Introduction to
Acceptance &
Commitment Therapy
JOHN A R MA NDO, LCSW
S OUT HEAST PA N ASW
DECE MBE R 5 , 2 0 1 5
Invitation to emit behavior…
You have to
emit behavior in
order to have it
shaped
Sally
Pete
Intro to the Intro to ACT
Acceptance & Commitment Therapy is
◦ …built on empirically based principles
◦ …aimed to increase psychological flexibility
◦ …using a mindfulness-based approach
◦ …with behavior change strategies
…built on empirically based principles
Severe substance abuse
Social Phobia
Depression
Smoking
Obsessive-Compulsive disorder
Chronic pain
Panic disorder
Medical problems
Generalized anxiety disorder
Psychosis
Post-traumatic stress disorder
Workplace stress
Trichotillomania
And more…
ACT RCTs to May 1st 2013
73 RCTs
…aimed at increasing psychological
flexibility
Psychological Flexibility is:
◦ …contacting the present moment fully
◦ …as a conscious, historical human being
◦ …and based on what the situation affords
◦ …changing or persisting in behavior
◦ …and broadening (vs. narrowing) one’s repertoire of behaviors
◦ …in the service of chosen values
Psychological inflexibility (rigidity)…
ACT suggests that psychological inflexibility is at the core of human
suffering
Inflexibility arises through entanglement with verbal rules and the
traps of literal language
Clients learn to mitigate literal language which takes the mind’s
messages at face value (rather than fusing with it)
This creates wiggle room to take actions that are guided by personal
values, rather than being driven by internal private events
Psychological
Inflexibility
…using a mindfulness-based approach
Mindfulness is:
…much easier learned by experience
…involves:
◦ Paying attention (noticing) in a particular way;
◦ On purpose (deliberately),
◦ In the present moment (right here, right now),
◦ And nonjudgmentally (with compassion vs. criticism)
◦ Jon Kabat-Zinn
“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
The Goal of ACT
Live a rich, full, meaningful life
with
less struggle against the inevitable pain of life
(Symptom reduction is not the goal)
ACT is Transdiagnostic
oNot focused on symptom reduction
oFocused on living a life consistent with one’s values
oIn theory, it works with any human problems in living
Why ACT?
“The single most remarkable fact of
human existence is how hard it is for
human beings to be happy.”
(Hayes, Strosahl, Wilson, 1999)
Why ACT?
“…if we add up all those humans who are or have been
depressed, addicted, anxious, angry, self-destructive,
alienated, worried, compulsive, workaholic, insecure,
painfully shy, divorced, avoidant of intimacy, stressed, and
so on, we are compelled to reach this startling conclusion:
Suffering is a basic characteristic of human life.”
(Hayes, Strosahl, Wilson, 1999)
The Ubiquity of Human Suffering
oAbout 30% of all adults have a major psychiatric disorder at any
point in time
oAbout 50% will have such a disorder at some point in their lives
oAbout 80% of these will have more than one serious psychological
problem (Kessler, et al. 1994)
oOnly about half of people who present for mental health care have
a diagnosable mental health disorder (Strosahl, 1994)
The Ubiquity of Human Suffering
oWe all have a 50/50 chance of struggling with suicidal thoughts for at least two
weeks in our lifetime (Chiles and Strosahl, 2004)
oAlmost 100% of all people on the planet will contemplate killing themselves in
their lifetime (Chiles and Strosahl, 2004)
oPreverbal children do not make suicide attempts, but even very young newly
verbal children occasionally do (Chiles and Strosahl, 2004)
oWe have little reason to believe that any nonhuman animals deliberately kill
themselves
Some Unconventional Concepts…
oPsychological pain is normal, it’s important, and everyone has it.
oYou can’t deliberately get rid of your psychological pain
oPain and suffering are two different states of being
oYou don’t have to identify with your suffering
oAccepting your pain is a step toward ridding yourself from your suffering
Some Unconventional Concepts…
oYou can live a life you value, beginning right now, but to do that
you’ll have to learn how to :
oGet out of Your Mind and Into Your Life
The Dilemma of Human Suffering
oThe Assumption of Healthy Normality
oPhysical Health
oMental Health
oThe Assumption of Destructive Normality
oDSM and diagnosis
oPathology vs. function
o Where there’s pain there’s life.
o In your pain, you’ll find your
values, and in your values,
you’ll find your pain.
o There’s as much life in a
moment of pain as there is in a
moment of joy
Normal???
Healthy Normality:
To be healthy is normal, therefore, to be normal is to be healthy
Destructive Normality:
To experience pain is abnormal, therefore to experience pain is to be
abnormal
The Solution is the Problem
Control is the problem, not the solution
Minds are language machines
Able to hold symbols of the past and the future
History and invention
Problem solving in the external, mechanical world
What about the internal, private world of thoughts,
emotions and body sensations?
What about the dynamic world of relationships?
Quicksand
Pathology & Self-stigma/Openess & Pain
I’M DIFFERENT/I’M NOT RIGHT
I AM THE SAME/THIS IS PART OF THE HUMAN
EXPERIENCE
I’m in this on my own
I’m part of the human race
I’m disconnected and apart
I’m connected to the greater whole
Dirty Pain
Clean Pain
Suffering
Pain
I don’t feel understood
I’m not alone
This pain is a sign that something is wrong
with me. I have to fix it!
When I turn toward my painful emotions, I feel
part of the human race - connected
Who Moved My Cheese?
The Hexaflex
Six Core Processes of ACT
The Present Moment
Be here now
Acceptance
Values
Open up
Know what matters
Psychological
Flexibility
Defusion
Committed action
Watch your thinking
Do what works
Self-as-context
Pure awareness
Creative
hopelessness
vs. experiential
avoidance
This then is the
overall
ACT model
Contact with the
Present Moment
Acceptance
Values
vs. fusion with thoughts Defusion
(rule governed)
vs. self as content
vs. being stuck in the
past or future
Committed
Action
Self as
Context
vs. lack of values
vs. impulsive action,
inaction, or
unworkable action
Workability
Acceptance and
Mindfulness
Processes
Contact with the
Present Moment
You can chunk
them into two
larger groups
Acceptance
Values
Defusion
Committed
Action
Self as
Context
and
Contact with the
Present Moment
Commitment
and Behavior
Change Processes
Acceptance
Values
Defusion
Committed
Action
Thus the name
“Acceptance and
Commitment
Therapy”
Self as
Context
ACT Question
Contact with the
Present Moment
(6) at this time, in
this situation?
(2) are you willing to
have that stuff, fully
and without defense
Acceptance
If the answer is
“yes,” that is
what builds...
Defusion
(3) as it is, and not as
what it says it is,
Values
(5) of your chosen
values
Psychological
Flexibility
(4) AND do what
takes you in the
direction
Committed
Action
Self as (1) Given a distinction between
Context
you and the stuff you are
struggling with and trying to
change
ACT Question (Kelly Wilson)
PSYCHOLOGICAL FLEXIBILITY
PSYCHOLOGICAL INFLEXIBILITY
oIn this very moment (present moment)
oNot the past or future (which does not exist)
oWill you (self-as-context)
oNot a story about you (self as content)
oAccept the sweet and the sad (acceptance)
oStruggle with life as it is (avoidance)
oHolding lightly stories about what is possible,
(defusion)
oGetting entangled with your stories (fusion)
oBe the author of a valued pattern of living
(values)
oWander without direction (lack of values)
oMiss your life by turning it into the struggle to
oAnd turn gently, in kindness, toward your own avoid pain (unworkable action)
life? (commitment)
Creative Hopelessness & Workability
“ACT strives to free clients from a flawed and costly feel-good
agenda, moving from unworkable, rigid behaviors toward
psychological flexibility.” (Westrup, 2014)
Does this behavior help, or not?
The definition of insanity is doing the same thing over and over, expecting
different results.
Creative Hopelessness is hard…
Right when we are trying to build rapport…
We’re also helping the patient to come to terms with
◦ A) what they’ve been doing has not been working
◦ B) the fix-it agenda that they would like therapy to be about will never work
Creative Hopelessness is hard…
Creative Hopelessness is about:
Joining
but not aligning (with a rescue fantasy)
Bold
but kind
Honest
but not glum (walk away from a fight that can’t be won)
uncompromising
but compassionate
Uncompromising but compassionate
Be unflinching – regarding what there is to see or to be had.
Be kind – in tone, in demeanor, in my choice of words (direct does
not me brusque)
Convey confidence – that this is doable. Be confident in the model
vs. feeling confident in myself.
Be humble – I’m in this soup, too, and my work isn’t about having
the right answer. It’s about offering an alternative
The Hexaflex
Six Core Processes of ACT
The Present Moment
Be here now
Acceptance
Values
Open up
Know what matters
Psychological
Flexibility
Defusion
Committed action
Watch your thinking
Do what works
Self-as-context
Pure awareness
Preoccupation with Past & Future vs.
Present Moment Experiencing
The Only Time is Now
o“There is only one time that is important – NOW! It is the most important time
because it is the only time we have any power.” Leo Tolstoy
oLife happens now – in this moment.
oThe past and the future only exist as thoughts occurring in the present.
Thoughts about the future
Not Now!
When I get my
PhD, I’ll finally be
happy.
Thoughts about the past
I should have
become a dentist
instead of a social
worker
Experiencing now
I can feel the cool
breeze on my face
Now is where your life is
There is your life and there is your life situation…
Your life situation is a story that your thinking mind is telling
you
The Thinking Mind
I remember
that time I
got rejected
I’ll probably
get rejected
next time
Mindfulness “Formula”
1. Notice X
2. Let your thoughts come and go
3. Let your feelings be as they are
4. Drift off, come back
Mindfulness of Five Senses
Present Moment
The Hexaflex
Six Core Processes of ACT
The Present Moment
Be here now
Acceptance
Values
Open up
Know what matters
Psychological
Flexibility
Defusion
Committed action
Watch your thinking
Do what works
Self-as-context
Pure awareness
Acceptance vs. Experiential Avoidance
Allowing our thoughts and feelings to be as they are
Opening up to our painful thoughts and feelings
Allowing ourselves to have painful private experiences if and when doing so will
enable us to act on our values
Acceptance is making full, open, undefended psychological contact with
unpleasant and unwanted private experiences
Experiential Avoidance can be a barrier to values-congruent action
Experiential
Avoidance
o Avoiding unwanted
thoughts and feelings
Experiential
Avoidance
Increases their intensity
Experiential
Avoidance
o And, their
frequency…
Therapist Avoidance Strategies
oNot being prepared
oAssigning LOTS of homework
oBeing really, really, really prepared
oBeing a “good listener”
oBeing big
oChoosing not to intervene
oBeing small
oKeeping it light – coffee talk
oBeing an expert
oChanging the subject
oBeing clever
oChasing understanding
oAlways bringing a clip-board
oProviding consolation
Marianne Williamson (not Nelson Mandela)
“Our deepest fear is not that we are inadequate. Our deepest fear is that we
are powerful beyond measure. It is our light, not our darkness that most
frightens us. We ask ourselves, Who am I to be brilliant, gorgeous, talented,
fabulous? Actually, who are you not to be? You are a child of God. Your
playing small does not serve the world. There is nothing enlightened about
shrinking so that other people won't feel insecure around you. We are all
meant to shine, as children do. We were born to make manifest the glory of
God that is within us. It's not just in some of us; it's in everyone. And as we
let our own light shine, we unconsciously give other people permission to do
the same. As we are liberated from our own fear, our presence automatically
liberates others.”
Acceptance Exercises
o Acceptance of Emotions
exercise
o Wade through the swamp
metaphor
o Chinese finger trap
Letting Suffering Get Close
Close your eyes or fix them on a spot, and
focus on my voice
Think of a situation where you’ve experienced
intense suffering
Notice what comes up for you…
Notice your thoughts…
Notice your feelings…
Where do they seem to inhabit your body?
See what vulnerabilities you notice
Let those experiences be there without
changing them
Let them be exactly as they are
Breathe into them and open up around them
Realize that you are not your pain
You are bigger than your suffering
Notice that what’s happening to you is part of
the human condition
When We Turn Away From Suffering
oWhen we turn away from suffering, we miss the other things, rich and varied, that are
inextricably linked to suffering. Values and vulnerabilities are poured from the same vessel.
Consider the ways you have been most deeply hurt in your own life and see if each hurt was
not connected to a deeply held value. The betrayal that led to divorce wouldn’t have hurt had
you not valued the trust and love of your spouse. The taunting of the kids at school wouldn’t
have hurt except that you valued companions and the respect and regard of your fellows. The
death of your mother wouldn’t have hurt, except for the great love you bore for her.
oI don’t know of a way to breathe in without being willing to breathe out. I don’t know of a
way to love without being willing to feel the sting of loss. I care about you… even though we
may not have met, but I don’t know how to say these words without knowing also the fear
that they will seem hollow to you.
(Mindfulness for Two by Kelly Wilson with Troy Dufrene)
A Little Context…
Radical Behaviorism
Behavior Modification
BF Skinner
Applied Behavior Analysis
Cognitive Behavioral Therapy
(Second Wave)?
Aaron Beck
CBT
Albert Ellis
REBT
Third Wave of Behaviorism
Steven Hayes
ACT/RFT
Marsha Linehan
DBT
Third Wave of Behaviorism
Mavis Tsai
FAP
Robert Kohlenberg
FAP
Functional Analytic Psychotherapy
FAP is based on the behavior analytic, or functional contextualistic, approach to human behavior
first described by B.F. Skinner.
The treatment, however, is not mechanistic.
In fact, FAP results in psychotherapy relationships that are more intense and personal than are
typically found in cognitive-behavioral treatments.
Third Wave of Behavior Therapy
Paul Gilbert
CFT
Zindel Segal
MBCT
The House of
ACT
Acceptance and Commitment
Therapy (ACT)
ACT
RFT
ABA
Relational Frame Theory (RFT)
Applied Behavioral Analysis
(ABA)
Functional Contextualism (FC)
FC
Functional
Contextualism
The Three Legged Chair
This chair is:
Damaged
Maladaptive
Dysfunctional
Functional
Contextualism
The Three Legged Chair
This Chair is:
An object of art
A prop for a show
A con for a personal
injury claim
Form or Function
By changing the context, we can change the function…
By being fused with the content (past/future, how things are, how things should be) we get
stuck on the form
Applied Behavioral Analysis (ABA)
Context
TEAMS & Actions +/- Reinforcement
(Aversives & appetitives)
Triggers, Behaviors, & Payoffs
Triggers (In what context does
this behavior show up/what
happens before the behavior)?
Behaviors (something an
Payoffs (what keeps this
organism does; private, public) Is behavior going)?
it workable or unworkable?
Giving an ACT presentation to a
group of really smart social
workers.
Lecture, get “mindy”,
intellectualize, play it safe
Survive, avoid embarrassment,
reduce anxiety
Started to read David Foster
Wallace’s book.
Compared myself to him. Burned
my writing.
Avoided future embarrassment of
not being good enough
Which one is bigger?
Which one is better?
Which one is better?
Which one is better?
Functional Contextualism
Which one is truer representation of the building?
Mechanistic View
1. Identify what’s bad
2. Eliminate what’s bad
3. Replace what’s bad with what’s good
Thoughts and feelings are not good or bad and can’t be replaced when they’re not working.
Thoughts might be
more like leaves on a
stream
Not as what they say
they are
Seeing thoughts as
what they are…
The truth that must
determine behavior
Looking at thoughts
Looking from thoughts
Relational Frame Theory (RFT)
Derived Relational Responding
So What…
The Hexaflex
Six Core Processes of ACT
The Present Moment
Be here now
Acceptance
Values
Open up
Know what matters
Psychological
Flexibility
Defusion
Committed action
Watch your thinking
Do what works
Self-as-context
Pure awareness
Defusion vs. Fusion
o Looking at thoughts rather than from
thoughts
o Noticing thoughts rather than getting
entangled
in thoughts
o Letting thoughts come and go rather
than holding onto them tightly
I’m so smart!
I’m such a loser!
Defusion: Looking at your thoughts
I’m noticing I’m
having a
thought…
No one will ever
love me…
There goes my
mind again
Thank you mind
for that thought
Defusion
oThat’s an interesting thought
oLet your thoughts come and go like clouds in the sky or leaves on a stream
oWhat's it like to get bullied by that thought? Do you want that thought to tell
you how to live your life?
oThis is just your mind problem solving. This is what minds do.
oName the story. e.g. “This is my ‘I’m not good enough story’.”
oWhen you buy into this thought, how does your behavior change?
oWhat does this thought help you to avoid? Could you choose to make room for
that?
Defusion exercises
oLemon, Lemon, Lemon
oLeaves on a stream
oComputer Screen, foreign language, silly voice, objectify it…
The Hexaflex
Six Core Processes of ACT
The Present Moment
Be here now
Acceptance
Values
Open up
Know what matters
Psychological
Flexibility
Defusion
Committed action
Watch your thinking
Do what works
Self-as-context
Pure awareness
Pure Awareness – The observing self
SELF-AS-CONTEXT
CONCEPTUALIZED SELF
oI am where the pain exists
oI am the pain/the pain is me
o“I feel depressed.”
o“I am depressed.”
o“I’m noticing that I’m feeling anxious.” oExcessive identification with certain
emotions, memories, or roles
o“I”
oEgo
oThe witness or watcher
Self-as-Context
oAKA self-as-perspective, the observing self, the silent self, the silent witness,
oThe “part of you” that is aware of everything else
oThe “place” from which you observe
oSees perspectives of others and other times/places
oShows empathy (taking perspective of others)
oShows compassion toward others (and self)
Chess Board Metaphor
Flexible Perspective Taking
oShift perspectives to expand possibilities
o If your best friend was watching this interaction, what would they say?
o If you were a therapist for a couple that acted this way, what would you think of them? What would you want
for them? For him, for him?
o If you were (someone client admires) [in the self chair], how would you act differently
o If you were me and you heard what you are saying right now, what would you think?
oNotice change in perspective
o When you look at this from another perspective, does it feel the same? Different? Do you see yourself the
same way when you take these different perspectives?
oCombine with augmentals
o If x (whatever the critic says) were not weighing you down, what would you be doing? What would you need
from him/her to make that possible?
o If x (whatever critic says) no longer held you back, what would you be doing?
The Younger You, The Older Wiser You
Your Life
The Sun
Your Life Situation
The Sun behind the clouds
Your Life
The Sun
Your Life Situation
The Sun behind the clouds
Now that we have some context…
oLet’s go back to the beginning
Establishing Rapport
oWe are in the same boat as our clients:
o We both get entangled in our mind
oDisappointment
oRejection
oFailure
o Lose touch with the present moment
oBetrayal
o Repeatedly lose touch with our core values
oLoss
o Act in self-defeating ways
o Encounter similar struggles in our lives,
Including:
oLoneliness
oIllness
oGrief
oResentment
oAnxiety
oInsecurity
oDeath
Two Mountains Metaphor
Revisiting Creative Hopelessness
“Creative hopelessness means fully opening to the reality that trying
too hard to control how we feel gets in the way of living a rich, full
life.” (ACT Made Simple, Harris)
1. What have you tried?
2. How has it worked?
3. What has it cost?
Digging to get out of a hole…
Math Problems and Sunsets
The Hexaflex
Six Core Processes of ACT
The Present Moment
Be here now
Acceptance
Values
Open up
Know what matters
Psychological
Flexibility
Defusion
Committed action
Watch your thinking
Do what works
Self-as-context
Pure awareness
Values vs. Lack of Values
oValues are statements about
◦
◦
◦
◦
What we want our life to be about
What we stand for
How we want to behave on an on-going basis
Leading Principles that can guide and motivate us
oDistinguish between values and goals
o Goals are in the future and we can succeed or fail to achieve them
o Values are on-going patterns of chosen behavior that give our existence meaning even in the context of
pain and misfortune
oValues Clarification
Values
oYou are 80 years old looking back on today. Complete these
sentences:
oI spent too much time worrying about …
oI spent too little time doing things such as ….
oGet into the present moment today. Complete these sentences
from that perspective:
oI long for…
oIf I had no fear I would…
oI would be willing to die for…
The Hexaflex
Six Core Processes of ACT
The Present Moment
Be here now
Acceptance
Values
Open up
Know what matters
Psychological
Flexibility
Defusion
Committed action
Watch your thinking
Do what works
Self-as-context
Pure awareness
Committed Action vs.
Inaction or Impulsivity
oTaking larger and larger patterns of effective action, guided and motivated by
values
oCommitted actions are flexible:
◦ Readily adapting to the challenges of the situation
◦ Persisting or changing behavior as required
◦ Doing what it takes to live by our values
oThe Tiniest Step – Once you’ve identified a life domain, and some core values:
o “What’s the smallest, tiniest, simplest step you can take in the next twenty-four hours that
will take you a little bit further in that direction.”
The ultimate test is workability
FUSION
Avoidance
Toward & Away
Behavior
Notice the difference
Efforts to avoid or control
Committed action
Observing Self
Connect the DOTS
What would the person you want to
be do in this situation?
Distraction
Opting out
What’s the smallest action you
can take in the direction of your
values, and that you’d be willing
to do today?
Thinking
Away
Substances/self harm
Unwanted, unpleasant
internal experiences –
things that hook you from
the flow of life
Toward
Values
Work/education
Recreation
Health/
personal growth
Relationships
Troublesome thoughts
Difficult emotions
Uncomfortable body
sensations
Thinking Self
Things we do to avoid or control
our unwanted inner experiences
Connect the DOTS:
Distraction – any activity we engage in to get away from an unwanted internal experience. (Internet,
TV, food, work, etc).
Opting Out – avoiding people, activities in order to minimize pain (avoiding call, emails, texts,
particular people, job opportunities, applying to college).
Thinking – how we respond to thoughts (ruminating, challenging, suppressing, positive thinking)
Substances/self-harm (numbing…)
WTF?
• What’s the function?
• (of this behavior)
• Is it a Toward or an Away move?
Psychological flexibility
• Doing what works
• By noticing the difference
• The Matrix is a stripped down approach to ACT
The Serenity Prayer
• God, grant me the serenity to
accept the things I cannot
change
• The courage to change the
things I can
• and the wisdom to know the
difference Reinhold Niebuhr(1892–1971)
The Serenity Prayer
• God, grant me the serenity to
accept the things I cannot
change
• The courage to change the
things I can
• and the wisdom to know
(notice) the difference Reinhold
Niebuhr(1892–1971)
Mental Experiencing or the
Thinking Mind
Unwanted Mental
or Inner Experiences
Difficult Emotions
Uncomfortable Body Sensations
Troublesome Thoughts
Notice Your Hooks?
When you consider what you could do to move toward your value what do you get hooked by?
Thoughts
◦ “I’m not smart enough.”
◦ “Everyone here knows more than me.”
Emotions
◦ Fear
Body Sensations
◦ Sweating
Guns and Roses
Being in the present momentLiving your value of appreciating beauty-
Response in the
service of Survival!
Efforts to Avoid or control
Run! Leave right now. Don’t look back!
Bull shit them! Give them your credentials. Tell them what
the research literature says…
Imagine them in their underwear???
Ask for reassurance.
Take a Xanax…
What are yours right here, right now?
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