ACCEPTANCE AND COMMITMENT
THERAPY: AN ADDICTIONS
FOCUSED INTRODUCTION
An Experiential Approach to Behavior Change
Richard L. Ogle, Ph.D.
Associate Dean, College of Arts and
Sciences
Professor of Psychology
University of North Carolina Wilmington
http://people.uncw.edu/ogler/
Welcome, I Am Grateful You Are Here
‘Having spent the better part of my life trying to either relive
the past or experiencing the future before it arrives, I have
come to believe that in between these two extremes is peace.’
ACT Assumptions - Philosophy
• Emphasis on pragmatic view of truth/right.
• Functionally “workable” relationships.
• What works for one might not work for another
• In the case of humans, there are three contextual fields:
• Covert behavior (thoughts, feelings, memories, sensations),
• Overt behavior
• Controlling environmental influences
• All contextual fields must be taken into account if you are
going to establish workability
ACT Assumptions – Basic Science (RFT)
• A behavioral account of
• Eliminating verbal relations is
language and cognition
• Language is based on arbitrary
learned relations between
stimuli
•
• Provides an evolutionary
advantage, but also expands
our ability to feel, predict,
categorize & evaluate
• Makes behavioral avoidance
possible and cognitive
dominance likely
•
•
• Experiential avoidance and
cognitive fusion are built into
language and amplified by the
culture; they are implicated in
psychopathology.
•
impossible because they are
historically acquired and
automatically conditioned
All forms of human experience,
both real and imagined, can
enter into these relations and
govern behavior - rules
Rule governed relations are
“insensitive” to direct
environmental contingencies
All verbal relations function
“behind the eyes” and therefore
operate directly in the moment
they exert behavioral control
It is possible to exert control
over the FUNCTIONS but not
the FORM of verbal relations
What the Heck is RFT
RFT
RFT
RFT
ACT Assumptions - The Bottom Line
• The root of suffering language
• We can’t live without it, but we can’t live with it
• Unwanted internal experiences simply cannot be avoided
• The two central “culprits” from an ACT point of view are. . .
• Cognitive Fusion: Mistaking private events as “reality”
• Experiential Avoidance: Unwillingness to make contact with
undesirable, unwanted private mental events, leading to ever
widening patterns of behavioral constriction
The Principle of Destructive Normalcy
• Health is defined as the absence of
distressing private content
• When you have distressing private content,
that is a sign you are not “healthy” and
abnormal
• The goal therefore is to eliminate the
distressing content in the service of being
normal (the culture of “feel goodism”)
• In the event distressing content cannot be
readily controlled or eliminated, the human
is required to come up with a justification
for why that is so (reasons)
• Reasons are culturally taught to be “good
causes”
• The goal therefore is to eliminate and/or
control the identified reasons in the service
of achieving health
The ACT Model of Human Suffering and
Psychopathology
• Human pain (physical and psychological) is ubiquitous,
•
•
•
•
normal, and self-restorative
Unwillingness to have pain leads to reliance on avoidance
and control based strategies
Excessive use of control & avoidance leads to a loss of
contact with committed actions & vital purposeful living
It is not physical/mental pain per se that is the “enemy”
but our attempts to avoid or control it lead to disorder and
suffering
This cycle of suffering is strongly supported in the culture
through language acquisition and socialization
ACT Model of
Psychopathology
Contact with the
Dominance of the
conceptualized
Present
Moment past and future;
limited self-knowledge
Acceptance
Values
Lack of values
clarity/contact
Experiential avoidance
Psychological
Inflexibility
Cognitive
fusion
Defusion
Committed
Inaction,
impulsivity,
Action
or avoidant persistence
Attachment toSelf
theasConceptualized Self
Context
The Essence of ACT – Psychological
Flexibility
• Psychological Flexibility
• … is contacting the present moment fully as a conscious human
being, and based on what the situation affords changing or
persisting in behavior in the service of chosen values.
• Accept: What is there to be experienced, fully and without defense, for
what it is, not what it says it is
• Choose: Based upon your closely held values, choose what you would
like to be about here
• Take Action: Engage in committed actions that embody your values,
“inhaling” the distressing personal content as it appears
The Six Core Processes
Contact with the
Present Moment
Acceptance
Values
Psychological
Flexibility
Defusion
Committed
Action
Self as
Context
ACT Hexaflex
AWARE
OPEN
Psychological
Flexibility
ENGAGED
Definition of ACT
• ACT is an experiential behavioral therapy that uses
acceptance and mindfulness processes, and commitment
and behavior change processes, to produce greater
psychological flexibility.
• ACT is considered a 3rd Wave CBT and is like:
• Dialectical Behavior Therapy
• Mindfulness Based CBT
• Also like:
• Mindfulness-Based Stress Reduction
• Mindfulness-Based Relapse Prevention
• Functional Analytic Psychotherapy
• “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.”
ACT Case Conceptualization
• Begin assessment with the presenting problem as understood by the client
• Discover the most central thoughts, feelings, memories, sensations, and
situations the client is fused with or is avoiding
• Consider behaviors that function as EA of events described in previous step
• Consider Domains in which living is narrowed or constricted or avoided altogether
• Consider other core ACT process that contribute to inflexibility and their treatment
implications
• Fusion, Dominance of CP & CF, Attachment to CS, Lack of Values Clarity, Inaction/Impulsivity
•
•
•
•
Consider factors that limit motivation to change
Consider aspect of social and physical environment that can inhibit change
Examine strengths that will promote flexibility
Describe a treatment plan
• What is the main issue this client is having and what is the best point of
entry to attack that problem
• Reevaluate conceptualization and functional analysis throughout treatment
ACT Hexaflex Formulation Exercise
The ACT Contract
• Understand History and Situation
• Validate the Natural Painful Reactions
• Thoughts, feelings, uncomfortable bodily sensations
•
Identify the Reaction to the Reaction
•
Experiential Avoidance
• Explore the Cost of EA
• Amplification of problem - fusion
• Loss of vitality – disconnect from values
• Workability - stuckness
• Lay Out the Two-Part Plan – Creative Hopelessness
• Work on how clients relates to self (thoughts, feelings, sensations)
• Bring into the room the life you want to live and the things you want to do; no
more waiting. What do you want your life to be about at the level of what you
want to do?
• Engage
• Decide where to start
• Get active ASAP
DEVELOPING
WILLINGNESS/ACCEPTANCE
Undermine the Agenda of Control
• In almost every case control is the problem not the solution
• Avoiding situations that produce unwanted private
experiences creates a paradoxical effect (missing work creates
more depression, not less depression)
• The arbitrary assumption that private events cause behavior
creates a trap; you can’t behave differently until you feel
differently (but since missing work is increasing depression,
the person is now locked into the causal equation and can’t
return to work)
• When the conditions specified in the change agenda can’t be
met, you can only “explain” your predicament but there is
actually little you can do about it.
Control Is the Problem, Not the Solution
• It is important to give this trap a “name”
• “Trying to avoid Mr. Anxiety”
• “Checking out rather than checking in”
• This trap has the paradoxical effect of adding to, rather
than subtracting from, suffering
• “Clean vs. Dirty Suffering”
• Would you be willing to have the “clean stuff” if we could find some
way to reduce the dirty stuff?
• The experiential cost:
• Gain control of your feelings, lose control of your life
• “Passengers on the bus exercise” makes this point
When is control called for?
• When the event in question is under the person’s direct
stimulus control
• Behavioral responses in the present moment
• Willingness to enter into a situation
• Being present
• Holding values
• Making commitments
Examine Workability
• What have you tried? How has it worked? What has it cost you?
• Functionally analyze the “scope of avoidance”
• Look at all the things the client has tried to solve the problem
• Consider that coming into therapy itself is another problem solving attempt
• Have client define what solving the problem “means”
• Look for controlling distressing content as the “goal”
• Ask the client to rate whether past actions have indeed solved the
problem
• Ask client to consider whether the problem has actually
worsened over time
• If appropriate, ask the client to assess the “cost” of using these
solutions
Engender Creative Hopelessness
• Experientially, the client has to make “contact” with this
paradox:
• The harder you try to control an unwanted private experience, the
bigger it gets
• Control and experiential avoidance might work temporarily, but
rarely do their effects last and most often there is a “rebound” effect
that makes things worse
• As logical as this approach seems, it will NEVER work
• It isn’t that YOU are hopeless, but that this STRATEGY for addressing
these unwanted events is hopeless
• Before you can try something new, you have to stop what doesn’t
work
Creative Hopelessness
• “Person in the hole metaphor”
• A basic ACT intervention
• Gives therapist a language “tag” to use throughout therapy
• “Are you digging right now?”
• “Refusing to walk in order to avoid holes sounds like a pretty boring life”
• “Analyzing how you fell in the hole isn’t going to help you get out”
• “Blaming life for producing holes won’t eliminate the holes”
Acceptance as the Alternative to Control
• When is acceptance called for?
• Remember the “serenity prayer?”
• With natural, conditioned uncontrollable private experiences such
as emotions, memories, thoughts, sensations
• When a situation cannot be changed
• Presence of chronic disease, pain, terminal state
• The attitudes, beliefs and behaviors of others
• When change or control strategies produce paradoxical results
(i.e., try not to think about X)
Therapist Strategies for Developing
Acceptance/Willingness
• Undermining Experiential Control
• Help client detect emotional control strategies and examine direct
experience instead
• Especially in session
• Use the concept of “workability” to help clients understand costs of
EA and control efforts
• Communicate that client is not broken, but using unworkable strategies
• Active encouragement to give up the struggle
• Help client make experiential contact with cost of being unwilling to
reach valued life goals
VIDEOS
UNDERMINING
COGNITIVE FUSION
Defusion and Acceptance
• Basically, defusion strategies are designed to. .
• Create a “space” between thought and thinker
• Undermine the client’s confidence in the utility of minding their mind
in certain circumstances
• Appreciate the limits of brain behavior as applied to natural, whole
human behaviors
• To look at mental events for what they are, not what they appear to
be
• All in the “service” of stalling sense making and reason
giving
• Defusion promotes willingness; willingness promotes
acceptance
Acceptance-Fusion Polarity
• Accepting the fact that things are not working as they
•
•
•
•
•
should (What have you tried? How has it worked?)
Accepting the cost of this unworkable behavior (What has
it cost you?)
Accepting the paradoxical nature of mental control,
despite the seeming logic of it all (Control is the problem)
Accepting that control is not working and won’t ever work
(Creative hopelessness)
Accepting the presence of rule infested reactive mind
(Mind is not your friend)
Accepting all mental experiences for what they are, not
what they appear to be (Defusion)
Teach Limits of Language
• The concept of “minding”
• The concept of reason giving
• Objectify Language
• Milk Exercise
• Reveal Hidden Properties of Language
Creating Distance Between Thought and
Thinker
• Looking at thoughts as opposed to through thoughts
• Giving properties to thoughts
• Color
• Texture
• Shape
• Mindfulness Exercises
• Metaphor
• http://www.youtube.com/watch?v=z-wyaP6xXwE&feature=related
Teach Clients to Recognized Fused
Qualities of Mind
• Presence of comparison and evaluation
• Complex/Busy
• Confused
• Adversarial
• Warnings about consequences
• Strong future or past orientation
• Strong orientation about what something means about
you or others
• Strong problem-solving orientation
Therapist Strategies for Undermining
Fusion
• Undermining Fusion
• Help clients defuse experience from action and direct attention to
present moment
• Actively contrast what client’s mind says will work versus what their
experience tells them doesn’t work
• Use metaphor and experiential exercises
• Help clients understand their “story” and the arbitrary nature of the
causal relations in the story
• Help client detect “minding.”
VIDEOS
GETTING IN CONTACT
W/PRESENT MOMENT
Developing Present Moment Awareness
• Mindfulness Exercises
• Mindfulness is really “Attentional Training”
• Clients can be skills deficit in attention or rigid in attention. The key is to
develop online mindfulness.
• Notice events with simple awareness
• Separate self-evaluations from the self that evaluates
• Detect client drifting into past and future and model coming back to the present
Getting in the Present Moment
• In session, the therapist looks for “shifts”, tries to elicit
avoided experiences and models this openness
• “What just showed up for you?”
• “Can you stay with that for just a minute?”
• “Is there anything about this that is actually toxic to you right here
and now?”
• “I’m willing to stay right here if you are willing to be here”
• Mindfulness exercises can help defuse the threatening
aspects of being in the present moment
CONCEPTUALIZED SELF
VS. SELF AS CONTEXT
Three Aspects of Self
• Self-as-Content
• Our stories about who we are – self as a product of our
experiences
• Self-as-Process
• Self experienced in the present moment
• Self-as-Context
• Self as the arena in which experience happens
• HOUSE METAPHOR
Observer “I” Exercise
• Ground client
• Breathing exercise
• Memory of this morning
• Notice sights, sounds, feelings, thoughts
• Remote Memory - Painful
• Notice sights, sounds, feelings, thoughts
• Remote Memory - Happy
• Notice sights, sounds, feelings, thoughts
• Notice the “noticer”
• Also dimensions of experience change, the “you” experiencing
them do not.
VIDEOS
DEFINING VALUED
DIRECTIONS
ACT Definition of Values
• Verbally constructed, global, desired, and chosen life
directions
• Deliberately chosen verbs and adverbs
• Embraced as qualities of ongoing action across time
• Raising one’s children kindly and attentively
Values vs. Goals
• Values are aspirational
• Never accomplished
• Lived out over time
• Goals are tangible and can be accomplished
• Marriage
• Children
• College Degree
• The main focus is to help clients learn the difference and
commit to what they want their lives to stand for and
MAKE THERAPY ABOUT THAT.
Domains for ACT Values Assessment
• Work/career/community usefulness
• Love/intimate relationships
• Family/parenting
• Friends/social connectedness
• Personal growth
• Health and hygiene
• Spirituality
• Recreation
• Education/Learning
Values Exercises
• Tombstone
• Eulogy
• Values Card-Sort
• Battery Exercise (next slide)
• Valued-Living Questionnaires (Later)
VIDEOS
BUILDING PATTERNS OF
COMMITTED ACTION
Clinical Aspects of
Committed Action
• Actions which are consistent with one’s self-identified
•
•
•
•
•
values
These actions are “choices” that will be made in the
presence of reasons, but not for reasons
Not choosing is a form of choice, often involving
succumbing to reason giving
Committed action is a qualitative rather than quantitative
act
The workability of life in the present moment is generally
greatest when actions are consistent with values
Committed actions invariably elicit distressing private
content! To be alive means to invite these in the door.
Committed Action
• Pick 1 or 2 top priority valued domains and develop an
action plan for behavior change
• Functional analysis
• Help client commit to action that are linked to values – to
be accomplished between sessions – being mindful of the
larger behavioral patterns being assembled
• Attend to barriers and obstacles to action with
acceptance, defusion, mindfulness skills, skills training,
etc.
• Return to Step 1 and generalize to larger patterns of
action, to other domains of living, to feared/avoided
private experiences
Addressing Barriers to
Committed Action
• Are skills deficits going to be an issue?
• If so, provide skills training
• Being righteous rather than being real
• Forgiveness: to give the grace that came before
• Being response-able and responsible
• Choose each step exercise
• Inhale broken commitments, name them honestly
• Hop A Long Cassidy metaphor
ACT FOR ADDICTIONS
ACT and the 12-Steps
• We admitted we were powerless over alcohol—that our lives had become unmanageable.
•
•
•
•
•
•
•
•
•
•
•
(Acceptance/Unworkability)
Came to believe that a Power greater than ourselves could restore us to sanity (Acceptance).
Made a decision to turn our will and our lives over to the care of God as we understood Him
(Acceptance).
Made a searching and fearless moral inventory of ourselves (Values Clarification).
Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
Were entirely ready to have God remove all these defects of character.
Humbly asked Him to remove our shortcomings.
Made a list of all persons we had harmed, and became willing to make amends to them all
(Values/Committed Action).
Made direct amends to such people wherever possible, except when to do so would injure them or
others (Committed Actions).
Continued to take personal inventory and when we were wrong promptly admitted it
(Acceptance/Defusion).
Sought through prayer and meditation to improve our conscious contact with God, as we understood
Him, praying only for knowledge of His will for us and the power to carry that out
(Mindfulness/Contact w/Present Moment).
Having had a spiritual awakening as the result of these Steps, we tried to carry this message to
alcoholics, and to practice these principles in all our affairs (Values/Committed Action).
Case Conceptualization - Addiction
• Avoidant Repertoires
• Pattern of SA involvement
• Non-SA avoidance
• Avoided Events
• Context that precipitate EA
• Fusion with thoughts, feelings and sensations that arise in SA
triggering contexts
• Immediate Reinforcing Effects of EA Strategies
• Values
• Workability of SA
• Discrepancy Between Valued Life Directions and Current
Behavior
ACT for Addictions – Structured
Interventions
• Think in terms of core topics
• Core Topic 1: Preparing to Begin
• Core-Topic 2: Making Contact with the Cost of Using
• Core-Topic 3: Creative Hopelessness
• Core-Topic 4: Control as the Problem
• Core-Topic 5: Willingness/Acceptance
• Core Topic 6: Distinguishing Person from Programming
• Core-Topic 7: Barriers to Acceptance
• Core-Topic 8: From Acceptance to Behavior Change
• Core-Topic 9: Values and Goals
• Core-Topic 10: Accepting Responsibility to Change
• Core-Topic 11: Making/Keeping Commitments
ACT for Self-Stigma and Shame in
Substance Abuse
• Three sessions focused on addressing and reducing
stigma and shame in the context of substance abuse
• Focus on Mindfulness and Acceptance
Mindfulness-Based Relapse Prevention
• http://www.mindfulrp.com/For-Clinicians.html
Using ACT in SA Groups
• Committing to the process
• Rescuing limits
• Things get worse before they get better
• Focus on experiential and didactic exercises
• Begin and end each session with experiential exercise
• Mindfulness
• Focus on letting group members be where they are
• Recognizing EA in group process
• Therapists role
• Irreverent and bold
Using ACT in SA Groups – Building our
Own Group Intervention
• Creative Hopelessness/Workability
• Values clarification
• Control as the problem
• Defusion
• Self as context
• Willingness and acceptance
• Commitment