Acceptance & Acceptance & Commitment Therapy Commitment Therapy
(ACT) (ACT) & Later Life Issues& Later Life Issues
Ray OwenRay Owen
[email protected]@gmail.com
DianeDiane
►7676►Widowed 8 years ago after 41 years Widowed 8 years ago after 41 years
marriage; nursed husband, appeared marriage; nursed husband, appeared to cope wellto cope well
►Two adult children, one nearby, one Two adult children, one nearby, one overseas; 5 grandchildrenoverseas; 5 grandchildren
►Since retiring from teaching has been Since retiring from teaching has been involved in church and communityinvolved in church and community
Now..Now..
► Worsening osteoarthritis, harder to do some Worsening osteoarthritis, harder to do some things (mobility, physical tasks)things (mobility, physical tasks)
► Withdrawal from social and community Withdrawal from social and community activities, less contact with childrenactivities, less contact with children
► Experiences low mood, lying awake at night Experiences low mood, lying awake at night fearing for future and feeling sad about fearing for future and feeling sad about losses, grief re-awakened, periods of anger losses, grief re-awakened, periods of anger at unfairness of lifeat unfairness of life
► ‘‘I’m useless’ ‘Just going to become more I’m useless’ ‘Just going to become more and more of a burden on others’and more of a burden on others’
► Poorer self-carePoorer self-care
‘‘later life issues’later life issues’
►Loss of partner – griefLoss of partner – grief►Changed familial rolesChanged familial roles►Loss of social rolesLoss of social roles►Declining healthDeclining health►Declining functional independenceDeclining functional independence►Fear for futureFear for future►Emotional impact of all the aboveEmotional impact of all the above►Reduced coping resourcesReduced coping resources
Acceptance & Acceptance & Commitment TherapyCommitment Therapy
(ACT)(ACT)
Historical backgroundHistorical background
► Key names: Key names: ► Steve Hayes, Kelly Wilson, Robyn Walser, Russ Harris, JoAnne Dahl, Kevin PolkSteve Hayes, Kelly Wilson, Robyn Walser, Russ Harris, JoAnne Dahl, Kevin Polk
►Some had background in radical behaviourism, applied Some had background in radical behaviourism, applied behaviour analysis, fundamental learning processesbehaviour analysis, fundamental learning processes
►Development during the 90s, most work Development during the 90s, most work since Hayes et al original book since Hayes et al original book published 1999published 1999
►Since applied across huge range of Since applied across huge range of problems and settings, including:problems and settings, including: depression, anxiety, anger, substance depression, anxiety, anger, substance
abuse, psychosis, pain, chronic health abuse, psychosis, pain, chronic health conditions, workplace stress, epilepsy, conditions, workplace stress, epilepsy, stigma, cultural awareness, learning new stigma, cultural awareness, learning new skillsskills
In a nutshell…In a nutshell…
Experiential avoidance
Cognitive Fusion
Loss of Contact with Present moment
‘Self as Content’ / rigid sense of self
Loss of contact with Values
Reduced, aimless or counter-productive behaviour
Sources of difficulty
Acceptance / Willingness to experience
“making room for
whatever shows up”
Defusion
“watching your thinking”
Present Moment Awareness / Mindfulness
“staying present”
Self-as-Context / self-as-observer
“just noticing”
Awareness of Values
“knowing what matters to you”
Committed Action (in service of Values)
“doing what it takes”
Core processes of ACT
Experiential avoidance -> Acceptance / Willingness
Cognitive Fusion -> Defusion
Loss of Contact with Present moment -> Present Moment Awareness / Mindfulness
Self-as-Content -> Self-as-Context
Loss of contact with Values -> Awareness of Values
Reduced, aimless or counter-productive behaviour -> Committed Action (in service of Values)
Shifting from ‘being stuck’ to ‘flexibility /
vitality’
How?How? – core techniques – core techniques► Recognising ‘stuck’ patterns of responding (esp Recognising ‘stuck’ patterns of responding (esp
experiential avoidance & fusion)experiential avoidance & fusion)► Recognising short-term relief vs long-term Recognising short-term relief vs long-term
increased sufferingincreased suffering► Defusion exercises; recognising thoughts as occurDefusion exercises; recognising thoughts as occur► Acceptance / Willingness exercises (similar to Acceptance / Willingness exercises (similar to
‘distress tolerance’ / exposure)‘distress tolerance’ / exposure)► Mindfulness skillsMindfulness skills► Identification of ValuesIdentification of Values► Encourage actions in support of these behaviours Encourage actions in support of these behaviours
(may need e.g. skills training, behavioural (may need e.g. skills training, behavioural activation, graded exposure)activation, graded exposure)
► I will do [I will do [actionaction] in the service of [] in the service of [valuevalue], and am ], and am willing to experience [willing to experience [thought, emotion, physical thought, emotion, physical sensationsensation] if that’s what it takes] if that’s what it takes
““Show, don’t tell”Show, don’t tell”
- universal process- universal process
- A health warning- A health warning
Who matters most to Who matters most to you in the world?you in the world?
How do you want to be How do you want to be towards them? towards them?
(How do you want to (How do you want to act in your dealings act in your dealings
with them?)with them?)
ValuesValues
► ‘‘what we want to stand for in life, how what we want to stand for in life, how we want to behave, what sort of we want to behave, what sort of person we want to be, what sort of person we want to be, what sort of strengths and qualities we want to strengths and qualities we want to develop’.develop’.
►Russ Harris, (2009)Russ Harris, (2009)
Some ValuesSome 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
Values are…Values are…► OngoingOngoing► Not the same as Goals (compass points, not destinations)Not the same as Goals (compass points, not destinations)► Not the same as Actions (ways of acting)Not the same as Actions (ways of acting)► Chosen (the person I want to be, not what I’m stuck with)Chosen (the person I want to be, not what I’m stuck with)► Not dependent on others’ approval (if no-one else ever Not dependent on others’ approval (if no-one else ever
knew)knew)► Not right or wrong Not right or wrong ► Ends in themselves, more or less… (intrinsically Ends in themselves, more or less… (intrinsically
reinforcing)reinforcing)► About fulfilment, not happiness:About fulfilment, not happiness:
““a life well-lived is a life lived according to a life well-lived is a life lived according to your Values”your Values”
Not a unique conceptNot a unique concept
► ““Everything can be taken from a Everything can be taken from a man or a woman but one thing: man or a woman but one thing: the last of human freedoms - to the last of human freedoms - to choose one's attitude in any choose one's attitude in any given set of circumstances, to given set of circumstances, to choose one's own way”choose one's own way”
► ““He who has a He who has a whywhy to live for to live for can bear almost any can bear almost any how how ””
Viktor Frankl, V.(1959) Viktor Frankl, V.(1959) Man's Search for MeaningMan's Search for Meaning
ValuesValues
Characteristics of ACTCharacteristics of ACT
► Linked to underlying model of cognitive development and Linked to underlying model of cognitive development and language (Relational Frame Theory – RFT)language (Relational Frame Theory – RFT)
► Awareness that if language and ‘mind-iness’ get us into Awareness that if language and ‘mind-iness’ get us into this, how can something as verbal and thoughtful as this, how can something as verbal and thoughtful as psychological therapy get us out of it?psychological therapy get us out of it?
► De-literalising language – lots of metaphorDe-literalising language – lots of metaphor► Constantly confronting the Control Agenda- including Constantly confronting the Control Agenda- including
‘creative hopelessness’ (not that use that term with client)‘creative hopelessness’ (not that use that term with client)► Lots of behaviours / exercises (esp. mindfulness, defusion)Lots of behaviours / exercises (esp. mindfulness, defusion)► Normality of suffering - therapist disclosure about their Normality of suffering - therapist disclosure about their
suffering suffering in service of better outcome for clientin service of better outcome for client► Modelling the process (“I notice I’m thinking..”)Modelling the process (“I notice I’m thinking..”)► Don’t evaluate Values (though have opt-out in agreeing to Don’t evaluate Values (though have opt-out in agreeing to
help)help)
EvidenceEvidence► OverallOverall
>100 RCTs, hundreds smaller studies>100 RCTs, hundreds smaller studies Emphasis on mediational analysesEmphasis on mediational analyses Problems from systematic reviews / meta-Problems from systematic reviews / meta-
analysis due to mismatched assumptions analysis due to mismatched assumptions (e.g.treating by diagnosis)(e.g.treating by diagnosis)
Almost all available at Almost all available at www.contextualscience.orgwww.contextualscience.org
► Evidence-based practice (EBP) listsEvidence-based practice (EBP) lists Accepted as EBP on US Dept of Health’s Accepted as EBP on US Dept of Health’s
SAMSHA listSAMSHA list APA Section 12 listings of EBP cites ‘strong APA Section 12 listings of EBP cites ‘strong
research support’ for use in chronic painresearch support’ for use in chronic pain
Values-led ethos Values-led ethos (principles of the club?)(principles of the club?)
► Include:Include:► For everyone, soFor everyone, so
‘‘us’ as well as ‘them’us’ as well as ‘them’ Live it, Disclosure, both climbing a cliffLive it, Disclosure, both climbing a cliff Only as much DSM as necessary to get past EBP police Only as much DSM as necessary to get past EBP police
► Never be ACTNever be ACTTMTM ► No certification No certification ► Values-based dues (average went up from fixed Values-based dues (average went up from fixed
$50) $50) ► circulate the papers circulate the papers ► publish your protocols publish your protocols ► use the message boardsuse the message boards► ANDAND► ““don’t have to get the tattoo & learn the chicken don’t have to get the tattoo & learn the chicken
ritual”ritual”
Can work alongside…Can work alongside…
► So long as handle incompatibilities around So long as handle incompatibilities around core assumptions, e.g.core assumptions, e.g. Cannot control thought and emotionCannot control thought and emotion Therefore problems with e.g. distress reduction Therefore problems with e.g. distress reduction
and cognitive restructuringand cognitive restructuring► Can work alongside other approachesCan work alongside other approaches
Other 3Other 3rdrd wave (MBCT, DBT, CFT) wave (MBCT, DBT, CFT) increasing cross-over with 2increasing cross-over with 2ndnd wave CT wave CT Some use with others (BSFT, gestalt, Some use with others (BSFT, gestalt,
psychodynamic)psychodynamic)
To learn more…To learn more…►One website:One website:
www.contextualscience.orgwww.contextualscience.org
►One book (to begin with):One book (to begin with): ‘‘ACT made Simple’ by Russ HarrisACT made Simple’ by Russ Harris
►Well, maybe two…Well, maybe two…
AVAILABLE FROM ROUTLEDGE, AT AMAZON AND ALL FINE BOOKSTORES!
Shortlisted for BMA Popular Medicine Book of the Year, 2012
Also ava
ilable on K
indle !
Shortlisted for BMA Popular Medicine Book of the Year, 2014
ACT formulationACT formulation
DianeDiane
DianeDiane
►7676►Widowed 8 years ago after 41 years Widowed 8 years ago after 41 years
marriage; nursed husband, appeared marriage; nursed husband, appeared to cope wellto cope well
►Two adult children, one nearby, one Two adult children, one nearby, one overseas; 5 grandchildrenoverseas; 5 grandchildren
►Since retiring from teaching has been Since retiring from teaching has been involved in church and communityinvolved in church and community
Now..Now..
► Worsening osteoarthritis, harder to do some things Worsening osteoarthritis, harder to do some things (mobility, physical tasks)(mobility, physical tasks)
► Withdrawal from social and community activities, Withdrawal from social and community activities, less contact with childrenless contact with children
► Experiences low mood, lying awake at night fearing Experiences low mood, lying awake at night fearing for future and feeling sad about losses, grief re-for future and feeling sad about losses, grief re-awakened, periods of anger at unfairness of lifeawakened, periods of anger at unfairness of life
► ‘‘I’m useless’ ‘Just going to become more and more I’m useless’ ‘Just going to become more and more of a burden on others’of a burden on others’
► Poorer self-carePoorer self-care
Experiential avoidance
Cognitive Fusion
Loss of Contact with Present moment
‘Self as Content’ / rigid sense of self
Loss of contact with Values
Reduced, aimless or counter-productive behaviour
Sources of difficulty
(inflexibility)
Experiential avoidance
Cognitive Fusion
Loss of Contact with Present moment
‘Self as Content’ / rigid sense of self
Loss of contact with Values
Reduced, aimless or counter-productive behaviour
Sources of difficulty
• Feel useless if can’t do what I used to, so don’t try
• If children worry about me, feel a burden, so minimise contact
• When anger builds up, need to hide it or vent it privately
• I’m turning into a cripple
•The future is terrible for me
• I’m no good to anyone
•Good people don’t get angry• I’m a cripple
• I’m the one who’s willing help out
•I don’t make a fuss
• Thinking about future
• Comparing to past
• Especially at night
Diane
• Activities seem pointless
• If not good carer, what am I for?
•Not engaged with family
• avoiding contact with others
• reducing self-care
• not following interests
Acceptance / Willingness to experience
“making room for
whatever shows up”
Defusion
“watching your thinking”
Present Moment Awareness / Mindfulness
“staying present”
Self-as-Context / self-as-observer
“just noticing”
Awareness of Values
“knowing what matters to you”
Committed Action (in service of Values)
“doing what it takes”
Core processes of ACT
Acceptance / Willingness to experience
Learn to ‘sit with’ unwanted feelings, without engaging in counterproductive attempts to control / avoid
Defusion
Learn to recognise thoughts AS THOUGHTS as occur
Learn not to see world through those thoughts
Present Moment Awareness / Mindfulness
Help her become more able to notice when mind wandering, and choose where to pay attention
Use this to help manage night-time rumination
Self-as-Context / self-as-observer
Help her notice what is going on inside herself
Help her recognise unhelpful, rigid views of self
Awareness of Values
Identify the things that matter most to Diane
Committed Action (in service of Values)
Work out what it will take to serve those values, and support her in doing them even with the thoughts & feelings they bring
Core processes of ACT
One more exercise?One more exercise?
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