Koke Saavedra, Psy.D. & Katherine Plambeck , M.A.

1. A Group-Based ACT Training for Problematic Anger:A New Functional-Contextual Solution to Anger-Related Problems Koke Saavedra, Psy.D. & Katherine Plambeck, M.A. ACBS World conFEREnce XII Minneapolis, June 2014

2. Hi there! • Presenters… • Would you say hi? Koke Saavedra & Katherine Plambeck

3. Today’s Workshop Overview I.) ACT Model/Context – Anger Functionally Speaking • Some data on ACT for problematic anger II.) ACT Group for Problematic Anger • Values & Anger: What Do I Want to Do? • Group-Based Exercise • Action & Anger: Waking Up to What I Actually Do • Group-Based Creative Hopefulness • Mindfulness • Promoting Willingness, Undermining Control • Self-as-Context & Defusion • A Focus on Committed Action Koke Saavedra & Katherine Plambeck

4. Context: A Ubiquitous Human Experience Koke Saavedra & Katherine Plambeck

5. Social Context: Stress in America - APA 2013 Survey I • Stress you have experienced over last month • 67% report emotional, 72% physical stress • Specific stress experience reported: • 1st – Irritability or anger – 41%  consistently #1 • 2nd - No interest, energy – 39% • 3rd - Nervous or anxious – 37% • 3rd - Feeling overwhelmed – 37% • 3rd - Fatigue or tired – 37% • 6th - Depressed or sad – 36% Koke Saavedra & Katherine Plambeck

6. Social Context: Stress in America - APA 2013 Survey II • Stress you have experienced over last month • 46% of adults report they lost patience or yelled at their spouse, partner or children • Among teens specific stress reported: • 1st – Irritability or anger – 40%  #1 • 2nd – Nervous or anxious – 36% • 3rd - Fatigue or tired – 36% • 4th - Feeling overwhelmed – 31% Koke Saavedra & Katherine Plambeck

7. Anger… A Functional-Contextual Perspective • Basic ACT metaphor: The ongoing act in context • Action (response) is inseparable from context (stimuli) • No truth to be revealed (a-ontological) • Pragmatic analysis – purpose is to meet chosen ends (help) Koke Saavedra & Katherine Plambeck

8. Anger… A Functional-Contextual Perspective • Acting/behaving is what a person does -- Context (stimuli) is anything in the psych. environment that influences what a person does, the stream of action • Change in behavior (response) follows change in context (stimuli) • Action changes through changes in context – so ACT aims to influence a person’s here/now living by changing context Koke Saavedra & Katherine Plambeck

9. Anger… A Functional-Contextual Perspective • ‘Anger’ is complex psychological context (stimuli) to a person’s stream of here/now actions (responses) • ANS arousal narrows our responses to functional control • Anger is a psychological context that intensely compels a person to act at the service of controlling the environment – experiential avoidance • Function of anger: control or moving away from what is • Anger is confusing: Its form/topography is a ‘moving towards’ objects in the environment to change them • ACT focus: Does it work in your broader life context? Koke Saavedra & Katherine Plambeck

10. ‘Problematic-Anger’ & the Topography of Anger • Stress/ANS arousal – promotes functional control • Problematic-anger is an anger context that controls unworkable behavior patterns in the broader context of the acting person’s life, given valued ends • The form of behaviors controlled by anger includes what we call aggression, rumination, avoidance, cruelty, etc. Forms are myriad, their function one and the same. • ACT targets context so as to change the function of a person’s actions from control to valued living Koke Saavedra & Katherine Plambeck

11. Subtle Anger Topography: Primary & Secondary Anger • Primary Anger: Visceral, immediate physical reaction to physical context, often suppressed by other classically conditioned emotion/cognition • Secondary Anger: Anger mediated by behavior & cognition (e.g., angry rumination, parent hitting child because he is wrong, anger towards past or self-concept, etc.) and (classically) associated to other emotion/experience (fear, low energy, sadness) Source: Emotion-Focused Therapy & Buddhist Psychology Koke Saavedra & Katherine Plambeck

12. Not-so-Subtle Anger Topography: From ‘Hot’ to ‘Cold’ Aggression • ‘Hot-blooded’ or ‘reactive’ aggression (e.g., tantrum, hit, yell, ruminate, suppress) occurs in context of ANS stress  point to behavior under control of aversive antecedent stimuli (Experiential Avoidance & Fusion ), & ST conseq. • ‘Cold-blooded’ or ‘proactive’ aggression (bullying, kidnap, torture, theft, cruelty) may not be assoc. with antecedent stress  point to behavior under control of whole hexaflex – pervasive psych. inflexibility • ‘Cold’ aggression is associated with a violence/trauma learning hx, incl. intense violence, fear, anger/rumination Koke Saavedra & Katherine Plambeck

13. The Actual Problem with Anger: Loss of Vitality/Quality of Life Problematic anger: Incongruity between inflexible action controlled by anger & what the person deeply cares for. • Anger typically directly undermines the main source of value and vitality for most people: personal relationships • An overwhelming share of the targets of problematic anger are fellow human beings (and 75% are very important relationships)* • Contact with and sharing of our psychological vulnerabilities is a requirement for intimacy & its suppression (e.g., in a controlling anger context) betrays valued relationships * (Deffenbacher, 1993; Deffenbacher, Oetting, Thwaites, et al., 1996). Koke Saavedra & Katherine Plambeck

14. . Problematic Anger: Or How Does the Anger Context Controls Action that Undermines Living? Koke Saavedra & Katherine Plambeck

15. . Living Well with Anger: What Can We Do to Undermine the Control the Anger Context Exerts Over Action? Psychological Flexibility Koke Saavedra & Katherine Plambeck

16. I. What We Can Do About Anger: Functional-Contextual Analysis of ‘Problematic Anger’ & ACT Intervention ACT changes the controlling functions of the contextual variables affecting a person’s action • Problematic action is under aversive antecedent control & thus promoted by ineffective suppression/avoidance • Problematic action is negatively reinforced by reductions of antecedent stress • Mindfulness/flexible present moment attention  direct contact with aversive antecedents & other context variables, promoting actual physical context to control effective action • Acceptancedissolves the controlling function of antecedent anger & associated emotion/physical context Koke Saavedra & Katherine Plambeck

17. II. What We Can Do About Anger: Functional-Contextual Analysis of ‘Problematic Anger’ & ACT Intervention ACT changes the controlling functions of the contextual variables affecting a person’s action • Problematic action is positively reinforced by desired, instrumental consequences  control over environment, especially change in others’ behavior (child doesn’t cry) • Problem. action is reinforced by ‘being right’: consistency of action w/rules reinforced by verbal community/pliance • Defusion deliteralizes anger cognition and so undermines the control a literal thinking context exerts over action • Values clarity changes controlling conseq. from emotion control, ‘being right’, unworkable rewards to valued action Koke Saavedra & Katherine Plambeck

18. The Problem with Being Right Stuck Chicken Koke Saavedra & Katherine Plambeck

19. III. What We Can Do About Anger: Functional-Contextual Analysis of ‘Problematic Anger’ & ACT Intervention ACT changes the controlling functions of the contextual variables affecting a person’s action • Problematic anger is maintained by skills deficits & difficulty engaging in flexible, workable action poor behavioral repertoires and mindfulness/perspective-taking skills; values disorientation; social skills/empathy deficits • Committed Action & Skills training expands action repertoire to behaviors that allow for changes in contextual variables to occur as well as action at the service of chosen values Koke Saavedra & Katherine Plambeck

20. IV. What We Can Do About Anger: Changing Subtle Anger Context • Primary Anger: Visceral, immediate physical reaction to physical context, often suppressed by other classically conditioned emotion/cognition • Experience it directly & respond consciously to actualize chosen values • Secondary Anger: Anger mediated by behavior & cognition (e.g., rumination, parent hitting child to educate, anger toward past/self-concept) & assoc. w/other emotion/exper. (fear, low energy, sad • Mindfulness/acceptance of primary emotion, defusion at the service of actualizing chose values Source: Emotion-Focused Therapy & Buddhist Psychology Koke Saavedra & Katherine Plambeck

21. The ABC’s of the Hexaflex: ACT Assessment & CF of Problematic Anger

22. . The actual choice Living at the service of: • Being right & enforcing socially learned arbitrary verbal rules on self and others (Fu & Concept. Self) • Automatically regulating unwanted emotion, stress, memory (Exp. Av.) • Controlling other human beings’ behaviors to fit my conditioned desires & interests (Autopilot Act.) Some of the costs I pay: • Chronic anger and stress • Health & wellbeing costs • Hurt family, friends & other significant relationships • Alienate myself from community, fellow humans, and from self • Other life constriction 1. Freely Set My Valued Directions in Significant Life/Relationship Contexts: Partner/spouse; family (parents, children, siblings, etc.); friends; community; education; fun; work/creativity; spirituality; health. 2. Take Freely Chosen Valued Actions in Those Contexts: Is doing that working for you? Is it moving you in the direction of who you want to be and what you want to offer the world? 3. Work with the Barriers in those Contexts: Are you willing to contact your experience undefendedly as it is and not as it says it is for the purpose of living a chosen, effective valued life?

23. To ‘ACT’ Consciously: The Antidote to Problematic Anger • Aware: of your present moment experience as it is, not as it says it is • Choosing: in contact with your freely chosen valued directions • Taking Action: that effectively actualizes what matters to youin that life or relational context Koke Saavedra & Katherine Plambeck

24. The End of ACT: Psychological Flexibility • The ability to live and relate to other humans/world to actualize chosen valued ends, irrespective of the presence or absence of psychological barriers (such as, an anger context of difficult thoughts & memories, emotional & physical discomfort, strong control impulses, etc.) • PSYCHOLOGICAL FLEXIBILITY promotes vitality & a sense of control over my quality of life, but not over experience or others Koke Saavedra & Katherine Plambeck

25. Exciting ACT for Anger Data Koke Saavedra & Katherine Plambeck

26. Ongoing ACT for Anger Group for Incarcerated Men - Preliminary Data Katherine Plambeck, Dissertation Research ACT group goal: to reduce problematic anger behaviors for incarcerated men at a California jail • 8 weekly 90-min. group sessions (group size: 8 to 13) • Non-controlled ACT pilot - males over 18 years old • Pre, post, and 1 month follow-up questionnaires looking at psych. flexibility (AAQ-II) and frequency of problematic anger behaviors (ACQ). • Study progress to date: • 41 men completed pre-treatment questionnaires • 10 participants have completed treatment & post questionnaires • 27 participants are currently in ongoing ACT groups Koke Saavedra & Katherine Plambeck

27. .V Non-Respond. with High Freq. Problems % Change in Problem Behaviors % Change in Psych. Inflexibility High Freq. Problems Behaviors > 50 Responders with High Freq. Problems All Completers To Date (n=10) 26 +20% 6 Percentage Change from Pre to Post 15 17 -20% 25 35 40 -40% Ongoing ACT for Anger Group for Incarcerated Men (Preliminary Data)Katherine Plambeck, M.A. 59 -60%

28. Quotes from Participants Who Completed the ACT Group – Acceptance & Valued Action Focus • “I’ve learned how to have compassion for myself. This has produced in me the ability to love others more and have compassion for them, which is huge! A heavy weight has been lifted!” • “…the focus on self-awareness enhanced my ability to express myself, and understand my thought-to-action process.” • “Before your class I never really thought much about what I am thinking about. …I have very little, if any, control over my crazy-ass mind. However, I have complete control over my actions. After all, I am not my thoughts. Right? That’s a damn good thing! …the monsters that reside in my head are NOT in the driver’s seat.” Koke Saavedra & Katherine Plambeck

29. Randomized Controlled Trial: ACT for Anger for Minority Adults in Recovery Koke Saavedra (2006) Randomized controlled trial: ACT+TAU vs. TAU • Group-based pilot study: 15 controlled participants • TAU: 4 hours, 6 days a week for 3 months • ACT: 8-weekly 90-minute group sessions of ACT • Study participants (equal samples): • Substance abuse in free outpatient recovery treatment • Age: average = 43; Gender: 47% Female • Self-identification: 86.7% African American; 6.7% Latino/a; and 6.7% Native American; 100% low income • 60% previous CBT anger management treatment 29 Koke Saavedra & Katherine Plambeck

30. Process of Change: ACT for Anger Change in acceptance but not in propensity to experience anger (3.7%) (7.7%) (12%) (15%) (9.9%)* Negative sign represents reduction in exp. avoidance (50.2%)* *Significant: p < 0.05% Koke Saavedra & Katherine Plambeck

31. Cool findings! Consistent with Mindfulness model, not with CBT • Promising new model: Cohen d = .76 .8 is large • Findings consistent ACT model: • Gains NOT mediated by changes in “trait anger” (STAXI-2); No cognitive restructuring • ACT & CBT work through different mechanisms • Acceptance improved for treatments only • Some limitations of the study: very small sample (but results consistent with other ACT trials); mediation analysis of acceptance failed (sample too small); no F/U (ACT tends to show further gains). Koke Saavedra & Katherine Plambeck

32. ACT impact by frequency of anger-related problematic behaviors Koke Saavedra & Katherine Plambeck

33. ACT for Anger Group Training

34. ACT for Anger Group Training Overview • Values Work & Valued Action Focus • Setting Valued Ends Against Which to Measure Action • Beginning with a Focus on Chosen Valued Action • Creative Hopefulness • Observing Action Patterns & their Consequences • Mindfulness • Promoting Willingness, Undermining Control • Self-as-Context & Defusion • Maintaining & Expanding Committed Action Koke Saavedra & Katherine Plambeck

35. Safety & Free Choice during Experiential Exercises • Experiential exercises may or may not put you in contact with difficult or uncomfortable experience • Freely choose if you participate or not, as well as your level of risk/involvement/disclosure • The expectation is not that you will participate, but that you will make your own free choices – also that we will all keep an open heart to fully allow others to show up as they choose to Koke Saavedra & Katherine Plambeck

36. Values Work IWhat do you really want to be about? Values Orient Our Actions: • Chosen verbal descriptions of intrinsically valued action patterns • Values make contacting unwanted, painful events desirable & dignified • Our values, like a lighthouse, they guide us through the storms… Drawing: Joseph Ciarrochi & David Mercer Koke Saavedra & Katherine Plambeck

37. Values Work IIWhat do you really want to be about? Some Key Discriminations: • Values are not goals • “Going west…” • Values are not feelings • You are what you do, not what you think/feel • Values point to the process of living, not to its outcomes • Playing to play vs. playing to win • Going for a Hike Koke Saavedra & Katherine Plambeck

38. The Problem with Goals… “When you reach the top of the ladder and realize it was leaning against the wrong wall.” ~ Joseph Campbell Midlife crisis Photo: http://goulddesigninc.wordpress.com/2013/05/30/5-keys-to-knowing-if-you-are-on-the-ladder-of-opportunity/ Koke Saavedra & Katherine Plambeck

39. What do you Want Your Life to be About? Write Your Own Epitaph “Here lies Anne who successfully avoided intimacy with her mother because she couldn’t forgive her” “Here lies Tom who yelled and screamed at his wife and kids because his work was so stressful” “Here lies Alicia who never enjoyed a stroll in the park, because there were too many inconsiderate people” Koke Saavedra & Katherine Plambeck

40. . Relationship/life domain ___________ Values _____________ Actions ____________ Values Exercise: What really matters to you? Values are not goals or things you can have, or feelings, they are your chosen life directions, the compass tat guides your actions now Bull’s Eye is a creation of Tobias Lundgren & Joanne Dahl

41. Koke Saavedra & Katherine Plambeck

42. Group-Based Creative Hopefulness:Undermining ineffective action by bringing awareness to what one is doing & its consequences Demonstration • What do you want? • What are you doing? • What are you getting? And over time? • Is this this consistent with your values? • What does your mind say? • What does your experience show? • Which one do you trust? Koke Saavedra & Katherine Plambeck

43. Person in the Hole Metaphor Isn’t acting on anger a bit like digging in a hole? We just keep acting it out because it feels so right, but it actually over time we are just sinking deeper? Koke Saavedra & Katherine Plambeck

44. What if Control is the Problem? • Digging in a Hole • Feeding the Tiger • Holding the Door Shut • Quicksand metaphor So, which one do you choose… being right or being effective? Koke Saavedra & Katherine Plambeck

45. Mindfulness: Undermining Barriers to Valued Action in the Contextof Anger • Mindfulness is willingness • Mindfulness/Present moment practice • Body scan & deep breathing for awareness • Self-as-Context & Defusion • Where do your thoughts come from? -Don’t think & instead watch -Who are you? Watch you hand, watch your mind • Chessboard & letting the river flow • Blue sky: Watching vs. struggling with weather Koke Saavedra & Katherine Plambeck

46. Fusion Controls Problematic Anger Koke Saavedra & Katherine Plambeck

47. Functional Control: Verbal Topography of Secondary Emotion (Fusion)

48. Being Like the Big Blue Sky • Thank you mind for those thoughts Putting your thoughts on clouds Koke Saavedra & Katherine Plambeck

49. “Wise Exiting”: Action at the Service of Value • The anger context is very powerful… • Often (and in particular when a person is beginning to work with anger) new behaviors are difficult to access in the presence of the physical and mental experience of anger • We wisely choose to exit the context that is eliciting our anger… to practice new helpful responses in the anger context • Lots of practice in the therapy room too! Koke Saavedra & Katherine Plambeck

50. Anger Rumination & Suppression of Thought/Experience • The power of mind – it’s magical • Imagine your favorite food • Imagine you are in a dungeon… • Having a conversation with the TV in the living room? • Take your mind for a walk… • Undermining suppression: Don’t think of an angry lion Undermining Blind Faith On Mind Koke Saavedra & Katherine Plambeck