Supercharging therapy with values

1. Dr. Joseph Ciarrochi, School of Psychology, University of Wollongong Supercharging therapy with values

2. Structure of talk • Part 1 Theory • Part II. Behavioral Activation • Evidence behavioral Activation is effective. • Part III: Values clarification • Evidence values clarification is effective • How to work with values

3. Part I: A Unified Theory

4. What happens to people’s dreams? “The very great majority kill themselves long long before their time. Live as children; grow pale as adolescents; show a flash of life in love; die in their twenties and join the poor things that creep angry and restless about the earth” (O’Brian, 1991, p. 526).

5. ACT as a Unified framework An extremely brief and pictorial description of Relational Frame Theory Fusion and Avoidance, two key processes that play a role in interfering with value-congruent living

6. How do we lose touch with what we value?Fusion is the dominance of particular verbal functions over other potentially available nonverbal and verbal functions (Hayes et al., 1999).

7. Fusion and avoidance. Fusion makes it possible for our private experiences (the bees above) to seem like physical threats. It allows us to spend time avoiding our experiences, just as we would avoid an outside threat

8. Avoidance takes a great deal of energy and is often inconsistent with other activities, e.g., distress provoking valued-activities

9. Desire (or values) and fear are two sides of the same coin. If can’t have distress, then you often must give up what you desire or value

10. Acceptance and Commitment Therapy (ACT) and Behavioural Activation (BA) • Shared philosophy of science: Functional Contextualism • Behaviourist • Emphasis on functional analysis • Emphasis on context rather than content • Shared therapeutic processes • Activation of behaviour • Undermining of harmful avoidance behavior • Mindfulness • Exposure

11. Distinctions between ACT and BA • ACT is based on a behavioral theory of language. Like traditional CBT, ACT views cognition as playing a key controlling role in suffering. However , ACT and traditional CBT differ in how they conceptualize and treat client problems (Ciarrochi & Bailey, 2008). • Cognitive Defusion. ACT attempts to change the way one interacts with or relates to thoughts by creating contexts in which their unhelpful functions are diminished. • Self-as-Context- ACT helps people to contact with the sense of self as a locus or perspective (e.g., the “observer” self). This self gives clients a place to observe their experience and learn to let go of unhelpful self-evaluations. They learn that they are not the same as their evaluations; they are not the same as their pain, their depression.

12. Distinctions between ACT and BA Activities versus values ACT tends to emphasize values more than traditional BA, which focuses a bit more on activity scheduling

13. Part II: Behavioral Activation

14. Study 1 supporting BA as“well-established” treatment for depression (Chambless et al., 1996) McLean and Hakstian (1979) JCCP. Behavior therapy superior to other therapies at immediate follow-up (9 of 10 indices), and marginally superior on follow-up (7 of 10 indices) Behaviour therapy had lowest dropout (5% compared to 26% to 36% for other treatments)

15. Study 2 supporting BA as“well-established” treatment for depression (Chambless et al., 1996) • Jacobson et al. , 1996, (JCCP) compared three conditions. • Conditions • Behavioural Activation (BA) • BA + automatic thought challenging (ATC) • BA+ATC+ downward arrow/core belief • Results • Behavioral activation alone was as effective in treating depression as BA combined with cognitive interventions. • Gortner et al. 1999 showed effects held at 2 year follow-up

16. More research supporting behavioural activation Dimidjian et al., 2006, JCCP. Study of Major Depression • Compared behavioural activation to Cognitive Therapy and Antidepressent medication (ADM) • BA found to be comparable in efficacy to ADM, and more efficacious than CT. • Differential treatment effects obtained only for most severely depressed • For more severly depressed participants, BA and ADM comparable Cuijpers et al., 2007 CPR. Meta-analysis • BA effective (effect size =.87) and effects fairly consistent across studies

17. Is behavioral activation effective for other disorders, such as anxiety? ACT theory posits similar processes: fusion and avoidance. Approximately 50% of individuals with depression have a coexistant anxiety disorder ( Kessler et al., 1996; Mineka, Watson, and Clark, 1998) Anxiety and depression share many symptoms (e.g., difficulties concentrating, restlessness, fatigue, and sleep problems. Decrease in control and predictability may be common in both disorders Anxiety and mood disorders may be variable manifestations of similar neurobiological processes (See Hopko, et al., 2006, for review of similarities between anxiety and depression)

18. Exposure in the service of activating valued behaviour

19. Is behavioral activation useful in treating anxiety Small study of pure B.A. with PTSD shows B.A. was effective (Jakupac, et al., 2006) Social anxiety: Exposure is as effective as CT and full CBT package in treating social anxiety (Powers, et al., 2008) ACT, with big BA component, is effective in treating anxiety (Block, & Wulfert, 2000; Dalrymple & herbert, 2007; Forman et al,2007; Zettle, 2003)

20. Part III: Values

21. What are values? • Wilson, Sandoz, Kitchens, and Roberts, 2008, under review • 1) Values are ongoing patterns of activity • Not achievable, can’t be completed • Goals are achievable and serve values

22. What are values? • 2) values are a special class of reinforcer • Can me distant in time, and occur in tiny increments • Can refer to benefits that , in principle , could never contact (e.g., afterlife)

23. What are values? • 3) values are verbal • Language makes present psychological functions without direct operant or classical conditioning processes

24. What are values? Values are a special class of reinforcers that are verbally constructed, dynamic, ongoing patterns of activity, for which the predominant reinforcer is intrinsic in the correspondence between the individual behaviour and valued behavoural pattern(Wilson, et al., 2008)

25. Values, what are they good for? Values have tremendous transformational power Theoretically, values set up the possibility for behaviours to become more reinforcing or punishing because of their relation to value statements

26. Empirical evidence: Values work is likely to be good for the client

27. Values affirmation buffers the stress response • All participants rank order values in terms of personal importance • Trier social stress task—involves telling subjects they will have to do stressful speech task and mental arithmetic. Cresswall et al., 2005, Psychological Science

28. Values affirmation buffers the stress response Affirmation manipulation • Answer question like: Assuming that you have sufficient ability, would you prefer to be (a) a banker (b) a politician • Experimental condition. Answered questions relating to top-ranked value • Control. Answers questions relating to fifth ranked value

29. Salivary cortisol response to stress in the value-affirmation and control groups

30. Pretest and postest self-report stress measure, as function of self-resources (self-esteem and optimism)

31. Value affirmation improves objective performance • Cohen et al., 2006, Science • Theory • People are motivated to maintain self-integrity • Negative group characterizations (e.g., black stereotypes in U.S.) pose chronic threat to self-integrity • This threat, if too severe, can undermine performance

32. Value affirmation improves objective performance Main study and replication Treatment and control condition presented a list of values Treatment condition: indicate most important values. Write about why value important to you Control condition. Indicate least important value and why this value might be important to someone else

34. Values clarification and tolerance for pain Is their benefit to connecting pain-related thoughts to actions in a valued direction? Paez-Blarrina, M. et al., 2007, Behavior Modification; Paez-Blarrina et al. ,2008, Behaviour Research and Therapy

35. Values clarification and tolerance for pain Pain task • Perform cognitive task. If do well, get points, which can be exchanged for a reward at the end of the task. • Red asterisk appears on screen. • If choose “finish”, then task ends and no shock. • If continue, more chance for points but also a shock. (this is behavioural measure of pain tolerance)

36. Values clarification and tolerance for pain Key Conditions • ACT-values protocol—depicted pain as a part of valued action • Control-values protocol—pain is opposed to valued living • No values protocol

37. Values clarification and tolerance for pain Findings • 7/10 ACT-values intervention tolerated maximum number of shocks; Only 1/10 and 2/10 tolerated in the control and untrained condition, respectively. • Pain believability. Do you keep going even when you think the task is causing you “very much pain.” • 9/10 kept going in ACT-values; Only 5/10 and 3/10 kept going in the control and untrained conditions respectively • These differences were significant

38. Measuring and using values in therapy ACT intervention Survey of Life Principles

39. Past research in values • Values work (Schwartz, et al., Rokeach et al.). • What is most important to you? • Are there Universal values? • Personal strivings (Sheldon, Emmons, Deci). • What do you strive for • Why do you strive? Is it for authentic or controlled reasons? • We will call both of these “guiding principles” for ease of reference

40. Towards a behavioural approach to values and goals: Recasting Needs Both value and striving literature seek to identify universal needs that underpin all guiding principles Need is identified by observing that positive psychological consequences result from conditions that allow its satisfaction and negative consequences accrue in situations that thrwart it (deci and ryan, 2001, pg 229) Instead of speaking in terms of “needs”, I will speak in terms of categories of reinforcer.

41. Towards a behavioural approach to values and goals: type of rule following • Pliance- rule governed behavior under control of apparent speaker-mediated consequences for a correspondence between the rule and the relevant behavior. (Zettle and Hayes, 1982; Hayes, Wilson, and Stroshal, 2001) • Factors that impact pliance • ability of speaker to monitor compliance, and deliver consequences • importance of consequences to listener • others (history, credibility; Hayes and zettle) • Problem with pliance. Excessive pliance, e.g., wanting to “be good” and please others, can dominate over ones direct, personal expeirence of what works • Reinforcers are arbitrary

42. Towards a behavioural approach to values and goals: type of rule following • Tracking- rule governed behavior under control of apparent correspondence between the rule and the way the world is arranged. (Zettle and Hayes, 1982) • Factors that impact tracking • Listeners history with the rule giver • Correspondence between the rule and other rules or events in the listener’s history • Importance of the consequence implied by the rule • Extent rule successfully leads to reinforcement, avoid punishment • Speaker does not mediate compliance (e.g., the rule could be conveyed by a book and have the same effect); (Hayes and Zettle, 1982)

43. Recasting Self-Determination Theory in behavioural terms. Pliance Tracking Deci and Ryban, 2000, psychological science

44. The ImPActS intervention model

45. Research on values The area emphasizes the Importance component of the ImPActS model.

46. The structure of values (Schwarz)

47. Values and behaviour • ImPActS • Values importance has predicted more than 15 different behaviours • e.g., voting for political party, choosing a university course • Other predicted behaviours: delinquency, cooperation, competition, consumer purchasing, environmental behaviours, religious behaviours (See Bardi and Schwartz, 2003)

48. Values and well-being • ImPActS • The following were positively related to subjective well-being • Achievement: Personal success through demonstrating competence according to social standards. (Successful, capable, ambitious, influential) • Stimulation: Excitement, novelty, and challenge in life. (Daring, a varied life, an exciting life) • Self-direction: Independent thought and action-choosing, creating, exploring. (Creativity, freedom, independent, curious, choosing own goals) • Sagiv and Schwarz, 2000, Eur. Jn., of Soc. Psyc

49. Values and well-being • ImPActS • The following were negatively related to well-being • Conformity: Restraint of actions, inclinations, and impulses likely to upset or harm others and violate social expectations or norms. (Politeness, obedient, self-discipline, honouring parents and elders) • Security: Safety, harmony and stability of society, of relationships, and of self. (Family security, national security, social order, clean, reciprocation of favors) • Sagiv and Schwarz, 2000, Eur. Jn., of Soc. Psyc

50. Values and well-being • ImPActS • The researchers failed to find a positive association of subjective well-being and • Universalism: Understanding, appreciation, tolerance and protection for the welfare of all people and for nature. (Broadminded, wisdom, social justice, equality, a world at peace, a world of beauty, unity with nature, protecting the environment) • Benevolence: Preservation and enhancement of the welfare of people with whom one is in frequent personal contact. (Helpful, honest, forgiving, loyal, responsible) • Seemed inconsistent with the notion that concern for others rather than self promotes subjective well-being • A false dichotomy? • Sagiv and Schwarz, 2000, Eur. Jn., of Soc. Psyc