act for cbt clinicians
DESCRIPTION
ACT for CBT Clinicians. Steven C. Hayes. How to get these slides Go to my blog at www.contextualpsychology.org. We will Do Today. You can start from where you are Look at places things can bog down Difficulty in restructuring thoughts Resistance Connection. Where Did ACT Come From?. - PowerPoint PPT PresentationTRANSCRIPT
ACT for CBT CliniciansACT for CBT Clinicians
Steven C. HayesSteven C. Hayes
How to get these slidesHow to get these slides
Go to my blog at www.contextualpsychology.orgGo to my blog at www.contextualpsychology.org
We will Do TodayWe will Do Today
• You can start from where you are
• Look at places things can bog down
– Difficulty in restructuring thoughts– Resistance– Connection
Where Did ACT Come From?Where Did ACT Come From?• ACT is part of CBT writ large• In the 1980’s I did a number of studies on the CBT
model and found problems; I also developed an anxiety disorder and found personal problems with the model
• I was a behavior analysts who thought the C in CBT was needed but that we needed a bottom up account grounded in behavioral principles
• We developed an approach based on eastern and human potential sensitivities, spent over 15 years developing it and the basic model, and final released the clinical model in 1999 and the basic model in 2001
What is ACT?What is ACT?• Philosophical basis (can’t skip it!) in functional
contextualism, which we take from Skinner • Monistic, radically pragmatic, contextualistic and
from all of that a-ontological– The world is. We assume the one. Call it “real” but mean
“the one that is”– Our behavior partitions it– The ontological leap add nothing but irresponsiblity– So it comes down to this: what works in and with the one
world– To determine that we need your values and goals
What is ACT?What is ACT?• Theoretical basis in Relational Frame Theory (RFT)
– Language is based on learned relations that can be controlled by arbitrarily cues
– Provides an evolutionary advantage, but also expands the ability to feel, predict and evaluation pain; makes situational avoidance impossible; and cognitive dominance likely
– Experiential avoidance and cognitive fusion are built into language and amplified by the culture, but they are a source of psychopathology and reduced behavioral flexibility
– Fortunately there are two types of contextual regulation: relational and functional
The Problem and Solution The Problem and Solution
– Eliminating verbal relations and reducing automatic emotional responding is difficult in part because they are historical
– A focus on the relational context tends to increase the functional context but not vice versa
– We can choose the context more safely than choose the content
Self asContext
Contact with the Present Moment
Defusion
Acceptance
Committed Action
Values
EssentialComponents
of ACT
Self asContext
Contact with the Present Moment
Defusion
Acceptance
Committed Action
Values
Acceptance and Mindfulness
Processes
You can chunk them into two larger groups
Self asContext
Contact with the Present Moment
Defusion
Acceptance
Committed Action
Values
Commitment and Behavior
Change Processes
Thus the name “Acceptance and
Commitment Therapy”
and
Self asContext
Contact with the Present Moment
Defusion
Acceptance
Committed Action
Values
Psychological Flexibility
The Common Core of
All of These Processes is
04/20/2304/20/23
Psychological FlexibilityPsychological 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.
04/20/2304/20/23
Definition of ACTDefinition of ACT
• ACT is a contextual cognitive and behavioral therapy that uses acceptance and mindfulness processes, and commitment and behavior change processes, to produce greater psychological flexibility.
The Bottom LineThe Bottom Line
• Dysfunction arises from experiential avoidance, cognitive fusion, and psychological inflexibility
• Said in another way: it arises from our relationship to cognitive and emotional content and its impact on behavior, not content itself (including irrational beliefs, distorted cognitions, difficult emotions, or dysfunctional core schemas)
ACT does normally seek to alter the cloud of ACT does normally seek to alter the cloud of evaluations; rather, one stays in intimate contact with evaluations; rather, one stays in intimate contact with the cloud, and sometimes “peeks around” the cloud to the cloud, and sometimes “peeks around” the cloud to
make direct contact with experience and valuesmake direct contact with experience and values
ACT StyleACT Style
• Mistrust of “reasoning”, persuasion, logic, rationality and language processes in general
• Heavy emphasis on pragmatic truth criteria
• Use of non-literal interventions such as metaphors, stories, mindfulness, and experiential exercises
• Modeling of core ACT processes by therapist
• Non-sequential application of core processes
There are Many Points of ConvergenceThere are Many Points of Convergence
• ACT is a behavior therapy that also takes cognition and emotion extremely seriously
• Uses all of the behavioral elements of CBT: skill building interventions, exposure strategies, functional analysis etc
• Incorporates out of session “homework” and self monitoring tasks
• Data from out of session work is often a focus of clinical sessions
So is ACT So is ACT ReallyReally Different than Different than Traditional CBT?Traditional CBT?
(i.e., More that Philosophy, Theory, and Development Strategy?) (i.e., More that Philosophy, Theory, and Development Strategy?)
• You cannot answer that by superficial examinations due to a basic cognitive process
• A great way is empirically:– Correlational evidence on processes– Outcomes– Processes accounting for these outcomes
CorrelationallyCorrelationally
• In more than 40 studies with nearly 10,000 participants, psychological flexibility accounts for 16 to 33% of most psychological outcomes
• There is evidence that the effects of negative thoughts, difficult feelings, maladaptive coping, emotional response styles, cognitive reappraisal, and perceived controllability, are all partially or fully mediated by psychological flexibility
Outcomes and MediatorsOutcomes and Mediators
• Outcomes: – Eight studies so far. All over the map.
– Two negative effect sizes, one equal, five positive
– Too soon to tell
• Processes– All show a difference, some formal mediational differences
Is ACT Really Different than Is ACT Really Different than Traditional CBT? Traditional CBT?
• Another, also good way: Try it
• Try some of these things with yourself– The “Get Out of Your Mind” book is perfect for
that
CBT and ACTCBT and ACT
• And apply to your cases– Start with your difficult cases, when you bog down
• Do analysis of where you’ve bogged down and recast the case from an ACT model
– You can use ACT methods inside a treatment protocol dominated by traditional methods provided only that you tweak the goal
A Distress Reduction Core: Therapeutic A Distress Reduction Core: Therapeutic Processes are Used to Reduce Distress or Processes are Used to Reduce Distress or
Distressing ThoughtsDistressing Thoughts
Mindfullness Behavioral experiments Cognitive structuring
Reducing depression, anxiety or
stress
Goal setting
Skills Training
Emotional Understanding
A Behavioral Core: Therapeutic Processes are Used for A Behavioral Core: Therapeutic Processes are Used for Promoting Flexible, Values Congruent BehaviorPromoting Flexible, Values Congruent Behavior
Self as context Cognitive Defusion Mindfullness Acceptance Cognitive elaboration
Increasing Flexible, Values
Congruent Behavior
Value clarification
Skills Training
Commitment
Emotional Understanding
• A - B - C
Versus
• A - BC - VA
Context
Model DifferencesModel Differences
• Usually the traditional CBT rationale, and learning to detect thoughts is no problem
• It can bog down in actually restructuring thoughts
• The ACT alternative: distinguish the person from the content
• Defuse from content
CBT and ACT: CBT and ACT: Cognitive ContentCognitive Content
• Bogging down in actually restructuring thoughts
• Examples from the audience and group practice
Traditional CBT to ACT: Traditional CBT to ACT: Cognitive ContentCognitive Content
• Model it yourself
• Create a transitional rationale
• Once you start down this road you will have a bit of a hard time going back with this patient
Traditional CBT to ACT: Traditional CBT to ACT: DefusionDefusion
A Few Principles of Defusion A Few Principles of Defusion and Examplesand Examples
Principle 1: Find overall metaphors that structure seeing the process
Sunglasses
Bubble on the head
Passengers on the Bus
DefusionDefusion
Principle 2. Notice the automaticity of thoughts and their ease of programming
Mary had a little lamb
What are the numbers?
DefusionDefusion
Principle 3. Notice their paradoxical nature when you try to control them
Don’t think X
DefusionDefusion
Principle 4. Distinguish the person from the programming
Observer exerciseWatching thoughts … and noting who is watching
DefusionDefusionPrinciple 5. Create a context that weakens the the illusion of
literality
Milk, milk, milkTalk about the mind as another entityThere are four of us in hereThank your mind for that thoughtFunny voices
DefusionDefusion
Principle 6. Notice their limitations and attachments
Tell me how to walk
Deliberately instruct the opposite
DefusionDefusion
Principle 7. Teach the discrimination between fusing and defusing
Leaves on a stream
Meditation
• Another place traditional CBT can bog down is in resistance
• I can’t because …
• It’s too ….
• I’m too …
Traditional CBT to ACT: Traditional CBT to ACT: ResistanceResistance
• The ACT Alternative: a) creative hopelessness and workability; b) values and acceptance
• Creative hopelessness (Acceptance of where you start)
Traditional CBT to ACT: Traditional CBT to ACT: ResistanceResistance
• Valuing is seldom directly addressed in CBT because the underlying assumption is that living rationally will lead to valued living
• In ACT values are not rational derivatives; they are chosen starting points
Traditional CBT to ACT: Traditional CBT to ACT: ResistanceResistance
Values and WorkabilityValues and Workability
• Values gives us workability, which defines “truth” (not the rational truth of traditional CBT)
• With that form of truth we have a lot of leverage with resistance to change
• Cognitive rigidity – what is that in the service of; how does that work
• Emotional rigidity – acceptance• Behavioral rigidity – breaking patterns in the service
of values
Values and WorkabilityValues and Workability
– Values are a direction, not an outcome– They are a choice, not a decision – Emphasize wants based on undefended choice,
vitality, wholeness, intrinsic value
Values and WorkabilityValues and Workability
• Many techniques, but the core approach:
• Use the common sense language of free choice
• Ask what they really want
• Consider using pain as a guide
• Shape the answer by: – distinguishing values from goals – confronting pliance and avoidance – being completely and sincerely supportive
• Bogging down in cognitive, emotional, or behavioral resistance
• Examples from the audience and group practice
Traditional CBT to ACT: Traditional CBT to ACT: ResistanceResistance
• Bogging down in a lack of vitality and connection in the room
• Therapeutic detachment, socratic dialogue, logic, analysis and personal science can sometimes and with some patients lead to a dryness in the room
Traditional CBT to ACT:Traditional CBT to ACT:Lack of Connection Lack of Connection
• The ACT solution
• 1. Work on a transcendent sense of self (spirituality), contact with the present moment, and values
• 2. Model, implement, and target ACT processes in the relationship itself
Traditional CBT to ACT:Traditional CBT to ACT:Lack of Connection Lack of Connection
Lack of ConnectionLack of Connection
• Getting mindful versus battling the mind– Mindful means experiencing experiences in the
moment for what they are, without judgment, evaluation or manipulation
– The mindful state is achieved by making experiential contact with a “bigger self” that contains all consciousness and yet is distinct from that content
Lack of ConnectionLack of Connection
• Getting present versus modifying the present– ACT elicits and sustains negative private
experience in session, not to modify it logically, but to teach the client to approach, rather than avoid it
Lack of ConnectionLack of Connection
• Walking the walk versus talking the talk– In addition to targeting them, ACT encourages the
therapist to model acceptance, defusion, getting present, and values through self disclosure and consistently applying these to oneself
– ACT also encourages the therapist to implement these in the interaction between the therapist and client so that they become defining features of the therapeutic relationship
• Bogging down in a lack of vitality and connection in the room
• Examples from the audience and group practice
Traditional CBT to ACT:Traditional CBT to ACT:Lack of Connection Lack of Connection
• Examples from the audience
Other Bogged Down Places? Other Bogged Down Places?
What to Do?What to Do?
• If something in the ACT data or message speaks to you, explore it
• How: www.contextualpsychology.org; the list serve; the books and tapes; do more extended training workshop
• Be open but keep any skepticism you prefer
CBT and ACTCBT and ACT
• Read these four books to start (plus a new one on CBT and ACT when it comes out)
Guilford Springer-Verlag New Harbinger