Acceptance & Commitment Therapy (ACT) Science Meets Mindfulness Joanne Steinwachs, LCSW Rocky Mountain Counselors Conference July 30, 2008 Denver, CO

Acceptance & Commitment Therapy

(ACT)

Science Meets Mindfulness

Joanne Steinwachs, LCSWRocky Mountain Counselors ConferenceJuly 30, 2008Denver, CO

2 Joanne Steinwachs, LCSW 303-691-9509 [email protected]

• How I came to ACT• Social work• Looking for a theory• Why do I need a theory?• What is a scientific model of human

behavior?


What is ACT?

“ACT is a therapeutic approach that uses acceptance and mindfulness processes, and commitment and behavior change processes, to produce greater psychological flexibility.”

Hayes, Wilson, Strosahl, 1999


Where did ACT come from?

• ACT has been called a “third wave” behavioral therapy; placing importance on changing the way individuals relate to their experience as opposed to changing the content of their experience.

• Other “third wave” behavioral therapies include DBT, MBCT and FAP.


The ACT Question

Given a distinction between you and the stuff you are struggling with and trying to change, are you willing to have that stuff, fully and without defense, as it is, and not as what it says it is, AND do what takes you in the direction of your chosen values at this time, in this situation?


• RFT, not rft

Relational Frame Theory


• This is where the cartoon goes


RFT tells us why humans suffer the way we do

Examples:• Saliva• Connect anything• Sunset• Dog watching TV


Relational Frame Theory

• Where can you go that your thoughts can't find you?

• We can relate anything to anything.

• Virtual reality.


Relational Frame Theory in a nutshell

WORDS MAKE MONSTERS REAL.


So what does all this mean for us clinicians?


The ACT Theory of Change

•Our psychological problems originate from thought and language.

•The goal is psychological flexibility to contact with the present moment to change or persist toward our valued ends.

•Verbal regulation, rigid rules, prevent us from moving in valued directions.


The Primary ACT Model of Psychopathology

Dominance of the Conceptualized Past and

Feared Future: Weak Self-

Knowledge

Inaction, Impulsivity,or AvoidantPersistence

Lack of Values Clarity;

Dominance of Pliance &

Avoidant Tracking

Attachment to the

Conceptualized Self

Experiential

Avoidance

Cognitive

Fusion

Psychological

Inflexibility


Cognitive Fusion

•Humans tend to live in a world excessively structured by literal language.

•Verbal constructions of life can even become a substitute for life itself.

•People cannot distinguish a verbally-based and evaluated world from the world as directly experienced through the senses.


Cognitive Fusion:Reason Giving

• We don’t just give reasons, we view reasons as causes for behavior.

• The reason is taken as a cause for not making progress, perhaps even in a highly valued domain of living.

• We are taught that we must have explanations for our behaviors and furthermore that these explanations must be coherent. Particular in the realm of behavior that doesn’t work, we really are expected to have a good explanations.


Examples of Fusion

• Saliva

• Lemons


Dominance of the Conceptualized Past and Feared Future,

Weak Self Knowledge

• Coulda, shoulda, woulda.• If only.• What if?• Fearful focus on the future, guilty,

shamed focus on the past.


Lack of values clarity, Dominance of pliance and

avoidant tracking

• I don't know what I want. • I should...• Nothing matters to me.• I don't know who I am or what I

want.• Tell me how I should be.• I just don't want to feel afraid,

ashamed, lonely, incompetent, etc.


Inactivity, Impulsivity or Avoidant Persistence

• The couch potato, depression

• The addict.

• “My strategy hasn't worked because I haven't done it long enough or hard enough.”


Attachment to the Conceptualized Self

• I am an attorney.• I am a mother.• I am a loser. • I am a rock star.• I am...• I must be a good (fill in the blank) or

I am nothing.


Experiential Avoidance

•In summary, the ACT processes of psychopathology all add up to efforts to avoid private experiences such as thoughts, images, emotions and physical sensations.

•There is a mounting body of empirical evidence that suggests that experiential avoidance is at the root of many, if not most, psychological disorders.


BREAK

Let's take 10 minutes.


The Primary ACT Model of Treatment

Contact with thePresent Moment

Committed

Action

Values

Self asContex

t

Acceptance

Defusion

Psychological

Flexibility


Acceptance

•An active embrace of the present moment, fully and without defense.

•Acceptance as an alternative to experiential avoidance.

•Willingness as a choice, not a decision, thought or feeling.

•Acceptance in the service of values-based action.


Holding your breath.


Cognitive Defusion

•ACT views thoughts as problematic more in terms of function vs. content.

•Fusion with thoughts limits one’s ability to be present and flexibly responsive

•Defusion aims to change the way one relates to their thoughts.

•Thoughts and feelings are not causes of behavior.


Defusion

Milk


Self as Context

•Simple awareness; a safe place from which we can have experiences as they are and not as they say they are.

•Distinguishing between conceptualized versions of self (life story, self-evaluations) and the context in which these events occur.

•Best understood as experienced.


Self as Context Exercise

The you that...


Contact with the Present Moment

•Acceptance and defusion are in the service of “showing up” to the present moment.

•Being present promotes vitality, creativity and spontaneity.

•Being present is reinforced within the context of the therapeutic relationship.


Contact with the Present Moment Exercise

– Type in here


Values

•Clarified values as important “guidance system” which leads to purposeful, enriching patterns of behavior.

•Differentiating values from goals.•Letting go of experiential control in

the service of pursuing valued ends in life.


Values Clarification Exercise

• Going west.• List.


Committed Action

•The ultimate goal of ACT is promoting committed action in valued directions.

•Any movement towards values, however small, leads to increased vitality.

•Emphasis on the process of growth vs. the achievement of specific goals.

•Action triggers barriers that breathe life into all other core interventions.


Committed Action Exercise

Bold move.


This, then is the

overall ACT model


Committed

Action

Values

Self asContex

t

Acceptance

Defusion


Acceptance and Mindfulness

Processes Contact with thePresent Moment

Committed

Action

Values

Self asContex

t

Acceptance

Defusion


Commitment and Behavior Change

Processes

Thus the name “Acceptance

and Commitment

Therapy”


Committed

Action

Values

Self asContex

t

Acceptance

Defusion


Self asContex

t

ACT Question

(1) Given a distinction between you and the stuff you are struggling with

and trying to change


Self as Context

Acceptance

(1) Given a distinction between you and the stuff you are struggling with and trying to change

(2) are you willing to have that stuff, fully and without

defense

ACT Question


Self as Context

Acceptance

Defusion




defense

(3) as it is, and not as what it says

it is,

ACT Question


Self as Context

Acceptance

Defusion




defense


it is,

(4) AND do what takes you in the direction

CommittedAction

ACT Question


Self as Context

Acceptance

Defusion




defense


it is,


CommittedAction

Values(5) of your

chosen values

ACT Question


Self as Context

Acceptance

Defusion




defense


it is,


CommittedAction

Values(5) of your

chosen values

ACT Question


Self as Context

Acceptance

Defusion




defense


it is,


CommittedAction

Values(5) of your

chosen values

Contact with the

Present Moment

(6) at this time, in this

situation?

ACT Question


If the answer is yes, that is what builds…


Psychological

Flexibility


CommittedAction

Values

Self asContext

Acceptance

Defusion


A Model of the ACT Therapeutic Relationship


ACT Therapeutic Posture

• Whatever the client is experiencing is not the enemy

• You can’t rescue clients from difficulty• Compassionately accept no reasons• If the client is trapped, confused,

frustrated, afraid, angry or anxious, be glad

• Be glad if you are experiencing this- you are in the same boat as your client


ACT Therapeutic Posture, Continued

• With acceptance, defusion, self, and values, it is more important to do as you say than to say what you do.

• Don’t argue, don’t persuade- it’s the client’s life and experience

• You are in the same boat- never protect yourself by moving one up

• The issue is always function, not form or frequency. When in doubt, ask yourself or the client “What is in the service of?”


ACT Empirical Evidence

• Substance abuse: one study reported less drug use than with a 12-step program

• Quit smoking: ACT worked better than nicotine patches n=67. Quit rates were similar at post, but, at a one-year follow up, the 2 groups were significantly different. The ACT group had maintained their gains (35% quit rates) while the nicotine patches quit rates had fallen, i.e. less than 10%



• Chronic pain: ACT gets chronic pain patients back to work faster, with fewer sick days and fewer visits to the GP, less self reported pain symptoms

• Stress management: Bond and Bounce study shows ACT is more effective than a previously supported behavioral approach to reducing worksite stress and anxiety


ACT Empirical Evidence•Depression: Study with Beck’s CT and

ACT- n=18, a 12 week study, ACT had better outcomes at a 6 month follow up with a reduction in believability of depressive thoughts

•Epilepsy: one study with 27 institutionalized South African epileptics who had just 9 hours of ACT in 2004 experienced significantly shorter and fewer seizures than those in a placebo treatment in which the therapist offered a supportive ear.



• Psychosis: ACT and re-hospitalization after 3 hours of ACT- •a) 50% reduction in hospitalization •b) an increase in self reporting of

symptoms, therefore, accepting the symptoms of psychosis if they admit the symptoms

•c) reduction in the believability of distressing thoughts, hence a change in the function of the thoughts


ACT Empirical Evidence• Panic Disorder: Acceptance methods

(drawn directly from the ACT book) did a better job than control strategies in promoting successful exposure in panic disordered clients

• High Risk Sexual Behaviors: Components of ACT were included as a component of a successful program to reduce high-risk sexual behavior in adolescents

• Social Phobia: ACT versus CBT: more willingness to be anxious in the situation and thus less fear over the time of public speaking, therefore ACT more successful


Ways to Learn More About ACT• Trainings: Russ Harris, Boulder, Sept ??• Join ACBS

• Values based dues.• Many trainings are listed on the site along with a

staggering amount of information. www.contextualpsychology.org

• Join and read the list serve. Talking ACT. • [email protected]

m• Read the books.• Go to a Conference

• 2009 International Conference, Amsterdam• 2010 in San Antonio

• Get into a consultation group• Seek supervision/consultation; I have a list

of local consultants.


Learning ACT• Join ACBS, the ACT (and maybe the

RFT) listserves, and spend hours on www.contextualpsychology.org,

• Read these books to start (plus others)


More books on ACT with specific

populations.


Now What?

Given that the only certainty is death, and the time of death is uncertain, what matters to do right now?

Acceptance and Commitment Therapy is one way to discover the answer to this question.


Questions

Joanne Steinwachs, LCSW, PC1776 S Jackson St

Suite 616Denver CO 80210

303-691-3369

www.joannesteinwachslcsw.com

[email protected]

Association for Contextual Behavioral Psychology

www.contextualpsychology.org

Documents

Acceptance & Commitment Therapy (ACT) Science Meets Mindfulness Joanne Steinwachs, LCSW Rocky Mountain Counselors Conference July 30, 2008 Denver, CO