Introduction to Acceptance
and Commitment Therapy
Patricia Bach, PhD
University of Central Florida
Get Out of Your Mind and Into Your
Life…and Into Your Therapy Sessions
Agenda





Introduction
An overview of the ACT Model
Does ACT work, and how is it related to other
evidence-based practices?
ACT techniques, some useful no matter what
your theoretical orientation
ACT processes for clinicians
Informed Consent
At times this workshop will be
experiential
 Your privacy will never be violated,
but you will be invited to take a few
risks if you choose
 Confidentiality
 No judging the level of risk taking of
others: go for it or not, it is up to you

Why now?
ACT and other mindfulness based
treatments are growing in popularity.
 The 21st century is prime time for the
emergence of mindfulness and acceptance
based treatments…

Mindlessness
Judgment: You’re not good
enough
“The single most
remarkable fact about
human existence is how
hard it is for humans to be
happy.”
(Hayes, Strosahl, & Wilson, 1999)
The Ubiquity of
Human Suffering
High lifetime incidence of major DSM
disorders
 High rates of divorce, sexual concerns,
abuse, obesity, violence, prejudice,
loneliness
 Some extremely destructive behaviors are
both common and non-syndromal, e.g.,
suicide, self-injury

The Ubiquity of
Human Suffering
People don’t just suffer when things are
bad
 We suffer when things may be bad
 What is the consequence of withdrawing
from suffering?

Question:
If that’s true, why don’t we all
struggle with anxiety, depressed
moods, insecurities, fears, etc….?
Answer:
Oh, wait…we DO!
That thing you do…
Destructive Normality

Normal psychological processes often
are destructive

We need to understand these processes
and work within them to promote
health

One cause: human language and
cognition – human verbal behavior
Language is a Blessing and a
Curse
Evaluation
 Problem solving
 Avoidance

Experiential Avoidance

Experiential avoidance is built into human
language and then amplified by the culture
– Experiential avoidance is the tendency to
attempt to alter the form, frequency, or
situational sensitivity of historically
produced negative private experience
(emotions, thoughts, bodily sensations)
even when attempts to do so cause
psychological and behavioral harm
4/8/2015
Higher Avoidance Scores Are ….

Associated with:
– Higher anxiety
– More depression
– More overall
pathology
– Poorer work
performance
– Inability to learn
– Substance abuse
– Lower quality of life
4/8/2015
– History of sexual
abuse
– High risk sexual
behavior
– BPD symptomatology
and depression
– Thought suppression
– Alexithymia
– Anxiety sensitivity
– Long term disability
Sources: Hayes et al (2004); Polusny (1997); Toarmino (1998); Pistorello (1997); Batten, Follette, &
Aban (1998); Stewart, Zvolensky, & Eifert (1998);
Central Clinical Insights





Trying to get rid of thoughts and feelings can
make difficult ones more important, and
Narrows behavioral Repertoires
But we can bring the functions of mind under
better contextual control
We do that by learning to relate to the mind in
a different way
That is one of the larger messages of
mindfulness methods -Hayes
What is ACT?
A form of CBT
 A form of clinical behavior analysis
 A mindfulness-based treatment
 Functional contextual therapy

– Behavior is situationally bound
– Behavior is functional
Acceptance and Commitment
Therapy

A contextually focused form of cognitive
behavioral therapy that uses mindfulness
and behavioral activation to increase
clients’ psychological flexibility – their
ability to engage in values-based
behaviors even while experiencing difficult
or unwanted thoughts, feelings, and
sensations. (http://nrepp.samhsa.gov, 2011)
ACT Therapeutic Stance



Universality - The struggles we have are not
fundamentally different from other human beings. We
communicate this to the client.
ACT is an experiential therapy in which the therapist is
personally invested in the client, but is radically respectful
of the client’s struggles and values.
To do ACT competently, you need to deal with your own
anxieties in the same way you are asking your clients to
deal with their anxieties.
– Open up to them
– Get in contact with your goals and values
– Do what is there to be done (Hayes, 2006)
Contact with
the Present
Moment
Acceptance
The ACT model
Values
Psychological
Flexibility
Committed
Action
Defusion
Self-asPerspective

A trip around the hexaflex
Contact with
the Present
Moment
Acceptance
The ACT model
Values
Psychological
Flexibility
Committed
Action
Defusion
Self-asPerspective
Psychological Flexibility

The ability to contact the present moment
fully as a conscious historical human being
and, based on what the situation affords,
changing or persisting in behavior in the
service of chosen values
-Hayes
How do you know you’ve got ‘psychological
flexibility’?
Vitality!
Assumptions of ACT
Pain in life is inevitable
 Normal verbal processes contribute to
psychopathology
 Control is best applied where it works - to
overt behavior rather than to thoughts,
feelings, and sensations
 “The aim of ACT is to create a rich, full,
meaningful life while accepting the pain
that inevitably goes with it.” (Harris, 2009)

Show up for your own life
What gets in the way of vitality?
The ACT ‘inflexahex’
Experiential Avoidance

Deliberate attempts
to avoid, control,
suppress, escape, or
get rid of negatively
evaluated or
unwanted thoughts,
feelings and body
sensations
Acceptance

Willingness to experience uncomfortable
or unwanted thoughts, feelings, and body
sensations in the service of response
flexibility.
– “Control is the problem, not the solution”
– “If you’re not willing to have it, then you’ve
got it”

Especially when control of thoughts and
feelings is limited or reduces quality of life
Cognitive Fusion
Thoughts dominate
behavior – “being
pushed around by
thoughts” (Harris, 2009)
 Entanglement with
judgments – thoughts
are taken literally
 Reduces the impact of
direct experience

Cognitive Defusion
Also known as cognitive distancing
 Observing thoughts without automatically
taking them literally

– “I’m having the thought that…”
No need to change thought content
 Changing ones relationship to thoughts

Dominance of the conceptualized
past and feared future
Loss of contact with
the here and now
 Out of touch with
thoughts and feelings
– lack of self
knowledge
 Rumination and worry

Dominance of the Conceptualized Past/Future
“A mind is a wonderful tool for detecting
and evaluating external dangers and
developing plans for adapting to these
demands, but we cannot avoid applying
these same processes to the content of our
private world. When we do so, we both
see and produce negativity.”
…Steven Hayes
Contact with the Present Moment

“Mindfulness means paying attention in a
particular way: on purpose, in the present
moment and non-judgmentally.” (Kabat-Zinn)
Openness to experience, engagement, flexibility,
awareness, attention, process vs outcome
 Mindfulness promotes and requires acceptance
and defusion.
 Vitality is only experienced in the present
moment.

Attachment to the conceptualized self
Buys into selfevaluations – “I am
too…” or “I am not…”
 I am my thoughts and
feelings
 Limiting – we are
more than we can
ever say about
ourselves

Self as Perspective
Thinking self Vs observing self
 You are not your thoughts and feelings
 Transcendent sense of self: thoughts,
feelings and experiences change, and the
YOU who notices these events doesn’t
change
 “Notice who’s having that
feeling/thought/sensation”

Lack of values clarity
What do you want
your life to be about?
 avoidant values
 People pleasing

Values & values clarification
Chosen life directions
 Different from goals
 Though values are verbally construed,
they are actions: you value with your feet
 “Outcome is the process through which
process becomes the outcome”

(Hayes, Strosahl, & Wilson, 1999)
Barriers to values
What is getting in the
way of valued living?
 Look for avoidance,
impulsivity, inaction.
 Often the presenting
complaint or most
obvious ‘problem
behavior’

Committed Action
Behavior in the service of values
 EBP’s, skill’s training, doing more or less of
something, joining a support group,
homework, etc.
 Value’s clarification builds motivation for
committed action.

– “what’s that in the service of?”
(2) are you willing
to have that stuff,
fully and without
defense
Contact with the
Present Moment
Acceptance
If the answer is
“yes,” that is
what builds...
Defusion
3) as it is, and not as
what it says it is,
(6) at this time, in this situation?
Values
Psychological
Flexibility
(5) of your chosen
values
Committed
Action
(4) AND do what
takes you in the
Self-as-Perspective
direction
(1) Given a distinction between you and the stuff
you are struggling with and trying to change
We can try to control the uncontrollable by
looking for security and predictability,
always hoping to be comfortable and safe.
But the truth is that we can never avoid
uncertainty and fear. So the central question
is not how we avoid uncertainty and fear but
how we relate to discomfort.
-Pema Chodron
Does ACT work?

Meta-analytic studies support effectiveness of
ACT
Hayes et al., 2006; Powers et al., 2009; Ost 2008

RCTs for treatment of many different problems
Anxiety disorders, chronic pain, psychosis,
trichotillomainia, substance abuse, depression, eating
disorders, management of medical problems, obesity,
epilepsy, impulse control disorder, etc.
Psychological Flexibility

The primary measure of PF is the
Acceptance and Action Questionnaire
– Differentiates patients from healthy controls
– Is correlated with variables largely consistent
with predictions
– Shows treatment sensitivity
– Explains unique variance
– mediates and moderates as predicted
Bond et al., 2011; Gloster et al., 2011
Is ACT an Evidence-Based Practice?
National Registry of Evidence-based
Programs and Practices (NREPP)
 APA Division 12

–
–
–
–
–

chronic pain
depression
mixed anxiety
Obsessive compulsive disorder
psychosis
Veterans Administration
One major difference between ACT and
many other treatment approaches
There is no attempt to reduce symptoms
in ACT.
 Symptom reduction often occurs, and it is
a byproduct of treatment rather than an
explicit goal of treatment.

Can you mix ACT with other
treatment approaches?
Mindfulness is widely applicable (just be
sure to apply it mindfully!)
 Values clarification can build tx motivation
 Most problematic is mixing acceptance
and cognitive defusion with cognitive
restructuring

Can you mix ACT with other
treatment approaches?

The ‘Committed Action’ process often
includes other EBP’s
– ERP
– Habit reversal
– Behavior activation
– skills training
ACT in practice…
Hopelessness
Nothing has helped
 You are my 6th (10th, 37th) therapist…
 Meds, CBT, EMDR, acupuncture, prayer,
etc. weren’t helpful, and I am hoping that
ACT might help.
 I’ve relapsed at least a dozen times
 I don’t expect this to help, and I’m here
because I promised my wife...

Creative Hopelessness
Experienced by the client when she
notices that there is an unworkable
change agenda.
 the client has tried to make things better
for herself by using control strategies in
contexts where they don’t work
 Creative hopelessness creates a space for
something new to happen.

The solution is part of the problem
Doing more of the same
 Using control in contexts where it is
unhelpful, difficult, or impossible

– When control is useful
– When it isn’t
– Pain Vs suffering
Acceptance of the
Unworkability of Control

Why we stick with it
– It works elsewhere
– It seems to work for others
– You are told it should work for you
– It even SEEMS to work in the short run
So what is the alternative?

Willingness
Willingness

Willing Vs wanting
diagnosis

DSM Vs functional diagnoses
– What brings you here?
– Why NOW?
– How would you know that you are better?
– What would you be doing if things were going
better for you?
– Tell me about a time when your life was going
better for you
Contact with
the Present
Moment
Acceptance
The ACT model
Values
Psychological
Flexibility
Committed
Action
Defusion
Self-asPerspective
Experiential Avoidance

Avoiding
unwanted
thoughts…

Increases
their
intensity

And their
frequency
Experiential avoidance

What behaviors might suggest that
experiential avoidance is an issue for your
client?
Presenting complaints
Behaviors with clear negative
consequences and obvious negative
reinforcement
 Substance abuse
 Escape from feared stimuli (e.g., phobias,
OCD, agoraphobia)

And then there are behaviors where it is
less obvious what is being avoided.
 Anger problems
 Underachievement
 Lack of intimacy

Avoidant behavior in the therapy
session
Does the client frequently change the subject,
‘zone out’, lose eye contact?
 Does the client often say “I don’t know” when
you ask an emotion laden or interpersonally
important question?
 Does the client have difficultly with process work
regarding his/her relationship with you?
 Does the client often provide vague answers to
questions, e.g., “I guess I like my job and stuff
”; “It was no big deal”

Avoidant behavior in the therapy
session

Watch for pseudo-acceptance
– If I accept it, then will it go away?
Acceptance

actively contacting psychological
experiences – directly, fully, and without
needless defense – while behaving
effectively.
Acceptance
Control is the problem/Two scales
metaphor
 Feeding a baby tiger
 Tug of war with a monster
 Chinese handcuffs/monkey trap
 If you’re not willing to have it/lose it…
 Polygraph exercise
 Clean Vs dirty discomfort

Cognitive fusion

Inflexible behavior influenced more by verbal
networks than by recently experienced
environmental consequences
Cognitive fusion
Verbally related antecedents and
consequences such as thoughts, feelings,
judgments and memories have more
influence over responding than direct
experience with the world
 i.e., the person ‘living in his head’

Cognitive fusion
Look for instances where responding is
guided by evaluations and inflexible rules
 This may look similar to ‘irrational beliefs’

Defusion
Looking at thoughts rather than from
thoughts
 Seeing thoughts as what they are, not as
what they say they are.
 In contact with direct experience rather
than thoughts about experience

Defusion metaphors and demos
The automaticity of language
 Mary had a little…
 Lemon, lemon, lemon
 sunglasses

Defusion exercises
Bad cup
 Physicalizing
 “I’m having the thought that…”
 Taking your mind for a walk

Notice that these exercises are not just
defusion exercises, but also entail
acceptance, i.e., are you willing to have
what shows up without trying to change
it?
 Fusion is also related to attachment to the
conceptualized self

Dominating concept of the
evaluated past and/or feared future
Fusion with the verbally constructed past
or future means that one is not in contact
with the present moment
 Words pull us into the past and future

– Rumination about the past or feared future
– Judgments about the self or others
– Procrastination
– Anticipatory anxiety and avoidance
Contact with the Present Moment
“Mindfulness means paying attention in a
particular way: on purpose, in the present
moment and non-judgmentally.” Kabat-Zinn
 Mindfulness practice is based on the premise
that only in the experience of the present
moment can one accurately perceive what is
really happening, when life is fully appreciated
without the need to judge it, and when effective
action can be taken.

Contact with the present moment
Meditation/mindfulness
 Leaves on a stream/soldiers in a parade
 Just noticing
 Tin can monster
 One minute mindfulness
 Counting to 10

Mindlessness in therapy
Mindfulness


Mindfulness takes practice
Do not invite your client to try any mindfulness technique you have
not first practiced yourself!
Self as context and Senses of Self
Self as content
 Self as process
 Self as context (self as perspective)
 These are not to be construed as three
different selves, or as the only three
possible senses of self
 They are three senses of self that pertain
to self-knowledge

Self as content
A conceptualized self is useful
 It allows us to participate in a verbal social
community and answer questions such as:

– What is your name?
– What do you do for a living?
– Where do you live?
– Is that your son?
– How old are you?
– Tell me about your hobbies
Attachment to the conceptualized
self

The conceptualized self is the same thing
as self-as-content and attachment to the
conceptualized self is usually related to
fusion with content
Attachment to the conceptualized
self
During case conceptualization look for
statements such as:
 I am too…
 If only I did…(or didn’t…) then I would
 My problem is that I…
 I am a (failure, loser, wimp, druggie, etc.)
 I am not (smart, pretty, strong) enough
 I can’t…

Weak self-knowledge
and self as content
Not usually problematic in most clinical setting –
clients are more likely to be too attached
to/fused with content
 May be problematic when one small piece of the
conceptualized self dominates, e.g., being
defined by “I got fired from a job” “I flunked
mathematics” “I was abused”, while ignoring
most other content
 May be problematic in lower functioning clients
who have others care for them and limited
opportunity to build up a sense of self

Self-as-process
Self-as-content refers to how one might
describe the self.
 Self-as process is noticing what one is
experiencing in the present moment, e.g.,
ongoing self-awareness
 The client with poor ongoing selfawareness doesn’t know what he is
thinking or feeling.

Self as process

It is experienced when we notice our own
private or public experience in the present
moment
–
–
–
–
–
–
–
I
I
I
I
I
I
I
feel sad (or hungry, tired, anxious, happy)
am thinking about what to have for dinner
am walking to the coffee shop
am typing an email message to my boss
am having the thought “I don’t want to go”
am having a panic attack
am obsessing about germs
Weak self-knowledge and
self as process
Alexithymia – the inability to describe ones
feelings
 Clients who show excessive pliance are
often out of touch with their own thoughts
and feelings and may answer “I don’t
know” or “what do you think?” or “what
do you want to do?”, when asked to share
an opinion or desire

Self as context
Sometimes described as ‘the observing self’ or
as ‘pure consciousness’ or ‘the self that is aware
but does not think’
 Purely experiential so difficult to put into words
 The sense of self we get a glimpse of when we
notice that we experience from a perspective or
locus; often experienced during mindfulness
practice.
 While our thoughts and feelings change and
events change over time they are experienced
from a unique perspective – YOU as the
perspective from which your life unfolds

Weak self-knowledge and
Self as Perspective
May be problematic when ability to
contact self as perspective has not been
learned or is immature
 Evidence for weak self-knowledge in this
domain might be a client who is at a loss
to describe values and life goals
 Aimlessness, inertia, lack of vitality

Self-as-context
As you can see, self-as-context is difficult
to describe in words.
 Best contacted experientially

The observing self

Guided exercise
Self as context exercises
Chessboard metaphor
 Three senses of self discussion/link with
defusion work
 Observing self exercise
 Mental polarity

Values
Chosen life directions; values give lives
meaning
 In values work, distinguish choices from
reasoned actions; to understand the
distinction between a value and a goal; to
help clients choose and declare their
values and to set behavioral tasks linked
to these values

Lack of values clarity

The client may describe a general lack of
vitality and be vague about values and
goals
Dominance of pliance and
avoidant tracking

Rule governed behavior (RGB)
– Tracking
– Pliance
– Augmenting
Tracking

“Rule governed behavior under the control
of the apparent correspondence between
the rule and the way the world is
arranged”
– Reading a map to get somewhere
– Following a recipe
– Putting on mittens after being told “it is cold,
and mittens will keep your hands warm”
– Noticing that meeting new people makes you
anxious and staying away from parties to
avoid anxiety
Avoidant tracking
Tracking is useful.
 Imagine learning traffic rules or trying to get
from Orlando to Tampa Bay through
contingency shaping rather than rule governed
behavior…
 Avoidant tracking is behavior under the control
of emotional avoidance. The rules tracked
pertain to thoughts and feelings to be avoided
rather than to other available contingencies

Pliance
“Rule governed behavior under the control
of apparent socially mediated
correspondence between the rule and
relevant behavior”
 Notice that “pliance” is the root word of
“compliance”

Excessive pliance
Excessive pliance is problematic when
behavior is under the control of pleasing
others or avoiding upsetting others rather
than under the control of other
consequences
 And note that it is problematic when it is
excessive; sometimes pliance is effective
and values-based baehavior…

Examples of excessive pliance
Staying in an unfulfilling relationship
because of what Mom & Dad will think or
so the other will not be upset
 Choosing a car or career or partner solely
to impress others
 Succumbing to peer pressure
 Excessive advice-seeking (which might
also be avoidance of ‘being wrong’)

Dominance of pliance and
avoidant tracking…
I always/never
 Life is (unfair, painful, perfect right now…)
 Yes, but…
 If I do (an important behavior), then I will
feel…
 If I do (an important behavior), then
others will think…
 What if…

Values clarification exercise
Values worksheets
 bullseye

Outcome Vs process

Outcome is the process through which
process becomes the outcome…
Values exercises
Defining values
 Values narrative
 Skiing metaphor
 Green pen.argyle socks
 Epitaph/lifetime achievement
 Deciding vs choosing
 Outcome is the process through which
process becomes the outcome

Committed Action

Overt behavior in the service of
values/moving in a valued direction
Persistent inaction, impulsivity, or
avoidance

This is often the domain that is most
obvious to clients (and significant others
and therapists!) and often is what
influences them to seek help
Persistent inaction, impulsivity, or
avoidance
The clinical question in this domain is:
 What is the client doing too much of, too
little of, or doing in inappropriate
contexts?
 What is the client doing in the service of
experiential avoidance?
 What is the client doing that gets in the
way of valued living?
 What does the client want to do, learn,
experience?

Barriers to valued living
Committed Action
and barriers to committed action
Eyes on
 Exposure
 Ball and chain
 Jump
 Garden metaphor
 Joe the bum
 Take your keys

Lack of values clarity and
committed actions
What’s that in the service of? Or, why are
you doing that intervention?
 Whose values are we talking about?
 What does the client want his/her life to
be about?

Get out of your mind and into your
therapy session
ACT and the practitioner

In ACT the core processes are regarded as
being relevant for all human beings, not
only for therapy clients

As such, ACT processes can be implicitly
or explicitly applied to the clinician as well
as the client
Avoidance in the therapy room
Therapist avoidance strategies
Not being prepared
 Being really, really,
really prepared
 Being big
 Being small
 Being an expert
 Being clever
 Always bringing a clipboard








Assigning LOTS of
homework
Being a “good listener”
Choosing not to intervene
Keeping it light – coffee
talk
Changing the subject
Chasing understanding
Providing consolation
Lack of vitality in the therapy room
Therapy process & experiential
work
Attention to therapy process








What is it like to sit in the room with the client?
The relationship
Are you fully present with the client?
Is thinking about therapy interfering with doing
therapy?
Counter-transference (in the generic sense)
Your feelings are data
Irreverence
Well timed process comments
– Avoidance especially common around process issues
Acceptance and defusion
Are you willing to be present with your
client and whatever thoughts, feelings,
sensation show up for him/her?
 Are you willing to be present with
whatever thoughts and feelings show up
in you during treatment sessions?

Fusion and attachment to the
conceptualized self in therapy









I’m a fraud
I’m not ready
I’m incompetent
I can’t do this
What if I screw up?
Her problem is too difficult
I have no idea what to do
I’ll never be able to relate to this client
I don’t like this client
Acceptance and defusion
Are you willing to be present with your
client and whatever thoughts, feelings,
sensation show up for him/her?
 Are you willing to be present with
whatever thoughts and feelings show up
in you during treatment sessions?

Values
What values bring you to this work?
 What do you want your professional practice to
be about?

Committed action
What actions will help you reach your
clinical training goals?
 What are the barriers to committed
action?
 “Be yourself: everyone else is already
taken” – Oscar Wilde

Commitment

What’s your commitment?
The outcome:
Psychological Flexibility!

Vitality, competence

Questions?
Useful references
[email protected]
 contextualpsychology.org
 www.newharbinger.com
 Bach & Moran (2008). ACT in Practice:
Case Conceptualization in Acceptance and
Commitment Therapy. New Harbinger

Download

Dominance of the Conceptualized Past/Future