ACCEPTANCE AND COMMITMENT THERAPY: AN ADDICTIONS FOCUSED INTRODUCTIONAn Experiential Approach to Behavior Change

Richard L. Ogle, Ph.D.Associate Dean, College of Arts and

SciencesProfessor of Psychology

University of North Carolina Wilmingtonhttp://people.uncw.edu/ogler/

Welcome, I Am Grateful You Are Here

‘Having spent the better part of my life trying to either relive the past or experiencing the future before it arrives, I have

come to believe that in between these two extremes is peace.’

ACT Assumptions - Philosophy• Emphasis on pragmatic view of truth/right.

• Functionally “workable” relationships. • What works for one might not work for another

• In the case of humans, there are three contextual fields: • Covert behavior (thoughts, feelings, memories, sensations), • Overt behavior • Controlling environmental influences

• All contextual fields must be taken into account if you are going to establish workability

ACT Assumptions – Basic Science (RFT)

• A behavioral account of language and cognition

• Language is based on arbitrary learned relations between stimuli

• Provides an evolutionary advantage, but also expands our ability to feel, predict, categorize & evaluate

• Makes behavioral avoidance possible and cognitive dominance likely

• Experiential avoidance and cognitive fusion are built into language and amplified by the culture; they are implicated in psychopathology.

• Eliminating verbal relations is impossible because they are historically acquired and automatically conditioned

• All forms of human experience, both real and imagined, can enter into these relations and govern behavior - rules

• Rule governed relations are “insensitive” to direct environmental contingencies

• All verbal relations function “behind the eyes” and therefore operate directly in the moment they exert behavioral control

• It is possible to exert control over the FUNCTIONS but not the FORM of verbal relations

What the Heck is RFT

RFT

RFT

RFT

ACT Assumptions - The Bottom Line• The root of suffering language

• We can’t live without it, but we can’t live with it• Unwanted internal experiences simply cannot be avoided

• The two central “culprits” from an ACT point of view are. . .• Cognitive Fusion: Mistaking private events as “reality”• Experiential Avoidance: Unwillingness to make contact with

undesirable, unwanted private mental events, leading to ever widening patterns of behavioral constriction

The Principle of Destructive Normalcy• Health is defined as the absence of distressing

private content

• When you have distressing private content, that is a sign you are not “healthy” and abnormal

• The goal therefore is to eliminate the distressing content in the service of being normal (the culture of “feel goodism”)

• In the event distressing content cannot be readily controlled or eliminated, the human is required to come up with a justification for why that is so (reasons)

• Reasons are culturally taught to be “good causes”

• The goal therefore is to eliminate and/or control the identified reasons in the service of achieving health

The ACT Model of Human Suffering and Psychopathology• Human pain (physical and psychological) is ubiquitous,

normal, and self-restorative• Unwillingness to have pain leads to reliance on avoidance

and control based strategies• Excessive use of control & avoidance leads to a loss of

contact with committed actions & vital purposeful living• It is not physical/mental pain per se that is the “enemy”

but our attempts to avoid or control it lead to disorder and suffering

• This cycle of suffering is strongly supported in the culture through language acquisition and socialization

Self asContext

Contact with the Present Moment

Defusion

Acceptance

Committed Action

Values

Psychological Inflexibility

ACT Model of Psychopathology

Experiential avoidance

Cognitive fusion

Attachment to the Conceptualized Self

Dominance of the conceptualized past and future; limited self-knowledge

Inaction, impulsivity, or avoidant persistence

Lack of values clarity/contact

The Essence of ACT – Psychological Flexibility • Psychological Flexibility

• … is contacting the present moment fully as a conscious human being, and based on what the situation affords changing or persisting in behavior in the service of chosen values. • Accept: What is there to be experienced, fully and without defense, for

what it is, not what it says it is• Choose: Based upon your closely held values, choose what you would

like to be about here• Take Action: Engage in committed actions that embody your values,

“inhaling” the distressing personal content as it appears

Self asContext

Contact with the Present Moment

Defusion

Acceptance

Committed Action

Values

Psychological Flexibility

The Six Core Processes

ACT Hexaflex

Psychological Flexibility

OPEN

AWARE

ENGAGED

Definition of ACT• ACT is an experiential behavioral therapy that uses

acceptance and mindfulness processes, and commitment and behavior change processes, to produce greater psychological flexibility.

• ACT is considered a 3rd Wave CBT and is like:• Dialectical Behavior Therapy• Mindfulness Based CBT

• Also like:• Mindfulness-Based Stress Reduction• Mindfulness-Based Relapse Prevention• Functional Analytic Psychotherapy

• “God, grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.”

ACT Case Conceptualization• Begin assessment with the presenting problem as understood by the client• Discover the most central thoughts, feelings, memories, sensations, and situations

the client is fused with or is avoiding• Consider behaviors that function as EA of events described in previous step• Consider Domains in which living is narrowed or constricted or avoided altogether• Consider other core ACT process that contribute to inflexibility and their treatment

implications• Fusion, Dominance of CP & CF, Attachment to CS, Lack of Values Clarity, Inaction/Impulsivity

• Consider factors that limit motivation to change• Consider aspect of social and physical environment that can inhibit change• Examine strengths that will promote flexibility• Describe a treatment plan

• What is the main issue this client is having and what is the best point of entry to attack that problem

• Reevaluate conceptualization and functional analysis throughout treatment

ACT Hexaflex Formulation Exercise

The ACT Contract• Understand History and Situation• Validate the Natural Painful Reactions

• Thoughts, feelings, uncomfortable bodily sensations

• Identify the Reaction to the Reaction• Experiential Avoidance

• Explore the Cost of EA• Amplification of problem - fusion• Loss of vitality – disconnect from values• Workability - stuckness

• Lay Out the Two-Part Plan – Creative Hopelessness• Work on how clients relates to self (thoughts, feelings, sensations)• Bring into the room the life you want to live and the things you want to do; no more

waiting. What do you want your life to be about at the level of what you want to do?

• Engage• Decide where to start• Get active ASAP

DEVELOPING WILLINGNESS/ACCEPTANCE

Undermine the Agenda of Control• In almost every case control is the problem not the solution

• Avoiding situations that produce unwanted private experiences creates a paradoxical effect (missing work creates more depression, not less depression)

• The arbitrary assumption that private events cause behavior creates a trap; you can’t behave differently until you feel differently (but since missing work is increasing depression, the person is now locked into the causal equation and can’t return to work)

• When the conditions specified in the change agenda can’t be met, you can only “explain” your predicament but there is actually little you can do about it.

Control Is the Problem, Not the Solution

• It is important to give this trap a “name”• “Trying to avoid Mr. Anxiety”• “Checking out rather than checking in”

• This trap has the paradoxical effect of adding to, rather than subtracting from, suffering• “Clean vs. Dirty Suffering”• Would you be willing to have the “clean stuff” if we could find some

way to reduce the dirty stuff?

• The experiential cost:• Gain control of your feelings, lose control of your life

• “Passengers on the bus exercise” makes this point

When is control called for?• When the event in question is under the person’s direct

stimulus control• Behavioral responses in the present moment• Willingness to enter into a situation• Being present• Holding values• Making commitments

Examine Workability• What have you tried? How has it worked? What has it cost you?

• Functionally analyze the “scope of avoidance”• Look at all the things the client has tried to solve the problem

• Consider that coming into therapy itself is another problem solving attempt• Have client define what solving the problem “means”

• Look for controlling distressing content as the “goal” • Ask the client to rate whether past actions have indeed solved the

problem• Ask client to consider whether the problem has actually

worsened over time• If appropriate, ask the client to assess the “cost” of using these

solutions

Engender Creative Hopelessness• Experientially, the client has to make “contact” with this

paradox:• The harder you try to control an unwanted private experience, the

bigger it gets• Control and experiential avoidance might work temporarily, but

rarely do their effects last and most often there is a “rebound” effect that makes things worse

• As logical as this approach seems, it will NEVER work• It isn’t that YOU are hopeless, but that this STRATEGY for addressing

these unwanted events is hopeless

• Before you can try something new, you have to stop what doesn’t work

Creative Hopelessness• “Person in the hole metaphor”

• A basic ACT intervention• Gives therapist a language “tag” to use throughout therapy

• “Are you digging right now?” • “Refusing to walk in order to avoid holes sounds like a pretty boring life”• “Analyzing how you fell in the hole isn’t going to help you get out”• “Blaming life for producing holes won’t eliminate the holes”

Acceptance as the Alternative to Control

• When is acceptance called for?• Remember the “serenity prayer?”

• With natural, conditioned uncontrollable private experiences such as emotions, memories, thoughts, sensations

• When a situation cannot be changed• Presence of chronic disease, pain, terminal state• The attitudes, beliefs and behaviors of others

• When change or control strategies produce paradoxical results (i.e., try not to think about X)

Therapist Strategies for Developing Acceptance/Willingness• Undermining Experiential Control

• Help client detect emotional control strategies and examine direct experience instead• Especially in session

• Use the concept of “workability” to help clients understand costs of EA and control efforts• Communicate that client is not broken, but using unworkable strategies

• Active encouragement to give up the struggle• Help client make experiential contact with cost of being unwilling to

reach valued life goals

VIDEOS

UNDERMINING COGNITIVE FUSION

Defusion and Acceptance• Basically, defusion strategies are designed to. .

• Create a “space” between thought and thinker• Undermine the client’s confidence in the utility of minding their

mind in certain circumstances• Appreciate the limits of brain behavior as applied to natural, whole

human behaviors• To look at mental events for what they are, not what they appear to

be

• All in the “service” of stalling sense making and reason giving

• Defusion promotes willingness; willingness promotes acceptance

Acceptance-Fusion Polarity• Accepting the fact that things are not working as they

should (What have you tried? How has it worked?)• Accepting the cost of this unworkable behavior (What has

it cost you?)• Accepting the paradoxical nature of mental control,

despite the seeming logic of it all (Control is the problem)• Accepting that control is not working and won’t ever work

(Creative hopelessness)• Accepting the presence of rule infested reactive mind

(Mind is not your friend)• Accepting all mental experiences for what they are, not

what they appear to be (Defusion)

Teach Limits of Language• The concept of “minding”• The concept of reason giving• Objectify Language

• Milk Exercise

• Reveal Hidden Properties of Language

Creating Distance Between Thought and Thinker

• Looking at thoughts as opposed to through thoughts• Giving properties to thoughts

• Color• Texture• Shape

• Mindfulness Exercises• Metaphor

• http://www.youtube.com/watch?v=z-wyaP6xXwE&feature=related

Teach Clients to Recognized Fused Qualities of Mind• Presence of comparison and evaluation• Complex/Busy• Confused• Adversarial• Warnings about consequences• Strong future or past orientation• Strong orientation about what something means about

you or others• Strong problem-solving orientation

Therapist Strategies for Undermining Fusion

• Undermining Fusion• Help clients defuse experience from action and direct attention to

present moment• Actively contrast what client’s mind says will work versus what their

experience tells them doesn’t work• Use metaphor and experiential exercises• Help clients understand their “story” and the arbitrary nature of the

causal relations in the story• Help client detect “minding.”

VIDEOS

GETTING IN CONTACT W/PRESENT MOMENT

Developing Present Moment Awareness

• Mindfulness Exercises• Mindfulness is really “Attentional Training”

• Clients can be skills deficit in attention or rigid in attention. The key is to develop online mindfulness.

• Notice events with simple awareness• Separate self-evaluations from the self that evaluates• Detect client drifting into past and future and model coming back to the present

Getting in the Present Moment• In session, the therapist looks for “shifts”, tries to elicit

avoided experiences and models this openness• “What just showed up for you?”• “Can you stay with that for just a minute?”• “Is there anything about this that is actually toxic to you right here

and now?”• “I’m willing to stay right here if you are willing to be here”

• Mindfulness exercises can help defuse the threatening aspects of being in the present moment

CONCEPTUALIZED SELF VS. SELF AS CONTEXT

Three Aspects of Self• Self-as-Content

• Our stories about who we are – self as a product of our experiences

• Self-as-Process• Self experienced in the present moment

• Self-as-Context• Self as the arena in which experience happens

• HOUSE METAPHOR

Observer “I” Exercise• Ground client

• Breathing exercise

• Memory of this morning• Notice sights, sounds, feelings, thoughts

• Remote Memory - Painful• Notice sights, sounds, feelings, thoughts

• Remote Memory - Happy• Notice sights, sounds, feelings, thoughts

• Notice the “noticer”• Also dimensions of experience change, the “you” experiencing

them do not.

VIDEOS

DEFINING VALUED DIRECTIONS

ACT Definition of Values• Verbally constructed, global, desired, and chosen life

directions• Deliberately chosen verbs and adverbs• Embraced as qualities of ongoing action across time

• Raising one’s children kindly and attentively

Values vs. Goals• Values are aspirational

• Never accomplished• Lived out over time

• Goals are tangible and can be accomplished• Marriage• Children• College Degree

• The main focus is to help clients learn the difference and commit to what they want their lives to stand for and MAKE THERAPY ABOUT THAT.

Domains for ACT Values Assessment• Work/career/community usefulness• Love/intimate relationships• Family/parenting• Friends/social connectedness• Personal growth• Health and hygiene• Spirituality• Recreation• Education/Learning

Values Exercises• Tombstone• Eulogy• Values Card-Sort• Battery Exercise (next slide)• Valued-Living Questionnaires (Later)

VIDEOS

BUILDING PATTERNS OF COMMITTED ACTION

Clinical Aspects of Committed Action• Actions which are consistent with one’s self-identified

values• These actions are “choices” that will be made in the

presence of reasons, but not for reasons• Not choosing is a form of choice, often involving

succumbing to reason giving• Committed action is a qualitative rather than quantitative

act• The workability of life in the present moment is generally

greatest when actions are consistent with values• Committed actions invariably elicit distressing private

content! To be alive means to invite these in the door.

Committed Action• Pick 1 or 2 top priority valued domains and develop an

action plan for behavior change• Functional analysis

• Help client commit to action that are linked to values – to be accomplished between sessions – being mindful of the larger behavioral patterns being assembled

• Attend to barriers and obstacles to action with acceptance, defusion, mindfulness skills, skills training, etc.

• Return to Step 1 and generalize to larger patterns of action, to other domains of living, to feared/avoided private experiences

Addressing Barriers to Committed Action• Are skills deficits going to be an issue?

• If so, provide skills training

• Being righteous rather than being real• Forgiveness: to give the grace that came before

• Being response-able and responsible• Choose each step exercise• Inhale broken commitments, name them honestly• Hop A Long Cassidy metaphor

ACT FOR ADDICTIONS

ACT and the 12-Steps• We admitted we were powerless over alcohol—that our lives had become unmanageable.

(Acceptance/Unworkability)• Came to believe that a Power greater than ourselves could restore us to sanity (Acceptance).• Made a decision to turn our will and our lives over to the care of God as we understood Him (Acceptance).

• Made a searching and fearless moral inventory of ourselves (Values Clarification).• Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.• Were entirely ready to have God remove all these defects of character.• Humbly asked Him to remove our shortcomings.• Made a list of all persons we had harmed, and became willing to make amends to them all

(Values/Committed Action).• Made direct amends to such people wherever possible, except when to do so would injure them or

others (Committed Actions).• Continued to take personal inventory and when we were wrong promptly admitted it

(Acceptance/Defusion).• Sought through prayer and meditation to improve our conscious contact with God, as we

understood Him, praying only for knowledge of His will for us and the power to carry that out (Mindfulness/Contact w/Present Moment).

• Having had a spiritual awakening as the result of these Steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs (Values/Committed Action).

Case Conceptualization - Addiction• Avoidant Repertoires

• Pattern of SA involvement• Non-SA avoidance

• Avoided Events• Context that precipitate EA• Fusion with thoughts, feelings and sensations that arise in SA triggering

contexts

• Immediate Reinforcing Effects of EA Strategies• Values• Workability of SA• Discrepancy Between Valued Life Directions and Current

Behavior

ACT for Addictions – Structured Interventions

• Think in terms of core topics• Core Topic 1: Preparing to Begin• Core-Topic 2: Making Contact with the Cost of Using• Core-Topic 3: Creative Hopelessness• Core-Topic 4: Control as the Problem • Core-Topic 5: Willingness/Acceptance• Core Topic 6: Distinguishing Person from Programming• Core-Topic 7: Barriers to Acceptance• Core-Topic 8: From Acceptance to Behavior Change• Core-Topic 9: Values and Goals• Core-Topic 10: Accepting Responsibility to Change• Core-Topic 11: Making/Keeping Commitments

ACT for Self-Stigma and Shame in Substance Abuse• Three sessions focused on addressing and reducing

stigma and shame in the context of substance abuse• Focus on Mindfulness and Acceptance

Mindfulness-Based Relapse Prevention

• http://www.mindfulrp.com/For-Clinicians.html

Using ACT in SA Groups• Committing to the process• Rescuing limits

• Things get worse before they get better

• Focus on experiential and didactic exercises• Begin and end each session with experiential exercise

• Mindfulness

• Focus on letting group members be where they are• Recognizing EA in group process• Therapists role

• Irreverent and bold

Using ACT in SA Groups – Building our Own Group Intervention• Creative Hopelessness/Workability• Values clarification• Control as the problem• Defusion• Self as context• Willingness and acceptance• Commitment