ACT for Health

EdinburghOctober 2014

Dr Ray OwenClinical Psychologistdrrayowen@gmail.com

Aims for the day

► Consider how core ACT processes relate to working with people who have physical health problems

► Look at specific problems related to Health, and useful ACT-based techniques E.g. living with uncertainty, altered sense of self,

carer burden, tolerating physical treatment, healthy behaviour change

► Reflect on own experience as clinician► Reflect on own experience as human being► Feedback suggests more experiences,

technique and clinical reflection, less literature survey All at contextualscience.org

To begin with…

Physical health

►Acute e.g. cancer with curative intent, recovery

from injury►Long-term / chronic

e.g. chronic pain, bowel disorders, neurological disorders, lung problems

►Palliative e.g. advanced cancer, late-stage MND

►Health Behaviour Change

The ACT Model of PsychopathologyThe ACT Model of Psychopathology

Psychological inflexibility

Dominance of Conceptualised Past & Future

Experiential avoidance

Cognitive Fusion

Attachment to the conceptualised self

Lack of Values Clarity,

dominance of pliance and

avoidant tracking

Inaction, impulsivity or

avoidant persistence

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

Think of a client…

The Positive Psychological The Positive Psychological

Processes ACT Seeks to StrengthenProcesses ACT Seeks to Strengthen

Psychological Flexibility

Being in the present moment /

mindfulness

Acceptance / Willingness

Defusion

Self as Context

Values

Committed Action

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

Think of a client…

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

Fusion and Avoidance

►On the buses►“Why does my mind hurt me that

way?”►Living with an uncertain future►Thoughts we should pay attention to

►What kind of feelings are we avoiding?

Using the basics

►Another trip on the bus..►Not just an explanatory metaphor

Ongoing tool

►A landslide blocking the road

While we’re on the bus…► Minds say unhelpful things► Take a minute..

Notice a passenger What are they saying What form they take Where’s that coming from What is the function of that passenger speaking up

► Actual► ‘intended’

► Mind is not usually our enemy► So why say these things?► Doing its job(s)

The stay alive machine (can become the EA machine) The Problem-solving machine (can become the worry-engine) The Learn From Experience machine (can become the dwell on

the past machine

Default assumption

► My mind is not ‘out to get me’► It’s mostly trying to help by doing one of its jobs► Most of the time it’s pretty good at that► Sometimes in trying to be ‘helpful’ (protect you

from harm, from social victimisation, isolation etc etc) its suggestions end up being unhelpful

► Recognising this makes it easier to use ‘Thanks, mind’

► Why this helps in Health

Uncertainty

►Back to your client How does uncertainty show up Potential impact on life Interaction with core processes

►?especially here-and-now, committed action?

Many paths

►More of a raft than a walk►Originally used with denial-like behaviours►BenefitsBenefits

Defusion from thoughts about prognosisDefusion from thoughts about prognosis Observing selfObserving self Acceptance of feelings that ariseAcceptance of feelings that arise Ability to focus on Values-driven committed Ability to focus on Values-driven committed

action (not being frozen in face of uncertainty)action (not being frozen in face of uncertainty)

But what about the thoughts we SHOULD attend to?

► “I’m sure that lump wasn’t here last week..”► In ACT, we’re interested in the behaviour in

context Behaviour here includes internal behaviour eg

thoughts Need to know context and function

► ‘Defuse and move on’ vs ‘pay attention to and act upon’ nb anyway more able to evaluate and act from

defused position► Old vs New thoughts► Risk-related

Approaches other than classic defusion

►Safe review period (if still here by… then I’ll..)

►Checking out with others►If new, evaluation / challenge►Looking at impact►Worry Time

Avoiding feeling bad

► Emotions► Physical sensations – emotion related► Physical sensations – health related

When distinct, when overlap When is it safe to accept?

►E.g. aching in fibromyalgia vs crushing chest pain in heart disease

In a war vs living with the enemy Narrowing lives in battle with symptom For highly intrusive symptoms, look at ACT for

chronic pain literature (Vowles, McCracken, Dahl)

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

The self

►Over-attachment to the conceptualised self

►Self-as-content, self-as-process, self-as-context

►Flexible perspective-taking►Development of key relational frames

►What’s your mind telling you right now?

How your (conceptualised) Self gets in the way..

► Stuck in a story ‘still the person I used to be’

►Someone who never gives up►The strong one►Carer

‘lost the person I used to be’► ‘shadow of my old self’►No use any more►That was the real me

Adjustment► I’m a burden

Versions► Version 1► Version 1.1► ...Version 1.5► …Version 1.6► Version 2.0► …Version 2.1► Version 2.1.1► Version 2.1.2► ..Version 2.2► ..Version 2.3► Version 3.0► Version 4.0► Version 4.0.4► Version 4.1► Version 4.4► etc

► Alpha► Beta► Cupcake► Donut► Eclair► ►

►

► Froyo► Gingerbread► Honeycomb► Ice cream sandwich►

► Jelly Bean► KitKat

I THEN, I NOW.. For you► At primary

school► Young adult ► Now► characteristics

► Psychological► Physical► Social

► A personality trait

► An ambition► A friendship► A talent

► ‘positive’ or ‘negative’

I THEN, I NOW.. For client(nb. tailored appropriately for their history)

► Young adult ► Pre-illness ► Now► characteristics

► Psychological► Physical► Social

► A personality trait

► An ambition► A friendship► A talent

► ‘positive’ or ‘negative’

Old me new me exercise

► Elicits ‘stories’ about self► Allows us to notice balance of them► How firmly held?

Can challenge if appropriate (new thought / insight)

► Doing the exercise is act of defusion► Mourn the past, accept the present► Are they fixed (e.g. ‘less sociable’)► Reinforces transitions over time

‘this too will pass’

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

►Doing treatment►Hopelessness►Carer burden►Making a choice

Values & Goals

Treatment

► Originally from cancer treatments (chemotherapy & radiotherapy), however..

► ‘doing’ not ‘having’► “Why did you choose to have treatment?”

“no choice” What hoping to achieve “not dying” vs “what do with more/better quality

life” Acknowledge cost of having Price you are willing to pay in order to increase your

chances of … e.g. being close to your children Fast initial way into Values (often session 1) Emphasises active role vs victim story

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

-Defusion

-Acceptance

-Flexible perspective taking

Effective goal-setting

etc

Adapted from Ciarrochi, Bailey & Harris 2013

Finally..

► The same core processes of ACT apply in living well with physical health problems as with any other adversity

► Same interventions can work► Some tailored/tweaked/specific ones too► True whether aiming to

Make healthy behaviour change Cope with an more acute health crisis ‘facing the

storm’ or live a fulfilling life despite chronic health

problem, where aim is ‘living with the enemy’

►Please leave feedback on this event

►At

www.surveymonkey.com/s/H33JMPT