ACT Workshop The basics…

1. ACT WorkshopThe basics… Matthew McKay, Ph.D. Patricia E. Zurita Ona, Psy.D.

2. Experiential exercise: Acceptance of thoughts & feelings.

3. 1st Wave S-R Behaviorism The Field’s Timeline 3rd wave Acceptance/Mindfulness experiential avoidance 2nd Wave Cognitive Behavioral Hayes, (2004) Mindfulness-Based Therapies

4. And what do the data say? Social Phobia Work Stress Chronic Pain & Stress End stage Cancer Smoking Type II Diabetes Stigma and Burnout Poly-Substance Abuse Agoraphobia Depression Psychosis BPD Epilepsy Trichotillomania From Hayes, et al., 2006, Behaviour Research and Therapy

5. ACT Case conceptualization • People experience painful private events (thoughts and feelings) that are unavoidable parts of living (primary pain). • People tend to avoid or block those painful private events (experiential avoidance). • As a result of experiential avoidance, people get locked into cycles of programmed behavior: pain…avoidance…pain…avoidance (psychological inflexibility). • The consequences of experiential avoidance are called secondary or “dirty pain.” • ACT targets the secondary, “dirty pain.”

6. ACTGoals Two major goals: • To foster acceptance of unwanted private experiences which are out of personal control. • To facilitate commitment and action towards living a valued life.

7. ACT- Definition in a nutshell 1. Accept thoughts and feelings. 2. Choose Actions. 3. Take Action.

8. ACTHexaflex

9. Acceptance and Mindfulness Processes Acceptance and Commitment Therapy

10. Thus the name “Acceptance and Commitment Therapy” Commitment and Behavior Change Processes Acceptance and Commitment Therapy

11. Psychological Flexibility Hexaflex (6) At this time, in this situation (2) are you willing to have that stuff, fully and without defense (5) Of your chosen values If the answer is “yes,” that is what builds. (4) AND do what takes you in the direction (3) as it is, and not as what it says it is, (1) Given a distinction between you and the stuff you’re struggling with and trying to change Acceptance and Commitment Therapy

12. Psychological flexibility is not about getting rid of the pain; it’s about learning to face pain and have a meaningful life.

13. A quick clarification … • Experiential vs. skill building exercises.

14. Contact with the Present Moment (a) Experiential exercises: • Inner – and – outer shuttle. (b) Skill building exercises: • Mindful breathing. • Mindfulness of daily activities.

15. Acceptance of emotions “For after all, the best thing one can do when it’s raining is to let it rain.” -Henry Wadworth Longfellow

16. Acceptance of emotions (1) (a) Experiential exercises • Eye-to-eye exercise. • Observe the barriers to the eye-to eye-exercise. • Meditation exercise: what’s the emotion you most avoid in life? • Observe the barriers to emotions on a larger scale (white board). • Uninvited guest metaphor.

17. Acceptance of emotions (2) • Emotional exposure (handout). • Notice clean vs. dirty pain.

18. Acceptance of emotions (3) (b) Skill building exercises: • Key choice: Leaning into experience vs. the old avoidance pattern (mindfulness). • Journaling about painful events.

19. Defusion of thoughts “I used to think that the brain was the most wonderful organ in my body. Then I realized what was telling me this.” -Emo Phillips

20. Defusion of thoughts (1) Key concepts: • Looking at your thoughts vs. from your thoughts. • Having thoughts vs. buying thoughts. • Observing and labeling vs. being thoughts. • Defusion vs. chaining (worry example). • Mind as an object. • What you don’t want you got: Pink elephant exercise. • Taking your mind for a walk (triad exercise).

21. Defusion of thoughts (2) Key elements: Learning about thoughts Distancing from thoughts Letting go of thoughts

22. Defusion of thoughts (3) Learning about thoughts - experiential exercises: • White Room. • Conveyor belt. Learning about thoughts: skill building exercises: • How old is this thought? • What’s the function/workability of the thought?

23. Defusion of thoughts (4) Distancing from thoughts – Experiential exercises: • Physicalizing/silly voices. • Titchener’s repetition (self-defeating thought). Distancing from thoughts – Skill building exercises: • Thank your mind. • I’m having the thought that… • Carry thought signs. • Card carrying.

24. Defusion of thoughts (5) Letting go of thoughts – Experiential exercises: • Tug of war. Letting go of thoughts – Skill building exercises: • Leaves on stream. • Balloons. • Clouds on the sky. • Billboards. • Fishing boats. • Balloons.

25. Self-as-a-Context “If you wake up at a different time, in a different place, could you wake up as a different person?” -Chuck Palahniuk

26. Self-as-a-Context (1) Key concepts: • Self-as-a-context is the self that observes the experiences, that watches without becoming what is thought and felt. • This self is in the context of the experience but is not the experience. • Sky metaphor. • Movie screen metaphor.

27. Self-as-a-context (2) Who is the observer? Observer self Thoughts Feelings Physical sensations

28. Self-as-a-context (3) • The Observer exercise.

29. Values “For success, like happiness, cannot be pursued; it must ensue…as the unintended side-effect of one’s personal dedication to a cause greater than oneself.” -Viktor E. Frankl

30. Values (1) Key concept: Values are life directions, not goals. Values include intentions. Experiential exercises: • Tombstone (handout) • Values questionnaire: Rating: I=importance; A= Action. Write down intention & barrier. • White board discussion (high importance/low action).

31. Values (2) • Values path (exercise). • Emotional avoidance detour (handout). • Monsters in the bus (exercise) • Monster in the bus (handout).

32. Committed action “Do or do not; there is no try.” -Yoda

33. Committed action (1) Key concepts: • A promise to oneself to do a specific thing at a specific time: it’s always behavioral! • A behavioral commitment in the face of painful barriers: • Cognitive (judgments, what if thoughts). • Emotional. • Behavioral (skills deficit, distance, logistics). • Physical.

34. Committed action (2) Experiential exercises: • Values compass (handout). • Willingness: Pen exercise (100% willingness). • Public commitment: importance of verbal commitment; set time, place, specific behavior (experiential exercise).

35. ACTOrder of treatment • Assess the real problem: Clean vs. dirty pain. • Identify client’s past coping strategies: Explore the workability of each strategy (creative hopelessness). (Role-play a client)

36. Applying ACT: Creative Hopelessness

37. Applying ACT: Creative Hopelessness

38. ACTOrder of treatment • Assess the real problem: Clean vs. dirty pain. • Identify client’s past coping strategies: Explore the workability of each strategy (creative hopelessness). (Role-play a client) • Re-conceptualize the problem: Client learns that feelings, thoughts, physical sensations cannot be controlled (the real problem is avoidance). • Set treatment goals: Treat the avoidance response. • Identify client’s values.

39. ACTOrder of treatment 6. Identify client’s barriers “monsters:” Thoughts, feelings, behaviors. 7. Identify interventions to deal with those barriers/monsters: Thoughts: Mindfulness/Defusion/Acceptance. Emotions: Mindfulness/Emotional Exposure/Acceptance. Avoidant behaviors: workability: Task training. 8. Create exposure situations: In-vivo exposure to real life situations.

40. Treatment choice: Fused thoughts? Experiential avoidance? No Yes Work with barriers: Thoughts: Defusion. Feelings: Mindful observation/acceptance. Avoidant behavior: Workability, function. Exposure/committed action (Based on values) Values + Willingness