Using ACT with Children, Adolescents, and Parents

1. Using ACT with Children, Adolescents, and Parents Lisa Coyne ACBS World Conference June 19-20, 2010

2. What We’ll Cover • Basic Overview of ACT • Research with Children, Adolescents, and Parents • Developmental Considerations • The Role of Parents • Working with Young Children • Working with Teens • Applications with Children • The Therapeutic Stance and Therapeutic Contract • Assessment • The Hexaflex • Experiential exercises and developing tools

3. Purpose • To set the context within which ACT is done • To explain the underlying theoretical model • To set out the general clinical approach • To give examples of the techniques and gain some skill in developing and flexibly using them with children, teens, and parents • To examine what stands between us and powerful work with our most difficult clients • To encourage you to explore using ACT with youth

4. Informed Consent • At times this will be experiential – may stir a few things up • Your privacy will never be violated, but you will be invited to take a few risks • For that reason we must agree to confidentiality • No rescuing

5. A Request • Intend for these two days to make a difference in your work with children and families • What if it required that WE play for bigger stakes? • My commitment: • To stay present • To step forward • To serve

6. Introductions • Your name • Where you work or study • What types/ages of clients; what presenting problems commonly see • Familiarity with ACT

7. What do you want to play for? • Think about work with a difficult child client or family • Have you worked with a child or family whom you weren’t able to help? • Did that make you feel • Sad • Frustrated • Lost • Confused • Doubting yourself • Doubting what you know • Incompetent • Like a failure

8. Are you willing… • To sit with all of your feelings, thoughts, experiences, with compassion, and without defense • To venture into new places where you don’t have a map: to keep a beginner’s mind • To act boldly and creatively in the service of your clients…if that is what it takes to make a real difference in their lives?

9. What You Might Want from this Workshop • What you care most about in your work with children and families • The floor is open

10. What do you see?

17. “Do you see? We hardly ever just see.” -J. Kabat-Zinn What did you all see? What do you all think you look like to them?

18. Did any of you think to ask them the following questions?

19. What does she dream of becoming?

20. What difference can they make in the world?

21. What will they teach us?

22. What do they care about?

23. Whose hero will he be?

24. What is her song?

25. If WE don’t ask these questions of our clients? Or go there? Who will?

26. What are we working for? • Becoming mindful and letting go of our stories of what is possible for our clients… • ..and their functions • Really…. discovering children and families and their songs across multiple interactions, contexts, and stories • Trusting our clients to do the next right thing

27. Nature of the Work I care about helping children and families to create lives that are meaningful and inspiring, and to live their lives with integrity and passion, regardless of the difficulties they face.

28. Basic Overview of ACT Bathroom break if needed! Or coffee!!

29. “The single most remarkable fact about human existence is how hard it is for humans to be happy.” (Hayes, Strosahl, & Wilson, 1999)

30. Why?

31. The Cultural Agenda Feel goodto live well. Underlying assumption: “Healthy Normality” Suffering is Pathological • Unless they are very transient, sadness, anxiety, fear, feelings of isolation and self-doubt are pathological. • As soon as I get rid of these “bad” thoughts and feelings and get more “good” thoughts and feelings, I will be able to live a valued life. • Is this really so?

32. A Little Data on “Disorders” in Youth… • Estimates from MECA, based on both child and parent interviews, ranged from 20%-5.4%, depending on level of impairment (Shaeffer et al., 1996) • On functional impairment: About 25% of children reported a disability in one or more areas. (Espeleta et al., 2001) • Suicide • 3rd leading cause of death in 15 to 24 year-olds • 6th in ages 5 to 14

33. Is it abnormal to be abnormal? • Many children, teens, and families suffer • Substantial rates of comorbidity • Doesn’t count the enormous number of “subclinical” cases or non-diagnosable functional impairment • Kids’ problems aren’t necessarily restricted to or captured by our diagnostic system • Parent-child relational problems • Peer rejection & victimization • Multiple contextual stressors of poverty • Teachers who think You can’t. You’re not smart enough. • What if suffering is the normal state of human existence?

34. THE ACT AGENDA Feel good and live well. Underlying assumption: Destructive Normality Suffering is Normal The social/verbal community teaches us to resist suffering, and that resistance is pathogenic. A valued life can be lived under any and all circumstances. There is as much living in a moment of pain as in a moment of joy.

35. What is ACT, After All? • Based on Contextual Behavioral Theory & Relational Frame Theory (RFT) • Views human psychological problems dominantly as problems of psychological inflexibility fostered by cognitive fusion and experiential avoidance

36. “Normal” Suffering: A Contextual-Behavioral Account • Learning Histories • Direct Conditioning • Classical • Operant • Indirect Conditioning • Relational

37. Shock TONE Direct Conditioning: Classical Conditioning Example TONE TIME CONDITIONING Shock Unidirectional Transformation of Psychological Functioning

38. Water Direct Conditioning Operant Conditioning Example KEY Food KEY TIME CONDITIONING Food KEY Water Unidirectional Transformation of Psychological Functioning

39. Indirect (Relational) Conditioning • In verbally* competent humans • No robust evidence (in the same way) in nonhumans • No robust evidence in non language-able humans • Evidence of these processes as young as two • Verbal refers not just to speech but to any and all communicative behavior and really any behavior that is the result of relational learning

40. Relational Framing • Simplest form emerges by 17 months Object Name 87.5% (4 pairs) Source: Lipkens, Hayes, & Hayes (1993)

41. Relational Framing • More complex by 23 months Object Name 90% (4 pairs) Sound Source: Lipkens, Hayes, & Hayes (1993)

42. Relational Framing • Ability to form multiple relations forms by 27 months of age • Language explosion Source: Lipkens, Hayes, & Hayes (1993)

43. Relational Framing • Emerges in toddlerhood • Gets more complex • Multiple relational forms • Correlates with cognitive/verbal ability Typical MR: Language Chance MR: No Language Source: Devany, Hayes, & Nelson (1986)

44. sounds speed smells “Car” or Car wind danger streets Indirect Learning Processes Relational Conditioning Example “Car” “Car” Burger Car Lemon “Car” Car Bidirectional Transformation of Psychological Functioning

45. What Indirect Conditioning Gives Us • Good- prevents you from being roadkill • Ability to balance long- and short- term contingencies • Communication over time and distance • Broad ability to evaluate, categorize, sort • Broad ability to plan and execute based on evaluations • Bad- keeps you from crossing the street EVER • Can’t turn it off • Some examples

46. That car is coming really fast. It could squash me! Stay out the road So, if the words are these? GREAT Smoking causes cancer. Don’t smoke Veggies are good for me. Eat healthy

47. Get aggressive Social isolation Cutting. He meant to knock me down! But what if the words are these? I can’t ask for a playdate She’ll laugh at me. I can't stand feeling like a loser any longer.

48. The ACT Model’s View of “Problems” • Our “mind” (emergence of verbal relations) generates an endless stream of associations and evaluations. These comparisons include not only actual events in the world that present themselves, but also include the imagined events of the past, present, and future- and any thoughts, feelings, or other reactions about those events, whether they are real or not. • Our minds turn on us!

49. When Behavior Loses Flexibility (Freedom) Psychopathology and restricted range of behavior Reactive aggressive children lose it and attack Socially anxious kids hide Depressed teens pull the blankets over their heads or cut Even when the form is erratic, it may be systematically erratic (behaviors belong to the same functional class) There is a certain stereotypy that cuts across categories (if you ignore categories for a moment) Not the behaviors per se, but instead the “have to”

50. The “HAVE TO” Disease: Flexibility and Stimulus Control Where do we find inflexibility? Impoverished environments (not enough to work for) Presence of aversives Where behavior is dominantly under aversive control Where do we find flexibility? Abundant environments (enough to work for) Where behavior is dominantly under appetitive control