White Pine Institute
whitepineinstitute.com
An Introduction to
Acceptance & Commitment Therapy
Joel Guarna, PhD
Thanks to…
Members of the Association for Contextual
Behavioral Science (ACBS) for their “open source”
attitude toward research, presentations, materials, info….
Special thanks to…
Steven C. Hayes, PhD
Sonja V. Batten, PhD
Thanks to…
Tracy Haskell
Introductions
(sort of)
• Psychologists, Social Workers,
Counselors, Physicians, Nurses, Other?
• Hospitals, CMHC, other agencies, private
practice
• How did you become interested in ACT?
(a sampling of anecdotes please!)
• What has been your exposure to ACT so
far?
Four Bits o’ Feedback
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•
•
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Slow down
Cover less
Less history (!)
Less science (!!!)
Today’s Workshop
•
•
•
•
Introduction to ACT
Focus on clinical application
“How to” but not just “how to”
Theory and model (we will get to why this
is necessary)
Today’s Workshop
• Didactic, yes, but also discussion &
exercises
• A workshop not a lecture at you
• Experiential: Do as you are willing
(AND consider that there is much about
willingness that is choice)
• At times will parallel ACT as done in the
therapy room
Today’s Workshop
One major distinction between learning ACT in
a workshop and doing ACT: Here we will
explain what we are doing and why.
Doing ACT in therapy:
 You lead the client through an experience of each
process not toward an intellectual understanding of
that process.
 Model each process within your relationship with
the client.
ACT in Context
What is ACT?
ACT as a Mindfulness-Based Therapy
(e.g., Mindfulness for Two by Kelly Wilson)
Experiential Exercise #1
Mindfulness/Centering
Several Invitations
• Observe your thoughts &
reactions with some interest
• Be open. Skeptical and open.
• Be awake
Experiential Exercise #2
Connecting with our values as therapists
Why are you here/now?
No, really, why are you here/now?
An invitation/take a (small) risk…
Think of a real person you work with…
I would like this to lead to… I wish…
Summarize this in one sentence, write it down.
Experiential Exercise #2
Connecting with our values as therapists
And now that we’ve played
with that expectation…what
if...?
What does that bring up?
ACT in Context
What is ACT?
“BF Skinner meets Carl Rogers”
Behavioral Activation +
Motivational Interviewing +
Mindfulness
(Blend, salt to taste….)
Yes, these are what it looks like.
ACT in Context
Comparison to learning
Motivational Interviewing
ACT in Context
What is ACT?
ACT is a comprehensive model of therapy
…not a set of techniques
(though includes many techniques,
some unique, but many found elsewhere)
ACT in Context
ACT as a…
 Mindfulness-Based Therapy
 Cognitive-Behavioral Therapy (CBT)
Contextual Behavioral Therapy
 Clinical Behavior Analysis
Part of larger trends in the field
(dare we say “third wave”?)
More
cognitive
Beck-style
CT
CBT
Combo
txs,
Barlow
More
behavioral
Exposure
txs, BA
Acceptance,
mindfulness,
“metacognitive”
Change/Control
CBT
DBT
Beck-style
CT
Traditional
BT
ACT
MBCT
ACT in Context
What is ACT?
At the level of technique:
Many familiar ideas and moves.
ACT in Context
What is ACT?
“Oh, I already do this!”
Er…well...maybe…probably not.
ACT in Context
What is ACT?
ACT is connected to a coherent underlying
model and a basic science of behavior
including cognition and language
(Relational Frame Theory - RFT)
ACT in Context
What is ACT?
This model influences every level
of the therapy experience:
•Therapy stance taken by therapist
•Therapeutic relationship
•Focus of therapy
•Appropriate goals and directions
•Techniques
Folk Wisdom: So close…
Serenity Prayer
(Reinhold Neibuhr?)
God grant me the
serenity to accept the
things I cannot change,
courage to change
the things I can,
and wisdom to know
the difference.
…yet so hard to do.
Folk Wisdom: So close…
Serenity Prayer
The essence of ACT work can be understood as
how to do (live) the Serenity Prayer…with
some particular ideas about what is likely to be
change-able vs. what is not…and how to do the
changing and accepting.
…yet so hard to do.
“The single most remarkable fact
about human existence is how
hard it is for humans to be
happy.”
(Hayes, Strosahl, & Wilson, 1999)
Folk Wisdom: So close yet…
Why is it so hard to live the Serenity
Prayer?
Why is peace of mind so elusive?
Normal mind processes, based in
language, make some amount of struggle
inevitable…and a tremendous of struggle
possible.
According to the
“Assumption of Healthy Normality”
• By their nature, humans are psychologically
healthy
• Abnormality is a disease or syndrome
driven by unusual pathological processes
• We need to understand these processes and
change them
The Major Reason to
Suspect this is False
• The ubiquity of human suffering
The Ubiquity of Suffering
• High lifetime incidence of major DSM
disorders
• High rates of divorce, sexual concerns,
abuse, violence, prejudice
The Ubiquity of Suffering
• Some extremely destructive behaviors are
both common and non-syndromal, e.g.,
suicide (example: estimates of SI in general
population)
• Other common forms of suffering (example:
estimates of panic in general population)
Alternative Assumption:
Destructive Normality
• Normal language & cognitive processes often are
destructive and can amplify or exacerbate unusual
pathological processes.
According to Relational Frame Theory:
Normal Language is the Context
According to RFT and ACT:
In summary, normal language &
cognitive processes are at the heart
of most suffering.
Question:
If that is true, why don’t we all
struggle with anxiety, depressed
moods, insecurities, fears, etc….?
Answer:
Oh, wait…we do.
Alternative Assumption:
Destructive Normality
• Normal language & cognitive processes often are
destructive and can amplify or exacerbate unusual
pathological processes.
We often use language tools when they are not
helpful, or use them in ineffective or in problematic
ways
We overextend problem-solving thinking from the
external world to our internal world
Rely on our mind over our experience yet our
thoughts are not as accurate
Word Play
• Don’t picture the pink elephant
• We don’t really control the process.
• Three feelings – a measure of response speed.
• It is difficult, sometimes impossible, to change
aspects of our thoughts.
• Blondes, rolling stones and mary.
• Automatic, context-bound, sticky.
Word Play
• Evaluate the room.
• Your body. What would you change?
• One really big mistake you have made.
• Evaluation is automatic and often detached from
any usefulness.
Word Play
• Forward (imagined futures & worries)
• Backward (limitations of memory: stories become
our realities)
• Our “languaging” can not only fail to accord with
reality, it can fail to accord with what will provide
us with meaning and happiness.
Alternative Assumption:
Destructive Normality
Normal language & cognitive processes often are
destructive and can amplify or exacerbate unusual
pathological processes.

We often use language tools when they are not
helpful, or use them in ineffective or in problematic
ways

We overextend problem-solving thinking from the
external world to our internal world

We increasingly rely on our mind over our experience
even when doing so causes or exacerbates our
struggles.
Alternative Assumption:
Destructive Normality
Normal language & cognitive processes often are
destructive and can amplify or exacerbate unusual
pathological processes.
 Rather than control them, we need to understand these
processes and work within them to promote health.
 Why? Because for many of these processes, trying to
control them makes the problem worse, the suffering
greater.
Language is the Context
• Fusion with Private Events
• Evaluation
• Avoidance
• Reason-giving (“story-making”)
A (relatively) benign example
The Lemon &
The Glass
Less benign examples
What if we replace the lemon?
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Images and memories of a rape
Harsh judgments about one’s self
Certainties about one’s future
An imagined future with all its problems
Stories about past mistakes and “what ifs?”
Language is the Context
Fusion with Private Events
• Evaluation (is automatic)
Avoidance
• Reason-giving (“story-making”)
Cognitive Fusion
• The tendency of human beings to get caught up in
the content of what they are thinking so that our
thinking dominates how we view and react to the
world.
• The event and our interpretation of the event fuse
into one (e.g., OCD and worries about
contamination)
• Fusion with thoughts organizes behavior, often in
unhelpful ways
• It is not what we think that is a problem, it is how
we relate to what we think
Methods of Avoidance
• Behavioral avoidance
• Distraction
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worry or rumination
self-injurious behavior
disordered eating
self-talk/ active suppression
• General numbing of experiences
 substance use
 dissociation
Experiential Avoidance
Prominent in many clinical disorders
•
•
•
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PTSD
Panic Disorder
GAD
Social Phobia
Substance Abuse
Borderline Personality Disorder
Eating Disorders
….and so on
Experiential Avoidance
Adverse effects demonstrated in many
areas of the scientific literature:
• Coping styles literature
-avoidant coping styles -> greater distress
• Psychotherapy process literature
-high experiencing and more open to feelings ->
better tx outcome
• Thought suppression literature
-when suppress a thought -> increse in the thought
• Emotional suppression literature
-suppress an emotion -. increase in the emotion
• Psychopathology literature
• Linked to other behaviors such as violence and suicide
• Psychotherapy outcome literature
Higher Experiential Avoidance
is associated with many problems
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–
–
–
Higher anxiety
More depression
More overall pathology
Poorer work
performance
– Inability to learn
– Substance abuse
– Lower quality of life
– History of sexual abuse
– High risk sexual
behavior
– BPD symptomatology
and depression
– Thought suppression
– Alexithymia
– Anxiety sensitivity
– Long term disability
Sources: Hayes et al (in press); Polusny (1997); Toarmino (1998); Pistorello (1997); Batten, Follette, & Aban
(1998); Stewart, Zvolensky, & Eifert (1998);
Language is the Context
• Fusion with Private Events
• Evaluation (is automatic)
• Avoidance
Reason-giving (“story-making”)
Reason-Giving
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•
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Story-making or Sense-making
Cause-effect
Automatic
Shaped by experience
Eventually, we believe our own reasons
It is almost certainly adaptive, on the whole
But….
Reasons Exercise
• Pick some behavior or activity you have been
meaning to change
• Imagine yourself in the “choice situation”
• Flip on the reason generator
• Push it, find more
Example: Running
Why is it so hard to live the Serenity
Prayer?
Why is peace of mind so elusive?
Normal mind processes, based in
language, make some amount of struggle
inevitable…and a tremendous of struggle
possible.
A few interesting implications
about these so-called normal
processes….
Our clients are stuck, not broken or sick.
The processes that get them stuck are
normal, expected “side effects” of
language.
You have these processes too. If you
haven’t been entangled in them yet
(unlikely), you probably will be at some
point.
Even knowing this, you will hand them to
your children and your grandchildren.
Sylvia Jean Guarna, born Jan. 26, 2009
At 6 months old—she hasn’t bitten from the apple yet
How is ACT different?
Question: But if normal language and
cognitive processes are part of the problem,
how do you use “talk therapy” (more
language and cognition) to help?
The Short Answer: Very carefully!
•Talking, yes, but differently.
•Deliberate and skillful use of a range of
experiential techniques.
Therapeutic Posture
• Whatever the client is experiencing is not the
enemy – it’s the struggle against it that’s harmful
• You can’t rescue clients from the difficulty and
challenge of growth
• Radical respect for clients’ values – the issue is the
workability of their lives, not your opinions
• Never forget that you are in the same boat
The Targets of ACT
• Ineffective change agenda
• Experiential avoidance
• Inability to differentiate self and behavior
from private events
• Inability to make and keep a commitment to
actions consistent with valued life directions
A Simpler Version of the
Barriers /ACT Targets
FEAR:
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•
•
•
Fusion
Evaluation
Avoidance
Reason-Giving
One more time:
What is ACT?
ACT Said Simply:
ACT uses acceptance and mindfulness processes,
and commitment and behavior change processes, to
produce greater psychological flexibility.
One more time:
What is ACT?
ACT Said Even More Simply:
•
•
•
Show Up
Let Go
Get Moving
One more time:
What is ACT?
Summarized in one sentence:
Living a rich, full life
with less struggle.
Enough already, on with the model!
But first, a word about models.
Example: Blue prints vs. 3D Model
Vs.
Hexaflex Model
(Clinical Tool)
Acceptance &
Commitment &
Mindfulness
Behavior Change
Processes
Processes
Experiential Avoidance & Fusion
Relational Frame Theory (RFT)
Behavioral Learning Theory
Contact with the
Present Moment
Acceptance
Values
Six Core
Processes
Committed
Action
Defusion
Self-as-Context
Contact with the
Present Moment
Acceptance
The “Hexaflex”
Values
Psychological
Flexibility
Committed
Action
Defusion
Self-as-Context
Contact with the
Present Moment
Acceptance
Values
Psychological
Flexibility
Committed
Action
Defusion
Self-as-Context
Acceptance and
Mindfulness
Processes
Contact with the
Present Moment
Acceptance
Values
Psychological
Flexibility
Committed
Action
Defusion
Self-as-Context
Contact with the
Present Moment
Acceptance
Commitment and
Behavior Change
Processes
Values
Psychological
Flexibility
Committed
Action
Defusion
Self-as-Context
Let
Go
Acceptance
Contact with the
Present Moment
Show
Up
Get
Moving
Values
Psychological
Flexibility
Committed
Action
Defusion
Self-as-Context
Contact with the
Present Moment
Acceptance
Values
Psychological
Flexibility
Committed
Action
Defusion
Self-as-Context
ACT Processes & Interventions
Acceptance
What comes to mind?
What it is not:
• Tolerating, putting up with
• Resignation
• Defeat, a “less than” alternative
ACT Processes & Interventions
Acceptance
What it is:
• An act, a behavior, a move
• Openness, without defense
• Dropping judgment
ACT Processes & Interventions
Acceptance
Inside Willingess (vs. Outside Willingness of Commitment)
Commitment: Be willing to do what you need to do (actual
forward movement now) to live a rich full life…
Acceptance: Be willing to experience whatever shows up
(privately) as you take those steps forward.
ACT Processes & Interventions
Acceptance
• Confronting the Agenda
• Creative Hopelessness
• Control-as-Problem
ACT Processes & Interventions
Acceptance
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Quicksand Metaphor
Fingercuffs
Ball and Chain
Thought Card (also defusion)
Physicalizing Exercise
Encouraging client to “sit with” and
“make space for” x and remain present,
continue moving in valued direction
ACT Processes & Interventions
Cognitive Defusion
Emo Philips:
I used to think that the brain was the most
wonderful organ in my body….
Then I realized who was telling me this.
ACT Processes & Interventions
Cognitive Defusion
• Learning to watch what our mind tells us
• We are like fish swimming in our thoughts
• Key targets for cognitive defusion:
See thoughts as what they are – images, bits of
language
• Attend to thinking as a process
• Parade metaphor
• Monsters on the Bus Exercise
• Milk, Milk, Milk exercise
Cognitive Defusion
More simple techniques:
• Just notice what your mind is telling you right now
Is this a helpful thought? Is this a good use of my time?
• Notice the form of the thought by describing it
Is it words, sounds or pictures? What does it sound like?
•
•
•
•
•
•
“That is an interesting thought”
Buying a thought vs having a thought
Label your thoughts (“I am having the thought that . . . “)
Say it slowly, sing it, say it in a different voice
Thank your mind
Mind vs Experience (“workability” not “truth”)
Cognitive Defusion
There is a story for everything . . . .
What is this story in the service of ?
How old is this story?
You are 100% correct, how does this help you?
If you buy (believe) this story, what does that do?
What happens next?
Results of Cognitive Defusion
• The content of thought remains
and is no longer struggled with.
• The thought loses its behavioral regulatory
functions – i.e.– the thought no longer organizes
subsequent behavior.
Taking Your Mind for A Walk
1 Person, 1 Mind
Person chooses path, minds follow
Mind communicates constantly (cajole, analyze, predict,
warn, etc)
Person cannot communicate with mind (never mind your
mind)
Person listen to mind and go where choose to go
Switch after 5 minutes
After 5 minutes, split up and walk quietly for 5 minutes
 continue to follow the rules above
 notice you are still taking your mind for a walk
Cognitive Defusion
Beyond cognitive defusion as
technique
• Cognitive defusion as part of the process
of therapy instead of as discrete
technique
• Mind as other
Traditional CBT
Uses interventions to alter relational networks
“black and white thinking”
What is your evidence for that?
“irrational”
What is “a failure” anyway?
“overgeneralization”
I will always be a failure
Let’s test that and see
Aren’t you sometimes a success?
Are you saying you must not be a failure?
• From an RFT point of view we worry about that strategy,
since these kinds of interventions could elaborate and
complicate the network, and paradoxically increase the
functions of negative thoughts
ACT
In ACT we attempt to diminish unhelpful control
Thought card exercise.
Thank your mind for that thought
If that thought was an object,
what would it look like?
I will always be a failure
Can we say “I’m having the thought that I will always be a failure?”
Let’s say “failure” 100 times
It is OK to have that thought?
If that thought were in the room,
where would it be?
Control is NOT the solution, in fact, it is a large
part of the problem.
ACT Processes & Interventions
Contact with the Present Moment
ACT Processes & Interventions
Contact with the Present Moment
How do you do Contact with the Present Moment?
Question for you: How did I do it here today?
ACT Processes & Interventions
Contact with the Present Moment
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Formal mindfulness exercise (i.e., #1)
Other experiential exercises
Direct instruction
“Noticing” and sharing the observations
Connecting to values
Humor
Voice: Pacing, Emphasis, Pauses/Silence
ACT Processes & Interventions
Three Senses of Self
• Self-as-Content (conceptualized self or story)
• Self-as-Process (moment-to-moment
awareness of internal & external stimuli)
• Self-as-Context
ACT Processes & Interventions
Self-as-Context
• The “you” that was aware of the sounds,
sensations.
• The Observer Self.
• Not “thing-like.” No “there” there
• Perspective from which…
• Best conveyed through metaphors
• Spirituality?
ACT Processes & Interventions
Self-as-Context
Chessboard Metaphor
Observer Exercise
“Safe Place”
ACT Processes & Interventions
Connecting with Values
Making values psychologically present.
Making values specific and tangible.
Values vs. Goals
ACT Processes & Interventions
Connecting with Values
Values Assessment
Values Compass
Bullseye
Batteries Exercise
1:49 PM
Bullseye
Very close
Close
In the vicinity
Far from
Developed by Tobias
Lundgren and JoAnne
Dahl at the University
of Uppsala
3:15
1:49 PM
ACT Processes & Interventions
Connecting with Values
Values Illness
Hour-by-hour values exercise
(Kevin Polk)
ACT Processes & Interventions
Commitment
• Values provide the compass…commitment provides the
walking.
• Voting with your feet. Don’t tell me what matters, show
me what matters… (goals connected to values)
• Traditional behavior therapy methods
exposure, social skills training, behavioral activation
• Build patterns of actions over time
ACT Processes & Interventions
Commitment
Outside Willingess (vs. Inside Willingness of Acceptance)
Commitment: Be willing to do what you need to do (actual
forward movement now) to live a rich full life…
Acceptance: Be willing to experience whatever shows up
(privately) as you take those steps forward.
ACT Processes & Interventions
How do you know where someone is
stuck/where to start?
The Targets of ACT
• Ineffective change agenda
• Experiential avoidance
• Inability to differentiate self and behavior from
private events
• Inability to make and keep a commitment to
actions consistent with valued life directions
ACT Processes & Interventions
How do you know where someone is
stuck/where to start?
Stages of Therapy
Functional Analysis (ABC)
Personal Preference
The ACT Question
Anywhere….?
ACT Processes & Interventions
Stages of Therapy
1. Confronting the Agenda
(Creative Hopelessness)
2. Cognitive Defusion
3. Acceptance
4. Self as Context
5. Valuing as a Choice
ACT Question
2. are you willing to
have that stuff, fully
and without defense
Contact with the
Present Moment
Acceptance
6. at this time, in
this situation?
Values
5. of your chosen
values
If the answer is
“yes,” that’s
Psychological
Flexibility
4. AND do what takes
you in the direction
Committed
Action
Defusion
3. as it is, and not as
what it says it is,
Self-as-Context
1. Given a distinction between you and the stuff you are
struggling with and trying to change
Dominance of
Conceptualized Past
& Feared Future
Lack of
Values Clarity
or Contact
Nonaccepting
Closed
Avoidance
Psychological
Flexibility
Inaction or
Disorganized
Activity
Fusion
Attachment to
Conceptualized Self;
No “Safe Place”
ACT Processes & Interventions
How do you know where someone is
stuck/where to start?
Anywhere….?
Examples
ACT Processes & Interventions
Large Group Exercise
How do you know where someone is
stuck/where to start?
I can’t do anything right.
ACT Processes & Interventions
Large Group Exercise
How do you know where someone is
stuck/where to start?
In session, the client reports that a
painful trauma memory has emerged
and “goes internal.”
ACT Processes & Interventions
Large Group Exercise
How do you know where someone is
stuck/where to start?
Client becomes restless, starts to squirm,
breaks eye contact, breathes heavily.
I need to get out of here (panic).
Conceptualizing A Clinical Case
Individual Exercise
• Remember the client from the initial
values exercise
• Refer to the ACT Question & Hexaflex
• Walk through the question
• At what point(s) does your client get a
“no” answer?
• How might you intervene?
Conceptualizing A Clinical Case
Small Group Exercise
• Share the case with everyone
• Large group: Generate Values
interventions
• Split groups into “processes”
Defusion, Acceptance
• Generate alternatives
• Switch the process per group
Additional Resources
Local:
• www.ACTinNewEngland.com
• ACT in New England e-newsletter
• White Pine Institute
small group trainings or individual coaching
www.whitepineinstitute.com
(www.whitepinei.com)
• More forms at www.whitepinepsych.com
Additional Resources
Local:
• Ask questions, stay in touch!
• Form peer supervision and study groups.
• I will be glad to assist with this process, just
contact me.
Additional Resources
Globally:
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•
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•
•
ACT is non-proprietary and “open source”
www.contextualpsychology.org
Join ACBS! Values-Based Dues
Listserv for professionals and public
Online Study Groups
Additional Resources
• Books for therapists and public
• ACT self-assessment by Jason Luoma
• Trainings listed on
www.contextualpsychology.org
• ACT Summer Institutes & World
Conferences
Additional Resources
Books!
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Your local bookstore!
Context Press (www.contextpress.com)
New Harbinger (www.newharbinger.com)
Amazon (www.amazon.com)
Additional Resources
Acceptance & Commitment Therapy:
An Experiential Approach to
Behavior Change
Steven Hayes, Kelly Wilson,
Kirk Strosahl
Additional Resources
A CBT-Practitioner’s
Guide to ACT
Joseph Ciarrochi &
Ann Bailey
Additional Resources
Learning ACT
Jason B. Luoma, Steven C. Hayes,
Robyn D. Walser
Additional Resources
Acceptance and Commitment Therapy
for Anxiety Disorders
Georg H. Eifert, John P. Forsyth
Additional Resources