Introduction to Acceptance and Commitment Therapy

1. Introduction to Acceptance and Commitment Therapy Patricia Bach, PhD University of Central Florida

2. Get Out of Your Mind and Into Your Life…and Into Your Therapy Sessions

3. Agenda • Introduction • An overview of the ACT Model • Does ACT work, and how is it related to other evidence-based practices? • ACT techniques, some useful no matter what your theoretical orientation • ACT processes for clinicians

4. Informed Consent At times this workshop will be experiential Your privacy will never be violated, but you will be invited to take a few risks if you choose Confidentiality No judging the level of risk taking of others: go for it or not, it is up to you

5. Why now? • ACT and other mindfulness based treatments are growing in popularity. • The 21st century is prime time for the emergence of mindfulness and acceptance based treatments…

6. Mindlessness

7. Judgment: You’re not good enough

8. “The single most remarkable fact about human existence is how hard it is for humans to be happy.” (Hayes, Strosahl, & Wilson, 1999)

9. The Ubiquity of Human Suffering High lifetime incidence of major DSM disorders High rates of divorce, sexual concerns, abuse, obesity, violence, prejudice, loneliness Some extremely destructive behaviors are both common and non-syndromal, e.g., suicide, self-injury

10. The Ubiquity of Human Suffering People don’t just suffer when things are bad We suffer when things may be bad What is the consequence of withdrawing from suffering?

11. Question: If that’s true, why don’t we all struggle with anxiety, depressed moods, insecurities, fears, etc….?

12. Answer: Oh, wait…we DO!

13. That thing you do…

14. Destructive Normality Normal psychological processes often are destructive We need to understand these processes and work within them to promote health One cause: human language and cognition – human verbal behavior

15. Language is a Blessing and a Curse Evaluation Problem solving Avoidance

16. Experiential Avoidance Experiential avoidance is built into human language and then amplified by the culture Experiential avoidance is the tendency to attempt to alter the form, frequency, or situational sensitivity of historically produced negative private experience (emotions, thoughts, bodily sensations) even when attempts to do so cause psychological and behavioral harm 8/9/2014

17. Higher Avoidance Scores Are …. Associated with: Higher anxiety More depression More overall pathology Poorer work performance Inability to learn Substance abuse Lower quality of life History of sexual abuse High risk sexual behavior BPD symptomatology and depression Thought suppression Alexithymia Anxiety sensitivity Long term disability 8/9/2014 Sources: Hayes et al (2004); Polusny (1997); Toarmino (1998); Pistorello (1997); Batten, Follette, & Aban (1998); Stewart, Zvolensky, & Eifert (1998);

18. Central Clinical Insights Trying to get rid of thoughts and feelings can make difficult ones more important, and Narrows behavioral Repertoires But we can bring the functions of mind under better contextual control We do that by learning to relate to the mind in a different way That is one of the larger messages of mindfulness methods -Hayes

19. What is ACT? • A form of CBT • A form of clinical behavior analysis • A mindfulness-based treatment • Functional contextual therapy • Behavior is situationally bound • Behavior is functional

20. Acceptance and Commitment Therapy • A contextually focused form of cognitive behavioral therapy that uses mindfulness and behavioral activation to increase clients’ psychological flexibility – their ability to engage in values-based behaviors even while experiencing difficult or unwanted thoughts, feelings, and sensations. (http://nrepp.samhsa.gov, 2011)

21. ACT Therapeutic Stance • Universality - The struggles we have are not fundamentally different from other human beings. We communicate this to the client. • ACT is an experiential therapy in which the therapist is personally invested in the client, but is radically respectful of the client’s struggles and values. • To do ACT competently, you need to deal with your own anxieties in the same way you are asking your clients to deal with their anxieties. • Open up to them • Get in contact with your goals and values • Do what is there to be done (Hayes, 2006)

22. The ACT model Contact with the Present Moment Acceptance Values Psychological Flexibility Committed Action Defusion Self-as-Perspective

23. A trip around the hexaflex

24. The ACT model Contact with the Present Moment Acceptance Values Psychological Flexibility Committed Action Defusion Self-as-Perspective

25. Psychological Flexibility • The ability to contact the present moment fully as a conscious historical human being and, based on what the situation affords, changing or persisting in behavior in the service of chosen values -Hayes

26. How do you know you’ve got ‘psychological flexibility’?

27. Vitality!

28. Assumptions of ACT • Pain in life is inevitable • Normal verbal processes contribute to psychopathology • Control is best applied where it works - to overt behavior rather than to thoughts, feelings, and sensations • “The aim of ACT is to create a rich, full, meaningful life while accepting the pain that inevitably goes with it.” (Harris, 2009)

29. Show up for your own life

30. What gets in the way of vitality?

31. The ACT ‘inflexahex’

32. Experiential Avoidance • Deliberate attempts to avoid, control, suppress, escape, or get rid of negatively evaluated or unwanted thoughts, feelings and body sensations

33. Acceptance • Willingness to experience uncomfortable or unwanted thoughts, feelings, and body sensations in the service of response flexibility. • “Control is the problem, not the solution” • “If you’re not willing to have it, then you’ve got it” • Especially when control of thoughts and feelings is limited or reduces quality of life

34. Cognitive Fusion • Thoughts dominate behavior – “being pushed around by thoughts” (Harris, 2009) • Entanglement with judgments – thoughts are taken literally • Reduces the impact of direct experience

35. Cognitive Defusion • Also known as cognitive distancing • Observing thoughts without automatically taking them literally • “I’m having the thought that…” • No need to change thought content • Changing ones relationship to thoughts

36. Dominance of the conceptualized past and feared future • Loss of contact with the here and now • Out of touch with thoughts and feelings – lack of self knowledge • Rumination and worry

37. Dominance of the Conceptualized Past/Future “A mind is a wonderful tool for detecting and evaluating external dangers and developing plans for adapting to these demands, but we cannot avoid applying these same processes to the content of our private world. When we do so, we both see and produce negativity.” …Steven Hayes

38. Contact with the Present Moment “Mindfulness means paying attention in a particular way: on purpose, in the present moment and non-judgmentally.” (Kabat-Zinn) Openness to experience, engagement, flexibility, awareness, attention, process vs outcome Mindfulness promotes and requires acceptance and defusion. Vitality is only experienced in the present moment.

39. Attachment to the conceptualized self • Buys into self-evaluations – “I am too…” or “I am not…” • I am my thoughts and feelings • Limiting – we are more than we can ever say about ourselves

40. Self as Perspective • Thinking self Vs observing self • You are not your thoughts and feelings • Transcendent sense of self: thoughts, feelings and experiences change, and the YOU who notices these events doesn’t change • “Notice who’s having that feeling/thought/sensation”

41. Lack of values clarity • What do you want your life to be about? • avoidant values • People pleasing

42. Values & values clarification • Chosen life directions • Different from goals • Though values are verbally construed, they are actions: you value with your feet • “Outcome is the process through which process becomes the outcome” (Hayes, Strosahl, & Wilson, 1999)

43. Barriers to values • What is getting in the way of valued living? • Look for avoidance, impulsivity, inaction. • Often the presenting complaint or most obvious ‘problem behavior’

44. Committed Action • Behavior in the service of values • EBP’s, skill’s training, doing more or less of something, joining a support group, homework, etc. • Value’s clarification builds motivation for committed action. • “what’s that in the service of?”

45. Contact with the Present Moment (2) are you willing to have that stuff, fully and without defense (6) at this time, in this situation? Acceptance Values (5) of your chosen values If the answer is “yes,” that is what builds... Psychological Flexibility Committed Action Defusion 3) as it is, and not as what it says it is, (4) AND do what takes you in the direction Self-as-Perspective (1) Given a distinction between you and the stuff you are struggling with and trying to change

46. We can try to control the uncontrollable by looking for security and predictability, always hoping to be comfortable and safe. But the truth is that we can never avoid uncertainty and fear. So the central question is not how we avoid uncertainty and fear but how we relate to discomfort. -Pema Chodron

47. Does ACT work? • Meta-analytic studies support effectiveness of ACT Hayes et al., 2006; Powers et al., 2009; Ost 2008 • RCTs for treatment of many different problems Anxiety disorders, chronic pain, psychosis, trichotillomainia, substance abuse, depression, eating disorders, management of medical problems, obesity, epilepsy, impulse control disorder, etc.

48. Psychological Flexibility • The primary measure of PF is the Acceptance and Action Questionnaire • Differentiates patients from healthy controls • Is correlated with variables largely consistent with predictions • Shows treatment sensitivity • Explains unique variance • mediates and moderates as predicted Bond et al., 2011; Gloster et al., 2011

49. Is ACT an Evidence-Based Practice? • National Registry of Evidence-based Programs and Practices (NREPP) • APA Division 12 • chronic pain • depression • mixed anxiety • Obsessive compulsive disorder • psychosis • Veterans Administration

50. One major difference between ACT and many other treatment approaches • There is no attempt to reduce symptoms in ACT. • Symptom reduction often occurs, and it is a byproduct of treatment rather than an explicit goal of treatment.