Acceptance and Commitment Therapy

1
Acceptance and Commitment Therapy

• Adaptation of Hayes Workshop Perth 2004

2
The single most remarkable fact about human
existence is how hard it is for humans to be
happy. (Hayes, Strosahl, Wilson, 1999)
3
The Assumption of Healthy Normality

• By their nature humans are psychologically
  healthy
• Abnormality is a disease or syndrome driven by
  unusual pathological processes
• We need to understand these processes and change
  them

4
The Major Reason to Suspect this is False

• The ubiquity of human suffering

5
The Ubiquity of Human Suffering

• High lifetime incidence of major DSM disorders
• High treatment demand from other persons
• High rates of divorce, sexual concerns, abuse,
  violence, prejudice, loneliness
• Some extremely destructive behaviors are both
  common and non-syndromal, e.g., suicide

6
The Example of Suicide

• Unknown in nonhumans but universal in human
  society
• About 10 incidence of attempts
• About 20 serious struggles including a plan
• About 20 serious struggles without a plan
• About 50 not associated with DSM disorder

7
A Real Example
I'm tired, so tired, but sleep does not
come. My only rest sits on the table waiting. I
am waiting, to be saved-- but I know that can't
happen.
No explanations left. Only action. The loaded
silver gun on the table... my answer. All I
have to do is pick it up, and
pull the trigger.
8
Alternative Assumption Destructive
Normality

• Normal psychological processes often are
  destructive
• We need to understand these processes and work
  within them to promote health
• The ancient nominee seems right human language
  and cognition

9
But if it is Language, Why ?

• We think we now know
• And in addition we have . . .

10
Cured Insomnia
11
Stimulus Equivalence An Example of the Core
Verbal Process
Limoo
Limoo
Betrang
Bervil
Norna
12
Derived Relations
Without this, would you know what a word means?
1. Mutual Entailment If we learn A-B we also
learn B-A
2. Combinatorial Entailment
13
RFT Argues That

• Its all kinds of bi-directional relations, each
  under particular forms of contextual control
  (Crel for relational context)

14
Derived Relations Alter Functions
3. Transformation of Functions
15
RFT argues that

• Functional transformation is under a second
  source of arbitrary contextual control (Cfunc for
  functional context) which can select, augment,
  or diminish derived functions

Cfunc Imagine the taste of selects
16
ACT / RFT Claims That . . .

• Increases in pain and the necessity of emotional
  avoidance resides inside the bi-directionality of
  human language itself

17
Bi-directional Relations Make
Self-Knowledge Useful
5
18
and Painful
Emotional trauma
Emotional trauma
Abuse
Description
Description
19
Unlike all Other Creatures on the Planet, You
Cannot Avoid Pain Situationally

• Remember a time when .
• Given that, what ARE we going to do?
• What we generally do is try to avoid pain itself
• Bad idea experiential avoidance is built into
  language

20
Experiential Avoidance

• Acceptance and Action Questionnaire
• 1. I am able to take action on a problem even if
  I am uncertain what is the right thing to do.
• 2. I often catch myself daydreaming about things
  Ive done and what I would do differently next
  time.
• 3. When I feel depressed or anxious, I am unable
  to take care of my responsibilities.
• 4. I rarely worry about getting my anxieties,
  worries, and feelings under control.
• 5. Im not afraid of my feelings.
• 6. When I evaluate something negatively, I
  usually recognize that this is just a reaction,
  not an objective fact.
• 7. When I compare myself to other people, it
  seems that most of them are handling their lives
  better than I do.
• 8. Anxiety is bad.
• 9. If I could magically remove all the painful
  experiences Ive had in my life, I would do so.
• Ratings on items 1, 4, 5, and 6 are reversed for
  scoring purposes.

21
Higher Experiential Avoidance (AAQ).

• Is associated with
• Higher anxiety
• More depression
• More overall pathology
• Poorer work performance
• Inability to learn
• Substance abuse
• Lower quality of life

• History of sexual abuse
• High risk sexual behavior
• BPD symptomatology and depression
• Thought suppression
• Alexithymia
• Anxiety sensitivity
• Long term disability

Sources Hayes et al (in press) Polusny (1997)
Toarmino (1998) Pistorello (1997) Batten,
Follette, Aban (1998) Stewart, Zvolensky,
Eifert (1998)
22
Typical Aspects of ACT

• Facing the futility of the current struggle
• Control is the problem
• Willingness is an alternative
• Self as context
• Defusion
• Choice and values
• Sensitivity to methods of entrapment
• Commitment
• Behavior change
• Practice values, goals, actions, barriers

23
Why Examine the Struggle?

• If you always do
• what youve always done
• youll always get
• what youve always got
• Its the agenda thats the problem, not the
  technique

24
There are six essential sub-processes in ACT
25
Acceptance Willingly take in privately aversive
events
26
Defusion Identify the processes and catch them
in flight (distancing)
27
Self As Context
28
Contact with the present moment
29
Values Need to find a value in struggle pain
30
Committed Action Decide to proceed despite pain
31
Acceptance and Mindfulness Processes
You can chunk them into two larger groups
32
Commitment and Behavior Change Processes
and
Thus the name Acceptance and Commitment Therapy
33
The Essence of ACT Work
and what it is, is the answer to this central ...
34
ACT Question
at this time, in this situation?
are you willing to have that stuff, fully and
without defense
of your chosen values
If the answer is yes, thats
AND do what takes you in the direction
as it is, and not as what it says it is,
Given a distinction between you and the stuff you
are struggling with and trying to change
35
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.

36
We Can Now Define ACT

• Said more simply, ACT uses acceptance and
  mindfulness processes, and commitment and
  behavior change processes, to produce greater
  psychological flexibility.

37

• ACT tries to ...

• Reduce the domination of literal, evaluative,
  temporal language
• e.g., decreased experiential avoidance live more
  here and now care less about being right etc
• Connect instead with our values
• Behave more flexibly and effectively focused on
  our values, not our fear

38

• A Simpler Version of the
• Barriers ACT Targets

• FEAR
• Fusion
• Evaluation
• Avoidance, and
• Reasons

39

• A Simpler Version of the
• Goals of ACT

• Accept
• Choose
• Take action

40
General ACT Techniques

• Deliteralization
• Inherent paradox
• Verbal confusion and sensible incoherence
• Creation of distance
• Metaphor--Point to the problem or encourage
  solutions without directly instructing them
• Experiential exercises--contact with raw
  experiential material in a safe context
• Radically functional talk
• Behavioral commitment and change exercise

41
Typical Aspects of ACT

• Facing the futility of the current struggle
• Control is the problem
• Willingness is an alternative
• Self as context
• Defusion
• Choice and values
• Sensitivity to methods of entrapment
• Commitment
• Behavior change
• Practice values, goals, actions, barriers

42
Why Examine the Struggle?

• If you always do
• what youve always done
• youll always get
• what youve always got
• Its the agenda thats the problem, not the
  technique

43
Acceptance of Where You Are

• Youve tried about everything
• Suppose your experience is valid? Suppose it
  wont work
• Metaphors
• Man in the hole
• Feedback screech
• Hammer on the head
• Rear view mirror
• Dont believe a word Im saying
• Upset / Struggle / Workability

44
Acceptance of the Unworkability of Control

• 95 solutions
• If you are not willing to have it, you will
• Self-esteem sandwich
• Metaphors
• Gun at the head
• Tug of war with a monster
• Quicksand
• Feed the tiger
• Train on tracks
• Remember three numbers

45
Defusion

• Overall purpose to catch language processes in
  flight, and bring them under contextual control,
  so that they can when needed be looked AT rather
  than looked from
• Notice their automaticity
• Notice their ease of programming
• Pop the illusion of literality
• Teach the discrimination between fusing and
  defusing
• Notice their limitations
• Learn the hooks and reduce them
• Notice their results

46
Defusion and Contact with the Moment

• Pop the illusion of literality
• Milk, milk, milk
• Physicalizing
• Notice the limitations of language
• Tell me how to walk
• Reduce the hooks
• But
• Im having the _____ that
• Thank your mind for that thought

47
Defusion

• Structure seeing the process
• Bubbles on the head
• Passengers on the bus
• Notice the automaticity of this process
• Mary had a little lamb
• Notice the ease of programming
• What are the numbers?
• Notice the paradoxical nature of controlling this
  process by instruction or deliberation
• Dont think this
• Trashcan full of things

48
Detecting Fusion

• Entanglement must be made visible
• But because it is everywhere, all-the-time,
  applied to everything, and unstoppable -- we
  dont notice it. Signs
• Time and evaluation
• Old / familiar / lifeless
• You disappear into it
• Comparative and evaluative
• Somewhen else / somewhere else
• Right and wrong conflicted
• Busy, confusing, clarifying

49
Practicing Defusion

• Pair up and each pick a negative evaluative
  thought that is troublesome
• Each rate for distress and believability
• Talk together for several minutes about what you
  might do but do NOT do anything yet

50
Practicing Defusion

• Take turns for doing defusion (5 minutes each)
• Rate again after each segment

51
Acceptance of Difficult Content

• If control is the problem, why does it persist?
• Willingness is the alternative
• Metaphors
• Two scales
• Skiing
• Chinese handcuffs
• Bum at the door
• Clean and dirty anxiety
• Leaping
• Exercises

52
Self

• Spirituality and transcendence as human
  experiences
• Metaphors
• Two computers
• Chessboard
• A box with stuff in it
• A house with furniture
• Exercises
• Observer exercise
• Find a free thought

53
Choice and Values

• Definition
• Why choice is necessary
• Exercise
• Declaration
• Values
• Traumatic deflection
• Sign on the bus
• Tombstone
• What matters

54
Entrapment

• Right and wrong
• Corpus dilecti
• Failing to forgive
• Two worms on a hook
• Process versus outcome
• Helicopter skiing
• Success and the old agenda
• Pain versus trauma
• Half measures
• The tantruming kid

55
Commitment

• Fear of commitment
• Chessboard moving
• Pen through the board
• Mt. Rose Highway
• Not a promise Not a prediction
• A stand a game selected
• Building larger patterns of behavior
• Values / goals / actions / barriers

56
The ACT Question

• Given a distinction between you and the things
  you are struggling with and trying to change, are
  you willing to experience those things, fully and
  without defense, as it is and not as it says it
  is, and do what takes you in the direction of
  your chosen values in this time and situation?

57
What if This Could be Important?

• Our deepest fear is not that we are inadequate.
  Our deepest fear is that we are powerful beyond
  measure. It is our light, not our darkness, that
  most frightens us. We ask ourselves, who am I
  to be brilliant, gorgeous, talented, fabulous?
  Actually, who are you NOT to be? You are a child
  of God. Your playing small does not serve the
  world. There is nothing enlightened about
  shrinking so that other people wont feel
  insecure around you. We are born to make
  manifest the glory of God that is within us. It
  is not just in some of us, it is in every one.
  And as we let our light shine, we give others
  permission to do the same. As we are liberated
  from our fears our presence liberates others.
• -- Nelson Mandela

58
Resources

• My email hayes_at_unr.edu
• www.relationalframetheory.com or
  www.acceptanceeandcommitmenttherapy.com
• There are list serves for ACT and RFT you can
  join
• www.contextpress.com
• The key books are available from the major dot
  com sites just search on my name
• Hayes, Barnes-Holmes, Roche (2001). Relational
  Frame Theory A Post-Skinnerian Account of Human
  Language and Cognition. New York Plenum.
• Hayes, Strosahl, Wilson (1999). Acceptance and
  Commitment Therapy An Experiential Approach to
  Behavior Change. New York Guilford Press.