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Act1 day

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Act1 day

  1. 1. Acceptance & Commitment Therapy - an introduction Abergavenny July 2015 Dr Ray Owen Clinical Psychologist drrayowen@gmail.com
  2. 2. Aims for the day ► Awareness of what Acceptance & Commitment Therapy (ACT) is  If being discussed  Make informed choice about whether interested to pursue further ► Awareness of  Principles underlying model  Core processes of ACT  Some examples of how used ► By means of  Presentation  Experience  Reflection  With head, heart and hands..
  3. 3. To begin with…
  4. 4. 3 people ► Peter feels sad and hopeless, and drinks too much since his wife left him ►Alina has given up on her career goals and her social life since developing a chronic pain condition ►Steve feels so stressed and anxious before difficult meetings or giving talks that he can’t face his job as a clinical psychologist
  5. 5. Office worker, 41 Married to Pete with 3 year-old son, Ben Several episodes of depression in past, good recovery each time Mother died when Sue and her twin sister Amy were 8 Partly brought up by grandmother, who died when they were 20 Sister Amy recurrent severe depression, Sue v supportive of her Amy killed herself 18 months ago Sue initially coped reasonably well, over last few months mood dropped lower and lower, stopped working, withdrawn at home, poor sleep, unresponsive to GP anti-depressants, failed to engage with IAPT input. Talking about suicide at times, attempted overdose last week, back home now. Sue
  6. 6. ► Pete just irritates me – doesn’t get why all these losses matter to me so much. Really unsympathetic after overdose. I have angry outbursts. Don’t know how much longer he’ll stay around ► Everyone I love dies; I miss them so much ► I get overwhelmed when I’m with Ben – what if he’s next?  Keep imagining awful things happening to him  Hurts so much I just let Pete look after him, and hide in bed all day, thinking ► I used to be the stronger one, and look at me now; I let everyone down, couldn’t save Amy, & I’m a lousy mother ► I can’t go on feeling like this ► Everyone – me included – would be better off if I was dead
  7. 7. Sue “Everyone I love dies” “What if Ben’s next?” “I can’t bear feeling this way” “Everyone better off without me” Rumination, mental arguments Sadness, frustration, anxiety, self-loathing ->withdrawal, avoidance Nostalgia for the past, worry & hopelessness for the future -> preoccupied, sleepless Not the same person I was -> self-loathing Not doing much, Not enjoying anything Not being good enough parent -> no sense of achievement What’s the point? What am I for now? (as couldn’t save Amy, & lousy mother) -> aimless, lack of direction STUCK UNFULFILLED
  8. 8. ►Pathological state? ►Psychological disorder? ►Mental illness?
  9. 9. ► Psychological effects common across conditions  Troubling thoughts ►And what happens next…  Unwanted feelings ►And what happens next…  Get caught up in past and future  Changed self-image  What’s the point? What am I FOR?  Decrease in sense of achievement / fulfilment, difficulties taking steps to improve life
  10. 10. STUCK UNFULFILLED Experiential avoidance: basing your actions on avoiding feeling bad Fusion: getting tangled up in thoughts Loss of contact with present moment : getting caught up in the past & the future Inflexible sense of self: getting stuck in an unhelpful 'story' about yourself Loss of contact with Values: not recognising what matters to you in life Lack of committed action: not acting effectively to live your life the way you want to
  11. 11. The Great Western Lie……. ►Our default state
  12. 12. Healthy, happy normality!
  13. 13. ► I’m not healthy, I’m not happy ► So I’m not normal
  14. 14. The answer has been found!
  15. 15. The Major Reason to Suspect this is False ►The ubiquity of human suffering
  16. 16. Alternative Assumption: Destructive Normality ►Normal psychological processes often are destructive ►Normal mental representation & processing  Role of language (Relational Frame Theory) ►We need to understand these processes and work within them to promote health and well-being
  17. 17. The struggle switch ►Suppress ►Dive in & Solve ►Push away ►Quicksand  By trying to fight, we get more drawn in
  18. 18. In a nutshell…
  19. 19. One way.. Acceptance & Commitment Therapy (ACT)  a ‘3rd-wave’ Cognitive Behaviour Therapy
  20. 20. Historical background ► Key names: ► Steve Hayes, Kelly Wilson, Robyn Walser, Russ Harris, JoAnne Dahl, Kevin Polk ►Some had background in radical behaviourism, applied behaviour analysis, fundamental learning processes
  21. 21. ►Development during the 90s, most work since Hayes et al original book published 1999 ►Since applied across huge range of problems and settings, including:  depression, anxiety, anger, substance abuse, psychosis, pain, chronic health conditions, workplace stress, epilepsy, stigma, cultural awareness, learning new skills
  22. 22. Evidence ► Overall  >125 RCTs, hundreds smaller studies  Emphasis on mediational analyses  Some problems from Ost meta-analysis (methodological differences, non-diagnosis)  Others show positive result ► A-Tjak J, G, L,. et al (2015), A Meta-Analysis of the Efficacy of Acceptance and Commitment Therapy for Clinically Relevant Mental and Physical Health Problems. Psychother Psychosom 84:30-36  Almost all available at www.contextualscience.org ► Evidence-based practice (EBP) lists  Accepted as EBP on US Dept of Health’s SAMSHA list  APA Section 12 listings of EBP cites ‘strong research support’ for use in chronic pain ► Many e.g.s with LTCs (e.g. Gregg et al 2007 JCCP)
  23. 23. Characteristics ► About building a fulfilling life, not about eliminating distress ► Rejection of concept of ‘healthy happy normality’  suffering is universal consequence of normal psychological function  Exists in context – e.g. LTCs ► Interested in psychological processes, diagnosis not seen as useful (or indeed valid) ► These processes are universal, not simply present in those with ‘a problem’ ► Hallmarks include:  metaphor  activity ► Linked to  a particular stance / philosophical approach ► ‘functional contextualism’ – development of radical behaviourism  A particular model of language, learning and behaviour ► Relational Frame Theory (RFT)
  24. 24. Functional contextualism (remember your ABCs..) ► Interested in the action in context  Think of a behaviour  In what context?  What consequence / function? ► We cannot understand, respond to or be helpful about a behaviour without knowing something about its context and function/consequence ► Easy to forget how fundamental this is  Events (actions, thoughts, feelings) often treated as intrinscially good/bad rather than considering them in context  E.g. leaving a crowded room, thinking “I can’t do this”, feeling scared
  25. 25. Relational Frame Theory ►Underpinned by a fundamental theory of  how learning occurs  how the relationships between objects builds up in human mind,  symbolic mental representation ( = language)
  26. 26. The ACT model ►Is a model of 6 interdependent and overlapping processes that help us to answer: ►What is influencing behaviour in this moment? ►How can this person lead a more fulfilling life?
  27. 27. STUCK UNFULFILLED Experiential avoidance: basing your actions on avoiding feeling bad Fusion: getting tangled up in thoughts Loss of contact with present moment : getting caught up in the past & the future Inflexible sense of self: getting stuck in an unhelpful 'story' about yourself Loss of contact with Values: not recognising what matters to you in life Lack of committed action: not acting effectively to live your life the way you want to
  28. 28. MOVING FORWARD: MORE FULFILLED Acceptance / willingness to experience: allowing whatever shows up just to be there. Defusion: treating thoughts as thoughts (not realities) Present moment awareness / mindfulness: living in the Here-and-Now Observing self / flexible perspective-taking: adopting a more flexible sense of self Awareness of Values: recognising what matters to you in life Committed action: doing the things that matter to you, even when it's difficult
  29. 29. How? ►In a nutshell…
  30. 30. Acceptance / Willingness to experience “allowing whatever shows up just to be there” Defusion “treating thoughts as thoughts (not realities)” Present Moment Awareness / Mindfulness* “living in the here-and-now” Flexible sense of self / self-as- observer “just noticing” / “not getting stuck in a story” Awareness of Values “knowing what matters to you” Committed Action (in service of Values) “doing the things that matter to you, even when it’s difficult” Core processes of ACT Moving forward: More fulfilled
  31. 31. Values From ►Loss of direction To ►Awareness of what matters in life, and how you want to be
  32. 32. “Show, don’t tell” - universal process - A health warning
  33. 33. Who matters most to you in the world? How do you want to be towards them? (How do you want to act in your dealings with them?)
  34. 34. Values ►‘what we want to stand for in life, how we want to behave, what sort of person we want to be, what sort of strengths and qualities we want to develop’. ► Russ Harris, (2009)
  35. 35. Some Values ► “respecting traditions” ► “influencing others” ► “leading” ► “experiencing new things” ► “having excitement” ► “being loyal” ► “being dependable” ► “helping those in need” ► “being creative” ► “being curious” ► “promoting justice / fairness” ► “appreciating beauty” ► “getting things done ► “looking after my health” ► “being emotionally close to those who matter to me” ► “living in a spiritual or religious way” ► “having self-control” ► “being honest” ► “looking after those I love” ► “being in contact with nature” ► “being competitive” ► “being respectful towards others” ► “nurturing others / helping them develop” ► “making a contribution to the world” ► “being sociable” ► “setting myself challenges (because I want to, not because I have to)” ► “being a good ‘team-player’” ► “being fun-loving” “something else, that’s not on this list?” N = not so important to me I = important to me V = very important to me
  36. 36. Values are… ► Ongoing ► Not the same as Goals (compass points, not destinations) ► Not the same as Actions (ways of acting) ► Chosen (the person I want to be, not what I’m stuck with) ► Not dependent on others’ approval (if no-one else ever knew) ► Not right or wrong ► Ends in themselves, more or less… (intrinsically reinforcing) ► About fulfilment, not happiness:  “a life well-lived is a life lived according to your Values”
  37. 37. Not a unique concept ► “Everything can be taken from a man or a woman but one thing: the last of human freedoms - to choose one's attitude in any given set of circumstances, to choose one's own way” ► “He who has a why to live for can bear almost any how ” Viktor Frankl, V.(1959) Man's Search for Meaning
  38. 38. So what’s stopping you?
  39. 39. CHOICE POINT AWAY FROM VALUES TOWARDS VALUES HOOKS, e.g. Urge to avoid discomfort Desire for short-term gains Old habits Hooked by thoughts Stuck in a story etc HELPERS, e.g. Awareness of Values Skills: -Present Moment Awareness / Mindfulness -Defusion -Acceptance -Flexible perspective taking Effective goal- setting Adapted from Ciarrochi, Bailey & Harris 2013
  40. 40. From ►Fused; losing the distinction between thought and reality to ►Defused; noticing thoughts as thoughts, and choosing your response
  41. 41. A warning…
  42. 42. Why are we like this?
  43. 43. Go to YouTube & watch ‘Struggling with Internal Hijackers’ https://www.youtube.com/watch?v=NdaCEO4WtDU
  44. 44. Troubling thoughts… ►An exercise
  45. 45. ‘SELF AS CONTEXT’ / flexible perspective taking from ►Stuck in a story about self to ►Flexible perspective taking, observing self
  46. 46. From ►experiential avoidance  Basing your actions on avoiding feeling bad to ►acceptance / willingness to experience  Allowing whatever shows up just to be there
  47. 47. EA as a Core Process Experiential Avoidance Depression Anxiety Chronic Pain Eating Disorders Substance Abuse Psychosis “Borderline PD” Treatment Dropout Burnout & Stress General Well Being/Functioning Work Performance Parenting Behaviors Stigma/ Prejudice Health Care Utilization Weight Loss/ Maintenance Chronic Medical Problems Recent Reviews: Biglan, Hayes & Pistorello, 2008; Chawla & Ostafin, 2007; Hayes et
  48. 48. Meet aunt Irma
  49. 49. An exercise in willingness…
  50. 50. How develop Willingness ►Noticing emotional state ►A hierarchy ►Stay aware of short-term vs long-term outcomes ►Many others
  51. 51. PRESENT MOMENT AWARENESS / mindfulness* From ►Dwelling in the past, the future, elsewhere To ►Staying present, here-and-now, noticing what’s actually happening
  52. 52. Here & Now…
  53. 53. Sue “Everyone I love dies” “What if Ben’s next?” “I can’t bear feeling this way” “Everyone better off without me” Rumination, mental arguments Sadness, frustration, anxiety, self-loathing ->withdrawal, avoidance Nostalgia for the past, worry & hopelessness for the future -> preoccupied, sleepless Not the same person I was -> self-loathing Not doing much, Not enjoying anything Not being good enough parent -> no sense of achievement What’s the point? What am I for now? (as couldn’t save Amy, & lousy mother) -> aimless, lack of direction STUCK UNFULFILLED
  54. 54. Acceptance / Willingness to experience “allowing whatever shows up just to be there” Defusion “treating thoughts as thoughts (not realities)” Present Moment Awareness / Mindfulness* “living in the here-and-now” Flexible sense of self / self-as- observer “just noticing” / “not getting stuck in a story” Awareness of Values “knowing what matters to you” Committed Action (in service of Values) “doing the things that matter to you, even when it’s difficult” Core processes of ACT Moving forward: More fulfilled
  55. 55. But why should I have to experience all those unwanted thought, unpleasant feelings and physical discomfort?
  56. 56. Your comfort zone Where the magic happens
  57. 57. To learn more… ► Formal courses  E.g. Birmingham University ‘ACT week’ October 2015 ► 2 day experiential Introductory ► 1 day clinical applications (intro) ► 2 day intermediate ► 1 day intermediate ACT for Long-term physical health conditions  See shop.bham.ac.uk ► One website:  www.contextualscience.org ► One book (to begin with):  ‘ACT made Simple’ by Russ Harris ► Well, maybe two…
  58. 58. Shameless plug Available from Routledge or usual suppliers Contact me: drrayowen@gmail.com Website: www.drrayowen.co.uk Both ‘Highly Commended’ in BMA Popular Medicine Book of Year

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