Acceptance and Commitment Therapy (ACT) with College and University Students

Acceptance and Commitment Therapy (ACT) with College and University Students Gregory T. Eells, Ph.D. Director, Counseling & Psychological Services Cornell University

Outline • I. Introduction • II. Philosophical and Theoretical Foundation • III. Model of Psychopathology • IV. Processes and Course of Therapy • V. Application to College and University Students

Outline • VI. Applications as a Director • VII. Efficacy Research • VIII. Conclusion

Introduction • Founded by Steven Hayes and colleagues • University of Nevada, Reno • former president of Association of Behavioral and Cognitive Therapies • So-called "third wave" therapy • first wave: behavioral therapy • second wave: cognitive behavioral therapy • third wave: acceptance based behavioral therapy

Introduction • Third wave vs. CBT • Emphasis on acceptance-willingness to have • Approach to cognition • Not disputing “negative thoughts” • Not trying to change thoughts (though change sometimes happens)

Introduction • Similarities with: • Dialectical Behavior Therapy (DBT), Linehan • Mindfulness-Based Stress Reduction (MBSR), Kabat-Zin • Mindfulness-Based Cognitive Therapy (MBCT), Segal, Williams, Teasdale • Gestalt Therapy • Existential Therapy

Introduction • very experiential • use of metaphor • perception of both therapist and client as people struggling with what life offers • Very relevant to our work with college students

Philosophical and Theoretical Foundations The Dilemma of Human Suffering • Humans as a species are suffering creatures. • The assumption of destructive normality is basic to many of our cultural traditions (religious), but is much less dominant in psychology. • All mystical traditions have practices that are oriented toward reducing or transforming the domination of analytical language over experience

Philosophical and Theoretical Foundations • Positive and negative of human language. • Human misery can be understood in the context of human achievement, because the most important source of each is the same: human symbolic activity. • Language is both the reason for our ascendance as a species and a primary cause of our suffering.

Philosophical and Theoretical Foundations Why language creates suffering • if your paint is peeling • scrape it off and repaint • if there is dirt on the floor • sweep it up • if you are sad or angry or fearful • ? • Terms we use to deal with the physical world can be used inappropriately to the internal world

Relational Frame Theory • An account of language that is the theoretical underpinning of ACT • Everything we say (or think) has multiple relations • We can globalize one experience to similar (according to our language) experiences • Example: panic disorder • Establishing behavior by direct rules can induce rigidity and should not be done lightly. Rules are useful but can often trick and be dangerous.

Relational Frame Theory • Suicide- • Suicide is purposive, has not been experienced directly and does have a verbal purpose. • People can formulate the consequences of their own death and verbally place it in a class with termination of suffering. • “If death then no suffering”

Philosophical and Theoretical Foundations • Functional Contextualism • 1) The whole event -ask “ And that is in the service of..?” • 2) The role of context- “And in what context does that occur?” • 3) Pragmatic Truth Criterion-Analyses are true only in terms of the accomplishment of particular goals. Clients often think “ It exists out there and thus I have to respond to it even though it does not work to do so.”

Philosophical and Theoretical Foundations • no "symptom" is a problem in and of itself • symptoms become problems when they get in the way of living a life worth living • example: social phobia • why confront your fears if you don't value relationships or feeling connected?

Philosophical and Theoretical Foundations • psychological pain is normal • cannot get rid of it • can avoid increasing it artificially • pain is different from suffering • accepting your pain reduces suffering (Hayes and Smith, 2005)

Philosophical and Theoretical Foundations :Psychopathology in ACT

Psychological Inflexibility ACT Model of Psychopathology Dominance of the conceptualized past and future; limited self-knowledge Experiential avoidance Lack of values clarity/contact Cognitive fusion Inaction, impulsivity, or avoidant persistence Attachment to the Conceptualized Self

What Traps Us • Problems, it seems, have to be here for a reason and the context of literality and reason giving dominate. • We all have poor access to actual motivations and verbal explanations have little chance of being fully accurate. • Mistakenly think that thoughts and feelings are good reasons and causes. • Mistakenly assume that to control the outcome we must control the cause.

What Traps Us • Our minds don’t really know what is good for us. • Our language did not evolve for fun or to accurately describe our internal experience.

What Traps Us • Culture sanctifies language and tells us: • Psychological problems can be defined as the presence of unpleasant feelings, thoughts, memories, bodily sensations, etc. • Undesirable experiences are signals that something is wrong and has to change. • Healthy living cannot occur until negative experiences are eliminated.

What Traps Us • Client needs to get rid of negative experiences by correcting the deficits that are causing them. • This is best achieved by understanding or modifying the adverse factors causing the difficulty. • ACT reduces down to “control of private experience =successful living” then asks “will you believe your mind or experience?”

Experiential Avoidance • also "experiential control" • the attempt to control or alter the form, frequency, or situational sensitivity of internal experiences -- thoughts, feelings, sensations, or memories -- even when doing so causes harm

Don’t think of pink elephants!

Examples of Avoidance (and Control) Leading to Suffering • Panic disorder • Obsessive-compulsive disorder • Substance abuse • Eating disorders • Depression • Etc.

Cognitive Fusion • We conflate the meaning of thoughts with the literal events we are thinking about • We don't notice the process of thinking • We look "from" our thoughts, not "at" them

Dominance of the Conceptualized Past and Future; Limited Self-knowledge • Or, “We are so focused on the past and future we don’t pay any attention to the present ” • Because of avoidance and fusion: • we are ruled by our stories about the past and our thoughts/worries about the future • Little knowledge of what’s going on right now • Our behavior becomes programmed by our histories and we continue to repeat the same stuff

Attachment to the Conceptualized Self • Or, “We are fused to who we think ‘I’ is” • We develop stories about ourselves that can trap us • Sometimes real solutions don't exist within our stories • The story feels so true that possible ways out of it would be experienced as invalidating

Lack of Values Clarity/Contact • Values are about living in a chosen and meaningful way • Values = our compass • doing important things sometimes HURTS

Inaction, Impulsivity, or Avoidant Persistence • Inability to behave in accordance with our values • So focused on feeling good, being right, managing anxiety, handling depression, etc., that we lose focus on what's important.

So what do we do?

Psychological Flexibility Six Core Therapeutic Processes

Acceptance • Alternative to avoidance • Active and aware embrace of what's going on inside • Without trying to change things, especially if attempting to change causes psychological harm

“Creative Hopelessness”- engendering a posture of giving up strategies when giving up is what is called for in the service of larger goals.

Man In The Hole Metaphor • In a field with a blindfold and a bag of tools. • You are told your job is to run around the field blindfolded but you don’ know there are widely spaced deep holes. • You fall in and find only a shovel in your tool bag and start digging. • You come to therapy thinking you can find a “gold plated steam shovel.”

Man In The Hole Metaphor • You can think “Maybe I should put up with it?” • “I need to understand my past?” • “Am I responsible for these problems?” • ”Should I blame myself?” • “What is the way out?” • The need to give up first. Take a leap of faith. • The opportunity presented by suffering. • The ultimate yardstick for any new strategy is the workability in the clients life.

Tug of War with a Monster Metaphor • You are in a tug of war with a big ugly very strong monster. • In between you and the monster is a bottomless pit. • So you pull and pull but the monster pulls harder. • The hard thing to see is that our job in therapy is not to win the tug of war but to learn how to drop the rope.

Control is the Problem, Not the Solution • Deliberate control works for me in the external world. • I was taught it should work with personal experiences (Don’t be afraid) • It seems to work for others around me (Dad never seemed scared) • It appears to work with certain experiences I’ve struggled with (relaxation techniques)

Polygraph Metaphor • Hooked up to the world’s best polygraph machine. Can pick up any anxiety. • All you have to do is stay relaxed. • You also have a gun to your head that will go off if you get anxious and the machine registers it. • So just stay relaxed.

The Alternative to Control is Willingness • Willingness diaries • Two scales metaphor-The scale on the left is anxiety (guilt, shame, etc) that goes from 0-10. • You have come to get help to pull this lever down but can’t • My job is to get you to look at the scale on the right. The willingness scale also 0-10. • When willingness is low anxiety is always ratcheted up high. • When willingness is high anxiety will float. Usually lower.

Let’s talk about milk!

Deliteralizing Language • Milk, milk, milk exercise • What comes to mind when I say milk?” • Usually white, cold, creamy, experience of drinking. • All of this brought up with a simple silly sound. • Together we are going to say “milk” over and over again for 1-2 minutes. • Where did the image of milk go? Other things we say to ourselves are the same. Nothing solid.

Deliteralizing Language • And/Be Out Convention. • We use the word “but” to enhance our internal conflict. • “And” is almost always more honest “ I love my partner and he/she drives me crazy sometimes” • Can use the root of but “be out”

Cognitive Diffusion • de-fusion • learn to notice thoughts as just thoughts • not change their content • rather, change their context and function

Being Present • contact with present moment, which undermines fusion, avoidance, and reason giving

Self as Context • or, "If I'm not my thoughts, then who am I?" • a continuous and secure "I" from which events are experienced, but that is also distinct from those events. • Helps to disentangle us from words, memories, thoughts, our histories

Observer Exercise • You are not Your programming. No one Can Fail. Whatever comes up is just right. • Notice surroundings and current feelings-introduce the “Observer You” • Remember something that happened last summer ..sights…sounds…feelings

Observer Exercise • Remember something that happened when you were a teenager ..sights…sounds…feelings • Remember something that happened when you were a young child (6 or 7 years old)..sights…sounds…feelings • Everywhere you have been you have been noticing

Observer Exercise • Observe roles student, son/daughter, wife/husband, etc • Observe constantly changing emotions • Observe thoughts constantly changing. Going to school to learn new thoughts. • As a matter of experience you are not just your body, your memories, your roles, your emotions or your thoughts

Defining Valued Directions • Values are chosen actions that can never be obtained as an object, but can be instantiated moment by moment. • Distinguishing between valuing as feeling versus valuing as action. • Differentiate between judgments and choices

Path up the Mountain Metaphor • Trails with switchbacks. Sometimes the path goes below previous heights. • If asked in a switchback or a drop how you were doing you may say not very well. • At the top of the mountain looking through binoculars back on other hikers and asked how they were doing would report positive progress every time. • See the overall direction not at any given point

Acceptance and Commitment Therapy (ACT) with College and University Students