Acceptance & Commitment Therapy (ACT) ‏ Science Meets Mindfulness Joanne Steinwachs, LCSW Rocky Mountain Counselors Conference July 30, 2008 Denver, CO

2 Joanne Steinwachs, LCSW   How I came to ACT Social work Looking for a theory Why do I need a theory? What is a scientific model of human behavior?

3 Joanne Steinwachs, LCSW   What is 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

4 Joanne Steinwachs, LCSW   Where did ACT come from? ACT has been called a “third wave” behavioral therapy; placing importance on changing the way individuals relate to their experience as opposed to changing the content of their experience. Other “third wave” behavioral therapies include DBT, MBCT and FAP.

5 Joanne Steinwachs, LCSW   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?

6 Joanne Steinwachs, LCSW   RFT, not rft Relational Frame Theory

7 Joanne Steinwachs, LCSW   This is where the cartoon goes

8 Joanne Steinwachs, LCSW   RFT tells us why humans suffer the way we do Examples: Saliva Connect anything Sunset Dog watching TV

9 Joanne Steinwachs, LCSW   Relational Frame Theory Where can you go that your thoughts can't find you? We can relate anything to anything. Virtual reality.

10 Joanne Steinwachs, LCSW   Relational Frame Theory in a nutshell WORDS MAKE MONSTERS REAL.

11 Joanne Steinwachs, LCSW   So what does all this mean for us clinicians?

12 Joanne Steinwachs, LCSW   The ACT Theory of Change Our psychological problems originate from thought and language. The goal is psychological flexibility to contact with the present moment to change or persist toward our valued ends. Verbal regulation, rigid rules, prevent us from moving in valued directions.

13 Joanne Steinwachs, LCSW   The Primary ACT Model of Psychopathology Dominance of the Conceptualized Past and Feared Future: Weak Self-Knowledge Inaction, Impulsivity, or Avoidant Persistence Lack of Values Clarity; Dominance of Pliance & Avoidant Tracking Attachment to the Conceptualized Self Experiential Avoidance Cognitive Fusion Psychological Inflexibility

14 Joanne Steinwachs, LCSW   Cognitive Fusion Humans tend to live in a world excessively structured by literal language. Verbal constructions of life can even become a substitute for life itself. People cannot distinguish a verbally-based and evaluated world from the world as directly experienced through the senses.

15 Joanne Steinwachs, LCSW   Cognitive Fusion: Reason Giving We don’t just give reasons, we view reasons as causes for behavior. The reason is taken as a cause for not making progress, perhaps even in a highly valued domain of living. We are taught that we must have explanations for our behaviors and furthermore that these explanations must be coherent. Particular in the realm of behavior that doesn’t work, we really are expected to have a good explanations.

16 Joanne Steinwachs, LCSW   Examples of Fusion Saliva Lemons

17 Joanne Steinwachs, LCSW   Dominance of the Conceptualized Past and Feared Future, Weak Self Knowledge Coulda, shoulda, woulda. If only. What if? Fearful focus on the future, guilty, shamed focus on the past.

18 Joanne Steinwachs, LCSW   Lack of values clarity, Dominance of pliance and avoidant tracking I don't know what I want. I should... Nothing matters to me. I don't know who I am or what I want. Tell me how I should be. I just don't want to feel afraid, ashamed, lonely, incompetent, etc.

19 Joanne Steinwachs, LCSW   Inactivity, Impulsivity or Avoidant Persistence The couch potato, depression The addict. “My strategy hasn't worked because I haven't done it long enough or hard enough.”

20 Joanne Steinwachs, LCSW   Attachment to the Conceptualized Self I am an attorney. I am a mother. I am a loser. I am a rock star. I am... I must be a good (fill in the blank) or I am nothing.

21 Joanne Steinwachs, LCSW   Experiential Avoidance In summary, the ACT processes of psychopathology all add up to efforts to avoid private experiences such as thoughts, images, emotions and physical sensations. There is a mounting body of empirical evidence that suggests that experiential avoidance is at the root of many, if not most, psychological disorders.

22 Joanne Steinwachs, LCSW   BREAK Let's take 10 minutes.

23 Joanne Steinwachs, LCSW   The Primary ACT Model of Treatment Contact with the Present Moment Committed Action Values Self as Context Acceptance Defusion Psychological Flexibility

24 Joanne Steinwachs, LCSW   Acceptance An active embrace of the present moment, fully and without defense. Acceptance as an alternative to experiential avoidance. Willingness as a choice, not a decision, thought or feeling. Acceptance in the service of values-based action.

25 Joanne Steinwachs, LCSW   Holding your breath.

26 Joanne Steinwachs, LCSW   Cognitive Defusion ACT views thoughts as problematic more in terms of function vs. content. Fusion with thoughts limits one’s ability to be present and flexibly responsive Defusion aims to change the way one relates to their thoughts. Thoughts and feelings are not causes of behavior.

27 Joanne Steinwachs, LCSW   Defusion Milk

28 Joanne Steinwachs, LCSW   Self as Context Simple awareness; a safe place from which we can have experiences as they are and not as they say they are. Distinguishing between conceptualized versions of self (life story, self-evaluations) and the context in which these events occur. Best understood as experienced.

29 Joanne Steinwachs, LCSW   Self as Context Exercise The you that...

30 Joanne Steinwachs, LCSW   Contact with the Present Moment Acceptance and defusion are in the service of “showing up” to the present moment. Being present promotes vitality, creativity and spontaneity. Being present is reinforced within the context of the therapeutic relationship.

31 Joanne Steinwachs, LCSW   Contact with the Present Moment Exercise –Type in here

32 Joanne Steinwachs, LCSW   Values Clarified values as important “guidance system” which leads to purposeful, enriching patterns of behavior. Differentiating values from goals. Letting go of experiential control in the service of pursuing valued ends in life.

33 Joanne Steinwachs, LCSW   Values Clarification Exercise Going west. List.

34 Joanne Steinwachs, LCSW   Committed Action The ultimate goal of ACT is promoting committed action in valued directions. Any movement towards values, however small, leads to increased vitality. Emphasis on the process of growth vs. the achievement of specific goals. Action triggers barriers that breathe life into all other core interventions.

35 Joanne Steinwachs, LCSW   Committed Action Exercise Bold move.

36 Joanne Steinwachs, LCSW   This, then is the overall ACT model Contact with the Present Moment Committed Action Values Self as Context Acceptance Defusion

37 Joanne Steinwachs, LCSW   Acceptance and Mindfulness Processes Contact with the Present Moment Committed Action Values Self as Context Acceptance Defusion

38 Joanne Steinwachs, LCSW   Commitment and Behavior Change Processes Thus the name “Acceptance and Commitment Therapy” Contact with the Present Moment Committed Action Values Self as Context Acceptance Defusion

39 Joanne Steinwachs, LCSW   Self as Context ACT Question (1) Given a distinction between you and the stuff you are struggling with and trying to change

40 Joanne Steinwachs, LCSW   Self as Context Acceptance (1) Given a distinction between you and the stuff you are struggling with and trying to change (2) are you willing to have that stuff, fully and without defense ACT Question

41 Joanne Steinwachs, LCSW   Self as Context Acceptance Defusion (1) Given a distinction between you and the stuff you are struggling with and trying to change (2) are you willing to have that stuff, fully and without defense (3) as it is, and not as what it says it is, ACT Question

42 Joanne Steinwachs, LCSW   Self as Context Acceptance Defusion (1) Given a distinction between you and the stuff you are struggling with and trying to change (2) are you willing to have that stuff, fully and without defense (3) as it is, and not as what it says it is, (4) AND do what takes you in the direction Committed Action ACT Question

43 Joanne Steinwachs, LCSW   Self as Context Acceptance Defusion (1) Given a distinction between you and the stuff you are struggling with and trying to change (2) are you willing to have that stuff, fully and without defense (3) as it is, and not as what it says it is, (4) AND do what takes you in the direction Committed Action Values (5) of your chosen values ACT Question

44 Joanne Steinwachs, LCSW   Self as Context Acceptance Defusion (1) Given a distinction between you and the stuff you are struggling with and trying to change (2) are you willing to have that stuff, fully and without defense (3) as it is, and not as what it says it is, (4) AND do what takes you in the direction Committed Action Values (5) of your chosen values ACT Question

45 Joanne Steinwachs, LCSW   Self as Context Acceptance Defusion (1) Given a distinction between you and the stuff you are struggling with and trying to change (2) are you willing to have that stuff, fully and without defense (3) as it is, and not as what it says it is, (4) AND do what takes you in the direction Committed Action Values (5) of your chosen values Contact with the Present Moment (6) at this time, in this situation? ACT Question

46 Joanne Steinwachs, LCSW   If the answer is yes, that is what builds…

47 Joanne Steinwachs, LCSW   Psychological Flexibility Contact with the Present Moment Committed Action Values Self as Context Acceptance Defusion

48 Joanne Steinwachs, LCSW   A Model of the ACT Therapeutic Relationship

49 Joanne Steinwachs, LCSW   ACT Therapeutic Posture Whatever the client is experiencing is not the enemy You can’t rescue clients from difficulty Compassionately accept no reasons If the client is trapped, confused, frustrated, afraid, angry or anxious, be glad Be glad if you are experiencing this- you are in the same boat as your client

50 Joanne Steinwachs, LCSW   ACT Therapeutic Posture, Continued With acceptance, defusion, self, and values, it is more important to do as you say than to say what you do. Don’t argue, don’t persuade- it’s the client’s life and experience You are in the same boat- never protect yourself by moving one up The issue is always function, not form or frequency. When in doubt, ask yourself or the client “What is in the service of?”

51 Joanne Steinwachs, LCSW   ACT Empirical Evidence Substance abuse: one study reported less drug use than with a 12-step program Quit smoking: ACT worked better than nicotine patches n=67. Quit rates were similar at post, but, at a one-year follow up, the 2 groups were significantly different. The ACT group had maintained their gains (35% quit rates) while the nicotine patches quit rates had fallen, i.e. less than 10%

52 Joanne Steinwachs, LCSW   ACT Empirical Evidence Chronic pain: ACT gets chronic pain patients back to work faster, with fewer sick days and fewer visits to the GP, less self reported pain symptoms Stress management: Bond and Bounce study shows ACT is more effective than a previously supported behavioral approach to reducing worksite stress and anxiety

53 Joanne Steinwachs, LCSW   ACT Empirical Evidence Depression: Study with Beck’s CT and ACT- n=18, a 12 week study, ACT had better outcomes at a 6 month follow up with a reduction in believability of depressive thoughts Epilepsy: one study with 27 institutionalized South African epileptics who had just 9 hours of ACT in 2004 experienced significantly shorter and fewer seizures than those in a placebo treatment in which the therapist offered a supportive ear.

54 Joanne Steinwachs, LCSW   ACT Empirical Evidence Psychosis: ACT and re-hospitalization after 3 hours of ACT- a) 50% reduction in hospitalization b) an increase in self reporting of symptoms, therefore, accepting the symptoms of psychosis if they admit the symptoms c) reduction in the believability of distressing thoughts, hence a change in the function of the thoughts

55 Joanne Steinwachs, LCSW   ACT Empirical Evidence Panic Disorder: Acceptance methods (drawn directly from the ACT book) did a better job than control strategies in promoting successful exposure in panic disordered clients High Risk Sexual Behaviors: Components of ACT were included as a component of a successful program to reduce high-risk sexual behavior in adolescents Social Phobia: ACT versus CBT: more willingness to be anxious in the situation and thus less fear over the time of public speaking, therefore ACT more successful

56 Joanne Steinwachs, LCSW   Ways to Learn More About ACT Trainings: Russ Harris, Boulder, Sept ?? Join ACBS Values based dues. Many trainings are listed on the site along with a staggering amount of information. Join and read the list serve. Talking ACT. Read the books. Go to a Conference 2009 International Conference, Amsterdam 2010 in San Antonio Get into a consultation group Seek supervision/consultation; I have a list of local consultants.

57 Joanne Steinwachs, LCSW   Learning ACT Join ACBS, the ACT (and maybe the RFT) listserves, and spend hours on Read these books to start (plus others) ‏

58 Joanne Steinwachs, LCSW   More books on ACT with specific populations.

59 Joanne Steinwachs, LCSW   Now What? Given that the only certainty is death, and the time of death is uncertain, what matters to do right now? Acceptance and Commitment Therapy is one way to discover the answer to this question.

60 Joanne Steinwachs, LCSW   Questions Joanne Steinwachs, LCSW, PC 1776 S Jackson St Suite 616 Denver CO   Association for Contextual Behavioral Psychology