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Acceptance and Commitment Therapy

A mindfulness-based behavior therapy

Travis Trayler

on 7 December 2012

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Transcript of Acceptance and Commitment Therapy

Acceptance and Commitment Therapy A mindfulness-based behavior therapy Counselor Role The therapeutic relationship is of utmost importance. Client/Human Nature Human language causes suffering
especially in the context of cognitive fusion and experiential avoidance Behind the Theory Acceptance and Commitment Therapy
Relational Frame Theory
Applied Behavioral Analysis
Functional Contextualism Theory Interventions - ACT dates back to 1982
- Corey states that many of the limitations and criticisms of behavior therapy have been addressed through mindfulness and acceptance-based approaches
- The therapist and client are considered equals and the 2 Mountains Metaphor explains this.... Page 52
- Counselor variables that work against change:
Harris (2009) says, “In working with defusion and acceptance, be alert for several common pitfalls: too much talk, not enough action; reinforcing avoidance; insensitivity; failing to link acceptance to values; and being too pushy” (p. 151). From an ACT perspective, negative thoughts and feelings of sadness anger or anxiety are not seen as problematic. They are viewed as natural and a part of the human experience that all people will encounter numerous times throughout life.

Harris (2009) postulates the following:
ACT regards the mind as a double-edged sword. It’s very useful for all sorts of purposes, but if we don’t learn how to handle it effectively, it will hurt us. On the bright side, language helps us predict and plan for the future; share knowledge; learn from the past; imagine things that have never existed and go on to create them. The dark side of language is that we use it to dwell on and “relive” painful events from the past; to scare ourselves by imagining unpleasant futures; to compare, judge, criticize, and condemn both ourselves and others; and to create rules for ourselves that can often be life constricting or destructive. (p.7)
According to the ACT model, there are 2 natural processes of the human mind that cause ordinary people to become depressed, addicted, isolated, phobic, suicidal, and so on. Those two processes are cognitive fusion and experiential avoidance. Cognitive fusion means there is no separation between a person and their thoughts. This lack of separation makes it hard to see that these thoughts may be dominating their behavior. Harris (2009) says, “Fusion means we’re stuck in the world of language: we’re so caught up in all those words and pictures running through our head that we lose contact with the world of direct experience” (p. 20). Experiential avoidance is trying to avoid, eliminate, reduce, or escape thoughts and feelings that are viewed as bad, negative, or painful which causes more suffering in the long term. Cognitive fusion and experiential avoidance lead to 4 other core pathological processes. ACT has been dated back to over 30 years ago, but the founders wanted the foundations to be strong and able to withstand scrutiny, therefore nothing on the approach was published until 1999.

Harris states it like this:

As a result of all this foundational work, ACT is now like the top floor of a fabulous three-story mansion. On the next floor down you’ll find relational frame theory, RFT, which is a behavioral theory of human language and cognition. Then on the ground floor you’ll find applied behavioral analysis, ABA: a powerful model for the prediction and influence of behavior, which has had an enormous impact on almost every branch of modern psychology. And the ground on which the entire mansion rests is a philosophy called functional contextualism (FC) which looks at how thoughts, feelings, and behaviors function in specific context. (p. 33) FC looks at how things function in a specific context. Harris (2009) declares, “From the viewpoint of FC, no thought, feeling or memory is inherently problematic, dysfunctional, or pathological: rather, it all depends on the context” (p. 34). In a context of cognitive fusion and experiential avoidance our thoughts, feelings, and memories often function in harmful ways, but in a context of defusion and acceptance those same thoughts, feelings, and memories have less impact and influence over us, even though they may still be painful. ABA is the next layer in the foundation of the work which is a powerful technology for predicting and influencing behavior, based on learning theory and behavior principles in which the behavior and function of the behavior are viewed. This is viewed as antecedent, behavior, consequence. RFT is an in depth explanation of human language and how humans are able to derive relationships that are not taught through bi-directionality. This gives us a huge cognitive advantage over our nonhuman counterparts, but also causes humans to end up using relational framing on ourselves.
Wilson, Hayes, Gregg, & Zettle (2001) state the following:
Thus comes the paradox that a species that has by far the fewest contacts with direct sources of pain… through language is able to suffer with a degree of intensity, constancy and pervasiveness that is literally unimaginable in the nonhuman world. Because of [bi-directionality], we can judge ourselves and find ourselves to be wanting; we can imagine ideals and find the present to be unacceptable by comparison; we can reconstruct the past; we can worry about imagined futures; we can suffer with the knowledge that we will die. (p. 215) Relational Frame Theory (RFT) Suppose there’s a plant that you judge as “ugly”, growing right in the center of your front garden. And suppose that there’s no way to get rid of it without destroying your entire garden. (You may be thinking, “But there must be some way to get rid of it.” If so, just step back for a minute and make a hypothetical leap: imagine, for the purposes of this exercise, that you can’t get rid of this plant without destroying your garden.) Now if you view this plant as a “weed”, what is likely to happen to your relationship with it? Chances are, you won’t like it, and you won’t want it there. And you may well get upset or angry about it. You could easily waste lots of time thinking about how much better your garden would be without it. You might even hesitate to let people into your front garden, for fear they’ll judge you on account of it. Perhaps you might even start leaving by the back of your house, so you don’t have to look at this “ugly weed”. In other words, this “ugly weed” has become A VERY IMPORTANT THING IN YOUR LIFE – so much so, that it now has a significant impact on your behavior. But what happens if instead of viewing that plant as an “ugly weed”, you view it as just an unfortunate fact of life: a natural part of the native environment; a common example of American indigenous flora? Now it’s the same plant, in the same location, but your relationship with it has fundamentally changed. Now you no longer have to struggle with it. Now you need no longer be upset or embarrassed about it, or waste so much time thinking about it. Now you can let people into your garden without hesitation, and you can leave by the front of the house. The plant itself has not changed, but you no longer make it into A VERY IMPORTANT THING IN YOUR LIFE. It now has much less impact or influence over you. Mindfulness enables us to make a similar attitude shift towards all those thoughts, feelings, sensations and memories that we so readily judge as “problematic”; it enables us to choose the relationship we have with them. By changing the context from one of fusion and avoidance to one of defusion and acceptance (i.e. mindfulness), we alter the function of those thoughts and feelings, so they have much less impact and influence over us. In a context of mindfulness they are no longer “symptoms” or “problems” or “things that stop us from living a rich and full life”; they are nothing more or less than thoughts, feelings, sensations, memories, and so on. Workability, psychological flexibility, and the six core processes The whole ACT model rests on the concept of workability. Workability is where it is determined whether what the client is doing is helping or hurting them in the long run. Harris (2009) declares that to determine workability we asks, “Is what you’re doing working to make your life rich, full, and meaningful?” (p. 22). If the answer is yes, then it is considered to be workable and no change is needed. If the answer is no, then it is deemed unworkable in which we look for alternatives that may work better. In ACT we are trying to increase psychological flexibility. Psychological flexibility is the ability to be in the present moment with full awareness and openness to our experience, and to take action guided by our values (Harris, 2009, p. 12). This is done through the six core processes of ACT which are defusion, acceptance, contacting the present moment, self-as context, values, and committed action. Initial Session, Goals and Treatment Plans, Case Conceptualization and Diagnosing, ACT vs. Mechanistic Approaches - In the first session we aim to establish rapport, take a history, obtain informed consent, agree on initial treatment goals and the number of sessions, and if time allows do a brief experiential exercise and give some simple homework.

-Taking history can be broken into the presenting complaint, initial values assessment, current life context, psychological inflexibility, motivational factors, and psychological flexibility and client strengths.

- Treatment goals are guided by asking the client which domain they would like to start with off of their values assessment. Many times clients will have emotional goals, dead person's goals, or insight goals and this will need to be addressed. With treatment goals the therapist breaks the issue down into three parts: Getting caught up in thoughts, struggling with feelings, and unworkable actions. This is intended, right from the beginning. This helps lay the foundation for two key elements. First, that our thoughts are not the main problem; it’s getting caught up in those thoughts and struggling with them that creates problems, and second, that our thoughts do not control our actions.
Harris (2009) postulates the following:
Our thoughts and feelings certainly influence our actions, but they don’t control our actions. Our behavior in any moment is under the influence of multiple streams of stimuli, coming both from the world inside our skin and from the world outside us. Our actions are influenced by whatever we can see, hear, smell, touch, taste, sense, feel, and think. So when do our thoughts and feelings have the most influence over our actions? In a context of fusion and avoidance, however in a context of defusion and acceptance, those same thoughts and feelings have much less influence over our behavior, which frees us to act on our values. (p. 67) According to Harris (2009)
Most models of psychology are based on a philosophy called “mechanism”. Mechanistic models treat the mind as if it as a machine made up of lots of separate parts. “Problematic” thoughts and feelings are seen as faulty parts of the machine, or errors in the structure of the machine. The aim in such models is to repair, replace or remove these faulty parts, so the machine can function normally. Mechanistic models of psychology assume that there are such things as inherently “dysfunctional”, “maladaptive”, or “pathological” thoughts, feelings and memories. In other words, there are memories, thoughts, feelings, emotions, urges, schemas, narratives, ego states, core beliefs, and so on, which are fundamentally problematic, dysfunctional or pathological; and need to be either fixed, replaced, or removed. (p. 34-35) ACT does not propose that models that operate from this standpoint are wrong or inferior; ACT just operates from a different philosophical standpoint which results in a different way of doing therapy.
Harris (2009) pronounces the following:
Our clients often come to therapy with mechanistic ideas. They believe that they’re faulty, damaged, or flawed, and they need to be fixed up or repaired. They often believe they are lacking important components such as “confidence” or “self-esteem.” Or they believe they have faulty parts – such as feelings of anxiety, negative thoughts, or painful memories – that need to be removed. Most mechanistic models readily reinforce these notions by using terms such as “dysfunctional”, “maladaptive”, “irrational” or “negative” – that imply we have faulty or damaged components in our minds. They also use a wide variety of tools and techniques to directly reduce, replace, or remove these unwanted thoughts and feelings (usually on the assumption that this is an essential step for improving quality of life). (p. 35) The aim of ACT is not to change or reduce negative thoughts and feelings, but to change the relationship clients have with these thoughts and feelings so they have less impact and influence over them. This is done through experiential exercises with defusion and acceptance. If clients are strongly attached to an agenda of emotional control, then we first work through creative hopelessness or confronting the agenda. Harris (2009) states, “The emotional control agenda is based on this idea: the more you can control how you feel, the better your life will be” (p. 81). Once clients realize that control is causing more of the suffering than alleviating it, we can then work throughout the hexaflex of psychological flexibility. Though the six core processes are discussed separately, they are all interconnected and there is overlap among them just as there is overlap among the pathological processes. Your client may be struggling with several of the pathological processes, therefore in any session you may be working with multiple core therapeutic processes on the hexaflex. Context Research, Typical Number of Sessions, and Applicability -ACT has been scientifically studied and shown to be effective with a wide variety of conditions including anxiety, depression, obsessive-compulsive disorder, social phobia, generalized anxiety disorder, schizophrenia, borderline personality disorder, workplace stress, chronic pain, drug use, psychological adjustment to cancer, epilepsy, weight control, smoking cessation, and self-management of diabetes.
-ACT has been used as an extensive therapy as well as a very brief therapy. One protocol for ACT with borderline personality disorder goes forty group sessions, each 2 hours long. One published study on ACT for chronic schizophrenia consisted of only 3 or 4 one hour sessions. That very brief intervention lead to an almost 50 percent reduction in hospital readmission rates. ACT is suitable for a range of clients across many different contexts. I felt that in the school system I was able to work effectively with students using the ACT model. When regarding whom ACT is suitable for Harris (2009) declares: Who wouldn’t benefit from being more psychologically present; more in touch with their values; more able to make room for the inevitable pain of life; more able to defuse from unhelpful thoughts, beliefs, and memories; more able to take effective action in the face of emotional discomfort; more able to engage fully in what they’re doing; and more able to appreciate each moment of their life, no matter how they’re feeling? Psychological flexibility brings all these benefits and more. ACT therefore seems just about relevant to just about everyone. (Of course, if humans have significant deficits in their ability to use language, such as some people with autism, acquired brain injury, or other disabilities, then ACT may be of limited use. However RFT (Relational Frame Theory) has all sorts of useful applications for these populations.) (p. 31) http://www.actmindfully.com.au/free_resources
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