Acceptance &

Commitment Therapy- an introduction

Abergavenny

July 2015

Dr Ray Owen

Clinical Psychologist

drrayowen@gmail.com

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..

To begin with…

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and lower, stopped working, withdrawn at home, poor sleep, unresponsive to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

►Pathological state?

►Psychological disorder?

►Mental illness?

► 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

The Great Western Lie…….

►Our default state

Healthy, happy normality!

► I’m not healthy, I’m not happy

► So I’m not normal

The answer has been found!

The Major Reason to

Suspect this is False

►The ubiquity of human suffering

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

In a nutshell…

One way..

Acceptance & Commitment

Therapy (ACT)

a ‘3rd-wave’ Cognitive Behaviour

Therapy

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

How?

►In a nutshell…

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

Values

From

►Loss of direction

To

►Awareness of what matters in life, and

how you want to be

“Show, don’t tell”

- universal process

- A health warning

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

So what’s stopping you?

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

A warning…

Why are we like this?

Go to YouTube & watch ‘Struggling with Internal Hijackers’

https://www.youtube.com/watch?v=NdaCEO4WtDU

Troubling thoughts…

►An exercise

‘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

Meet aunt Irma

An exercise in willingness…

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

Here & Now…

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?

Your comfort zone

Where the

magic

happens

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: drrayowen@gmail.com

Website: www.drrayowen.co.uk

Both ‘Highly Commended’ in BMA Popular Medicine Book of Year