Introduction to Introduction to Acceptance and Acceptance and

Commitment TherapyCommitment TherapyPatricia Bach, PhDPatricia Bach, PhD

University of Central FloridaUniversity of Central Florida

Get Out of Your Mind and Into Your Get Out of Your Mind and Into Your Life…and Into Your Therapy Life…and Into Your Therapy

SessionsSessions

AgendaAgenda IntroductionIntroduction An overview of the ACT ModelAn overview of the ACT Model Does ACT work, and how is it related to Does ACT work, and how is it related to

other evidence-based practices?other evidence-based practices? ACT techniques, some useful no matter ACT techniques, some useful no matter

what your theoretical orientationwhat your theoretical orientation ACT processes for cliniciansACT processes for clinicians

Informed ConsentInformed Consent At times this workshop will be At times this workshop will be

experientialexperiential Your privacy will never be violated, Your privacy will never be violated,

but you will be invited to take a few but you will be invited to take a few risks if you chooserisks if you choose

ConfidentialityConfidentiality No judging the level of risk taking of No judging the level of risk taking of

others: go for it or not, it is up to youothers: go for it or not, it is up to you

Why now?Why now? ACT and other mindfulness based ACT and other mindfulness based

treatments are growing in popularity.treatments are growing in popularity. The 21The 21stst century is prime time for the century is prime time for the

emergence of mindfulness and emergence of mindfulness and acceptance based treatments…acceptance based treatments…

MindlessnessMindlessness

Judgment: You’re not good Judgment: You’re not good enoughenough

“The single most remarkable fact about human existence is how hard it is for humans to be happy.”

(Hayes, Strosahl, & Wilson, 1999)

The Ubiquity of The Ubiquity of Human SufferingHuman Suffering

High lifetime incidence of major DSM High lifetime incidence of major DSM disordersdisorders

High rates of divorce, sexual High rates of divorce, sexual concerns, abuse, obesity, violence, concerns, abuse, obesity, violence, prejudice, lonelinessprejudice, loneliness

Some extremely destructive Some extremely destructive behaviors are both common and non-behaviors are both common and non-syndromal, e.g., suicide, self-injurysyndromal, e.g., suicide, self-injury

The Ubiquity of The Ubiquity of Human SufferingHuman Suffering

People don’t just suffer when things People don’t just suffer when things are are badbad

We suffer when things We suffer when things may bemay be bad bad What is the consequence of What is the consequence of

withdrawing from suffering?withdrawing from suffering?

If that’s true, why don’t we all struggle with anxiety, depressed moods, insecurities, fears, etc….?

Question:

Answer:

Oh, wait…we DO!

That thing you do…That thing you do…

Destructive NormalityDestructive Normality

Normal psychological processes Normal psychological processes often are destructiveoften are destructive

We need to understand these We need to understand these processes and work within them to processes and work within them to promote healthpromote health

One cause: human language and One cause: human language and cognition – human verbal behaviorcognition – human verbal behavior

Language is a Blessing and a Language is a Blessing and a CurseCurse

EvaluationEvaluation Problem solvingProblem solving AvoidanceAvoidance

04/22/2304/22/23

Experiential AvoidanceExperiential Avoidance Experiential avoidance is built into human Experiential avoidance is built into human

language and then amplified by the culturelanguage and then amplified by the culture– Experiential avoidance is the tendency Experiential avoidance is the tendency

to attempt to alter the form, frequency, to attempt to alter the form, frequency, or situational sensitivity of historically or situational sensitivity of historically produced negative private experience produced negative private experience (emotions, thoughts, bodily sensations) (emotions, thoughts, bodily sensations) even when attempts to do so cause even when attempts to do so cause psychological and behavioral harm psychological and behavioral harm

04/22/2304/22/23

Higher Avoidance Scores Higher Avoidance Scores Are ….Are ….

Associated with:Associated with:– Higher anxietyHigher anxiety– More depression More depression – More overall More overall

pathologypathology– Poorer work Poorer work

performanceperformance– Inability to learnInability to learn– Substance abuseSubstance abuse– Lower quality of Lower quality of

lifelife

– History of sexual History of sexual abuseabuse

– High risk sexual High risk sexual behaviorbehavior

– BPD symptomatology BPD symptomatology and depressionand depression

– Thought suppressionThought suppression– AlexithymiaAlexithymia– Anxiety sensitivityAnxiety sensitivity– Long term disabilityLong term disability

Sources: Hayes et al (2004); Polusny (1997); Toarmino (1998); Pistorello (1997); Batten, Follette, & Aban (1998); Stewart, Zvolensky, & Eifert (1998);

Central Clinical InsightsCentral Clinical Insights Trying to get rid of thoughts and feelings Trying to get rid of thoughts and feelings

can make difficult ones more important, can make difficult ones more important, andand

Narrows behavioral RepertoiresNarrows behavioral Repertoires But we can bring the But we can bring the functionsfunctions of mind of mind

under better contextual controlunder better contextual control We do that by learning to relate to the We do that by learning to relate to the

mind in a different waymind in a different way That is one of the larger messages of That is one of the larger messages of

mindfulness methods mindfulness methods -Hayes-Hayes

What is ACT?What is ACT? A form of CBTA form of CBT A form of clinical behavior analysisA form of clinical behavior analysis A mindfulness-based treatmentA mindfulness-based treatment Functional contextual therapyFunctional contextual therapy

– Behavior is situationally boundBehavior is situationally bound– Behavior is functionalBehavior is functional

Acceptance and Commitment Acceptance and Commitment TherapyTherapy

A contextually focused form of A contextually focused form of cognitive behavioral therapy that cognitive behavioral therapy that uses mindfulness and behavioral uses mindfulness and behavioral activation to increase clients’ activation to increase clients’ psychological flexibility – their ability psychological flexibility – their ability to engage in values-based behaviors to engage in values-based behaviors even while experiencing difficult or even while experiencing difficult or unwanted thoughts, feelings, and unwanted thoughts, feelings, and sensations. sensations. (http://nrepp.samhsa.gov, 2011)(http://nrepp.samhsa.gov, 2011)

ACT Therapeutic StanceACT Therapeutic Stance Universality - The struggles we have are not Universality - The struggles we have are not

fundamentally different from other human beings. We fundamentally different from other human beings. We communicate this to the client.communicate this to the client.

ACT is an experiential therapy in which the therapist is ACT is an experiential therapy in which the therapist is personally invested in the client, but is radically personally invested in the client, but is radically respectful of the client’s struggles and values.respectful of the client’s struggles and values.

To do ACT competently, you need to deal with your To do ACT competently, you need to deal with your own anxieties in the same way you are asking your own anxieties in the same way you are asking your clients to deal with their anxieties.clients to deal with their anxieties.– Open up to themOpen up to them– Get in contact with your goals and valuesGet in contact with your goals and values– Do what is there to be done Do what is there to be done (Hayes, 2006)(Hayes, 2006)

Acceptance

Committed Action

Values

Defusion

Self-as-Perspective

Contact with the Present Moment

The ACT model

PsychologicalFlexibility

A trip around the hexaflexA trip around the hexaflex

Acceptance

Committed Action

Values

Defusion

Self-as-Perspective

Contact with the Present Moment

The ACT model

PsychologicalFlexibility

Psychological FlexibilityPsychological Flexibility The ability to contact the present The ability to contact the present

moment fully as a conscious moment fully as a conscious historical human being and, based on historical human being and, based on what the situation affords, changing what the situation affords, changing or persisting in behavior in the or persisting in behavior in the service of chosen valuesservice of chosen values-Hayes-Hayes

How do you know you’ve got How do you know you’ve got ‘psychological flexibility’?‘psychological flexibility’?

Vitality!Vitality!

Assumptions of ACTAssumptions of ACT Pain in life is inevitablePain in life is inevitable Normal verbal processes contribute to Normal verbal processes contribute to

psychopathologypsychopathology Control is best applied where it works Control is best applied where it works

- to overt behavior rather than to - to overt behavior rather than to thoughts, feelings, and sensationsthoughts, feelings, and sensations

““The aim of ACT is to create a rich, The aim of ACT is to create a rich, full, meaningful life while accepting full, meaningful life while accepting the pain that inevitably goes with it.” the pain that inevitably goes with it.” (Harris, 2009)(Harris, 2009)

Show up for your own lifeShow up for your own life

What gets in the way of What gets in the way of vitality?vitality?

The ACT ‘inflexahex’The ACT ‘inflexahex’

Experiential AvoidanceExperiential Avoidance Deliberate Deliberate

attempts to avoid, attempts to avoid, control, suppress, control, suppress, escape, or get rid escape, or get rid of negatively of negatively evaluated or evaluated or unwanted unwanted thoughts, feelings thoughts, feelings and body and body sensationssensations

AcceptanceAcceptance Willingness to experience Willingness to experience

uncomfortable or unwanted thoughts, uncomfortable or unwanted thoughts, feelings, and body sensations in the feelings, and body sensations in the service of response flexibility.service of response flexibility.– ““Control is the problem, not the solution”Control is the problem, not the solution”– ““If you’re not willing to have it, then If you’re not willing to have it, then

you’ve got it”you’ve got it” Especially when control of thoughts Especially when control of thoughts

and feelings is limited or reduces and feelings is limited or reduces quality of lifequality of life

Cognitive FusionCognitive Fusion Thoughts dominate Thoughts dominate

behavior – “being behavior – “being pushed around by pushed around by thoughts” thoughts” (Harris, 2009)(Harris, 2009)

Entanglement with Entanglement with judgments – judgments – thoughts are taken thoughts are taken literallyliterally

Reduces the impact Reduces the impact of direct experienceof direct experience

Cognitive DefusionCognitive Defusion Also known as cognitive distancingAlso known as cognitive distancing Observing thoughts without Observing thoughts without

automatically taking them literallyautomatically taking them literally– ““I’m having the thought that…”I’m having the thought that…”

No need to change thought contentNo need to change thought content Changing ones relationship to Changing ones relationship to

thoughtsthoughts

Dominance of the Dominance of the conceptualized past and feared conceptualized past and feared

futurefuture Loss of contact Loss of contact

with the here and with the here and nownow

Out of touch with Out of touch with thoughts and thoughts and feelings – lack of feelings – lack of self knowledgeself knowledge

Rumination and Rumination and worryworry

Dominance of the Conceptualized Past/Future

“A mind is a wonderful tool for detecting and evaluating external dangers and developing plans for adapting to these demands, but we cannot avoid applying these same processes to the content of our private world. When we do so, we both see and produce negativity.”

…Steven Hayes

Contact with the Present Contact with the Present MomentMoment

““Mindfulness means paying attention in a Mindfulness means paying attention in a particular way: on purpose, in the present particular way: on purpose, in the present moment and non-judgmentally.” moment and non-judgmentally.” (Kabat-Zinn)(Kabat-Zinn)

Openness to experience, engagement, Openness to experience, engagement, flexibility, awareness, attention, process vs flexibility, awareness, attention, process vs outcomeoutcome

Mindfulness promotes and requires acceptance Mindfulness promotes and requires acceptance and defusion. and defusion.

Vitality is only experienced in the present Vitality is only experienced in the present moment.moment.

Attachment to the conceptualized Attachment to the conceptualized selfself

Buys into self-Buys into self-evaluations – “I am evaluations – “I am too…” or “I am too…” or “I am not…”not…”

I am my thoughts I am my thoughts and feelingsand feelings

Limiting – we are Limiting – we are more than we can more than we can ever say about ever say about ourselvesourselves

Self as PerspectiveSelf as Perspective Thinking self Vs observing selfThinking self Vs observing self You are not your thoughts and feelingsYou are not your thoughts and feelings Transcendent sense of self: thoughts, Transcendent sense of self: thoughts,

feelings and experiences change, and feelings and experiences change, and the YOU who notices these events the YOU who notices these events doesn’t changedoesn’t change

““Notice who’s having that Notice who’s having that feeling/thought/sensation”feeling/thought/sensation”

Lack of values clarityLack of values clarity What do you want What do you want

your life to be your life to be about?about?

avoidant valuesavoidant values People pleasingPeople pleasing

Values & values clarificationValues & values clarification Chosen life directionsChosen life directions Different from goalsDifferent from goals Though values are verbally Though values are verbally

construed, they are actions: you construed, they are actions: you value with your feetvalue with your feet

““Outcome is the process through Outcome is the process through which process becomes the which process becomes the outcome” outcome” (Hayes, Strosahl, & Wilson, 1999)(Hayes, Strosahl, & Wilson, 1999)

Barriers to valuesBarriers to values What is getting in What is getting in

the way of valued the way of valued living?living?

Look for avoidance, Look for avoidance, impulsivity, inaction.impulsivity, inaction.

Often the presenting Often the presenting complaint or most complaint or most obvious ‘problem obvious ‘problem behavior’behavior’

Committed ActionCommitted Action Behavior in the service of valuesBehavior in the service of values EBP’s, skill’s training, doing more or EBP’s, skill’s training, doing more or

less of something, joining a support less of something, joining a support group, homework, etc.group, homework, etc.

Value’s clarification builds motivation Value’s clarification builds motivation for committed action.for committed action.– ““what’s that in the service of?”what’s that in the service of?”

Acceptance

Committed Action

Values

Defusion

Self-as-Perspective

Contact with the Present Moment

PsychologicalFlexibility

(1) Given a distinction between you and the stuff you are struggling with and trying to

change

(4) AND do what takes you in the

direction

(5) of your chosen values

(6) at this time, in this situation?(2) are you willing to have that stuff, fully and without defense

3) as it is, and not as what it says it is,

If the answer is “yes,” that is what builds...

We can try to control the uncontrollable by We can try to control the uncontrollable by looking for security and predictability, looking for security and predictability,

always hoping to be comfortable and safe. always hoping to be comfortable and safe.

But the truth is that we can never avoid But the truth is that we can never avoid uncertainty and fear. So the central question uncertainty and fear. So the central question is not how we avoid uncertainty and fear but is not how we avoid uncertainty and fear but

how we relate to discomfort.how we relate to discomfort.

-Pema Chodron

Does ACT work?Does ACT work? Meta-analytic studies support effectiveness of Meta-analytic studies support effectiveness of

ACTACTHayes et al., 2006; Powers et al., 2009; Ost 2008Hayes et al., 2006; Powers et al., 2009; Ost 2008

RCTs for treatment of many different problemsRCTs for treatment of many different problems

Anxiety disorders, chronic pain, psychosis, Anxiety disorders, chronic pain, psychosis, trichotillomainia, substance abuse, depression, trichotillomainia, substance abuse, depression, eating disorders, management of medical eating disorders, management of medical problems, obesity, epilepsy, impulse control problems, obesity, epilepsy, impulse control disorder, etc.disorder, etc.

Psychological FlexibilityPsychological Flexibility The primary measure of PF is the The primary measure of PF is the

Acceptance and Action QuestionnaireAcceptance and Action Questionnaire– Differentiates patients from healthy controlsDifferentiates patients from healthy controls– Is correlated with variables largely Is correlated with variables largely

consistent with predictionsconsistent with predictions– Shows treatment sensitivityShows treatment sensitivity– Explains unique varianceExplains unique variance– mediates and moderates as predictedmediates and moderates as predictedBond et al., 2011; Gloster et al., 2011Bond et al., 2011; Gloster et al., 2011

Is ACT an Evidence-Based Is ACT an Evidence-Based Practice?Practice?

National Registry of Evidence-based National Registry of Evidence-based Programs and Practices (NREPP)Programs and Practices (NREPP)

APA Division 12APA Division 12– chronic painchronic pain– depressiondepression– mixed anxietymixed anxiety– Obsessive compulsive disorderObsessive compulsive disorder– psychosispsychosis

Veterans AdministrationVeterans Administration

One major difference between ACT One major difference between ACT and many other treatment and many other treatment

approachesapproaches There is no attempt to reduce There is no attempt to reduce

symptoms in ACT. symptoms in ACT. Symptom reduction often occurs, and Symptom reduction often occurs, and

it is a byproduct of treatment rather it is a byproduct of treatment rather than an explicit goal of treatment.than an explicit goal of treatment.

Can you mix ACT with other Can you mix ACT with other treatment approaches?treatment approaches?

Mindfulness is widely applicable (just Mindfulness is widely applicable (just be sure to apply it mindfully!)be sure to apply it mindfully!)

Values clarification can build tx Values clarification can build tx motivationmotivation

Most problematic is mixing Most problematic is mixing acceptance and cognitive defusion acceptance and cognitive defusion with cognitive restructuringwith cognitive restructuring

Can you mix ACT with other Can you mix ACT with other treatment approaches?treatment approaches?

The ‘Committed Action’ process The ‘Committed Action’ process often includes other EBP’soften includes other EBP’s– ERPERP– Habit reversalHabit reversal– Behavior activationBehavior activation– skills trainingskills training

ACT in practice…ACT in practice…

Hopelessness Hopelessness

Nothing has helpedNothing has helped You are my 6You are my 6thth (10 (10thth, 37, 37thth) therapist…) therapist… Meds, CBT, EMDR, acupuncture, Meds, CBT, EMDR, acupuncture,

prayer, etc. weren’t helpful, and I am prayer, etc. weren’t helpful, and I am hoping that ACT might help.hoping that ACT might help.

I’ve relapsed at least a dozen timesI’ve relapsed at least a dozen times I don’t expect this to help, and I’m I don’t expect this to help, and I’m

here because I promised my wife...here because I promised my wife...

Creative HopelessnessCreative Hopelessness Experienced by the client when she Experienced by the client when she

notices that there is an unworkable notices that there is an unworkable change agenda.change agenda.

the client has tried to make things the client has tried to make things better for herself by using control better for herself by using control strategies in contexts where they don’t strategies in contexts where they don’t workwork

Creative hopelessness creates a space Creative hopelessness creates a space for something new to happen.for something new to happen.

The solution is part of the The solution is part of the problemproblem

Doing more of the sameDoing more of the same Using control in contexts where it is Using control in contexts where it is

unhelpful, difficult, or impossibleunhelpful, difficult, or impossible– When control is usefulWhen control is useful– When it isn’tWhen it isn’t– Pain Vs sufferingPain Vs suffering

Acceptance of the Acceptance of the Unworkability of ControlUnworkability of Control

Why we stick with itWhy we stick with it– It works elsewhereIt works elsewhere– It seems to work for othersIt seems to work for others– You are told it should work for youYou are told it should work for you– It even It even SEEMSSEEMS to work in the short run to work in the short run

So what is the alternative?So what is the alternative? WillingnessWillingness

WillingnessWillingness Willing Vs wantingWilling Vs wanting

diagnosisdiagnosis DSM Vs functional diagnosesDSM Vs functional diagnoses

– What brings you here?What brings you here?– Why NOW?Why NOW?– How would you know that you are How would you know that you are

better?better?– What would you be doing if things were What would you be doing if things were

going better for you?going better for you?– Tell me about a time when your life was Tell me about a time when your life was

going better for yougoing better for you

Acceptance

Committed Action

Values

Defusion

Self-as-Perspective

Contact with the Present Moment

The ACT model

PsychologicalFlexibility

Experiential AvoidanceExperiential Avoidance

Avoiding Avoiding unwanted unwanted thoughts…thoughts…

IncreaseIncreases their s their intensitintensityy

And their And their frequencyfrequency

Experiential avoidanceExperiential avoidance What behaviors might suggest that What behaviors might suggest that

experiential avoidance is an issue for experiential avoidance is an issue for your client?your client?

Presenting complaintsPresenting complaints Behaviors with clear negative Behaviors with clear negative

consequences and obvious negative consequences and obvious negative reinforcementreinforcement

Substance abuseSubstance abuse Escape from feared stimuli (e.g., Escape from feared stimuli (e.g.,

phobias, OCD, agoraphobia)phobias, OCD, agoraphobia)

And then there are behaviors where And then there are behaviors where it is less obvious what is being it is less obvious what is being avoided.avoided.

Anger problemsAnger problems UnderachievementUnderachievement Lack of intimacyLack of intimacy

Avoidant behavior in the Avoidant behavior in the therapy sessiontherapy session

Does the client frequently change the Does the client frequently change the subject, ‘zone out’, lose eye contact?subject, ‘zone out’, lose eye contact?

Does the client often say “I don’t know” Does the client often say “I don’t know” when you ask an emotion laden or when you ask an emotion laden or interpersonally important question?interpersonally important question?

Does the client have difficultly with process Does the client have difficultly with process work regarding his/her relationship with work regarding his/her relationship with you?you?

Does the client often provide vague Does the client often provide vague answers to questions, e.g., “I guess I like answers to questions, e.g., “I guess I like my job and stuff ”; “It was no big deal”my job and stuff ”; “It was no big deal”

Avoidant behavior in the Avoidant behavior in the therapy sessiontherapy session

Watch for pseudo-acceptanceWatch for pseudo-acceptance– If I accept it, then will it go away?If I accept it, then will it go away?

AcceptanceAcceptance actively contacting psychological actively contacting psychological

experiences – directly, fully, and experiences – directly, fully, and without needless defense – while without needless defense – while behaving effectively.behaving effectively.

AcceptanceAcceptance Control is the problem/Two scales Control is the problem/Two scales

metaphormetaphor Feeding a baby tigerFeeding a baby tiger Tug of war with a monsterTug of war with a monster Chinese handcuffs/monkey trapChinese handcuffs/monkey trap If you’re not willing to have it/lose it…If you’re not willing to have it/lose it… Polygraph exercisePolygraph exercise Clean Vs dirty discomfortClean Vs dirty discomfort

Cognitive fusionCognitive fusion Inflexible behavior influenced more by Inflexible behavior influenced more by

verbal networks than by recently verbal networks than by recently experienced environmental consequencesexperienced environmental consequences

Cognitive fusionCognitive fusion

Verbally related antecedents and Verbally related antecedents and consequences such as thoughts, consequences such as thoughts, feelings, judgments and memories feelings, judgments and memories have more influence over responding have more influence over responding than direct experience with the worldthan direct experience with the world

i.e., the person ‘living in his head’i.e., the person ‘living in his head’

Cognitive fusionCognitive fusion Look for instances where responding Look for instances where responding

is guided by evaluations and is guided by evaluations and inflexible rulesinflexible rules

This may look similar to ‘irrational This may look similar to ‘irrational beliefs’beliefs’

DefusionDefusion Looking at thoughts rather than from Looking at thoughts rather than from

thoughtsthoughts Seeing thoughts as what they are, Seeing thoughts as what they are,

not as what they say they are. not as what they say they are. In contact with direct experience In contact with direct experience

rather than thoughts about rather than thoughts about experienceexperience

Defusion metaphors and Defusion metaphors and demosdemos

The automaticity of languageThe automaticity of language Mary had a little…Mary had a little… Lemon, lemon, lemonLemon, lemon, lemon sunglassessunglasses

Defusion exercisesDefusion exercises Bad cupBad cup PhysicalizingPhysicalizing ““I’m having the thought that…”I’m having the thought that…” Taking your mind for a walkTaking your mind for a walk

Notice that these exercises are not Notice that these exercises are not just defusion exercises, but also just defusion exercises, but also entail acceptance, i.e., are you entail acceptance, i.e., are you willing to have what shows up willing to have what shows up without trying to change it?without trying to change it?

Fusion is also related to attachment Fusion is also related to attachment to the conceptualized selfto the conceptualized self

Dominating concept of the Dominating concept of the evaluated past and/or feared evaluated past and/or feared

futurefuture Fusion with the verbally constructed Fusion with the verbally constructed

past or future means that one is not in past or future means that one is not in contact with the present momentcontact with the present moment

Words pull us into the past and futureWords pull us into the past and future– Rumination about the past or feared Rumination about the past or feared

futurefuture– Judgments about the self or othersJudgments about the self or others– ProcrastinationProcrastination– Anticipatory anxiety and avoidanceAnticipatory anxiety and avoidance

Contact with the Present Contact with the Present MomentMoment

““Mindfulness means paying attention in a Mindfulness means paying attention in a particular way: on purpose, in the present particular way: on purpose, in the present moment and non-judgmentally.” Kabat-Zinnmoment and non-judgmentally.” Kabat-Zinn

Mindfulness practice is based on the premise Mindfulness practice is based on the premise that only in the experience of the present that only in the experience of the present moment can one accurately perceive what is moment can one accurately perceive what is really happening, when life is fully really happening, when life is fully appreciated without the need to judge it, appreciated without the need to judge it, and when effective action can be taken. and when effective action can be taken.

Contact with the present Contact with the present momentmoment

Meditation/mindfulnessMeditation/mindfulness Leaves on a stream/soldiers in a Leaves on a stream/soldiers in a

paradeparade Just noticingJust noticing Tin can monsterTin can monster One minute mindfulnessOne minute mindfulness Counting to 10Counting to 10

Mindlessness in therapyMindlessness in therapy

MindfulnessMindfulness Mindfulness takes practiceMindfulness takes practice Do not invite your client to try any mindfulness technique Do not invite your client to try any mindfulness technique

you have not first practiced yourself!you have not first practiced yourself!

Self as context and Senses of Self as context and Senses of SelfSelf

Self as contentSelf as content Self as processSelf as process Self as context (self as perspective)Self as context (self as perspective) These are not to be construed as These are not to be construed as

three different selves, or as the only three different selves, or as the only three possible senses of selfthree possible senses of self

They are three senses of self that They are three senses of self that pertain to self-knowledgepertain to self-knowledge

Self as contentSelf as content A conceptualized self is usefulA conceptualized self is useful It allows us to participate in a verbal It allows us to participate in a verbal

social community and answer questions social community and answer questions such as:such as:– What is your name?What is your name?– What do you do for a living?What do you do for a living?– Where do you live?Where do you live?– Is that your son?Is that your son?– How old are you?How old are you?– Tell me about your hobbiesTell me about your hobbies

Attachment to the Attachment to the conceptualized selfconceptualized self

The conceptualized self is the same The conceptualized self is the same thing as self-as-content and thing as self-as-content and attachment to the conceptualized attachment to the conceptualized self is usually related to fusion with self is usually related to fusion with contentcontent

Attachment to the Attachment to the conceptualized selfconceptualized self

During case conceptualization look for During case conceptualization look for statements such as:statements such as:

I am too…I am too… If only I did…(or didn’t…) then I wouldIf only I did…(or didn’t…) then I would My problem is that I…My problem is that I… I am a (failure, loser, wimp, druggie, I am a (failure, loser, wimp, druggie,

etc.)etc.) I am not (smart, pretty, strong) enoughI am not (smart, pretty, strong) enough I can’t…I can’t…

Weak self-knowledge Weak self-knowledge and self as contentand self as content

Not usually problematic in most clinical Not usually problematic in most clinical setting – clients are more likely to be setting – clients are more likely to be tootoo attached to/fused with contentattached to/fused with content

May be problematic when one small piece of May be problematic when one small piece of the conceptualized self dominates, e.g., the conceptualized self dominates, e.g., being defined by “I got fired from a job” “I being defined by “I got fired from a job” “I flunked mathematics” “I was abused”, while flunked mathematics” “I was abused”, while ignoring most other contentignoring most other content

May be problematic in lower functioning May be problematic in lower functioning clients who have others care for them and clients who have others care for them and limited opportunity to build up a sense of selflimited opportunity to build up a sense of self

Self-as-processSelf-as-process Self-as-content refers to how one Self-as-content refers to how one

might describe the self.might describe the self. Self-as process is noticing what one is Self-as process is noticing what one is

experiencing in the present moment, experiencing in the present moment, e.g., ongoing self-awarenesse.g., ongoing self-awareness

The client with poor ongoing self-The client with poor ongoing self-awareness doesn’t know what he is awareness doesn’t know what he is thinking or feeling.thinking or feeling.

Self as processSelf as process It is experienced when we notice our own It is experienced when we notice our own

private or public experience in the present private or public experience in the present momentmoment– I feel sad (or hungry, tired, anxious, happy)I feel sad (or hungry, tired, anxious, happy)– I am thinking about what to have for dinnerI am thinking about what to have for dinner– I am walking to the coffee shopI am walking to the coffee shop– I am typing an email message to my bossI am typing an email message to my boss– I am having the thought “I don’t want to go”I am having the thought “I don’t want to go”– I am having a panic attackI am having a panic attack– I am obsessing about germsI am obsessing about germs

Weak self-knowledge andWeak self-knowledge andself as processself as process

Alexithymia – the inability to describe Alexithymia – the inability to describe ones feelingsones feelings

Clients who show excessive pliance Clients who show excessive pliance are often out of touch with their own are often out of touch with their own thoughts and feelings and may thoughts and feelings and may answer “I don’t know” or “what do answer “I don’t know” or “what do you think?” or “what do you want to you think?” or “what do you want to do?”, when asked to share an opinion do?”, when asked to share an opinion or desireor desire

Self as contextSelf as context Sometimes described as ‘the observing self’ or Sometimes described as ‘the observing self’ or

as ‘pure consciousness’ or ‘the self that is as ‘pure consciousness’ or ‘the self that is aware but does not think’aware but does not think’

Purely experiential so difficult to put into wordsPurely experiential so difficult to put into words The sense of self we get a glimpse of when we The sense of self we get a glimpse of when we

notice that we experience from a perspective notice that we experience from a perspective or locus; often experienced during mindfulness or locus; often experienced during mindfulness practice. practice.

While our thoughts and feelings change and While our thoughts and feelings change and events change over time they are experienced events change over time they are experienced from a unique perspective – YOU as the from a unique perspective – YOU as the perspective from which your life unfoldsperspective from which your life unfolds

Weak self-knowledge andWeak self-knowledge andSelf as PerspectiveSelf as Perspective

May be problematic when ability to May be problematic when ability to contact self as perspective has not contact self as perspective has not been learned or is immaturebeen learned or is immature

Evidence for weak self-knowledge in Evidence for weak self-knowledge in this domain might be a client who is this domain might be a client who is at a loss to describe values and life at a loss to describe values and life goalsgoals

Aimlessness, inertia, lack of vitalityAimlessness, inertia, lack of vitality

Self-as-contextSelf-as-context As you can see, self-as-context is As you can see, self-as-context is

difficult to describe in words. difficult to describe in words. Best contacted experientiallyBest contacted experientially

The observing selfThe observing self Guided exerciseGuided exercise

Self as context exercisesSelf as context exercises Chessboard metaphorChessboard metaphor Three senses of self discussion/link Three senses of self discussion/link

with defusion workwith defusion work Observing self exerciseObserving self exercise Mental polarityMental polarity

ValuesValues Chosen life directions; values give Chosen life directions; values give

lives meaninglives meaning In values work, distinguish choices In values work, distinguish choices

from reasoned actions; to understand from reasoned actions; to understand the distinction between a value and a the distinction between a value and a goal; to help clients choose and goal; to help clients choose and declare their values and to set declare their values and to set behavioral tasks linked to these behavioral tasks linked to these values values

Lack of values clarityLack of values clarity The client may describe a general The client may describe a general

lack of vitality and be vague about lack of vitality and be vague about values and goalsvalues and goals

Dominance of pliance andDominance of pliance and avoidant tracking avoidant tracking

Rule governed behavior (RGB)Rule governed behavior (RGB)– TrackingTracking– PliancePliance– AugmentingAugmenting

TrackingTracking ““Rule governed behavior under the Rule governed behavior under the

control of the apparent correspondence control of the apparent correspondence between the rule and the way the world between the rule and the way the world is arranged”is arranged”– Reading a map to get somewhereReading a map to get somewhere– Following a recipeFollowing a recipe– Putting on mittens after being told “it is cold, Putting on mittens after being told “it is cold,

and mittens will keep your hands warm”and mittens will keep your hands warm”– Noticing that meeting new people makes you Noticing that meeting new people makes you

anxious and staying away from parties to anxious and staying away from parties to avoid anxietyavoid anxiety

Avoidant trackingAvoidant tracking Tracking is useful.Tracking is useful. Imagine learning traffic rules or trying to Imagine learning traffic rules or trying to

get from Orlando to Tampa Bay through get from Orlando to Tampa Bay through contingency shaping rather than rule contingency shaping rather than rule governed behavior…governed behavior…

Avoidant tracking is behavior under the Avoidant tracking is behavior under the control of emotional avoidance. The rules control of emotional avoidance. The rules tracked pertain to thoughts and feelings to tracked pertain to thoughts and feelings to be avoided rather than to other available be avoided rather than to other available contingenciescontingencies

PliancePliance ““Rule governed behavior under the Rule governed behavior under the

control of apparent socially mediated control of apparent socially mediated correspondence between the rule correspondence between the rule and relevant behavior”and relevant behavior”

Notice that “pliance” is the root word Notice that “pliance” is the root word of “compliance”of “compliance”

Excessive plianceExcessive pliance Excessive pliance is problematic when Excessive pliance is problematic when

behavior is under the control of behavior is under the control of pleasing others or avoiding upsetting pleasing others or avoiding upsetting others rather than under the control others rather than under the control of other consequencesof other consequences

And note that it is problematic when it And note that it is problematic when it is is excessive;excessive; sometimes pliance is sometimes pliance is effective and values-based effective and values-based baehavior… baehavior…

Examples of excessive Examples of excessive pliancepliance

Staying in an unfulfilling relationship Staying in an unfulfilling relationship because of what Mom & Dad will think because of what Mom & Dad will think or so the other will not be upsetor so the other will not be upset

Choosing a car or career or partner Choosing a car or career or partner solely to impress otherssolely to impress others

Succumbing to peer pressureSuccumbing to peer pressure Excessive advice-seeking (which might Excessive advice-seeking (which might

also be avoidance of ‘being wrong’) also be avoidance of ‘being wrong’)

Dominance of pliance andDominance of pliance and avoidant tracking… avoidant tracking…

I always/neverI always/never Life is (unfair, painful, perfect right now…)Life is (unfair, painful, perfect right now…) Yes, but…Yes, but… If I do (an important behavior), then I will If I do (an important behavior), then I will

feel…feel… If I do (an important behavior), then If I do (an important behavior), then

others will think…others will think… What if…What if…

Values clarification exerciseValues clarification exercise Values worksheetsValues worksheets bullseyebullseye

Outcome Vs processOutcome Vs process Outcome is the process through Outcome is the process through

which process becomes the which process becomes the outcome…outcome…

Values exercisesValues exercises Defining valuesDefining values Values narrativeValues narrative Skiing metaphorSkiing metaphor Green pen.argyle socksGreen pen.argyle socks Epitaph/lifetime achievementEpitaph/lifetime achievement Deciding vs choosingDeciding vs choosing Outcome is the process through Outcome is the process through

which process becomes the outcomewhich process becomes the outcome

Committed ActionCommitted Action Overt behavior in the service of Overt behavior in the service of

values/moving in a valued directionvalues/moving in a valued direction

Persistent inaction, impulsivity, Persistent inaction, impulsivity, or avoidanceor avoidance

This is often the domain that is most This is often the domain that is most obvious to clients (and significant obvious to clients (and significant others and therapists!) and often is others and therapists!) and often is what influences them to seek helpwhat influences them to seek help

Persistent inaction, impulsivity, Persistent inaction, impulsivity, or avoidanceor avoidance

The clinical question in this domain is:The clinical question in this domain is: What is the client doing too much of, too What is the client doing too much of, too

little of, or doing in inappropriate little of, or doing in inappropriate contexts?contexts?

What is the client doing in the service of What is the client doing in the service of experiential avoidance?experiential avoidance?

What is the client doing that gets in the What is the client doing that gets in the way of valued living?way of valued living?

What does the client want to do, learn, What does the client want to do, learn, experience?experience?

Barriers to valued livingBarriers to valued living

Committed Action Committed Action and barriers to committed and barriers to committed

actionaction Eyes onEyes on ExposureExposure Ball and chainBall and chain JumpJump Garden metaphorGarden metaphor Joe the bumJoe the bum Take your keysTake your keys

Lack of values clarity and Lack of values clarity and committed actionscommitted actions

What’s that in the service of? Or, why What’s that in the service of? Or, why are you doing that intervention?are you doing that intervention?

Whose values are we talking about?Whose values are we talking about? What does the client want his/her life What does the client want his/her life

to be about?to be about?

Get out of your mind and into Get out of your mind and into your therapy sessionyour therapy session

ACT and the practitionerACT and the practitioner In ACT the core processes are In ACT the core processes are

regarded as being relevant for regarded as being relevant for all all human beings, not only for therapy human beings, not only for therapy clientsclients

As such, ACT processes can be As such, ACT processes can be implicitly or explicitly applied to the implicitly or explicitly applied to the clinician as well as the clientclinician as well as the client

Avoidance in the therapy Avoidance in the therapy roomroom

Therapist avoidance Therapist avoidance strategiesstrategies

Not being preparedNot being prepared Being really, really, Being really, really,

really preparedreally prepared Being bigBeing big Being smallBeing small Being an expertBeing an expert Being cleverBeing clever Always bringing a Always bringing a

clip-boardclip-board

Assigning LOTS of Assigning LOTS of homeworkhomework

Being a “good listener”Being a “good listener” Choosing not to Choosing not to

interveneintervene Keeping it light – coffee Keeping it light – coffee

talktalk Changing the subjectChanging the subject Chasing understandingChasing understanding Providing consolationProviding consolation

Lack of vitality in the therapy Lack of vitality in the therapy roomroom

Therapy process & experiential Therapy process & experiential workwork

Attention to therapy processAttention to therapy process What is it like to sit in the room with the What is it like to sit in the room with the

client?client? The relationshipThe relationship Are you fully present with the client?Are you fully present with the client? Is thinking about therapy interfering with Is thinking about therapy interfering with

doing therapy?doing therapy? Counter-transference (in the generic sense)Counter-transference (in the generic sense) Your feelings are dataYour feelings are data IrreverenceIrreverence Well timed process commentsWell timed process comments

– Avoidance especially common around process Avoidance especially common around process issuesissues

Acceptance and defusionAcceptance and defusion

Are you willing to be present with Are you willing to be present with your client and whatever thoughts, your client and whatever thoughts, feelings, sensation show up for feelings, sensation show up for him/her?him/her?

Are you willing to be present with Are you willing to be present with whatever thoughts and feelings show whatever thoughts and feelings show up in you during treatment sessions?up in you during treatment sessions?

Fusion and attachment to the Fusion and attachment to the conceptualized self in therapyconceptualized self in therapy

I’m a fraudI’m a fraud I’m not readyI’m not ready I’m incompetentI’m incompetent I can’t do thisI can’t do this What if I screw up?What if I screw up? Her problem is too difficultHer problem is too difficult I have no idea what to doI have no idea what to do I’ll never be able to relate to this clientI’ll never be able to relate to this client I don’t like this clientI don’t like this client

Acceptance and defusionAcceptance and defusion

Are you willing to be present with Are you willing to be present with your client and whatever thoughts, your client and whatever thoughts, feelings, sensation show up for feelings, sensation show up for him/her?him/her?

Are you willing to be present with Are you willing to be present with whatever thoughts and feelings show whatever thoughts and feelings show up in you during treatment sessions?up in you during treatment sessions?

ValuesValues What values bring you to this work?What values bring you to this work? What do you want your professional What do you want your professional

practice to be about?practice to be about?

Committed actionCommitted action What actions will help you reach your What actions will help you reach your

clinical training goals?clinical training goals? What are the barriers to committed What are the barriers to committed

action?action? ““Be yourself: everyone else is Be yourself: everyone else is

already taken” already taken” – Oscar Wilde– Oscar Wilde

CommitmentCommitment What’s your commitment?What’s your commitment?

The outcome: The outcome: Psychological Flexibility!Psychological Flexibility!

Vitality, competenceVitality, competence

Questions?Questions?

Useful referencesUseful references Patricia.bach@ucf.edu contextualpsychology.org www.newharbinger.com Bach & Moran (2008). ACT in Bach & Moran (2008). ACT in

Practice: Case Conceptualization in Practice: Case Conceptualization in Acceptance and Commitment Acceptance and Commitment Therapy. New HarbingerTherapy. New Harbinger