Enhancing Psychotherapy with Values: practical tools

1. Enhancing Psychotherapy with Values: practical tools JoAnne Dahl University of Uppsala, Sweden Jennifer Plumb University of Nevada Reno, USA A workshop presented June 22, 2010 at ACBS World Conference VIII, Reno, NV

2. Listening to your values • What is difficult about doing values work? • What does “values work” mean to you?

3. Why values in therapy? • Values can: • Help clients define what matters to them • Create a sense of meaning and purpose • Provide a framework for setting specific goals • Provide a context in which contacting uncomfortable experiences is worthwhile • Help clients practice direct experience of valued activity, sustaining desired behavior patterns

4. therapist is coach?

5. own values as the coach

6. What brings clients in to treatment? • 1. Unwanted experiences • 2. A narrowed life • LACK OF VALUES CONSISTENT BEHAVIOR

7. Some ways clients narrow • What are some ways in which your clients have narrowed their lives? • Symptoms • Take too much time • Thoughts dictate impossibility of valued living in some way • Avoidance • Of discomfort that comes from doing certain things – very often things that matter

8. Therapeutic Contract • Early on, discriminating in the body – vitality and not (Exercise) • Moving from symptom reduction to creating a life worth living • Validate the client’s experience in wanting to reduce the ‘problem’

9. Language and values • Think about what you care about most… • At any moment in time, have you really achieved it? • Most things we care about involve temporally distant consequences • We can value things we never directly experience • World Peace, Healthy Environment • The upside of language abilities!

10. RFT: A quick overview • Transformation of functions • Process by which language can control our behavior • A good thing, in certain contexts • Rule-governed behavior • Values are a form of self-directed rules • In non-technical language, freely chosen • Pliance • Beh under control of reinforcement from social community for rule-following • Tracking • Beh under control of coordination of the rule and the natural consequences in environment • “Wear a coat, it’s cold!” • I wear it because I have kept warm in the cold by wearing coat in the past.

11. Bringing Values into the whole model • Therapeutic Role Play • Chronic pain patient • Life Compass: 0 on intimate relations/friends

12. A valued path • The quick and dirty model of valuing • Identify a Valued Direction • Look at Function • Choose Goals in Service of Values • Evaluate Choices • Establish a Pattern

13. Reconnecting to values through Suffering • In your pain you find your values, in your values you find your pain • Group Activity: • Turning Over Suffering: What Matters?

14. Valuing can be hard! • Which Master do You Serve? • Appetitive vs. aversive • Living in Service of Experiential Avoidance • Valuing can be scary!! • Uncertainty • Fear of certain outcomes • When we care, ‘real’ risks occur • Striving for Secondary Reinforcers • Show me the MONEY! • Keeping Up Appearances • Looking good, feeling empty • In RFT: Pliance or avoidance versus tracking

15. Life Line • An exercise to use throughout therapy • Applied example available in Values book • 1. Identify valued direction – suggestion, use self-compassion first • 2. Examples when turned away from self-compassion (painful events in life) • 3. What rule was learned? • 4. Ask client to experientially identify when on line towards self-compassion and when turned away from self in experiential avoidance, etc. • 5. Practice moving toward self-compassion even when get pulled into circles off the line

16. Attending to values every day • Marriage of mindfulness and values • Anything can become aversive • Practicing attending to values in activity • Landing in the positive reinforcement • Paying attention – what matters to you here? • Can you approach the situation from that place rather than a “Have To” place?

17. You have to be present to win

18. Even when it’s difficult…. • I miss Mom. • I call Mom. • She’s mad I haven’t called in a few weeks. • I feel bad. • AND I lived my values. • Will I do it again? • Where’s the reinforcer??? • = Values-Consistent Reinforcement • Because sometimes the environment doesn’t support valuing!!

19. Relationships Values loving, open, caring towards myself Treating everyone I meet with respect and kindness caring , open and honest with my family caring and open with friends seeing, listening and showing respect to those I work with Goals

20. Health Values Listening to what my body needs and taking best possible care, no matter what condition Eating nutrias foods, exercising regularly, sleeping properly taking walks every day go to yoga classes play tennis once a week Goals

21. Work Values Being useful, contributing in any context Remembering why I wanted to become a teacher being present in my job Being a caring teacher Goals

22. Own Time Values Creating a space for me to be alone with myself Getting into contact with my own voice Being willing to sit with my restlessness, loneliness Painting, dancing, writing, meditating Goals

23. Valued action tools • Life Line • Values Compass* • Trying On a Value • Bulls Eye • Valued Action Plans • Looking for Value Inside Aversives

24. Valued action tools • Trying on a Value (handout) • Use when impoverished history with valuing, need to build commitment patterns, highly fused (right/wrong) • Considerations: Seems arbitrary, requires some present moment skills to track reinforcement and attention to commitment • Values Compass • Use throughout therapy, attends to many valued domains, encourages attention to function • Considerations: Can be overwhelming for clients to do all at once, or if clients have difficulty clarifying values -- use in small doses over sessions, pick one domain

25. Revised Values compass Relationships pliance, satisfying others at my own cost 0..............10 present, loving with myself Own time 0...........10 work 10.....................0 being useful Being useless Giving myself what I need Disregarding myself Taking care of my physical needs 10...........0 Disregarding my needs Health

26. Relationships pliance, satisfying others at my own cost 0..............10 present, loving with myself Own time Balance 0...........10 being useful work 10.....................0 Being useless Giving myself what I need Disregarding myself Taking care of my physical needs 10...........0 Disregarding my needs Health

27. Valued action tools • Bulls Eye (handout) • Simple (uses common life domains), has many uses • Each session, weekly process measure, ‘outcome’ measure • Easily see progress • Valued Action Plans • Best if establish short, middle, and long-term goals • Use of “team”: Brings in social reinforcement/accountability • Attends to incremental behaviors • Considerations: Be specific, identify internal and external barriers (and internal barriers inside external barriers)

28. Valued action tools • Looking for the Value in Aversives • Unpacking anger and judgment • What value may have been transgressed? • Can you let go of judgment and move toward the value? • Looking at ‘unpleasant’ activity – reconnecting to vitality • So much of what we do doesn’t ‘feel good’ in the moment • Is there vitality inside why you do this? • Caution: Not about reframing (for it’s own sake), cheerleading, or asserting that we should seek to feel vital in all things

29. Ways to bring values to all parts of psychotherapy • Your clinical examples… • Early in Therapy • Mid-Therapy • Later in Therapy • In the Therapeutic Relationship itself

30. Values related experiential exercises • File Drawer (see Values DVD in ACT in Action Series) • Turning Over Suffering: What Matters? • Unpacking Anger & Judgment • Postures - Non-verbal way of getting values into therapy • Can you recall a time when you felt completely alive, nothing was missing? Show me a posture that demonstrates this. • How about a time when you felt like your mind was trying to protect you from getting hurt? What is that posture? • Can we make treatment about having more moments like A versus B? • All can be clinical tools, exercises for yourself, used in supervision

31. Evaluating CHoices: workability • Not about ‘right’ or ‘wrong’ • Is doing X, Y or Z the most effective way to live the life you want? • Self-injury • Compulsive behavior • If not, what could you do differently to move toward your values? • What shows up in committing to doing that? • Opportunity for mindfulness (acceptance, defusion, etc.) • Flexibility to persist or change

32. Consider: Parallel processes • What do I care about most in my life? • What is difficult about living consistent with these values? • How do my values show up inside what I do in my larger life, and in therapy? • How can I model valuing in the room? • Handout: Parallel Process Questions

33. Values related exercises: Things to remember • Discrimination training • Process vs. outcome • Building attention to positive reinforcers • Present moment awareness • Transformation of function • Reinforcement comes from values-consistent living • Vitality inside aversives? • Willingness = All or Nothing • Fully engage (acceptance for imperfection likely to arise), regardless of outcome

34. Wrap up • Slides will be posted online • Contact us anytime: • joanne.dahl@psyk.uu.se • jcplumb@gmail.com