Wrestling with a Gooey Monster: ACT for OCD in Children

1. ACBS Worldcon XII Minneapolis – June 2014 Wrestling with a Gooey Monster: ACT for OCD in Children Koke Saavedra, Psy.D. Licensed Clinical Psychologist California, USA

2. Hi there! Presenter… Would you say hi? ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

3. Workshop Overview ACT for OCD – Model& Context -> OCD Functionally Speaking – A Focus on Context -> A Word on the Childhood Context of OCD ACT for OCD in Kids: Wrestling with a Gooey Monster -> A Focus on Values & Valued Action • Values Exercises for Children -> Art-Based Perspective-Taking & Workability • Drawing the Scary Monster(s) & You • What Does the Monster(s) Do? What Do You Do? -> Promoting Willingness, Mindfulness & Valued Action • Wrestling with a Gooey Monster Metaphor • Acceptance & Defusion Exercises -> ‘Exposure’: Willingness & Committed Action ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

4. OCD… Functional- Contextually Speaking I OCD is a psychological context characterized by lack of mindfulness: • Fusion with catastrophic/anxious cognition –> child believes thoughts literally (context of literality) • Experiential Avoidance: Avoidant relationship to unpleasant body sensation/emotion (‘anxiety’) • No self-as-perspective & disorientation to valued ends • Attention & action narrowly focused on control or moving away from unwanted psychological content ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

5. OCD… Functional- Contextually Speaking II The psychological context of OCD controls actions narrowly at the service of moving away from unpleasant experience: • Acting on Fusion since thoughts are experienced literally, child acts mindlessly to directly suppress cognition and/or avoid its literal, feared consequences • Action at the service of Experiential Avoidance child acts mindlessly to move away from unwanted body, emotional experience & the situations that may elicit them ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

6. OCD… Functionally- Contextually Speaking III The psychological context of OCD controls actions narrowly at the service of control (moving away): • No self-as-perspective & disorientation to chosen valued ends child’s actions are mindlessly oriented toward moving away regardless of valued life consequences • Attention & action narrowly focused on control of literal, unwanted psychological event child acts automatically to move away from unwanted psych. content Action is negatively reinforced as well as a by ‘avoidant tracking’ and pliance (doing the right ‘problem solving’ thing) ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

7. . Another Way of Saying the Same Thing – The Behavioral Context of OCD or Living for Control ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

8. A Metaphor: A Child’s Actions in the Context of OCD - The Child is living as if chased by scary monsters (made of myriad thoughts & feelings)… and so, naturally, his life is put at the service of avoiding and moving away from these scary monsters - The price the child pays is his life as well as the monsters becoming more present and scary, as well as over time new monsters joining the gang, such as thoughts & feelings of being weird, worthless, hopeless, etc. ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

9. A Word on ACT & the Context of Childhood OCD I • ACT is non-evaluative & truly non-directive  child valued ends and not control of content guide intervention • Focus on strengths, oriented to learning to live a valued life • ACT by its nature is best done thought child-friendly means: playful, creative, hands-on focus on activities; role plays, art, drama, music, poetry; metaphors and experiential exercises • Flexibility: Easily adaptable to developmental levels/needs – e.g. values clarification exercises for various ages/preferences • Non-literality of ACT undermines young people’s tendencies to comply (or resist) in content-based (literal) contexts • No diagnosis/illness, problem is unworkability of behavior: Whole child-centered and valued action-focused ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

10. A Word on ACT & the Context of Childhood OCD II • Involvement of parents  parents/family are key contextual variables of OCD and so ACT aims to change parents behavior so they promote actions at the service of valued living and undermine unworkable control • Remembering & practicing is important (can be supported by parents) and is driven by child’s chosen valued ends • Attention in children requires adapting length and content of exercises/sessions • Children are sensory oriented and love art, movement; use lots of metaphors, exercises & make it creative, fun ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

11. The ACT Path Out of OCD ACT works by changing context not content  willingness • Defusion: from a context in which thoughts are literal to mindfulness of thoughts • Acceptance: from a context of experiential control to mindfulness of bodily experience • From narrow, control-focused attention & autopilot action to self-as-context and flexible, intentional action at the service of effectively actualizing chosen valued ends ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

12. . Living Well in the Context of OCD – ACT Promotes Psychological Flexibility, i.e., Helps the Child Develop a Flexible Action Repertoire in the Presence of Unwanted Thoughts & Feelings to Sustain Long Term Valued Living Psychological Flexibility ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

13. . The ACT Question: How to promote action that instead of promoting movement away from the monsters, helps the child move towards the life they love, no matter what the monsters do? Mary had a little… ACT claims that ‘monsters’ (psych. pain) are unavoidable, given human language-based, conditioned, learning… and, even more, that struggling to control them is the problem & a main source of human suffering! This Road is Your Valued Life Unwanted experience must be faced to walk our chosen valued path – willingness to contact the monsters is a requirement to valued living

14. . The Actual Choice… Living at the service of: • Not experiencing unwanted thoughts or feelings • Acting compulsively & ineffectively to control imagined futures • Disregarding what is truly loved and the actual long term life consequences of my actions Some of the costs I pay: • Further suffering: Unwanted thoughts turning into obsessions, chronic unwanted feelings • Neglect/avoid valued relationships & activities & time spent struggling, engaged in meaningless actions • Health/stress & wellbeing costs • Other life constriction 1. Set My Valued Directions in Significant Life/Relationship Contexts: Family; friends; play; school/learning; community; fun & activities; health. 2. Take Freely Chosen Valued Actions in Those Contexts: Is wrestling with & moving away from the monster working? Is it moving you towards the life & relationships that you love? 3. Work with the Barriers in those Contexts: Are you willing to contact the monsters for the purpose of living a chosen, effective valued life? ACBS XII Minneapolis 2014 - Koke Saavedra, Psy.D.

15. ACT: Stop Struggling with Monsters & Start Living Your Chosen Life • Aware: of your present moment experience as it is, not as it says it is – are you willing to embrace the monsters & let them be? • Choose: in contact with your freely chosen valued directions – become clear about what you really value in life • Take Action: that works and actualizes the life you love – instead of struggling with the monsters ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

16. ACT for OCD in Kids: Wrestling with a Gooey Monster -> Focus on Values & Valued Action • Values Exercises for Children -> Art-Based Perspective-taking & Observing Workability of Control-Focused Actions • Drawing the Scary Monster & You • What Does the Monster Do? What Do You Do? -> Promoting Willingness, Mindfulness & Valued Action • Wrestling with a Gooey Monster Metaphor • Acceptance & Defusion Exercises -> Exposure: Willingness & Committed Action ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

17. ACT Assessment: Some helpful baseline measures ACT assessment is intervention – wrap it up with the process of therapy Assess using drawings and art – it’s not standardized and it works better! Bull’s Eye values assessment - adapted for kids Identify avoided content & avoidant actions – basic psych flexibility processes Daily Compulsions Tally [weekly] White Bear Thought Suppression Inventory – for kids ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

18. ACT Treatment: Oriented Squarely Towards Valued Action Values are directions… like going “West” Values are not goals – they orient us to the process of living, not to its outcomes Values are not feelings – we are what we do Our values are a compass that orient us – & like a lighthouse guide us through storms Drawing by Joseph Ciarrochi & David Mercer

19. Assessment: What you love & who’s getting in the way?Adapted from Rikard Wicksell • Hey, let’s talk about what you love… • Are you doing these things? • Catching the monsters and naming them… Use a dry erase or paper board, or just a sheet of paper ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

20. Values for Kids: The Chocolate Box & The Poison Bottle Source: Amy Murrell & Kelly Wilson What do you love? What do you want in your life? ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

21. . Significant Area of life ____________ 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

22. Awareness of Values:The Chocolate Box & The Poison Bottle ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D. & Amy Jenks, Psy.D. Source: Amy Murrell

23. Art-based Perspective-taking as Assessment & Intervention • Would you draw you with the scary monster? • Coloring your feelings: What do you feel? Where do you feel it? • Thought Bubbles: What does the monster say or tell you that don’t want to hear or that scares you? • How scared are you of the monster? How much do you believe it? (0 to 10) • Does the monster stop you from doing things you love? Can you see how all six basic ACT processes are being assessed in the OCD context? ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

24. The Case of Tim: Wrestling with a “Gooey Monster” 10 year old with intrusive thoughts about his parents dying in an accident. Calling parents from schools about 12 times per day. School performance, social life and participation in his favorite activities collapsed. ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

25. Tim – Week 1 out of 8 ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D. & Amy Jenks, Psy.D.

26. The Case of Tracy & The “that-was-wrong-say-sorry” Monster Six year-old girl who was afraid of being wrong and would compulsively apologize each time she had the thought that she had done something wrong. She would apologize to the point she was damaging her relationships and was developing ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

27. Tracy’s drawing # 1 here

28. Observing Workability of the Struggle with the Monster(Creative Hopefulness) • What Does the Monster Do? What Do You Do? & How does it work? • Help child observe the actual consequences (including values cost) of the following behaviors: (1) believe thoughts & believe the monster is dangerous (2) try to suppress or not to think thoughts (3) try to avoid feelings & sensations (4) avoid people, activities & situations (5) seek reassurance and other control behaviors ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

29. Monster Diary: What I Do & Get When the Monster Visits(Creative Hopefulness) When? Where? With whom? What did the monster say & what did it make you feel? What did you do? Make sure to note the following: believed monster; tried to suppress or struggle with thoughts; tried to avoid feelings; avoided activities or situations; other control-oriented behaviors What is the life cost in terms of what you love? ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

30. Metaphor: Wrestling with a Gooey Monster • Isn’t what you are doing like wrestling with a monster made of goo? • What happens if you wrestle with a gooey monster to try to get away from it? If you don’t want it you’ve got it? Is that what is happening to you? • Does it work to wrestle with a monster made of goo? Does it work for you to do what you are doing? • What does your experience tell you? Can you trust what you see rather than what you think? ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

31. Promoting Willingness & Practicing Mindfulness Drawing by Joseph Ciarrochi Wrestling with a gooey monster Quicksand metaphor Chinese finger traps Tug of war with the monster ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

32. Committed Action: What Do I Want to Do Instead? You are learning to live the life you want even when the monster shows up • Have child identify one or two truly valued actions they are willing to engage in that they have avoided as a result of the OCD – e.g., playing soccer or playing with friends during the break ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

33. Committed Action is Learning to Move with Barriers: Befriending the Scary Monster Sometimes a life well lived feels like walking through a swamp… we can learn to keep moving and keep living the life we love • Works? Is what you are doing how you want to live? • Willing? Can you welcome the monster inside your backpack so you can keep doing what you love? Can you let the monster be there & roar? • Mindfulness skills (self-as-context, defusion, acceptance, attention to now) help dissolve barriers to chosen action Source: Georg Eifert & John Forsyth.

34. Defusion: Undermining the Context of Literality Your Mind is Like a Pop-Corn Machine …and the greatest witch/wizard in the world – imagine your favorite food (Dumbledore: “In my not so humble opinion, words are the most extraordinary source of magic”) …and you don’t control it: “Try not to think for a minute…” ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

35. Try Not to Think of a White Kiwi See what happens when you try to control your thoughts? Is this what happens when you try not to hear what the monster says? ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

36. dr.kokesaavedra@gmail.com

37. Being Like the Big Blue Sky Putting your thoughts on clouds… and thanking the monster for those thoughts ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

38. . Sing it out loud with the monster!

39. Tim – Week 4 out of 8 dr.kokesaavedra@gmail.com

40. More Mindfulness Exercises: Turning Monsters into Friends • Still Quiet Place (Amy Saltzman – www.stillquietplace.com) • Body Scan for Kids & Watching your breath • Painting or sculpting your thoughts & feelings • Parade of Thoughts • “I’m your mind, let’s talk? & talking to the TV in the living room • Walking with your mind • The Ridiculus Curse - dress up the monster or have it talk in the voice of a silly character • Cartoon or a puppet show: “Me and my monster” ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

41. Making Mindfulness Child-Friendly • Attention in children is different than in teenagers or adults - shorten & simplify sessions & exercises • Children are less verbal and more sensory oriented - use more art, movement & activities - avoid being literal • Involve parents/primary caregivers in therapy & train teachers when possible • Make it fun, playful, non-judgmental, develop a nurturing, caring relationship – don’t rush to intervene and follow the child’s preferences ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

42. Monsters in the Bus ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

43. Exposure as Willingness & Committed Action An opportunity to practice mindfulness & behavioral skills while moving towards a valued life • Have child select a valued direction & identify an immediate action that will move child in that chosen direction (e.g., join football game during break time) • Help client face psychological barriers (‘monsters’) with new mindfulness & behavioral skills • Expand this work throughout treatment • Developing committed action (exposure) hierarchies ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

44. Valued Living Practice Making it work pointers Involving parents Involving schools A focus on chosen valued action not on control of experience ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

45. Tim - Last Week of Treatment Tim – Week 8 out of 8

46. “Your steps tell you where you’ve been, not where you are going…”

47. That’s all folks!

48. . BIBLIOGRAPHY • Hayes, Strosahl, & Wilson (2012). Acceptance & Commitment Therapy: The Process & Practice of Mindful Change. Gilford. • Coyne, McHugh, & Martinez (2011). ACT: Advances and applications with children, adolescents, and families. Child & Adolescent Psychiatric Clinics of North America, 20(2), 397-399. • Laurie Greco & Steven Hayes (Eds.) (2008). Acceptance and mindfulness treatments for children and adolescents: A practitioner’s guide. New Harbinger. • Rikard Wicksell – in ACT in Action DVD Series (New Harbinger) • Steven Hayes & Kirk Strosahl (Eds.) (2004) A Practical Guide to ACT. New York: Springer. • Dahl & Lundgren (2004). Living Beyond Your Pain. New Harbinger. • Wicksell, Olsson, & Hayes (2011). Mediators of change in ACT for pediatric chronic pain. Pain, 152 , 2792–2801. • . Koke Saavedra, Psy.D.