1. Acceptance and Commitment Therapy: An Addictions Focused Introduction
An Experiential Approach to Behavior Change
Richard L. Ogle, Ph.D.
Associate Dean, College of Arts and Sciences
Professor of Psychology
University of North Carolina Wilmington

2. Welcome, I Am Grateful You Are Here
‘Having spent the better part of my life trying to either relive the past or experiencing the future before it arrives, I have come to believe that in between these two extremes is peace.’

3. ACT Assumptions - Philosophy
Emphasis on pragmatic view of truth/right.
Functionally “workable” relationships.
What works for one might not work for another
In the case of humans, there are three contextual fields:
Covert behavior (thoughts, feelings, memories, sensations),
Overt behavior
Controlling environmental influences
All contextual fields must be taken into account if you are going to establish workability

4. ACT Assumptions – Basic Science (RFT)
Eliminating verbal relations is impossible because they are historically acquired and automatically conditioned
All forms of human experience, both real and imagined, can enter into these relations and govern behavior - rules
Rule governed relations are “insensitive” to direct environmental contingencies
All verbal relations function “behind the eyes” and therefore operate directly in the moment they exert behavioral control
It is possible to exert control over the FUNCTIONS but not the FORM of verbal relations
A behavioral account of language and cognition
Language is based on arbitrary learned relations between stimuli
Provides an evolutionary advantage, but also expands our ability to feel, predict, categorize & evaluate
Makes behavioral avoidance possible and cognitive dominance likely
Experiential avoidance and cognitive fusion are built into language and amplified by the culture; they are implicated in psychopathology.

5. What the Heck is RFT

6. RFT

7. RFT

8. RFT

9. ACT Assumptions - The Bottom Line
The root of suffering language
We can’t live without it, but we can’t live with it
Unwanted internal experiences simply cannot be avoided
The two central “culprits” from an ACT point of view are. . .
Cognitive Fusion: Mistaking private events as “reality”
Experiential Avoidance: Unwillingness to make contact with undesirable, unwanted private mental events, leading to ever widening patterns of behavioral constriction

10. The Principle of Destructive Normalcy
Health is defined as the absence of distressing private content
When you have distressing private content, that is a sign you are not “healthy” and abnormal
The goal therefore is to eliminate the distressing content in the service of being normal (the culture of “feel goodism”)
In the event distressing content cannot be readily controlled or eliminated, the human is required to come up with a justification for why that is so (reasons)
Reasons are culturally taught to be “good causes”
The goal therefore is to eliminate and/or control the identified reasons in the service of achieving health

11. The ACT Model of Human Suffering and Psychopathology
Human pain (physical and psychological) is ubiquitous, normal, and self-restorative
Unwillingness to have pain leads to reliance on avoidance and control based strategies
Excessive use of control & avoidance leads to a loss of contact with committed actions & vital purposeful living
It is not physical/mental pain per se that is the “enemy” but our attempts to avoid or control it lead to disorder and suffering
This cycle of suffering is strongly supported in the culture through language acquisition and socialization

12. ACT Model of Psychopathology
Dominance of the conceptualized past and future;
limited self-knowledge
Experiential avoidance
Lack of values
clarity/contact
Psychological Inflexibility
Cognitive fusion
Inaction, impulsivity,
or avoidant persistence
Attachment to the Conceptualized Self

13. The Essence of ACT – 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.
Accept: What is there to be experienced, fully and without defense, for what it is, not what it says it is
Choose: Based upon your closely held values, choose what you would like to be about here
Take Action: Engage in committed actions that embody your values, “inhaling” the distressing personal content as it appears

14. Psychological Flexibility
The Six Core Processes
Psychological Flexibility

15. ACT Hexaflex
AWARE
OPEN
ENGAGED
Psychological
Flexibility

16. Definition of ACT
ACT is an experiential behavioral therapy that uses acceptance and mindfulness processes, and commitment and behavior change processes, to produce greater psychological flexibility.
ACT is considered a 3rd Wave CBT and is like:
Dialectical Behavior Therapy
Mindfulness Based CBT
Also like:
Mindfulness-Based Stress Reduction
Mindfulness-Based Relapse Prevention
Functional Analytic Psychotherapy

17. “God, grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.”

18. ACT Case Conceptualization
Begin assessment with the presenting problem as understood by the client
Discover the most central thoughts, feelings, memories, sensations, and situations the client is fused with or is avoiding
Consider behaviors that function as EA of events described in previous step
Consider Domains in which living is narrowed or constricted or avoided altogether
Consider other core ACT process that contribute to inflexibility and their treatment implications
Fusion, Dominance of CP & CF, Attachment to CS, Lack of Values Clarity, Inaction/Impulsivity
Consider factors that limit motivation to change
Consider aspect of social and physical environment that can inhibit change
Examine strengths that will promote flexibility
Describe a treatment plan
What is the main issue this client is having and what is the best point of entry to attack that problem
Reevaluate conceptualization and functional analysis throughout treatment

19. ACT Hexaflex Formulation Exercise

20. The ACT Contract Understand History and Situation
Validate the Natural Painful Reactions
Thoughts, feelings, uncomfortable bodily sensations
Identify the Reaction to the Reaction
Experiential Avoidance
Explore the Cost of EA
Amplification of problem - fusion
Loss of vitality – disconnect from values
Workability - stuckness
Lay Out the Two-Part Plan – Creative Hopelessness
Work on how clients relates to self (thoughts, feelings, sensations)
Bring into the room the life you want to live and the things you want to do; no more waiting. What do you want your life to be about at the level of what you want to do?
Engage
Decide where to start
Get active ASAP

21. Developing Willingness/Acceptance

22. Undermine the Agenda of Control
In almost every case control is the problem not the solution
Avoiding situations that produce unwanted private experiences creates a paradoxical effect (missing work creates more depression, not less depression)
The arbitrary assumption that private events cause behavior creates a trap; you can’t behave differently until you feel differently (but since missing work is increasing depression, the person is now locked into the causal equation and can’t return to work)
When the conditions specified in the change agenda can’t be met, you can only “explain” your predicament but there is actually little you can do about it.

23. Control Is the Problem, Not the Solution
It is important to give this trap a “name”
“Trying to avoid Mr. Anxiety”
“Checking out rather than checking in”
This trap has the paradoxical effect of adding to, rather than subtracting from, suffering
“Clean vs. Dirty Suffering”
Would you be willing to have the “clean stuff” if we could find some way to reduce the dirty stuff?
The experiential cost:
Gain control of your feelings, lose control of your life
“Passengers on the bus exercise” makes this point

24. When is control called for?
When the event in question is under the person’s direct stimulus control
Behavioral responses in the present moment
Willingness to enter into a situation
Being present
Holding values
Making commitments

25. Examine Workability
What have you tried? How has it worked? What has it cost you?
Functionally analyze the “scope of avoidance”
Look at all the things the client has tried to solve the problem
Consider that coming into therapy itself is another problem solving attempt
Have client define what solving the problem “means”
Look for controlling distressing content as the “goal”
Ask the client to rate whether past actions have indeed solved the problem
Ask client to consider whether the problem has actually worsened over time
If appropriate, ask the client to assess the “cost” of using these solutions

26. Engender Creative Hopelessness
Experientially, the client has to make “contact” with this paradox:
The harder you try to control an unwanted private experience, the bigger it gets
Control and experiential avoidance might work temporarily, but rarely do their effects last and most often there is a “rebound” effect that makes things worse
As logical as this approach seems, it will NEVER work
It isn’t that YOU are hopeless, but that this STRATEGY for addressing these unwanted events is hopeless
Before you can try something new, you have to stop what doesn’t work

27. Creative Hopelessness
“Person in the hole metaphor”
A basic ACT intervention
Gives therapist a language “tag” to use throughout therapy
“Are you digging right now?”
“Refusing to walk in order to avoid holes sounds like a pretty boring life”
“Analyzing how you fell in the hole isn’t going to help you get out”
“Blaming life for producing holes won’t eliminate the holes”

28. Acceptance as the Alternative to Control
When is acceptance called for?
Remember the “serenity prayer?”
With natural, conditioned uncontrollable private experiences such as emotions, memories, thoughts, sensations
When a situation cannot be changed
Presence of chronic disease, pain, terminal state
The attitudes, beliefs and behaviors of others
When change or control strategies produce paradoxical results (i.e., try not to think about X)

29. Therapist Strategies for Developing Acceptance/Willingness
Undermining Experiential Control
Help client detect emotional control strategies and examine direct experience instead
Especially in session
Use the concept of “workability” to help clients understand costs of EA and control efforts
Communicate that client is not broken, but using unworkable strategies
Active encouragement to give up the struggle
Help client make experiential contact with cost of being unwilling to reach valued life goals

30. VIDEOS

31. Undermining Cognitive Fusion

32. Defusion and Acceptance
Basically, defusion strategies are designed to. .
Create a “space” between thought and thinker
Undermine the client’s confidence in the utility of minding their mind in certain circumstances
Appreciate the limits of brain behavior as applied to natural, whole human behaviors
To look at mental events for what they are, not what they appear to be
All in the “service” of stalling sense making and reason giving
Defusion promotes willingness; willingness promotes acceptance

33. Acceptance-Fusion Polarity
Accepting the fact that things are not working as they should (What have you tried? How has it worked?)
Accepting the cost of this unworkable behavior (What has it cost you?)
Accepting the paradoxical nature of mental control, despite the seeming logic of it all (Control is the problem)
Accepting that control is not working and won’t ever work (Creative hopelessness)
Accepting the presence of rule infested reactive mind (Mind is not your friend)
Accepting all mental experiences for what they are, not what they appear to be (Defusion)

34. Teach Limits of Language
The concept of “minding”
The concept of reason giving
Objectify Language
Milk Exercise
Reveal Hidden Properties of Language

35. Creating Distance Between Thought and Thinker
Looking at thoughts as opposed to through thoughts
Giving properties to thoughts
Color
Texture
Shape
Mindfulness Exercises
Metaphor

36. Teach Clients to Recognized Fused Qualities of Mind
Presence of comparison and evaluation
Complex/Busy
Confused
Adversarial
Warnings about consequences
Strong future or past orientation
Strong orientation about what something means about you or others
Strong problem-solving orientation

37. Therapist Strategies for Undermining Fusion
Help clients defuse experience from action and direct attention to present moment
Actively contrast what client’s mind says will work versus what their experience tells them doesn’t work
Use metaphor and experiential exercises
Help clients understand their “story” and the arbitrary nature of the causal relations in the story
Help client detect “minding.”

38. VIDEOS

39. Getting in Contact w/Present Moment

40. Developing Present Moment Awareness
Mindfulness Exercises
Mindfulness is really “Attentional Training”
Clients can be skills deficit in attention or rigid in attention. The key is to develop online mindfulness.
Notice events with simple awareness
Separate self-evaluations from the self that evaluates
Detect client drifting into past and future and model coming back to the present

41. Getting in the Present Moment
In session, the therapist looks for “shifts”, tries to elicit avoided experiences and models this openness
“What just showed up for you?”
“Can you stay with that for just a minute?”
“Is there anything about this that is actually toxic to you right here and now?”
“I’m willing to stay right here if you are willing to be here”
Mindfulness exercises can help defuse the threatening aspects of being in the present moment

42. Conceptualized Self vs. Self as Context

43. Three Aspects of Self Self-as-Content Self-as-Process Self-as-Context
Our stories about who we are – self as a product of our experiences
Self-as-Process
Self experienced in the present moment
Self-as-Context
Self as the arena in which experience happens
HOUSE METAPHOR

44. Observer “I” Exercise Ground client Memory of this morning
Breathing exercise
Memory of this morning
Notice sights, sounds, feelings, thoughts
Remote Memory - Painful
Remote Memory - Happy
Notice the “noticer”
Also dimensions of experience change, the “you” experiencing them do not.

45. VIDEOS

46. Defining Valued Directions

47. ACT Definition of Values
Verbally constructed, global, desired, and chosen life directions
Deliberately chosen verbs and adverbs
Embraced as qualities of ongoing action across time
Raising one’s children kindly and attentively

48. Values vs. Goals Values are aspirational
Never accomplished
Lived out over time
Goals are tangible and can be accomplished
Marriage
Children
College Degree
The main focus is to help clients learn the difference and commit to what they want their lives to stand for and MAKE THERAPY ABOUT THAT.

49. Domains for ACT Values Assessment
Work/career/community usefulness
Love/intimate relationships
Family/parenting
Friends/social connectedness
Personal growth
Health and hygiene
Spirituality
Recreation
Education/Learning

50. Values Exercises Tombstone Eulogy Values Card-Sort
Battery Exercise (next slide)
Valued-Living Questionnaires (Later)

52. VIDEOS

53. Building Patterns of Committed Action

54. Clinical Aspects of Committed Action
Actions which are consistent with one’s self-identified values
These actions are “choices” that will be made in the presence of reasons, but not for reasons
Not choosing is a form of choice, often involving succumbing to reason giving
Committed action is a qualitative rather than quantitative act
The workability of life in the present moment is generally greatest when actions are consistent with values
Committed actions invariably elicit distressing private content! To be alive means to invite these in the door.

55. Committed Action
Pick 1 or 2 top priority valued domains and develop an action plan for behavior change
Functional analysis
Help client commit to action that are linked to values – to be accomplished between sessions – being mindful of the larger behavioral patterns being assembled
Attend to barriers and obstacles to action with acceptance, defusion, mindfulness skills, skills training, etc.
Return to Step 1 and generalize to larger patterns of action, to other domains of living, to feared/avoided private experiences

56. Addressing Barriers to Committed Action
Are skills deficits going to be an issue?
If so, provide skills training
Being righteous rather than being real
Forgiveness: to give the grace that came before
Being response-able and responsible
Choose each step exercise
Inhale broken commitments, name them honestly
Hop A Long Cassidy metaphor

57. ACT for Addictions

58. ACT and the 12-Steps
We admitted we were powerless over alcohol—that our lives had become unmanageable. (Acceptance/Unworkability)
Came to believe that a Power greater than ourselves could restore us to sanity (Acceptance).
Made a decision to turn our will and our lives over to the care of God as we understood Him (Acceptance).
Made a searching and fearless moral inventory of ourselves (Values Clarification).
Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
Were entirely ready to have God remove all these defects of character.
Humbly asked Him to remove our shortcomings.
Made a list of all persons we had harmed, and became willing to make amends to them all (Values/Committed Action).
Made direct amends to such people wherever possible, except when to do so would injure them or others (Committed Actions).
Continued to take personal inventory and when we were wrong promptly admitted it (Acceptance/Defusion).
Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out (Mindfulness/Contact w/Present Moment).
Having had a spiritual awakening as the result of these Steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs (Values/Committed Action).

59. Case Conceptualization - Addiction
Avoidant Repertoires
Pattern of SA involvement
Non-SA avoidance
Avoided Events
Context that precipitate EA
Fusion with thoughts, feelings and sensations that arise in SA triggering contexts
Immediate Reinforcing Effects of EA Strategies
Values
Workability of SA
Discrepancy Between Valued Life Directions and Current Behavior

60. ACT for Addictions – Structured Interventions
Think in terms of core topics
Core Topic 1: Preparing to Begin
Core-Topic 2: Making Contact with the Cost of Using
Core-Topic 3: Creative Hopelessness
Core-Topic 4: Control as the Problem
Core-Topic 5: Willingness/Acceptance
Core Topic 6: Distinguishing Person from Programming
Core-Topic 7: Barriers to Acceptance
Core-Topic 8: From Acceptance to Behavior Change
Core-Topic 9: Values and Goals
Core-Topic 10: Accepting Responsibility to Change
Core-Topic 11: Making/Keeping Commitments

61. ACT for Self-Stigma and Shame in Substance Abuse
Three sessions focused on addressing and reducing stigma and shame in the context of substance abuse
Focus on Mindfulness and Acceptance

62. Mindfulness-Based Relapse Prevention

63. Using ACT in SA Groups Committing to the process Rescuing limits
Things get worse before they get better
Focus on experiential and didactic exercises
Begin and end each session with experiential exercise
Mindfulness
Focus on letting group members be where they are
Recognizing EA in group process
Therapists role
Irreverent and bold

64. Using ACT in SA Groups – Building our Own Group Intervention
Creative Hopelessness/Workability
Values clarification
Control as the problem
Defusion
Self as context
Willingness and acceptance
Commitment