ACT for CBT Clinicians

1. ACT for CBT Clinicians Steven C. Hayes How to get these slides Go to my blog at www.contextualpsychology.org

2. We will Do Today • You can start from where you are • Look at places things can bog down • Difficulty in restructuring thoughts • Resistance • Connection

3. Where Did ACT Come From? ACT is part of CBT writ large In the 1980’s I did a number of studies on the CBT model and found problems; I also developed an anxiety disorder and found personal problems with the model I was a behavior analysts who thought the C in CBT was needed but that we needed a bottom up account grounded in behavioral principles We developed an approach based on eastern and human potential sensitivities, spent over 15 years developing it and the basic model, and final released the clinical model in 1999 and the basic model in 2001

4. What is ACT? • Philosophical basis (can’t skip it!) in functional contextualism, which we take from Skinner • Monistic, radically pragmatic, contextualistic and from all of that a-ontological • The world is. We assume the one. Call it “real” but mean “the one that is” • Our behavior partitions it • The ontological leap add nothing but irresponsiblity • So it comes down to this: what works in and with the one world • To determine that we need your values and goals

5. What is ACT? • Theoretical basis in Relational Frame Theory (RFT) • Language is based on learned relations that can be controlled by arbitrarily cues • Provides an evolutionary advantage, but also expands the ability to feel, predict and evaluation pain; makes situational avoidance impossible; and cognitive dominance likely • Experiential avoidance and cognitive fusion are built into language and amplified by the culture, but they are a source of psychopathology and reduced behavioral flexibility • Fortunately there are two types of contextual regulation: relational and functional

6. The Problem and Solution • Eliminating verbal relations and reducing automatic emotional responding is difficult in part because they are historical • A focus on the relational context tends to increase the functional context but not vice versa • We can choose the context more safely than choose the content

8. Acceptance and Mindfulness Processes You can chunk them into two larger groups

9. and Commitment and Behavior Change Processes Thus the name “Acceptance and Commitment Therapy”

10. Psychological Flexibility The Common Core of All of These Processes is

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. Definition of ACT • ACT is a contextual cognitive and behavioral therapy that uses acceptance and mindfulness processes, and commitment and behavior change processes, to produce greater psychological flexibility.

13. The Bottom Line • Dysfunction arises from experiential avoidance, cognitive fusion, and psychological inflexibility • Said in another way: it arises from our relationship to cognitive and emotional content and its impact on behavior, not content itself (including irrational beliefs, distorted cognitions, difficult emotions, or dysfunctional core schemas)

14. ACT does normally seek to alter the cloud of evaluations; rather, one stays in intimate contact with the cloud, and sometimes “peeks around” the cloud to make direct contact with experience and values

15. ACT Style • Mistrust of “reasoning”, persuasion, logic, rationality and language processes in general • Heavy emphasis on pragmatic truth criteria • Use of non-literal interventions such as metaphors, stories, mindfulness, and experiential exercises • Modeling of core ACT processes by therapist • Non-sequential application of core processes

16. There are Many Points of Convergence • ACT is a behavior therapy that also takes cognition and emotion extremely seriously • Uses all of the behavioral elements of CBT: skill building interventions, exposure strategies, functional analysis etc • Incorporates out of session “homework” and self monitoring tasks • Data from out of session work is often a focus of clinical sessions

17. So is ACT Really Different than Traditional CBT?(i.e., More that Philosophy, Theory, and Development Strategy?) • You cannot answer that by superficial examinations due to a basic cognitive process • A great way is empirically: • Correlational evidence on processes • Outcomes • Processes accounting for these outcomes

18. Correlationally • In more than 40 studies with nearly 10,000 participants, psychological flexibility accounts for 16 to 33% of most psychological outcomes • There is evidence that the effects of negative thoughts, difficult feelings, maladaptive coping, emotional response styles, cognitive reappraisal, and perceived controllability, are all partially or fully mediated by psychological flexibility

19. Outcomes and Mediators • Outcomes: • Eight studies so far. All over the map. • Two negative effect sizes, one equal, five positive • Too soon to tell • Processes • All show a difference, some formal mediational differences

20. Is ACT Really Different than Traditional CBT? • Another, also good way: Try it • Try some of these things with yourself • The “Get Out of Your Mind” book is perfect for that

21. CBT and ACT • And apply to your cases • Start with your difficult cases, when you bog down • Do analysis of where you’ve bogged down and recast the case from an ACT model • You can use ACT methods inside a treatment protocol dominated by traditional methods provided only that you tweak the goal

22. Mindfullness Behavioral experiments Reducing Cognitive structuring depression, anxiety or stress Goal setting Skills Tra ining Emotional U nderstanding A Distress Reduction Core: Therapeutic Processes are Used to Reduce Distress or Distressing Thoughts

23. Self as context Cognitive Defusion Mindfullness Acceptance Increasing Flexible, Values Congruent Behavior Cognitive elaboration Value clarification Skills Training Commitme nt Emotional U nderstanding A Behavioral Core: Therapeutic Processes are Used for Promoting Flexible, Values Congruent Behavior

24. A - B - C Versus A - BC - VA Context Model Differences

25. CBT and ACT: Cognitive Content • Usually the traditional CBT rationale, and learning to detect thoughts is no problem • It can bog down in actually restructuring thoughts • The ACT alternative: distinguish the person from the content • Defuse from content

26. Traditional CBT to ACT: Cognitive Content • Bogging down in actually restructuring thoughts • Examples from the audience and group practice

27. Traditional CBT to ACT: Defusion • Model it yourself • Create a transitional rationale • Once you start down this road you will have a bit of a hard time going back with this patient

28. A Few Principles of Defusion and Examples Principle 1: Find overall metaphors that structure seeing the process Sunglasses Bubble on the head Passengers on the Bus

29. Defusion Principle 2. Notice the automaticity of thoughts and their ease of programming Mary had a little lamb What are the numbers?

30. Defusion Principle 3. Notice their paradoxical nature when you try to control them Don’t think X

31. Defusion Principle 4. Distinguish the person from the programming Observer exercise Watching thoughts … and noting who is watching

32. Defusion Principle 5. Create a context that weakens the the illusion of literality Milk, milk, milk Talk about the mind as another entity There are four of us in here Thank your mind for that thought Funny voices

33. Defusion Principle 6. Notice their limitations and attachments Tell me how to walk Deliberately instruct the opposite

34. Defusion Principle 7. Teach the discrimination between fusing and defusing Leaves on a stream Meditation

35. Traditional CBT to ACT: Resistance • Another place traditional CBT can bog down is in resistance • I can’t because … • It’s too …. • I’m too …

36. Traditional CBT to ACT: Resistance • The ACT Alternative: a) creative hopelessness and workability; b) values and acceptance • Creative hopelessness (Acceptance of where you start)

37. Valuing is seldom directly addressed in CBT because the underlying assumption is that living rationally will lead to valued living In ACT values are not rational derivatives; they are chosen starting points Traditional CBT to ACT: Resistance

38. Values and Workability • Values gives us workability, which defines “truth” (not the rational truth of traditional CBT) • With that form of truth we have a lot of leverage with resistance to change • Cognitive rigidity – what is that in the service of; how does that work • Emotional rigidity – acceptance • Behavioral rigidity – breaking patterns in the service of values

39. Values and Workability • Values are a direction, not an outcome • They are a choice, not a decision • Emphasize wants based on undefended choice, vitality, wholeness, intrinsic value

40. Values and Workability • Many techniques, but the core approach: • Use the common sense language of free choice • Ask what they really want • Consider using pain as a guide • Shape the answer by: • distinguishing values from goals • confronting pliance and avoidance • being completely and sincerely supportive

41. Traditional CBT to ACT: Resistance • Bogging down in cognitive, emotional, or behavioral resistance • Examples from the audience and group practice

42. Traditional CBT to ACT:Lack of Connection • Bogging down in a lack of vitality and connection in the room • Therapeutic detachment, socratic dialogue, logic, analysis and personal science can sometimes and with some patients lead to a dryness in the room

43. Traditional CBT to ACT:Lack of Connection • The ACT solution • 1. Work on a transcendent sense of self (spirituality), contact with the present moment, and values • 2. Model, implement, and target ACT processes in the relationship itself

44. Lack of Connection • Getting mindful versus battling the mind • Mindful means experiencing experiences in the moment for what they are, without judgment, evaluation or manipulation • The mindful state is achieved by making experiential contact with a “bigger self” that contains all consciousness and yet is distinct from that content

45. Lack of Connection • Getting present versus modifying the present • ACT elicits and sustains negative private experience in session, not to modify it logically, but to teach the client to approach, rather than avoid it

46. Lack of Connection • 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 also encourages the therapist to implement these in the interaction between the therapist and client so that they become defining features of the therapeutic relationship

47. Traditional CBT to ACT:Lack of Connection • Bogging down in a lack of vitality and connection in the room • Examples from the audience and group practice

48. Other Bogged Down Places? • Examples from the audience

49. What to Do? • If something in the ACT data or message speaks to you, explore it • How: www.contextualpsychology.org; the list serve; the books and tapes; do more extended training workshop • Be open but keep any skepticism you prefer

50. CBT and ACT • Read these four books to start (plus a new one on CBT and ACT when it comes out) Guilford Springer-Verlag New Harbinger