ACT WITH DEPRESSION

1. ACT WITH DEPRESSION Rob Zettle, Ph.D. Wichita State University

2. INITIAL ORIENTING EXERCISE

3. WORKSHOP OBJECTIVES At the end of the session, participants will be able to: 1. Identify and clarify client values salient in depression. 2. Use a case-conceptualization approach to identify core processes and variables that contribute to deficits in valued action. 3. Select, adapt, and apply ACT-consistent interventions that target these same processes in order to increase valued living.

4. GROUND RULES ACT – like swimming - is best learned by doing it, rather than reading and talking about it. Structure of workshop: Didactic presentations Experiential exercises All are invited and encouraged to participate. None are required to do so. May opt to discontinue at any time.

6. YOUR LIFE STORY WITH DEPRESSION Take 5 minutes and write down at least part of your life story with depression. Recall a time in the past (or present) when you have struggled with depression. Describe how it first began, ways in which you struggled with it, and the key historical, situational, and personal life events that contributed to your struggles with depression.

7. THE ACT MODEL OF DEPRESSION AND ITS TREATMENT

9. The Primary ACT Model of Treatment Contact with the Present Moment Values Acceptance Psychological Flexibility Committed Action Defusion Self as Context

10. RELATED EXPERIENTIAL EXERCISE

11. NATURE OF PSYCHOLOGICAL INFLEXIBILILTY Being “stuck” Inability to freely choose various ways of leading a vital and valued life. Dysfunctional persistence Cognitive and behavioral rigidity

12. CONCEPTUALIZATION OF DEPRESSION Depression = Both overt behavior and private events (thinking and feeling) = Struggle with feeling the right way to feel = Secondary, reactive emotion = Dirty pain of unsuccessful efforts to control clean pain of dysphoria, sorrow, guilt, and bereavement. Not all cases of depression are usefully treated with ACT as the primary intervention (e.g., social skills deficit)

13. DEALING WITH SORROW TYPES OF SORROW: 1. Actual Loss of What Once Had 2. Projected Loss of What Have Now 3. Constructed Loss of What Could Have Had

14. ACTUAL LOSS OF WHAT ONCE HAD Comparison of Now to a Preloss Past Role of rumination: Living in a Regretted Past “Poster child” of complicated bereavement Grief = Bereavement Grief + Rumination = Complicated Bereavement “Don’t they know it’s the end of the world? It ended when I lost your love.” – Skeeter Davis

15. PROJECTED LOSS OF WHAT HAVE NOW Comparison of Now to a Bereft Future Role of worrying: Living in a Dreaded Future “When I get older, losing my hair many years from now, will you still be sending me a Valentine, birthday greetings, bottle of wine?” “Will you still need me, will you still feed me, when I’m 64?” – The Beatles Related exercise

16. CONSTRUCTED LOSS OF WHAT COULD HAVE HAD Comparison of Actual Now to What Now Might Have Been Living in a Unfulfilled Present “You can lose what you never had.” – Muddy Waters “I coulda had class. I coulda been a contender. I coulda been somebody instead of a bum, which is what I am.” - Terry Malloy (Marlon Brando) in On the Waterfront Related exercise

17. FUNCTIONS OF DEPRESSION Why is depression problematic? 1. Clients “can’t stand” feeling that way – drives experiential control agenda. 2. Clients want to be “normal” – suggests fusion with self-as-concept. 3. Client are prevented for certain activities - serves as barrier to committed, valued behavior. Different forms of depression (e.g., MDD vs. DD vs. DDNOS) may serve same function; same form may serve different functions.

18. PRIMARY PATHWAY TO DEPRESSION: DYSPHORIA Dysphoria as natural, psychologically-healthy, and “normal” mood fluctuation Functions: Adaptive response to “unpropitious situations in which efforts to pursue a major goal will likely result in danger, loss, bodily damage, or wasted effort” (Neese, 2000) Terminates goal seeking; helps conserve resources

19. The Primary ACT Model of Psychopathology Dominance of the Conceptualized Past and Feared Future Weak Self-Knowledge Lack of Values Clarity; Dominance of Pliance and Avoidant Tracking Experiential Avoidance Psychological Inflexibility Inaction, Impulsivity, or Avoidant Persistence Cognitive Fusion Attachment to the Conceptualized Self Several paradigmatic and philosophical perspectives are available to serve as a foundational base for applied psychology. Among these, functional contextualism seems most useful in adequately meeting the challenge of the human condition with suffcient scope, depth, and precision. The basic tenets, truth citerion, and root metaphor of functional contextualism will first be defined and contrasted with those of mechanism, which at least implicitly appears to be the dominant paradigmatic perspective within most of applied psychology. This will be followed by an overview of Relational Frame Theory (RFT) as a functional contextualistic account of language and cognition. Finally, research on the application of RFT through acceptance and commitment therapy (ACT) and in work with developmentally delayed populations will discussed and summarized.

20. 1. EXPERIENTIAL AVOIDANCE AND RUMINATION Rumination = Experiential Avoidance Attempts to solve the problem of “feeling bad” by figuring it out. Exacerbates dysphoria/sorrow into “dirty pain” of clinical depression. Effects of Rumination: Increase in depressed mood Reduction in generation of effective solutions, confidence in them, and likelihood of implementation Perpetuation of rumination and perception of its “insight-value”

21. The Primary ACT Model of Psychopathology Dominance of the Conceptualized Past and Feared Future Weak Self-Knowledge Lack of Values Clarity; Dominance of Pliance and Avoidant Tracking Experiential Avoidance Psychological Inflexibility Inaction, Impulsivity, or Avoidant Persistence Cognitive Fusion Attachment to the Conceptualized Self

22. 2. RUMINATION AND FUSION Fusion = Dominance of derived stimulus functions over those arising from direct contingencies Evaluating: Increases self-criticism and negative self-referential thoughts Reason-giving: Asking and answering “why?” increases self-blame Story telling: Increases arbitrary verbal constructions that “make sense” of evaluating and reason-giving

23. PRIORITY OF “BEING RIGHT” 1. “Life story” as reason-giving on a grand scale. 2. “Getting better” may be incompatible with a life story of “being wronged” (“Given the way I was mistreated, I have every right to be depressed.”) (“Anyone who had to undergo what I’ve had to put up with would be depressed.”) Transgressors not worthy of forgiveness 3. “Being right” more important than “getting better” “Being right” and “holding other accountable” trumps “getting better” Can also extend to holding oneself accountable and withholding of forgiveness 4. Possible additional function of suicidal behavior (revenge, “getting even”) (“They’ll be sorry when I’m gone.”).

24. The Primary ACT Model of Psychopathology Dominance of the Conceptualized Past and Feared Future Weak Self-Knowledge Lack of Values Clarity; Dominance of Pliance and Avoidant Tracking Experiential Avoidance Psychological Inflexibility Inaction, Impulsivity, or Avoidant Persistence Cognitive Fusion Attachment to the Conceptualized Self

25. 3. FUSION WITH A FLAWED CONCEPTUALIZED SELF Rumination produces increased negative self-evaluation. Fusion with flawed, conceptualized self. “Self-worth” = “Life worth” Precludes contact with a transcendent sense of self: If “I” (self as context) = “me” (conceptualized self), and “me” = “worthless,” then “I” = “worthless”

26. FUSION + EXPERIENTIAL AVOIDANCE = SUICIDE Suicide as the ultimate experiential escape act. If “life” = “suffering” “No life” = “no suffering” And “no life” = “death,” Then “death” = “no suffering” Because of fusion with the damaged conceptualized self, “killing yourself” is taken literally rather than figuratively

27. The Primary ACT Model of Psychopathology Dominance of the Conceptualized Past and Feared Future; Weak Self-Knowledge Lack of Values Clarity; Dominance of Pliance and Avoidant Tracking Experiential Avoidance Psychological Inflexibility Inaction, Impulsivity, or Avoidant Persistence Cognitive Fusion Attachment to the Conceptualized Self

28. 4. LIVING IN A REGRETTED PAST AND DREADED FUTURE Rumination also incompatible with mindfully living in the present moment by: Increased recall of and fusion with previous negative life events Increased construction of and fusion with a pessimistic future

29. The Primary ACT Model of Psychopathology Dominance of the Conceptualized Past and Feared Future; Weak Self-Knowledge Lack of Values Clarity; Dominance of Pliance and Avoidant Tracking Experiential Avoidance Psychological Inflexibility Inaction, Impulsivity, or Avoidant Persistence Cognitive Fusion Attachment to the Conceptualized Self

30. 5. EXCESSIVE RULE-FOLLOWING Obscures values and limits valued living Two types of RGB that contribute to psychological inflexibility: Pliance – Under the control of socially-mediated consequences for doing what one is told to do and “should” do. Avoidant Tracking – Under the control of naturally occurring aversive consequences in a “risky” world.

31. The Primary ACT Model of Psychopathology Dominance of the Conceptualized Past and Feared Future; Weak Self-Knowledge Lack of Values Clarity; Dominance of Pliance and Avoidant Tracking Experiential Avoidance Psychological Inflexibility Inaction, Impulsivity, or Avoidant Persistence Cognitive Fusion Attachment to the Conceptualized Self

32. 6. PURSUIT OF VALUE-INCONGRUENT GOALS Through pliance, do what is expected or what one is “supposed to do” Feeling dispirited, disengaged from life, and unfulfilled as natural consequence of pursuing and successfully attaining value-incongruent goals. “Success depression:” “Midlife is when you reach the top of the ladder and find that it was against the wrong wall.” -- Joseph Campbell

33. 6. FAILURE TO PURSUE VALUE-CONGRUENT GOALS 1. Avoidant tracking leads to leading a cautious, risk-averse approach to living. 2. Initial depression may be maintained and exacerbated by withdrawal from pursuit of value-congruent goals (“It takes too much effort to do X.” “Why waste my time.” 3. Complicated by ruminative coping style that implicates conceptualized self. (“What’s wrong with me?)

34. The Primary ACT Model of Treatment Contact with the Present Moment Values Acceptance Psychological Flexibility Committed Action Defusion Self as Context

35. NATURE OF PSYCHOLOGICAL FLEXIBILITY Involves the ability to: Defuse from problematic private events Accept private experience for what it is Stay in touch with the present moment Differentiate a transcendent self from the contents of consciousness Make contact with valued life ends, and Build committed action in pursuit of such ends

36. CASE-CONCEPTUALIZATION APPROACH Guided by “hexaflex” and level of functioning Lower: Follow same order as “hexainflex” Higher: Follow reverse order of “hexainflex” Three major steps: 1. Values identification and clarification 2. Identify variables and processes contributing to a lack of valued action 3. Increase level of value-directed activities

37. The Primary ACT Model of Psychopathology Dominance of the Conceptualized Past and Feared Future Weak Self-Knowledge Lack of Values Clarity; Dominance of Pliance and Avoidant Tracking Experiential Avoidance Psychological Inflexibility Inaction, Impulsivity, or Avoidant Persistence Cognitive Fusion Attachment to the Conceptualized Self Several paradigmatic and philosophical perspectives are available to serve as a foundational base for applied psychology. Among these, functional contextualism seems most useful in adequately meeting the challenge of the human condition with suffcient scope, depth, and precision. The basic tenets, truth citerion, and root metaphor of functional contextualism will first be defined and contrasted with those of mechanism, which at least implicitly appears to be the dominant paradigmatic perspective within most of applied psychology. This will be followed by an overview of Relational Frame Theory (RFT) as a functional contextualistic account of language and cognition. Finally, research on the application of RFT through acceptance and commitment therapy (ACT) and in work with developmentally delayed populations will discussed and summarized.

38. 1. IDENTIFYING AND CLARIFYING VALUES Values = Verbally construed global desired life consequences Process, not an outcome Distinguishable from goals Questions to ask?

39. IDENTIFYING VALUING: KEY QUESTIONS “What are your goals in coming to therapy?” “If you no longer struggled with depression, how would your life be different?” “What in life is so important to you that you would be willing to experience depression to get it?” “What’s the worst thing for you about being depressed?” “What was it about X that was so depressing to you?”

40. IDENTIFYING VALUING: OTHER MEANS Follow the suffering “Life’s joys and misery walk hand-in-hand and keep each other company.” - Donovan Revisiting childhood wishes Whose life do you admire? What do you want your life to stand for? (eulogy exercise) Epitaph exercise “Sweet spot” exercise

41. CLARIFYING VALUING Assess for pliance/counterpliance from multiple sources of control: Societal/cultural: What if no one knew? Parental: What if parents never knew? Therapist: What if I said X was a waste of time? Assess for avoidant tracking

42. CLARIFYING VALUING Magic Pill Metaphor Helps clarify distinction between values as a process and related goals as an outcome Choose between a guaranteed outcome (goal) inversely related to process (value) vs. commitment to a process (value) with no assured outcome (goal)

43. MAGIC PILL METAPHOR Example: Magic pill if taken by children cause them to see you as a loving, caring parent only if you are increasingly mean to them vs. Commitment to the process of being a loving, caring parent with no guarantee that children will ever see you that way

44. 2. ASSESSING VALUED ACTION Level of valued action not equal to overall activity level Three major questions: What are you already doing that is value-congruent? What else could you be doing? What is stopping you?

45. 3. INCREASING VALUED ACTION: REFRAMING Client may already be engaging in valued action that has been overlooked, “not counted” “I long to accomplish a great and noble task, but it is my chief duty to accomplish humble tasks as though they were great and noble.” – Helen Keller Valuing may have been obscured by pliance and avoidant tracking.

46. INCRREASING VALUED ACTION: AUGMENTING Formative Augmenting: Infinite number of ways in which to enact values. Places small activities (changing a dirty diaper) in hierarchical frames with valuing (being a caring parent): X is an instance of Y. Motivative Augmenting: Dignifies suffering in service of valuing: Would you be willing to be depressed to recontact “sweet spots?”

47. RELATED EXERCISE Form groups of 3 Rotate following roles through 5 minute role-plays each: Therapist – Identify and clarify client’s values, smallest valued action willing to take, and associated barriers. Depressed client – Can be self or client Consultant – Assist therapist, provide observations and feedback

48. 3. INCREASING VALUED ACTION: REMOVING BARRIERS Addresses other points on the hexaflex Defusion Acceptance Mindfulness Self as context/self as perspective Approach in case conceptualization manner

49. DEFUSION CHALLENGES Rumination in depression instrumental in multiple levels of fusion with its byproducts: Life-story Reason-giving Automatic thoughts

50. DEFUSING THE LIFE STORY WITH DEPRESSION Rewrite your life story with depression Take the earlier life story written at the start of this session and first underline the facts (including the presence of sorrow) that it contained. Take these same facts and weave them into a different story about them that does not result in struggling with depression. If needed, new facts can be introduced.