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Acceptance &
Commitment Therapy- an introduction
Abergavenny
July 2015
Dr Ray Owen
Clinical Psychologist
Aims for the day►Awareness of what Acceptance & Commitment
Therapy (ACT) is If being discussed
Make informed choice about whether interested to pursue further
►Awareness of Principles underlying model
Core processes of ACT
Some examples of how used
►By means of Presentation
Experience
Reflection
With head, heart and hands..
3 people
► Peter feels sad and hopeless, and drinks too much since his wife left him
►Alina has given up on her career goals and her social life since developing a chronic pain condition
►Steve feels so stressed and anxious before difficult meetings or giving talks that he can’t face his job as a clinical psychologist
Office worker, 41
Married to Pete with 3 year-old son, Ben
Several episodes of depression in past, good recovery each
time
Mother died when Sue and her twin sister Amy were 8
Partly brought up by grandmother, who died when they were 20
Sister Amy recurrent severe depression, Sue v supportive of her
Amy killed herself 18 months ago
Sue initially coped reasonably well, over last few months mood dropped lower
and lower, stopped working, withdrawn at home, poor sleep, unresponsive to
GP anti-depressants, failed to engage with IAPT input.
Talking about suicide at times, attempted overdose last week, back home now.
Sue
► Pete just irritates me – doesn’t get why all these losses matter to me so much. Really unsympathetic after overdose. I have angry outbursts. Don’t know how much longer he’ll stay around
► Everyone I love dies; I miss them so much
► I get overwhelmed when I’m with Ben – what if he’s next? Keep imagining awful things happening to him
Hurts so much I just let Pete look after him, and hide in bed all day, thinking
► I used to be the stronger one, and look at me now; I let everyone down, couldn’t save Amy, & I’m a lousy mother
► I can’t go on feeling like this
► Everyone – me included – would be better off if I was dead
Sue
“Everyone I love dies”
“What if Ben’s next?”
“I can’t bear feeling this way”
“Everyone better off without me”
Rumination, mental arguments
Sadness, frustration, anxiety, self-loathing
->withdrawal, avoidance
Nostalgia for the past, worry & hopelessness for the future
-> preoccupied, sleepless
Not the same person I was
-> self-loathing
Not doing much,
Not enjoying anything
Not being good enough parent
-> no sense of achievement
What’s the point?
What am I for now? (as couldn’t save Amy, & lousy mother)
-> aimless, lack of direction
STUCK
UNFULFILLED
► Psychological effects common across conditions
Troubling thoughts
►And what happens next…
Unwanted feelings
►And what happens next…
Get caught up in past and future
Changed self-image
What’s the point? What am I FOR?
Decrease in sense of achievement / fulfilment,
difficulties taking steps to improve life
STUCK
UNFULFILLED
Experiential avoidance: basing
your actions on avoiding feeling bad
Fusion: getting tangled up in
thoughts
Loss of contact with present moment : getting caught up in the past & the future
Inflexible sense of self: getting stuck in an unhelpful 'story' about yourself
Loss of contact with Values: not recognising what matters to you in life
Lack of committed action: not acting effectively to live your life the way you want to
► I’m not healthy, I’m not happy
► So I’m not normal
Alternative Assumption:
Destructive Normality
►Normal psychological processes often
are destructive
►Normal mental representation &
processing
Role of language (Relational Frame Theory)
►We need to understand these processes
and work within them to promote health
and well-being
The struggle switch
►Suppress
►Dive in & Solve
►Push away
►Quicksand
By trying to fight, we get more drawn in
Historical background
►Key names: ► Steve Hayes, Kelly Wilson, Robyn Walser, Russ Harris, JoAnne Dahl, Kevin Polk
►Some had background in radical behaviourism, applied behaviour analysis, fundamental learning processes
►Development during the 90s, most work
since Hayes et al original book published
1999
►Since applied across huge range of
problems and settings, including:
depression, anxiety, anger, substance abuse,
psychosis, pain, chronic health conditions,
workplace stress, epilepsy, stigma, cultural
awareness, learning new skills
Evidence► Overall
>125 RCTs, hundreds smaller studies
Emphasis on mediational analyses
Some problems from Ost meta-analysis (methodological
differences, non-diagnosis)
Others show positive result► A-Tjak J, G, L,. et al (2015), A Meta-Analysis of the Efficacy of Acceptance and
Commitment Therapy for Clinically Relevant Mental and Physical Health Problems.
Psychother Psychosom 84:30-36
Almost all available at www.contextualscience.org
► Evidence-based practice (EBP) lists
Accepted as EBP on US Dept of Health’s SAMSHA list
APA Section 12 listings of EBP cites ‘strong research support’ for
use in chronic pain
► Many e.g.s with LTCs (e.g. Gregg et al 2007 JCCP)
Characteristics► About building a fulfilling life, not about eliminating
distress
► Rejection of concept of ‘healthy happy normality’ suffering is universal consequence of normal psychological function
Exists in context – e.g. LTCs
► Interested in psychological processes, diagnosis not seen as useful (or indeed valid)
► These processes are universal, not simply present in those with ‘a problem’
► Hallmarks include: metaphor
activity
► Linked to a particular stance / philosophical approach
► ‘functional contextualism’ – development of radical behaviourism
A particular model of language, learning and behaviour► Relational Frame Theory (RFT)
Functional contextualism(remember your ABCs..)
► Interested in the action in context Think of a behaviour
In what context?
What consequence / function?
► We cannot understand, respond to or be helpful about a behaviour without knowing something about its context and function/consequence
► Easy to forget how fundamental this is Events (actions, thoughts, feelings) often treated as intrinscially good/bad
rather than considering them in context
E.g. leaving a crowded room, thinking “I can’t do this”, feeling scared
Relational Frame Theory
►Underpinned by a fundamental theory of
how learning occurs
how the relationships between objects builds
up in human mind,
symbolic mental representation ( = language)
The ACT model
►Is a model of 6 interdependent and
overlapping processes that help us to
answer:
►What is influencing behaviour in this
moment?
►How can this person lead a more fulfilling
life?
STUCK
UNFULFILLED
Experiential avoidance: basing
your actions on avoiding feeling bad
Fusion: getting tangled up in
thoughts
Loss of contact with present moment : getting caught up in the past & the future
Inflexible sense of self: getting stuck in an unhelpful 'story' about yourself
Loss of contact with Values: not recognising what matters to you in life
Lack of committed action: not acting effectively to live your life the way you want to
MOVING FORWARD:
MORE FULFILLED
Acceptance / willingness to
experience: allowing whatever
shows up just to be there.
Defusion: treating thoughts as
thoughts (not realities)
Present moment awareness / mindfulness: living in the Here-and-Now
Observing self / flexible perspective-taking: adopting a more flexible sense of self
Awareness of Values: recognising what matters to you in life
Committed action: doing the things that matter to you, even when it's difficult
Acceptance / Willingness
to experience
“allowing whatever shows
up just to be there”
Defusion
“treating thoughts
as thoughts (not
realities)”
Present Moment Awareness / Mindfulness*
“living in the here-and-now”
Flexible sense of self / self-as-
observer
“just noticing” / “not getting stuck in a
story”
Awareness of Values
“knowing what matters
to you”
Committed Action (in
service of Values)
“doing the things that
matter to you, even when
it’s difficult”
Core processes of
ACT
Moving forward:
More fulfilled
Who matters most to you
in the world?
How do you want to be
towards them?
(How do you want to act in
your dealings with them?)
Values
►‘what we want to stand for in life, how we
want to behave, what sort of person we
want to be, what sort of strengths and
qualities we want to develop’.
►
Russ Harris, (2009)
Some Values
► “respecting traditions” ► “influencing others” ► “leading” ► “experiencing new things” ► “having excitement” ► “being loyal” ► “being dependable” ► “helping those in need” ► “being creative” ► “being curious” ► “promoting justice / fairness” ► “appreciating beauty” ► “getting things done► “looking after my health” ► “being emotionally close to
those who matter to me” ► “living in a spiritual or religious
way”
► “having self-control” ► “being honest” ► “looking after those I love” ► “being in contact with nature” ► “being competitive” ► “being respectful towards others” ► “nurturing others / helping them
develop” ► “making a contribution to the
world” ► “being sociable” ► “setting myself challenges
(because I want to, not because I have to)”
► “being a good ‘team-player’” ► “being fun-loving”
“something else, that’s not on this list?”
N = not so important to me
I = important to me
V = very important to me
Values are…
► Ongoing
► Not the same as Goals (compass points, not destinations)
► Not the same as Actions (ways of acting)
► Chosen (the person I want to be, not what I’m stuck with)
► Not dependent on others’ approval (if no-one else ever knew)
► Not right or wrong
► Ends in themselves, more or less… (intrinsically reinforcing)
► About fulfilment, not happiness:
“a life well-lived is a life lived according to your Values”
Not a unique concept
► “Everything can be taken from a man or a woman but one thing: the last of human freedoms - to choose one's attitude in any given set of circumstances, to choose one's own way”
► “He who has a why to live for can bear almost any how ”
Viktor Frankl, V.(1959) Man's Search for Meaning
CHOICE POINT
AWAY FROM VALUES TOWARDS VALUES
HOOKS, e.g.
Urge to avoid discomfort
Desire for short-term gains
Old habits
Hooked by thoughts
Stuck in a story
etc
HELPERS, e.g.
Awareness of Values
Skills:
-Present Moment Awareness / Mindfulness
-Defusion
-Acceptance
-Flexible perspective taking
Effective goal-setting
Adapted from Ciarrochi, Bailey & Harris 2013
From
►Fused; losing the distinction between
thought and reality
to
►Defused; noticing thoughts as
thoughts, and choosing your
response
Why are we like this?
Go to YouTube & watch ‘Struggling with Internal Hijackers’
https://www.youtube.com/watch?v=NdaCEO4WtDU
‘SELF AS CONTEXT’ /
flexible perspective taking
from
►Stuck in a story about self
to
►Flexible perspective taking, observing
self
From
►experiential avoidance
Basing your actions on avoiding feeling bad
to
►acceptance / willingness to experience
Allowing whatever shows up just to be there
EA as a Core Process
Experiential
Avoidance
Depression
Anxiety
Chronic Pain
Eating
Disorders
Substance
Abuse
Psychosis
“Borderline PD”
Treatment
Dropout
Burnout & Stress
General Well Being/Functioning
Work
Performance
Parenting Behaviors
Stigma/
PrejudiceHealth Care
Utilization
Weight Loss/ Maintenance
Chronic Medical Problems
Recent Reviews: Biglan, Hayes & Pistorello,
2008; Chawla & Ostafin, 2007; Hayes et
al., 2006
How develop Willingness
►Noticing emotional state
►A hierarchy
►Stay aware of short-term vs long-term
outcomes
►Many others
PRESENT MOMENT AWARENESS /
mindfulness*
From
►Dwelling in the past, the future,
elsewhere
To
►Staying present, here-and-now, noticing
what’s actually happening
Sue
“Everyone I love dies”
“What if Ben’s next?”
“I can’t bear feeling this way”
“Everyone better off without me”
Rumination, mental arguments
Sadness, frustration, anxiety, self-loathing
->withdrawal, avoidance
Nostalgia for the past, worry & hopelessness for the future
-> preoccupied, sleepless
Not the same person I was
-> self-loathing
Not doing much,
Not enjoying anything
Not being good enough parent
-> no sense of achievement
What’s the point?
What am I for now? (as couldn’t save Amy, & lousy mother)
-> aimless, lack of direction
STUCK
UNFULFILLED
Acceptance / Willingness
to experience
“allowing whatever shows
up just to be there”
Defusion
“treating thoughts
as thoughts (not
realities)”
Present Moment Awareness / Mindfulness*
“living in the here-and-now”
Flexible sense of self / self-as-
observer
“just noticing” / “not getting stuck in a
story”
Awareness of Values
“knowing what matters
to you”
Committed Action (in
service of Values)
“doing the things that
matter to you, even when
it’s difficult”
Core processes of
ACT
Moving forward:
More fulfilled
But why should I have to
experience all those unwanted
thought, unpleasant feelings and
physical discomfort?
To learn more…
► Formal courses E.g. Birmingham University ‘ACT week’ October 2015
► 2 day experiential Introductory
► 1 day clinical applications (intro)
► 2 day intermediate
► 1 day intermediate ACT for Long-term physical health conditions
See shop.bham.ac.uk
► One website: www.contextualscience.org
► One book (to begin with): ‘ACT made Simple’ by Russ Harris
► Well, maybe two…
Shameless plug
Available from
Routledge or
usual suppliers
Contact me: [email protected]
Website: www.drrayowen.co.uk
Both ‘Highly Commended’ in BMA Popular Medicine Book of Year