act for cbt clinicians

50
ACT for CBT ACT for CBT Clinicians Clinicians Steven C. Hayes Steven C. Hayes How to get these slides How to get these slides Go to my blog at Go to my blog at www.contextualpsychology.org www.contextualpsychology.org

Upload: montgomery-arjun

Post on 03-Jan-2016

56 views

Category:

Documents


0 download

DESCRIPTION

ACT for CBT Clinicians. Steven C. Hayes. How to get these slides Go to my blog at www.contextualpsychology.org. We will Do Today. You can start from where you are Look at places things can bog down Difficulty in restructuring thoughts Resistance Connection. Where Did ACT Come From?. - PowerPoint PPT Presentation

TRANSCRIPT

Page 1: ACT for CBT Clinicians

ACT for CBT CliniciansACT for CBT Clinicians

Steven C. HayesSteven C. Hayes

How to get these slidesHow to get these slides

Go to my blog at www.contextualpsychology.orgGo to my blog at www.contextualpsychology.org

Page 2: ACT for CBT Clinicians

We will Do TodayWe will Do Today

• You can start from where you are

• Look at places things can bog down

– Difficulty in restructuring thoughts– Resistance– Connection

Page 3: ACT for CBT Clinicians

Where Did ACT Come From?Where Did ACT Come From?• ACT is part of CBT writ large• In the 1980’s I did a number of studies on the CBT

model and found problems; I also developed an anxiety disorder and found personal problems with the model

• I was a behavior analysts who thought the C in CBT was needed but that we needed a bottom up account grounded in behavioral principles

• We developed an approach based on eastern and human potential sensitivities, spent over 15 years developing it and the basic model, and final released the clinical model in 1999 and the basic model in 2001

Page 4: ACT for CBT Clinicians

What is ACT?What is ACT?• Philosophical basis (can’t skip it!) in functional

contextualism, which we take from Skinner • Monistic, radically pragmatic, contextualistic and

from all of that a-ontological– The world is. We assume the one. Call it “real” but mean

“the one that is”– Our behavior partitions it– The ontological leap add nothing but irresponsiblity– So it comes down to this: what works in and with the one

world– To determine that we need your values and goals

Page 5: ACT for CBT Clinicians

What is ACT?What is ACT?• Theoretical basis in Relational Frame Theory (RFT)

– Language is based on learned relations that can be controlled by arbitrarily cues

– Provides an evolutionary advantage, but also expands the ability to feel, predict and evaluation pain; makes situational avoidance impossible; and cognitive dominance likely

– Experiential avoidance and cognitive fusion are built into language and amplified by the culture, but they are a source of psychopathology and reduced behavioral flexibility

– Fortunately there are two types of contextual regulation: relational and functional

Page 6: ACT for CBT Clinicians

The Problem and Solution The Problem and Solution

– Eliminating verbal relations and reducing automatic emotional responding is difficult in part because they are historical

– A focus on the relational context tends to increase the functional context but not vice versa

– We can choose the context more safely than choose the content

Page 7: ACT for CBT Clinicians

Self asContext

Contact with the Present Moment

Defusion

Acceptance

Committed Action

Values

EssentialComponents

of ACT

Page 8: ACT for CBT Clinicians

Self asContext

Contact with the Present Moment

Defusion

Acceptance

Committed Action

Values

Acceptance and Mindfulness

Processes

You can chunk them into two larger groups

Page 9: ACT for CBT Clinicians

Self asContext

Contact with the Present Moment

Defusion

Acceptance

Committed Action

Values

Commitment and Behavior

Change Processes

Thus the name “Acceptance and

Commitment Therapy”

and

Page 10: ACT for CBT Clinicians

Self asContext

Contact with the Present Moment

Defusion

Acceptance

Committed Action

Values

Psychological Flexibility

The Common Core of

All of These Processes is

Page 11: ACT for CBT Clinicians

04/20/2304/20/23

Psychological FlexibilityPsychological 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.

Page 12: ACT for CBT Clinicians

04/20/2304/20/23

Definition of ACTDefinition of ACT

• ACT is a contextual cognitive and behavioral therapy that uses acceptance and mindfulness processes, and commitment and behavior change processes, to produce greater psychological flexibility.

Page 13: ACT for CBT Clinicians

The Bottom LineThe Bottom Line

• Dysfunction arises from experiential avoidance, cognitive fusion, and psychological inflexibility

• Said in another way: it arises from our relationship to cognitive and emotional content and its impact on behavior, not content itself (including irrational beliefs, distorted cognitions, difficult emotions, or dysfunctional core schemas)

Page 14: ACT for CBT Clinicians

ACT does normally seek to alter the cloud of ACT does normally seek to alter the cloud of evaluations; rather, one stays in intimate contact with evaluations; rather, one stays in intimate contact with the cloud, and sometimes “peeks around” the cloud to the cloud, and sometimes “peeks around” the cloud to

make direct contact with experience and valuesmake direct contact with experience and values

Page 15: ACT for CBT Clinicians

ACT StyleACT Style

• Mistrust of “reasoning”, persuasion, logic, rationality and language processes in general

• Heavy emphasis on pragmatic truth criteria

• Use of non-literal interventions such as metaphors, stories, mindfulness, and experiential exercises

• Modeling of core ACT processes by therapist

• Non-sequential application of core processes

Page 16: ACT for CBT Clinicians

There are Many Points of ConvergenceThere are Many Points of Convergence

• ACT is a behavior therapy that also takes cognition and emotion extremely seriously

• Uses all of the behavioral elements of CBT: skill building interventions, exposure strategies, functional analysis etc

• Incorporates out of session “homework” and self monitoring tasks

• Data from out of session work is often a focus of clinical sessions

Page 17: ACT for CBT Clinicians

So is ACT So is ACT ReallyReally Different than Different than Traditional CBT?Traditional CBT?

(i.e., More that Philosophy, Theory, and Development Strategy?) (i.e., More that Philosophy, Theory, and Development Strategy?)

• You cannot answer that by superficial examinations due to a basic cognitive process

• A great way is empirically:– Correlational evidence on processes– Outcomes– Processes accounting for these outcomes

Page 18: ACT for CBT Clinicians

CorrelationallyCorrelationally

• In more than 40 studies with nearly 10,000 participants, psychological flexibility accounts for 16 to 33% of most psychological outcomes

• There is evidence that the effects of negative thoughts, difficult feelings, maladaptive coping, emotional response styles, cognitive reappraisal, and perceived controllability, are all partially or fully mediated by psychological flexibility

Page 19: ACT for CBT Clinicians

Outcomes and MediatorsOutcomes and Mediators

• Outcomes: – Eight studies so far. All over the map.

– Two negative effect sizes, one equal, five positive

– Too soon to tell

• Processes– All show a difference, some formal mediational differences

Page 20: ACT for CBT Clinicians

Is ACT Really Different than Is ACT Really Different than Traditional CBT? Traditional CBT?

• Another, also good way: Try it

• Try some of these things with yourself– The “Get Out of Your Mind” book is perfect for

that

Page 21: ACT for CBT Clinicians

CBT and ACTCBT and ACT

• And apply to your cases– Start with your difficult cases, when you bog down

• Do analysis of where you’ve bogged down and recast the case from an ACT model

– You can use ACT methods inside a treatment protocol dominated by traditional methods provided only that you tweak the goal

Page 22: ACT for CBT Clinicians

A Distress Reduction Core: Therapeutic A Distress Reduction Core: Therapeutic Processes are Used to Reduce Distress or Processes are Used to Reduce Distress or

Distressing ThoughtsDistressing Thoughts

Mindfullness Behavioral experiments Cognitive structuring

Reducing depression, anxiety or

stress

Goal setting

Skills Training

Emotional Understanding

Page 23: ACT for CBT Clinicians

A Behavioral Core: Therapeutic Processes are Used for A Behavioral Core: Therapeutic Processes are Used for Promoting Flexible, Values Congruent BehaviorPromoting Flexible, Values Congruent Behavior

Self as context Cognitive Defusion Mindfullness Acceptance Cognitive elaboration

Increasing Flexible, Values

Congruent Behavior

Value clarification

Skills Training

Commitment

Emotional Understanding

Page 24: ACT for CBT Clinicians

• A - B - C

Versus

• A - BC - VA

Context

Model DifferencesModel Differences

Page 25: ACT for CBT Clinicians

• Usually the traditional CBT rationale, and learning to detect thoughts is no problem

• It can bog down in actually restructuring thoughts

• The ACT alternative: distinguish the person from the content

• Defuse from content

CBT and ACT: CBT and ACT: Cognitive ContentCognitive Content

Page 26: ACT for CBT Clinicians

• Bogging down in actually restructuring thoughts

• Examples from the audience and group practice

Traditional CBT to ACT: Traditional CBT to ACT: Cognitive ContentCognitive Content

Page 27: ACT for CBT Clinicians

• Model it yourself

• Create a transitional rationale

• Once you start down this road you will have a bit of a hard time going back with this patient

Traditional CBT to ACT: Traditional CBT to ACT: DefusionDefusion

Page 28: ACT for CBT Clinicians

A Few Principles of Defusion A Few Principles of Defusion and Examplesand Examples

Principle 1: Find overall metaphors that structure seeing the process

Sunglasses

Bubble on the head

Passengers on the Bus

Page 29: ACT for CBT Clinicians

DefusionDefusion

Principle 2. Notice the automaticity of thoughts and their ease of programming

Mary had a little lamb

What are the numbers?

Page 30: ACT for CBT Clinicians

DefusionDefusion

Principle 3. Notice their paradoxical nature when you try to control them

Don’t think X

Page 31: ACT for CBT Clinicians

DefusionDefusion

Principle 4. Distinguish the person from the programming

Observer exerciseWatching thoughts … and noting who is watching

Page 32: ACT for CBT Clinicians

DefusionDefusionPrinciple 5. Create a context that weakens the the illusion of

literality

Milk, milk, milkTalk about the mind as another entityThere are four of us in hereThank your mind for that thoughtFunny voices

Page 33: ACT for CBT Clinicians

DefusionDefusion

Principle 6. Notice their limitations and attachments

Tell me how to walk

Deliberately instruct the opposite

Page 34: ACT for CBT Clinicians

DefusionDefusion

Principle 7. Teach the discrimination between fusing and defusing

Leaves on a stream

Meditation

Page 35: ACT for CBT Clinicians

• Another place traditional CBT can bog down is in resistance

• I can’t because …

• It’s too ….

• I’m too …

Traditional CBT to ACT: Traditional CBT to ACT: ResistanceResistance

Page 36: ACT for CBT Clinicians

• The ACT Alternative: a) creative hopelessness and workability; b) values and acceptance

• Creative hopelessness (Acceptance of where you start)

Traditional CBT to ACT: Traditional CBT to ACT: ResistanceResistance

Page 37: ACT for CBT Clinicians

• Valuing is seldom directly addressed in CBT because the underlying assumption is that living rationally will lead to valued living

• In ACT values are not rational derivatives; they are chosen starting points

Traditional CBT to ACT: Traditional CBT to ACT: ResistanceResistance

Page 38: ACT for CBT Clinicians

Values and WorkabilityValues and Workability

• Values gives us workability, which defines “truth” (not the rational truth of traditional CBT)

• With that form of truth we have a lot of leverage with resistance to change

• Cognitive rigidity – what is that in the service of; how does that work

• Emotional rigidity – acceptance• Behavioral rigidity – breaking patterns in the service

of values

Page 39: ACT for CBT Clinicians

Values and WorkabilityValues and Workability

– Values are a direction, not an outcome– They are a choice, not a decision – Emphasize wants based on undefended choice,

vitality, wholeness, intrinsic value

Page 40: ACT for CBT Clinicians

Values and WorkabilityValues and Workability

• Many techniques, but the core approach:

• Use the common sense language of free choice

• Ask what they really want

• Consider using pain as a guide

• Shape the answer by: – distinguishing values from goals – confronting pliance and avoidance – being completely and sincerely supportive

Page 41: ACT for CBT Clinicians

• Bogging down in cognitive, emotional, or behavioral resistance

• Examples from the audience and group practice

Traditional CBT to ACT: Traditional CBT to ACT: ResistanceResistance

Page 42: ACT for CBT Clinicians

• Bogging down in a lack of vitality and connection in the room

• Therapeutic detachment, socratic dialogue, logic, analysis and personal science can sometimes and with some patients lead to a dryness in the room

Traditional CBT to ACT:Traditional CBT to ACT:Lack of Connection Lack of Connection

Page 43: ACT for CBT Clinicians

• The ACT solution

• 1. Work on a transcendent sense of self (spirituality), contact with the present moment, and values

• 2. Model, implement, and target ACT processes in the relationship itself

Traditional CBT to ACT:Traditional CBT to ACT:Lack of Connection Lack of Connection

Page 44: ACT for CBT Clinicians

Lack of ConnectionLack of Connection

• Getting mindful versus battling the mind– Mindful means experiencing experiences in the

moment for what they are, without judgment, evaluation or manipulation

– The mindful state is achieved by making experiential contact with a “bigger self” that contains all consciousness and yet is distinct from that content

Page 45: ACT for CBT Clinicians

Lack of ConnectionLack of Connection

• Getting present versus modifying the present– ACT elicits and sustains negative private

experience in session, not to modify it logically, but to teach the client to approach, rather than avoid it

Page 46: ACT for CBT Clinicians

Lack of ConnectionLack of Connection

• Walking the walk versus talking the talk– In addition to targeting them, ACT encourages the

therapist to model acceptance, defusion, getting present, and values through self disclosure and consistently applying these to oneself

– ACT also encourages the therapist to implement these in the interaction between the therapist and client so that they become defining features of the therapeutic relationship

Page 47: ACT for CBT Clinicians

• Bogging down in a lack of vitality and connection in the room

• Examples from the audience and group practice

Traditional CBT to ACT:Traditional CBT to ACT:Lack of Connection Lack of Connection

Page 48: ACT for CBT Clinicians

• Examples from the audience

Other Bogged Down Places? Other Bogged Down Places?

Page 49: ACT for CBT Clinicians

What to Do?What to Do?

• If something in the ACT data or message speaks to you, explore it

• How: www.contextualpsychology.org; the list serve; the books and tapes; do more extended training workshop

• Be open but keep any skepticism you prefer

Page 50: ACT for CBT Clinicians

CBT and ACTCBT and ACT

• Read these four books to start (plus a new one on CBT and ACT when it comes out)

Guilford Springer-Verlag New Harbinger