
Commitment and Behavior Change Processes
and
Thus the name Acceptance and Commitment Therapy
16
The Common Core of All of These Processes is
17
The Essence of ACT
  • Accept What is there to be experienced, fully
    and without defense, for what it is, not what it
    says it is
  • Choose Based upon your closely held values,
    choose what you would like to be about here
  • Take Action Engage in committed actions that
    embody your values, inhaling the distressing
    personal content as it appears

18
Core Attributes of the ACT Therapist
  • Walking the walk versus talking the talk
  • In addition to targeting them, ACT encourages the
    therapist to model acceptance, defusion, getting
    present, and values through self disclosure and
    consistently applying these to oneself
  • ACT encourages the therapist to implement these
    in the interaction between the therapist and
    client so that they become defining features of
    the therapeutic relationship

19
Case Formulation Identify the Unworkable Change
Agenda
  • A depressed client might give you a string like
    this
  • I have been put on work disability because of my
    depression. (reasons as causes)
  • When you feel as down as I have been feeling, you
    cant function on the job like the others and you
    feel like a failure (evaluation)
  • The only way I can control my depression is by
    staying away from work. (emotional and behavioral
    avoidance)
  • I need to figure out what is causing my
    depression in the first place and then I will be
    able to get on top of it. (fusion)
  • Once my depression is under control, I can go
    back to work (fusion)

20
Why Doesnt the Change Agenda Work?
  • In almost every case. . .
  • Avoiding situations that produce unwanted private
    experiences creates a paradoxical effect (missing
    work creates more depression, not less
    depression)
  • The arbitrary assumption that private events
    cause behavior creates a trap you cant behave
    differently until you feel differently (but since
    missing work is increasing depression, the person
    is now locked into the causal equation and cant
    return to work)
  • When the conditions specified in the change
    agenda cant be met, you can only explain your
    predicament but there is actually little you can
    do about it.

21
ACT Case Formulation
  • In your functional analysis, look for the
    following
  • To do behavior X requires me to have attribute
    Z
  • Fusion with a rule
  • I have too much (little) attribute Z, which
    means Im not healthy
  • Evaluation
  • Since I have a problem with attribute Z, I cant
    do X
  • Avoidance
  • Attribute Z is causing me not to do X Ergo,
    we need to work on factor Z
  • Reason giving, using reasons as causes

22
What have you tried? How has it worked? What has
it cost you?
  • Functionally analyze the scope of avoidance
  • Look at all the things the client has tried to
    solve the problem
  • Consider that coming into therapy itself is
    another problem solving attempt
  • Have client define what solving the problem
    means
  • Look for controlling distressing content as the
    goal
  • Ask the client to rate whether past actions have
    indeed solved the problem
  • Ask client to consider whether the problem has
    actually worsened over time
  • If appropriate, ask the client to assess the
    cost of using these solutions

23
Creative Hopelessness
  • Experientially, the client has to make contact
    with this paradox
  • The harder you try to control an unwanted private
    experience, the bigger it gets
  • Control and experiential avoidance might work
    temporarily, but rarely do their effects last and
    most often there is a rebound effect that makes
    things worse
  • As logical as this approach seems, it will NEVER
    work
  • It isnt that YOU are hopeless, but that this
    STRATEGY for addressing these unwanted events is
    hopeless
  • Before you can try something new, you have to
    stop what doesnt work

24
Creative Hopelessness
  • Person in the hole metaphor
  • A basic ACT intervention
  • Gives therapist a language tag to use
    throughout therapy
  • Are you digging right now?
  • Refusing to walk in order to avoid holes sounds
    like a pretty boring life
  • Analyzing how you fell in the hole isnt going
    to help you get out
  • Blaming life for producing holes wont eliminate
    the holes

25
Control Is the Problem, Not the Solution
  • It is important to give this trap a name
  • Trying to avoid Mr. Anxiety
  • Checking out rather than checking in
  • This trap has the paradoxical effect of adding
    to, rather than subtracting from, suffering
  • Clean vs. Dirty Suffering
  • Would you be willing to have the clean stuff if
    we could find some way to reduce the dirty stuff?
  • The experiential cost
  • Gain control of your feelings, lose control of
    your life
  • Monsters on the bus exercise makes this point

26
Listen With ACT Ears
  • Watch the video segment
  • Two Groups
  • Group 1 looks at the tape from a content level
    focusing on insight, motivation, therapist bait
  • Group 2 looks at tape using an ACT framework such
    as what core processes are invoked, what is the
    function of the problem, role of fusion,
    emotional avoidance, etc.

27
Three Main Polarities In ACT Practice
  • AcceptanceFusion polarity contains defusion,
    willingness, acceptance
  • This undermines emotional avoidance
  • Choose mindfullymindless choosing polarity
    contains self experience, evaluation/reason
    giving and valuing
  • This undermines rule following, hidden
    evaluations, reason giving and attachment to the
    self story
  • Take action-avoidance of action polarity contains
    willingness, value based goal setting to create
    exposure to vitality producing life moments
  • This undermines behavioral avoidance

28
Simplify Your Approach
  • You dont have to go through all six core
    processes to be doing ACT!
  • In more functional patients, there might be one
    polarity that you are going to target
  • You want to use your assessment data to answer
    this question
  • What is the main issue this client is having and
    what is the best point of entry to attack that
    problem?
  • In many cases, ACT might turn out to be a single
    session therapy or a very brief intervention
  • As patients become more chronically distressed,
    the number of polarities involved increases and
    this will lengthen therapy

29
Acceptance-Fusion Polarity
  • Accepting the fact that things are not working as
    they should (What have you tried? How has it
    worked?)
  • Accepting the cost of this unworkable behavior
    (What has it cost you?)
  • Accepting the paradoxical nature of mental
    control, despite the seeming logic of it all
    (Control is the problem)
  • Accepting that control is not working and wont
    ever work (Creative hopelessness)
  • Accepting the presence of rule infested reactive
    mind (Mind is not your friend)
  • Accepting all mental experiences for what they
    are, not what they appear to be (Defusion)

30
Acceptance as the Alternative to Control
  • When is acceptance called for?
  • Remember the serenity prayer?
  • With natural, conditioned uncontrollable private
    experiences such as emotions, memories, thoughts,
    sensations
  • When a situation cannot be changed
  • Presence of chronic disease, pain, terminal state
  • The attitudes, beliefs and behaviors of others
  • When change or control strategies produce
    paradoxical results (i.e., try not to think about
    X)

31
When is control called for?
  • When the event in question is under the
    organisms direct stimulus control
  • Behavioral responses in the present moment
  • Willingness to enter into a situation
  • Being present
  • Holding values
  • Making commitments

32
When Lack of Acceptance Is A Problem
  • Usually, it starts with unwillingness statements.
  • I wont go there if I have to feel anxious or sad
  • Unwilling to get in front of unpleasant feelings
  • Thinking about my divorce is just too painful
  • Unwillingness to be in the presence of grief,
    loss or self critical thoughts
  • I want to put this behind me and get rid of it
  • Unwillingness to make contact with personal
    history or present moment
  • I just want to get over this
  • Unwillingness to be exposed to distressing
    content

33
Defusion and Acceptance
  • Basically, defusion strategies are designed to. .
  • Create a space between thought and thinker
  • Undermine the clients confidence in the utility
    of minding their mind in certain circumstances
  • Appreciate the limits of brain behavior as
    applied to natural, whole human behaviors
  • To look at mental events for what they are, not
    what they appear to be
  • All in the service of stalling sense making and
    reason giving
  • Defusion promotes willingness willingness
    promotes acceptance

34
Choose Mindfully-Mindless Choosing Polarity
  • Being mindful that reactive mind leads to living
    in the past or future, not the present
    (attachment to conceptualized self)
  • Being mindful that reactive mind traps you in an
    illusory process of sense making and story
    telling (description-evaluation)
  • Using wise mind to offset the mindless rule
    following of reactive mind (do what works, not
    what ought to work)
  • Getting in the present moment allows you to see
    the world the way it actually is (Mindfulness
    exercises)
  • Using wise mind to reveal your true values
    (values work exercises) and the course you are
    on (Bulls Eye)
  • Using wise mind to respond flexibly in the
    present moment (workability)

35
Addressing Obstacles Posed by the Conceptualized
Self
  • In ACT, we talk about each patient having a
    story that can function like a lockbox
  • Heres who I am and how I came to be that way and
    why nothing can ever change my reality
  • The key is to get the client to lose confidence
    in the sanctity and unquestioned truth of the
    story
  • Autobiography re-write exercise
  • Self story wheel
  • Time line
  • DONT argue about how rational the story is
    let the experiential exercise show that each
    story is arbitrary and there are endless possible
    stories

36
Two Forms of Self Experience Comprise Wise Mind
  • Present Moment Awareness
  • Being in the moment and absorbing what is there
    without mental interference (observer self)
  • This is an attention skill that can be learned
  • Simple Awareness
  • The you that is aware of the present moment
  • The you that is your consciousness
  • The you that has always been there
  • This is not a skill but rather is a result of
    sustained present moment awareness that is a skill

37
Getting in the Present Moment
  • In session, the therapist looks for shifts,
    tries to elicit avoided experiences and models
    this openness
  • What just showed up for you?
  • Can you stay with that for just a minute?
  • Is there anything about this that is actually
    toxic to you right here and now?
  • Im willing to stay right here if you are
    willing to be here
  • Mindfulness exercises can help defuse the
    threatening aspects of being in the present
    moment

38
Simple Awareness
  • A transcendent sense of self that is bigger
    than all of the products of consciousness
  • Contact with this space can have life changing
    impacts
  • Various ACT exercises make the point
  • Chessboard metaphor
  • Leaves on a stream
  • The you that you call you
  • Various meditation and mindfulness exercises

39
Role of Values
  • Values are seldom talked about in relation to
    mindful action they are normally thought of as
    the top end of committed action
  • Important to distinguish values from valued
    actions
  • Valued actions ARE the twin of commitment
  • In ACT, values perform a number of important
    purposes
  • Contact with values organizes present moment
    experience
  • Values allow the clients to parse contingencies
    in the present situation (i.e., you cant know
    whether something is working unless there is an
    existing framework for knowing what working is)

40
Workability, Vitality and Values
  • The pathway to vitality is basically engaging in
    actions that resonate with personal values
  • Workability is the ACT term for the extent to
    which actions are or are not consistent with
    values. It is the yardstick for measuring how
    therapy is working.
  • Workability can be assessed situation ally.
  • How did it work for you to get drunk last night
    when your wife got angry at you?
  • Workability can also be assessed globally.
  • How do you feel your life is working right now in
    terms of giving you a sense of vitality purpose
    and meaning?
  • Workability is a good place to go to when you get
    stuck in session!

41
Clinically Important Properties of Values
  • Values are a product of wise mind and thus can be
    suppressed, but not eliminated, by certain
    activities of reactive mind
  • Fusion with a toxic self story
  • Excessive pliance
  • Excessive behavioral control through reason
    giving
  • Not based upon reasons, but rather represent
    starting assumptions (I stand for X) and cannot
    be intellectually derived
  • Cannot be obtained by any single achievement and
    thus exerts continuous behavioral control (there
    is always more west to go)
  • Values function as the fuel for committed
    action

42
Areas for ACT Values Assessment
  • Work/career/community usefulness
  • Love/intimate relationships
  • Family/parenting
  • Friends/social connectedness
  • Personal growth
  • Health and hygiene
  • Spirituality

43
ACT Value Clarification Strategies
  • Many techniques, but the core approach
  • Use the common sense language of free choice
  • Ask what they really want
  • Shape the answer by
  • distinguishing values from goals
  • confronting pliance and avoidance
  • being completely and sincerely supportive
  • Funeral Exercise is the most often used ACT
    strategy

44
Take Action-Avoid Action Polarity
  • Commit to voting with your feet, in accordance
    with your values (valued actions)
  • Take action knowing that it will trigger
    distressing content and commit to continuing to
    act (willingness the overt behavior)
  • Committed actions are choices that are made with
    reasons, but not for reasons (choosing versus
    deciding)
  • Committed acts are qualities no matter how small
    or large as you want them to be (like jumping)
  • Committed action triggers a process that never
    ends until you do (journey metaphors)
  • Re-attaching to the self story is the main
    barrier to following the path of committed action
    (who would be made right if you got healthy)

45
Clinical Aspects of Committed Action
  • Actions which are consistent with ones
    self-identified values
  • These actions are choices that will be made in
    the presence of reasons, but not for reasons
  • Not choosing is a form of choice, often involving
    succumbing to reason giving
  • Committed action is a qualitative rather than
    quantitative act
  • The workability of life in the present moment is
    generally greatest when actions are consistent
    with values
  • Committed actions invariably elicit distressing
    private content! To be alive means to invite
    these in the door.

46
Clinical Use of Choice
  • Choice is one of the trickier concepts in ACT and
    is not always understood and can generate
    resistance.
  • Think of choice as a for the sake of which
    behavior. It occurs as an act of free will.
    (Diving on a hand grenade to protect other people
    from being hurt)
  • However, choices are ongoing behavioral
    processes, not outcomes. You have to choose over
    and over again (a good example is recovery from
    addiction)
  • You dont HAVE to choose a particular act over
    any other actyou get to pick. It is OK to let a
    client choose NOT to change!
  • Reframe reason giving as choice making.
  • Dont use choosing as a way of brow beating the
    client!

47
Addressing Barriers to Committed Action
  • Are skills deficits going to be an issue?
  • If so, provide skills training
  • Being righteous rather than being real
  • Corpus Delecti no body, no crime
  • Forgiveness to give the grace that came before
  • Fish hook metaphor
  • Being response-able and responsible
  • Choose each step exercise
  • Inhale broken commitments, name them honestly
  • Hop A Long Cassidy metaphor
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