Wisconsin Public Psychiatry Network Teleconference (WPPNT)

1. 1 Wisconsin Public Psychiatry Network Teleconference (WPPNT) This teleconference is brought to you by the Wisconsin Department of Health Services (DHS) Bureau of Prevention, Treatment, and Recovery and the University of Wisconsin-Madison, Department of Psychiatry. The Department of Health Services makes no representations or warranty as to the accuracy, reliability, timeliness, quality, suitability or completeness of or results of the materials in this presentation. Use of information contained in this presentation may require express authority from a third party.

2. Acceptance & Commitment Therapy An Exciting New Treatment Approach Amanda Krupp, MFT

3. Acknowledgements • THANK YOU • Steven Hayes, Kirk Strosahl, Kelly Wilson, and others • for developing this amazing therapy model • ACT community for being open and generously sharing there materials • Ciarrochi, Blackledge & Mercer (2006) for providing • the images related to ACT processes

4. Acceptance & Commitment Therapy (ACT) “ACT is a therapeutic approach that uses acceptance and mindfulness processes, and commitment and behavior change processes, to produce greater psychological flexibility.” Hayes, Wilson, Strosahl, 1999

5. Goal of ACT Live a rich, full, meaningful life with less struggle

6. The Serenity Prayer(Reinhold Neibuhr) God grant me the Serenity to accept the Things I cannot change, Courage to change The things I can, And wisdom to know the difference But How???

7. Acceptance & Commitment Therapy (ACT) So What is ACT? • A behavioral & experiential model of therapy • Based on a new model of why humans suffer • Provides a model of how one might respond more • effectively to suffering • Aims to help people live a vital and meaningful life

8. Traditional Perspective of Suffering • Humans, given the right circumstances, are naturally • psychologically healthy, happy and content • Psychological pain is abnormal, meaning something • is wrong that needs to be fixed • If we are suffering due to difficult thoughts, feelings, or • emotions, then we should (and can) avoid, reduce, alter, • or eliminate them

9. ACT Perspective on Suffering ACT assumes that the normal psychological processes of the human mind (thoughts, feelings, memories) are often destructive, and create psychological suffering for all of us at some point If we are suffering, that means we are stuck, not broken or sick

10. ACT Perspective on Suffering Look to your experience. Have you met anyone who has never experienced . . . • Sadness • Fear • Anxiety • Negative thoughts • Scary dreams • Bad memories These are normal human experiences Our suffering is due to our use of language and our attempts to control our internal experiences

11. Philosophical & Theoretical Foundations • Relational Frame Theory • Our mind makes arbitrary connections between things. • Connections are based on history and context Tastes Yummy Apple Healthy If I say “Sand,” what shows up for you?

12. Philosophical & Theoretical Foundations: RFT It’s futile and frustrating to control the uncontrollable (Our Mind) Example: Whatever you do, don’t think about a PINK ELEPHANT Our mind has made associations between things and your body will react accordingly, but it doesn’t mean your mind is right. Example: Tornado Siren

13. “Language . . . has created the word “loneliness” to express the pain of being alone. And it has created the word “solitude” to express the glory of being alone. Paul Tillich Psychopathology evolves in part because We let our mental activity dictate our behavior

14. Brief Example • A girl is riding a horse outside. It is windy. • The horse at one point bucks and she falls off. • She forms relations in her mind between riding, falling, and the wind. • She later rides the horse and the wind starts to blow. Even though • she and the horse are fine, her heart starts racing , she starts to feel • the sensations she had when falling, and has images of falling. • Although the horse did not buck and she did not fall, her psychological • pain is the same. • She may choose to never ride outside again – not because it is • inherently dangerous, but because she is wrapped up in the psychological • pain (fear, anxiety, stress, worry, memories) when it’s windy and letting • the content of her mind dictate her behavior

15. ACT Response to Example . . . Help the girl develop Psychological Flexibility 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 (what’s most important to you)

16. Psychological Flexibility Means not holding on too tightly (or totally buying into) our own thoughts and emotions, and acting on longer term values rather than short term impulses, thoughts, and feelings Why Important • Thoughts & emotions are not good indicators of long term value • Our minds are not always right • We have no control over thoughts and emotions • If we buy into and act on them, we may overlook the more important, • sustained patterns of action which bring true meaning, vitality and • richness to our lives (i.e. 100+ horseback rides in the wind with no incident)

17. Psychological Inflexibility Preoccupation with the past or future and Loss of awareness of the present Rumination, worry, depression, anxiety Avoidance of Sensations, feelings, Thoughts, or memories Loss of contact with Or clarity of Personal values Suffering Escapism, AODA Not in touch with, or not Using what matters as Your guide Inaction, Impulsivity, Or persistent avoidance Entanglement in thoughts; Listening to our mind And ignoring experience Reactive, lacking direction Restrictive sense of self (Believing that we are what our thoughts say we are) Anxiety, OCT “You can’t do it,” “You’re not worthy”

18. Psychological Inflexibility Dominance of Conceptualizations Preoccupation with past or future and Loss of awareness of the present Lack of Values Clarity Or Contact Experiential Avoidance Avoidance of Sensations, feelings, Thoughts, or memories Loss of contact with Or clarity of Personal values Suffering Inactivity or Disorganized Activity Cognitive Fusion Entanglement in thoughts; Listening to our mind And ignoring experience Inaction, Impulsivity, Or persistent avoidance Self As Content (descriptions) Holding tightly to identity descriptions Believing that we are what our thoughts say we are

19. Preoccupation with the Pastor Imagined Future “If you aren’t in the moment, you are either looking forward to uncertainty, or back to pain and regret.” Jim Carrey

20. When we are not fully present in the moment, we miss opportunities to discover what works Loss of Contact With Present Moment

21. Dominance of the Conceptualized Past/Future Borrowed from presentation by Ron Kimball

22. We also miss enjoyment of what’s in front of us • Example: • Man forgets key and he and dog are stuck outside in the cold rain for 2 hours • Wife comes home and lets them in • Man spends an hour ruminating and complaining about what an awful • experience it was The dog goes and gets a drink And snuggles up and enjoys the Warmth of the home

23. Experiential Avoidance

24. It seems like your thoughts are blocking your way, but really they’re just along for the ride

25. Cognitive Fusion When are we fused or stuck: • “Buying into” our thoughts • Following rules about how to behave rather than • responding to the present circumstances • Attachment to the “Conceptualized Self” • Rigid ideas about who we are and who we ought to be

26. Cognitive Fusion Entanglement with our thoughts limits and shapes what we see

27. Cognitive Fusion Our thoughts are like passengers on a bus. Some give helpful advice, some not so helpful. Just because they’re on the bus and in our mind doesn’t mean we have to listen to them or follow their directions. Who’s driving your life?

28. ACT Model of Effective Living Contact with the Present Moment Preoccupation with Past or Future Be in the moment, mindful, engaged with The here-and-now Acceptance & Willingness Lack of Contact With And Clarity of Values Values, Purpose And Meaning Experiential Avoidance Psychological Flexibility Active openness to Experience without Defense or judgment Not goals, but how you Want to live your life, what you want it to be about Cognitive Defusion Inactivity or Disorganized Activity Committed Action Cognitive Fusion See our thoughts for what they are – products of the mind Content remains, but no longer Controls your behavior Moving towards what’s Most important to you Self as Context Self as Content Transcendent sense of self We are not our thoughts, feelings, images

29. ACT Model of Effective Living Contact with the Present Moment Be in the moment, mindful, engaged with The here-and-now Acceptance & Willingness Values, Purpose And Meaning Psychological Flexibility Active openness to Experience without Defense or judgment Not goals, but how you Want to live your life, what you want it to be about Cognitive Defusion Committed Action See our thoughts for what they are – products of the mind Content remains, but no longer Controls your behavior Moving towards what’s Most important to you Self as Context Transcendent sense of self We are not our thoughts, feelings, images

30. “Hexaflex”

31. Acceptance & Willingness Given the distinction between you and the stuff you struggle with, are you willing to have that stuff, as it is and not as what it says it is, and do what works in this situation?

32. Acceptance & Willingness “Today I choose life. Every morning when I wake up I can choose joy, happiness, negativity, pain . . . To feel the freedom that comes from being able to continue to make mistakes and choices – today I choose to feel life, not to deny my humanity but to embrace it.” Kevyn Aucoin

33. Experiential AvoidanceAcceptance & Willingness Actively open to and contacting psychological experiences without defense or judgment • Exercises: • Bothersome thoughts on paper • Passengers on a bus

34. Cognitive Defusion • Exercises: • Leaves on a stream • Watching a movie

35. Cognitive Fusion

36. What happens if you stop struggling? The monster might still follow you around, but now You are free to live 36

37. Self as Context A sense of self that is a consistent perspective from which to observe and accept all changing experiences • Exercises: • What are you • Chessboard or house metaphor

38. Values: What you want your life to be about Imagine you can plan your own eulogy How do you want to be remembered? What would you want people to say about you? Values are not goals or feelings – they are choices about how to live

39. Case Example • 48 year old male • Raised in Missouri • Lost job two years ago, wants to return to work • Previous diagnoses of Generalized Anxiety & Depression • Moved to WI a year ago and is living with his girlfriend • Presenting concerns: depression

40. Case Example

41. Case Example: What did I do • Start with values – develop a sense of hope and direction • Defusion and self-as-context exercises • You’re not your thoughts, feelings, memories • You aren’t your identity descriptions • Document avoidance activities • What are the costs of avoidance? • Mindfulness exercises – • be in the moment • notice and accept whatever shows up

42. The ACT Question Given a distinction between you and the stuff you are struggling with and trying to change, are you willing to have that stuff, fully and without defense, as it is, and not as what it says it is, AND do what takes you in the direction of your chosen values at this time, in this situation?

43. Research • As of March 2012, there are over 60 randomized controlled trials • Considered “empirically-based” by the American Psychological • Association for depression and chronic pain • Approaching empirically-based status for anxiety, psychosis, • substance abuse, and worksite stress • See www.contextualpsychology.org for specifics

44. Resources • www.contextualpsychology.org