Acceptance & Commitment Therapy INTRODUCTORY Workshop with Russ Harris
Contact With The Present Moment
Acceptance Values
Psychological Flexibility
Defusion Committed Action
Self-as-context C B T physiological emotional physical genetic and environment epigenetic
ANTECEDENT → BEHAVIOUR → CONSEQUENCE
interpersonal cognitive social and development and cultural learning history
Slide courtesy of Jennifer Villatte The Challenge We Face
I. Life is difficult II. A full human life = the full range of emotions III. The normal, healthy human mind naturally amplifies pain
17 Be Present
Contact with the Present Moment
Acceptance Values
Open up Psychological Do What Flexibility Matters
Defusion Committed Action
Self-as-context
18 Distractibility,Contact WithDisengagement The Disconnection,Present Moment Dissociation
Remoteness from ExperientialAcceptance Avoidance Values values
Psychological RigidityFlexibility
Fusion: past, future, reasons, rules,Defusion CommittedUnworkable Action action judgments
FusionSelf-as with-context the conceptualised self 19 “WORKABILITY”
Is it workingContact with to the give you Present Moment a rich, full and meaningful life?
Acceptance Values If yes, keep doing it.
If not, wouldPsychological you consider doing somethingFlexibility different? What works short term to get rid of unpleasant Defusion thoughts & feelings, often does not workCommitted long Action term to give us a rich and full life
Self-as-context
21 AWAY TOWARDS What you do What you want to that’s ineffective, do that’s effective, behaving unlike behaving like the the person you person want to be you want to be
HOOKS HELPERS
Thoughts, Images, Memories, What matters to you? Who Emotions, Sensations that do you care about? What “hook” you and pull you skills, values strengths can into “away moves” you use?
Challenging Situation INFORMED CONSENT • ACT is a very active form of therapy/coaching – not just talking about problems. • Learning skills to handle difficult thoughts and feelings more effectively, so they have less impact and influence over you • Clarifying your ‘values’: what kind of person you want to be, how you want to treat yourself and others, what you want to stand for in life, what gives you a sense of meaning or purpose • Taking action: to solve problems, and do things that make life better • I want you to leave each session with an action plan – something you can do between sessions to improve your life • NB Modify this as needs – e.g. in grief work, this would sound very different
23 2 Questions
Q: 1. What valued direction does the client want to move in? Q: 2: What is getting in the way?
So where do I start?
24 TOWARDS
What I want to do that’s effective, behaving like the A: What’s the valued direction? person I want to be -Values clarification -Goal Setting -Committed Action HELPERS -Skills training What matters to you? Who do you care about? What skills, values, strengths can you use?
25 B: What’s getting in the way? AWAY What I do that’s -Fusion => Defusion ineffective, behaving unlike -Avoidance => Acceptance the person I want -Automaticity => Awareness to be
HOOKS
Thoughts, Images, Memories, Emotions, Sensations that “hook” you
26 AWAY TOWARDS What you do What you want to that’s ineffective, do that’s effective, behaving unlike behaving like the the person you person want to be you want to be
HOOKS HELPERS
Thoughts, Images, Memories, What matters to you? Who Emotions, Sensations that do you care about? What “hook” you and pull you skills, values strengths can into “away moves” you use?
Challenging Situation Where to start?
For clients in crisis/panic/dissociative states/overwhelmed by emotions: start with grounding/centering For clients with major grief/loss: Start with self-compassion For the poorly motivated: Values
28 The Resilience Formula
4 approaches to any problem situation: 1. Leave 2. Stay & change what can be changed 3. Stay & accept what can’t be changed & live by your values 4. Stay & give up & do stuff that makes it worse
29 Contact With The Present Moment
Acceptance Values
Psychological Flexibility
Defusion Committed Action
Self-as-context 30 (Copy me) Imagine your hands are your thoughts and feelings Imagine in front of you is everything that matters: the people, places, activities you love etc (give examples). And also the problems/challenges you need to face/deal with, and the important tasks you need to do. (give examples) Now (copy me) see what happens when we get all caught up in our thoughts and feelings Notice 3 things: 1) How much are you missing out on? 2) How disconnected and disengaged are you; how difficult to stay focused, keep your attention on the task? 3) How difficult is it to take action, to do the things that make your life work? (give examples) Now (copy me) slowly separate from your thoughts & feelings What’s your view of the room like now? How much easier is it to engage and connect; to keep your attention focused on the task at hand? Move your arms around: how much easier is it to to do the things that make your life work (give examples) Notice these things (i.e. hands) haven’t disappeared. If you can use them, do so. Many thoughts and feelings give us valuable information we can make good use of. But if you can’t make use of them, just let them sit there.
31 3 Tricky Reactions
- I feel safe behind here - How will that solve my problems? - I can’t do that with my real thoughts & feelings
32 33 34 35 36 37 WHAT AM I GOING THIS IS SO TOBORING!I’MI’M NOT NOT HAVE FOR HAVINGDOING ITANY DINNERTHOUGHTS!RIGHT! TODAY?
38 NB. Leaves On A Stream
Non-visual version (e.g. black space)? Let them come, stay and go as they please It’s okay if the leaves hang around or the river stops flowing - just keep watching Do this for all thoughts: positive and negative Invite clients to creatively modify the exercise: e.g. conveyor belt, blackboard Watch for avoidance: e.g. writing thoughts on blackboard then erasing them
39 ‘Cognitive’ Defusion?
ACT is based on RFT, relational frame theory RFT is a theory of symbolic behaviour: how we create, manipulate & respond to symbols ‘Cognition’ in ACT = symbolic behaviour Symbolic behaviour is involved in all private experiences: thoughts, feelings, emotions, memories, sensations, etc. So ‘cognition’ in ACT refers to the symbolic aspects of any/all of the above experiences.
40 ‘Cognitive’ Defusion
ACT textbooks emphasise defusion from ‘thoughts’ – including assumptions, attitudes, beliefs, judgments, etc. I personally tend to talk about defusion from ‘thoughts and feelings’ because cognition is such a huge ‘part’ of any emotional response
41 HEAR SEE TOUCH
FEELINGS TASTE
THOUGHTS FUSION SMELL
MEMORYPAINFEELING HALLUCINATIONEMOTIONCRAVINGSENSATIONURGEPAINTHOUGHT
42 HEAR SEE TOUCH
FEELINGS TASTE
THOUGHTS SMELL SELF-COMPASSION PAIN VALUES & ACTION
43 Change the context
Thoughts & feelings function differently in different contexts
44 Pain in a context of FUSION HEAR SEE TOUCH
FEELINGS TASTE
THOUGHTS SMELL
MEMORYPAINFEELING HALLUCINATIONEMOTIONCRAVINGSENSATIONURGEPAINTHOUGHT
45 Pain in a context of Mindfulness & Values
HEAR SEE TOUCH
FEELINGS TASTE
THOUGHTS SMELL SELF-COMPASSION PAIN VALUES & ACTION
46 Drop Anchor EXPANSIVE AWARENESS EXERCISE (Dropping anchor/grounding)
• I can see something very painful (e.g. thought/feeling/memory) has just shown up, for you, and I want to help you handle it • Push your feet hard into the floor • Sit forward in your chair • Push your fingertips together, • As well as this painful thought/feeling/memory, notice your body in the chair – hands, feet, back • Also look around – notice 5 things you can see • And notice 3 or 4 things you can hear • And also notice you and I, working together • So there is a painful thought/feeling/memory here • And your body in the chair • And a room around you • And you and I working together
48 Dropping anchor - notes
Indication: if and when client is so fused that he is unable to effectively engage/participate in the session If client is in pain, but is able to be present, engage, participate, then it’s not necessary. NB: If therapist uses dropping anchor to try to stop the client crying/ to distract her/ to reduce her anxiety etc, this is a misuse. The aim is to help the client be present, regain control of his actions, engage, focus.
49 Dropping anchor – notes – cont.
Modify script – use anything present (other than the storm itself) – e.g. glass of water, stretching arms, breathing, sound of air con Goes for as long as needed Repeat as often as needed If client is ready and able to talk, identify the elements of the storm first. If client is too overwhelmed to speak, just go into the exercise. Debrief it afterwards
50 Debrief
Do you notice any difference? Are you less caught up in the storm? Less swept away or pushed around? Is it easier for you to engage with me, to be present, to focus? Do you have more control over your actions? (Move your arms and legs – check it out.) How could this be helpful outside the room? Can we do more of this in our sessions? Would you be willing to practise this?
51 Cognitive Defusion
What’s your “I’m not good enough story”? How have you tried to get rid of it? How did that work, long term? Ready to try something different?
52 Beliefs?
A ‘belief’ is simply a thought held as ‘true’ ACT does not traditionally classify cognitions into types: attitudes, assumptions, schemas, core beliefs, automatic thoughts, categories of “dysfunctional thinking” etc.. But you can do this, if desired, for defusion: ‘There’s my schema showing up.’ ‘I’m noticing my core belief’ ‘There’s my mind making an assumption’ ‘I’m noticing “black and white thinking” again’
53 Believability versus Fusion
Defusion usually leads to decreases in believability, but not always. But we can defuse from thoughts even if we continue to believe them 100%, and even if they can never be disputed (e.g. ‘One day I will die’; ‘The plane might crash’) We can also fuse with thoughts we don’t believe (e.g. fantasising)
54 3 steps to defusion – mix & match
Notice Name Neutralise
55 Psycho-education Exercises
Pop-up thoughts Lift your arm Delete a memory Make your leg go numb Don’t think about … “Falling in love” metaphor “Polygraph” metaphor Lemons, lemons, lemons
56 Contact With The Present Moment
Acceptance Values
Psychological Flexibility
Defusion Committed Action
Self-as-context 57 Establish Goals For Therapy
How will we know this is working? What will you be doing differently? What will you start/stop, do more/less? How will you treat yourself, others, the world differently? What areas of life do you want to work on improving? What relationships would you like to improve? These are NOT useful goals:
‘reduce depression’ ‘reduce anxiety’ ‘increase self-worth or build self-esteem’ ‘recover from DSM disorder X’ ‘get over what happened’ ‘get my old self back’ ‘feel happy’, ‘feel good’, ‘stop feeling like shit’ ‘have more confidence/ regain my confidence/ stop doubting myself’ ‘feel calmer’
(copyright) Russ Harris 2015 www.ImlearningACT.com To turn them into useful goals….
If I could wave a magic wand so your difficult thoughts and feelings are no longer an issue, like water off a duck’s back….. What would you stop doing or start doing, do more of or less of? How would you treat yourself, others, life, the world, differently? What goals would you pursue? What activities would you start or resume? What people, places, events, activities, challenges, would you approach, start, resume or contact - rather than avoid or withdraw?
(copyright) Russ Harris 2015 www.ImlearningACT.com Naming What Matters
What matters to the client: people, places, activities, events, aspects of life, goals, values, desires, needs, and so on; anything the client cares about, considers important? Basically anything that triggers a strong negative reaction in the client – whether that be a person, a place, a problem, an event, a situation, a domain of life, a goal, a desire – is likely to be important.
(copyright) Russ Harris 2015 www.ImlearningACT.com Naming What Matters
So as we take the history and validate the client’s suffering, we can repeatedly name the things that seem to matter most to the client. For example, if the client is worrying/stressing/complaining about her marriage we might say, “So your marriage really matters to you”
(copyright) Russ Harris 2015 www.ImlearningACT.com Naming Who Matters?
Who, in your life today, matters to you most? Who is important to you? Who do you care about? Who do you look after, or take care of? Who would you like to care about more? Are there any relationships you’d like to improve, or conflicts you’d like to resolve? Are there any relationships you’d like to start? If our work here could improve just one relationship in your life, who would you pick? How would that relationship improve?
(copyright) Russ Harris 2015 www.ImlearningACT.com From “What I’ll Stop” to “What I’ll Do Instead”
(copyright) Russ Harris 2015 www.ImlearningACT.com From “What I can’t do” to “What I can do”
If people keep talking about what they can't do any more … "So would you like to be able to do that again?“ If “yes”: "Okay. So two things we need to look at then: a) if it's possible to start doing it again and b) if it's not possible to do exactly the same, to find out what was meaningful in doing that and find out if there are other ways to get that same sense of meaning.”
(copyright) Russ Harris 2015 www.ImlearningACT.com From “What I don’t want to feel” to “Learning to handle feelings more effectively” If people keep talking about what they DON’T want to feel? “So seems like it’s important to you to learn better ways of handling these difficult thoughts/ feelings/ emotions/ memories?”
(copyright) Russ Harris 2015 www.ImlearningACT.com “What I DO want to feel” What if people keep talking about what they DO want to feel (e.g. happy, confident, high self-esteem, calm, in love)? “So right now, you don’t feel the way you want to? Can you tell me what kind of difficult thoughts and feelings are showing up for you?” “So seems like it’s important to you to learn better ways of handling these difficult thoughts & feelings?”
(copyright) Russ Harris 2015 www.ImlearningACT.com Values ‘Desired qualities of ongoing action’ Heart’s deepest desires for how you want to behave How you want to treat anyone or anything What kind of person do you want to be? Can usually be said in one or two words
68 69 Goals or Values?
Nurturing, maintaining and caring for my body Lose 10 kg Get a great job Being helpful, friendly and responsible
70 Goals or Values?
Buy a house Being supportive, protective, caring for my family Get good grades Curiosity, learning, persistence
71 Goals or Values?
Being sensual and intimate Have an orgasm Have children Being caring, kind, loving
72 Goals or Values?
Win the match Playing enthusiastically, fairly, skillfully Being creative Write a book Why does this distinction matter?
73 Trickier: Goals or Values?
Be respected Be respectful Be loved Be loving
74 Needs & Values
‘Needs’ = ‘very important goals’ Values are: how I want to behave as I try to get my needs met how I want to behave when I don’t get my needs met how I want to behave when I do get my needs met
75 Mind-Reading Machine -What you stand for -Your personal strengths and qualities -The role you have played in their life
76 ‘Stepping Stones’ to Values
‘Good friend’, ‘Good mother’ etc. Strength Role model Inspiring Mateship, friendship Happiness
77 Bull’s Eye: Values To Goals
Pick a quadrant on the Bull’s Eye & identify 2 or 3 key values Then set a values-guided SMART goal for the next week Specific, Meaningful, Adaptive, Realistic, Time-framed A “live person’s goal” 0-10: How realistic? If <7, make it smaller/easier
78 Bull’s Eye: Values To Goals
In pairs, stand up and share your goals Begin with: “Here is my commitment …” Notice what thoughts and feelings show up Afterwards share: a) What unhelpful things did your mind say? b) What uncomfortable feelings showed up in your body?
79 I shouldn’t I shouldn’t I can’t do do it have to do it because because … it because … … The Resilience Formula
4 approaches to any problem situation: 1. Leave 2. Stay & change what can be changed 3. Stay & accept what can’t be changed & live by your values 4. Stay & give up & do stuff that makes it worse
81 Contact With The Present Moment
Acceptance Values
Psychological Flexibility
Defusion Committed Action
Self-as-context 82 The Alternative to Self-Esteem? “I've missed more than 9000 shots in my career. I’ve lost almost 300 games. 26 times I've been trusted to take the game winning shot ... and missed. I've failed over and over and over again in my life. That is why I succeed.” Self-Acceptance
You are not who you think you are!
89 Which Is The Real you?
Take 30 seconds to tell your partner as much as possible about who you are as a human being – just positive stuff Take 30 seconds to tell your partner as much as possible about who you are as a human being – just negative stuff
93 Self-Acceptance
You are not who you think you are! If your mind tells you a negative story … ‘Thanks, mind!’ And if it’s a positive story … ‘Thanks, mind!’ =>The ‘Good self/Bad Self’ exercise
94 She was so caring, Self-AcceptanceSheloving, had akind. really Alwayshigh opinion there offor me whenherself! I needed her!
95 The Conceptualised Self
Your ‘conceptualised self’ is important and often useful. You wouldn’t want to get rid of it You may even want to work on developing it But hold it lightly – it is not you! =>The ‘I am’ exercise
96 The Observing Self
98 The Observing Self
When do we make it explicit, and why? What are the benefits?
99 ACT
RFT
BA
Functional Contextualism physiological emotional physical genetic and environment epigenetic
ANTECEDENT → BEHAVIOUR → CONSEQUENCE
interpersonal cognitive social and development and cultural learning history
Slide courtesy of Jennifer Villatte A – Antecedents B – Behaviour C- Consequences Situation Something an Immediate outcomes Thoughts organism does that either increase or Feelings - Public decrease the behaviour - Private
If consequences => lNCREASE in behaviour, C they are ‘REINFORCING’ If consequences => DECREASE in behaviour, they are ‘PUNISHING’
POSITIVE REINFORCEMENT – ‘access something you want’ NEGATIVE REINFORCEMENT – ‘avoid something you don’t want’ DIFFERENTIAL REINFORCEMENT
103 A – Antecedents B – Behaviour C- Consequences (reinforcing) Something an ‘TRIGGERS’ ‘PAYOFFS’ organism does Situation immediate outcomes - Public Thoughts that maintain the - Private Feelings behaviour Present Moment, Values & Defusion, Committed action Feeling of relief; Acceptance painful thoughts, Situation: alone in Smokes marijuana feelings, urges house at night, tired disappear
Thoughts & Feelings: Workability ‘I have no friends’ ‘I payoffs VS costs wish I had a social life’ Sadness, loneliness, Costs: Anxiety, boredom Addiction worsens; Urge to smoke dope stays home more & social isolation increases; more DIFFERENTIAL REINFORCEMENT feelings of loneliness OF A MORE WORKABLE BEHAVIOUR and sadness 104 A – Antecedents B – Behaviour C- Consequences (reinforcing) Something an ‘TRIGGERS’ ‘PAYOFFS’ organism does Situation immediate outcomes - Public Thoughts that maintain the - Private Feelings behaviour
Painful thoughts, feelings, urges lose Situation: alone in Mindfulness some of their impact house at night, tired (Defusion, acceptance and influence; switch contacting the present) off ‘automatic pilot’ & Thoughts & Feelings: get present; ‘I have no friends’ ‘I experience a sense of wish I had a social life’ greater self-control, Sadness, loneliness, more freedom to Anxiety, boredom choose behaviour Urge to smoke dope
DIFFERENTIAL REINFORCEMENT
OF A MORE WORKABLE BEHAVIOUR 105 A – Antecedents B – Behaviour C- Consequences (reinforcing) Something an ‘TRIGGERS’ ‘PAYOFFS’ organism does Situation immediate outcomes - Public Thoughts that maintain the - Private Feelings behaviour
Sense of clarity and self-awareness; sense Situation: Alone in Connects with of purpose; making house at night, tired, values. sense of this pain and mindfully “This painful loneliness responding to painful reminds me that what I thoughts, feelings, really want is to be urges engaging and – defusing & connecting with my accepting friends.” – surfing urges – dropping anchor DIFFERENTIAL REINFORCEMENT
OF A MORE WORKABLE BEHAVIOUR 106 A – Antecedents B – Behaviour C- Consequences (reinforcing) Something an ‘TRIGGERS’ ‘PAYOFFS’ organism does Situation immediate outcomes - Public Thoughts that maintain the - Private Feelings behaviour
Feeling of vitality or satisfaction; sense of Situation: Alone in Committed action living by values & house at night, tired, Picks up phone, calls moving in a positive and mindfully a friend, arranges to life direction; sense of responding to go over to her house. self-empowerment or thoughts and feelings personal growth – and in touch with values of engaging and connecting
DIFFERENTIAL REINFORCEMENT
OF A MORE WORKABLE BEHAVIOUR 107 Fusion with thoughts & feelings => manifests in various ways ‘Overwhelmed’, ‘Pushed around’ ,‘Lost in’, ‘Wallowing in’, ‘Consumed by’, ‘Dwelling on’, ‘Controlled by’, ‘Entangled in’, ‘Jerked around by’, ‘In the grip of’, ‘Ruled by’, ‘Dominated by’, ‘Held back’, ‘Pulled down’ Often we try to avoid/ get rid of them: ‘Experiental avoidance’
108 Higher Experiential Avoidance
–Higher anxiety levels –More depression –Drug and alcohol addiction –More overall pathology –Poorer work performance –Inability to learn –Lower quality of life –Long term disability
109 “Acceptance” – not a good word!
Drop the struggle with it Make room for it/ give it space Expand around it Open up But why accept pain? Let it flow through you Hold it gently/lightly/softly/kindly Breathe into it Let it be/Allow it Sit with it Soften up/loosen up around it Willing to have it Lean into it 110 (Copy me) Imagine this paper is all your difficult thoughts and feelings Imagine in front of you is everything that matters: the people, places, activities you love etc. And also all the problems/challenges you need to solve/tackle, and the importantPushing tasks you need Away to do Paper Now push these thoughts and feelings away from you, hard as you can Notice 3 things: 1) How tiring is it? 2) How distracting is it; how difficult is it to fully engage or connect; to stay focused, keep your attention on the task? 3) How difficult is it to take action, to do the things that make your life work? (give examples) Now rest it on your lap. How much less effort is that? How much easier is it to engage and connect; stay focused; keep your attention on the task? Move your arms around: how much easier is it now to take action? Notice your thoughts and feelings (i.e. the paper) haven’t disappeared. But you have a new way of responding to them, so they don’t hold you back or tie you down or stop you engaging in your life. If there’s something useful you can do with them, use them; (thoughts and feelings often give you useful information). But if not, just let them sit there.
111 Creative Hopelessness
What have you tried? How has it worked, long term? What has it cost you?
112 An Important Close Relationship
What is painful or difficult in this relationship? Tap into a painful emotion – e.g. fear, sadness, anger, guilt – so you can work with it
115 NAME your feelings
Notice Acknowledge Make room Expand awareness
116 Self-compassion: 6 Elements
1. Contact the present moment: notice & acknowledge your painful thoughts & feelings 2. Kindness: pursue the value of kindness towards yourself – (in words, thoughts, imagery & action) 3. Defusion: defuse from harsh judgmental self-talk 4. Acceptance: open up and make room for painful thoughts and feelings 5. Validation: validate your pain as a normal & natural part of being human 6. Connectedness with others: acknowledging and empathizing with pain of others; recognizing your commonality; sharing your pain with others Kindness To Self
Kind self-talk (in both content and tone) Kind imagery Kind self-touch Kind deeds What kind of ….?
Pick an important role – e.g. mother, father, son, daughter, therapist, coach T: What kind of ___ do you want to be? T: Suppose we interviewed one of the people you interact with in that role, live on national TV, and we say ‘What was he/she like? What were his/her three greatest qualities? How did he/she treat you?’ – if magic could happen, if dreams could come true - what would you like them to answer?
120 Values Are Not:
Goals What you want or need from others Rules or commandments, codes of conduct ‘Shoulds’, ‘musts’, obligations
121 Are These My Real Values?
The proof of the pudding is in the eating You won’t find out by analyzing and pondering if these are your real values You will only find out by acting on them, and noticing what happens when you do so.
122 Properties of Values
Here and now Freely chosen Dynamic Evolving Never completed Intrinsically rewarding
123 Properties of Values
Often need prioritising Never need justifying Values ,Virtues & Strengths Pursue vigorously, but hold lightly
124 What Prevents Action?
FEAR Fusion Excessive goals Avoidance of discomfort Remoteness from values
126 The Antidote
DARE Defusion Acceptance of discomfort Realistic goals Embracing values
127 The Resilience Formula
4 approaches to any problem situation: 1. Leave 2. Stay & change what can be changed 3. Stay & accept what can’t be changed & live by your values 4. Stay & give up & do stuff that makes it worse
129