Acceptance and Commitment Therapy

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Acceptance and Commitment Therapy

• An Experiential Approach to Behavior Change

Kirk D. Strosahl PhD Patricia Robinson PhD Email
mconsultinggrp_at_embarqmail.com
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Workshop Objectives

• First An ACT Primer for novice clinicians
• Appreciate the core assumptions about human
  suffering that underpin the ACT model
• Appreciate the change agenda that clients bring
  into therapy and why it is bound to fail
• Understand the six core processes of ACT and the
  role they play in promoting psychological
  flexibility
• Demonstrate various ACT interventions that
  support work in each of the six core process
  areas
• We will titrate this based upon how much you
  already know about ACT

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Workshop Objectives

• Next Learn how to think like and act like an ACT
  therapist!
• Learn a simple model for ACT case formulation
• Learn to listen with ACT ears and see with ACT
  eyes
• Learn how to consolidate and simplify ACT
  interventions so that you can be effective
  quickly
• Learn how to apply ACT with children
• The focus will be on building fluency through
  practice, practice and more practice!

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Last But Not Least

• We are going to have you do ACT on yourself
• Pick something in your life that you are
  struggling with and havent been able to fix
• We are going to ask you to take this issue along
  for the ride over the next two days
• We will have you practice ACT experiential
  interventions on this issue over time
• At the end, we will have you stand up (if you
  want to) and make a commitment to do something
  valuable in this area of your life

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Basic Assumptions

• Philosophical basis in functional contextualism
• Emphasis on pragmatic truth constructfunctionally
  workable relationship are truth
• 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

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Basic Assumptions

• Basic Science Underpinning in Relational Frame
  Theory (RFT)
• Language is based on arbitrary learned relations
  that are controlled within relational frames
  (rule governed behaviors ,bi-directional
  relations, transformation of functions)
• Provides an evolutionary advantage, but also
  expands the ability to feel, predict, categorize
  evaluate makes behavioral avoidance possible
  and cognitive dominance likely (stimulus
  equivalence and equivalence class)
• Experiential avoidance and cognitive fusion are
  built into language and amplified by the culture
  they are implicated in psychopathology (pliance,
  tracking augmentals)

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Basic Assumptions

• Basic human condition is we cant live without
  language . . . And we cant live with it
• 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 relational frames and
  govern behavior
• 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 (i.e., they are not
  transparent)
• It is possible to exert control over the
  FUNCTIONS but not the FORM of verbal relations

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Basic Assumptions

• The hegemony of language is embedded in the
  culture language acquisition is the vehicle
• Although we are the most advanced species, we are
  also the only species that commits suicide
• The very properties that make language so
  beneficial give it a dark side (evaluate,
  compare, justify and project futures, self
  reference)
• Language processes that serve the community may
  be detrimental to the client and are often
  buried in the process of thinking

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The Bottom Line

• When this powerful computer is focused inward,
  the very properties that moved us to the top of
  the feeding chain can become toxic
• The two central culprits from a ACT point of
  view are. . .
• Cognitive fusion Mistaking private events as
  reality
• Emotional avoidance Unwillingness to make
  contact with undesirable, unwanted private mental
  events, leading to ever widening patterns of
  behavioral constriction

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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

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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

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The Paradox How the Drive for Normality Insures
Suffering

• The focus on controlling distressing content is a
  retread of the mental model for solving
  physical challenges in the outside world (define,
  analyze, locate and eliminate)
• But . . .what if those same rules guaranteed
  failure if applied between the ears The RULE
  of MENTAL EVENTS
• Why?? Because the historical cause not only is an
  arbitrary construction but also because history
  cannot be eliminated
• Result The harder the client tries to decrease
  depression or increase confidence, the worse the
  situation gets and the more the client engages in
  emotional avoidance
• At its worst, the client becomes functionally
  dominated by historical factor X, not by virtue
  of its actual causal influence, but by virtue of
  the relational frame that is established in the
  reason giving process

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FEAR A Formula for Human Suffering

• Fusion Attaching to unwanted private experiences
  (thoughts, feeling, memories, sensations) and
  their rule governed functions
• Evaluation Imbuing events/experiences with
  evaluative properties that become functionally
  associated as primary properties
• Avoidance Using behavioral or psychological
  strategies designed to eliminate or constrict
  exposure to distressing private content
• Reason Giving Providing a socially supportable
  justification for dysfunctional and unworkable
  behaviors

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Your Personal ACT

• Pick a problem that is uncomfortable for you
  emotionally and has persisted for at least a
  while in your life. Then contemplate the
  following questions
• How will you know when this problem is solved?
  What will you notice is different?
• What have you been trying to accomplish with your
  actions thus far?
• What role is emotional avoidance playing?
• What role is behavioral avoidance playing?
• How would you define a healthy outcome for
  this situation? Why havent you been able to
  achieve it?

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Definition of ACT

• ACT uses acceptance and mindfulness processes,
  and commitment and behavior change processes, to
  produce greater psychological flexibility.

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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.

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The Six Core Processes of ACT

• Defusion Establishing new functions for
  thoughts, feelings, memories, sensations
• Acceptance Non-judgmental awareness
• Getting in the present moment Showing up
• Self as context Contacting the transcendental
  sense of self in which all experience is safe
• Valuing A process that instantiates goal
  directed behavior
• Committed action Engaging in behaviors that are
  consistent with personal values

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(No Transcript)
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Acceptance and Mindfulness Processes
You can chunk them into two larger groups
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Commitment and Behavior Change Processes
and
Thus the name Acceptance and Commitment Therapy
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The Common Core of All of These Processes is
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One Important Caveat

• The six core processes are not empirically
  derived and we dont know how they relate or even
  if they exist as functionally separate processes!
• We do know that psyflex as a construct shows up
  as a powerful mediator of treatment effects in
  ACT
• Our best attempts to measure acceptance and
  mindfulness have at most revealed two factors
• A general factor that seems to involve
  willingness to have unpleasant experience
• A weak second factor involving a tendency to
  approach rather than avoid situations
• Oakum's razor actually helps us poor clinicians!

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What Does This Mean?

• We might be taking something that is actually
  simple and making it into something that is
  complex (something that eggheads have been known
  to do!)
• Basically, if ACT is having an impact, it will
  probably be in two main areas
• Increased willingness and ability of the client
  to stay psychologically present when confronted
  with painful content
• Increased willingness to approach rather than
  avoid potentially painful situations
• This leads to a higher probability of workable
  outcomes.

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Core Attributes of the ACT Therapist

• 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 encourages the therapist to implement these
  in the interaction between the therapist and
  client so that they become defining features of
  the therapeutic relationship

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Part II How to Do ACT

• 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

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Three Main Polarities In ACT Practice

• AcceptanceFusion polarity contains defusion,
  willingness, acceptance
• This undermines emotional avoidance
• Choose mindfullymindless choosing polarity
  contains self experience, evaluation/reason
  giving and valuing
• This undermines rule following, hidden
  evaluations, reason giving and attachment to the
  self story
• Take action-avoidance of action polarity contains
  willingness, value based goal setting to create
  exposure to vitality producing life moments
• This undermines behavioral avoidance

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ACT Case Formulation The Functional Analysis

• Prior to initiating ACT interventions, it is very
  important to conduct a functional analysis
• FA allows the therapist to innocently collect
  information and reflect themes
• FA provides data on core aspects of covert/overt
  behavior-environment relationships
• FA allows the therapist to listen strategically
  and for the client to tell and invest in their
  story
• FA will typically reveal what the clients
  approach has been to addressing distressing
  content
• FA allows the therapist to immediately begin
  inserting the clients direct experience with
  control avoidance strategies

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ACT Case Formulation

• In your functional analysis, look for the
  following
• To do behavior X requires me to have attribute
  Z
• Fusion with a rule
• I have too much (little) attribute Z, which
  means Im not healthy
• Evaluation
• Since I have a problem with attribute Z, I cant
  do X
• Avoidance
• Attribute Z is causing me not to do X Ergo,
  we need to work on factor Z
• Reason giving, using reasons as causes

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Case Formulation Identify the Unworkable Change
Agenda

• A depressed client might give you a string like
  this
• I have been put on work disability because of my
  depression. (reasons as causes)
• When you feel as down as I have been feeling, you
  cant function on the job like the others and you
  feel like a failure (evaluation)
• The only way I can control my depression is by
  staying away from work. (emotional and behavioral
  avoidance)
• I need to figure out what is causing my
  depression in the first place and then I will be
  able to get on top of it. (fusion)
• Once my depression is under control, I can go
  back to work (fusion)

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Why Doesnt the Change Agenda Work?

• In almost every case. . .
• 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 cant behave
  differently until you feel differently (but since
  missing work is increasing depression, the person
  is now locked into the causal equation and cant
  return to work)
• When the conditions specified in the change
  agenda cant be met, you can only explain your
  predicament but there is actually little you can
  do about it.

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Simplify Your Approach

• You dont have to go through all six core
  processes to be doing ACT!
• In more functional patients, there might be one
  polarity that you are going to target
• You want to use your assessment data to answer
  this question
• What is the main issue this client is having and
  what is the best point of entry to attack that
  problem?
• In many cases, ACT might turn out to be a single
  session therapy or a very brief intervention
• As patients become more chronically distressed,
  the number of polarities involved increases and
  this will lengthen therapy

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Listen With ACT Ears

• Watch the video segment
• Two Groups
• Group 1 looks at the tape from a content level
  focusing on insight, motivation, therapist bait
• Group 2 looks at tape using an ACT framework such
  as what core processes are invoked, what is the
  function of the problem, role of fusion,
  emotional avoidance, etc.

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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 wont
  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)

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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

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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 isnt 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 doesnt work

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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 isnt going
  to help you get out
• Blaming life for producing holes wont eliminate
  the holes

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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
• Monsters on the bus exercise makes this point

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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)

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When is control called for?

• When the event in question is under the
  organisms direct stimulus control
• Behavioral responses in the present moment
• Willingness to enter into a situation
• Being present
• Holding values
• Making commitments

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Willingness and Acceptance

• Often confused as being one and the same but they
  are not
• Willingness is an action of willfully exposing
  oneself
• Purposely putting oneself in front of distressing
  content
• This type of willingness is addressed as a part
  of acceptance
• Acting and continuing to act in a particular way
  even though the action produces distressing
  content
• This type comes up in the context of committed
  action
• Acceptance is a stance of holding distressing
  content without evaluation or struggle

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Role of Willingness

• Without willingness, there is no acceptance, but
  there can be no acceptance even though
  willingness is present (you expose yourself on
  purpose and then struggle with what shows up,
  even though you dont run)
• Behavioral avoidance is mainly caused by low
  willingness
• Would you be willing to go to the super market
  even though doing so will push your buttons?
• Experiential avoidance is mainly caused by low
  acceptance
• Can you simply watch your anxiety without trying
  to suppress, control or eliminate it?

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Role of Willingness

• Willingness work tends to come earlier than
  acceptance, but sometimes they can be paired
• Do not assume that low levels of willingness
  automatically predict low levels of acceptance
• Client might be behaviorally avoidant but quite
  capable of accepting distressing content.
• This could be a fusion or values issue, rather
  than an acceptance issue
• Willingness-suffering-workability exercise is a
  form of emotional willingness practice that you
  can use very early to begin preparing the client
  for acceptance work

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When Lack of Acceptance Is A Problem

• Usually, it starts with unwillingness statements.
  
• I wont go there if I have to feel anxious or sad
• Unwilling to get in front of unpleasant feelings
• Thinking about my divorce is just too painful
• Unwillingness to be in the presence of grief,
  loss or self critical thoughts
• I want to put this behind me and get rid of it
• Unwillingness to make contact with personal
  history or present moment
• I just want to get over this
• Unwillingness to be exposed to distressing
  content

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When Lack of Acceptance Is a Problem

• But it can morph into a problem with taking an
  accepting posture, usually as a result of fusion
• I just cant get my mind to stop giving me these
  thoughts
• These memories are just too scary for me to stay
  with them
• Why cant I feel normal like everyone else
• I know I shouldnt believe these thoughts but
  they are just so real
• Im having so much chest pain right now that I
  cant focus on my anxiety

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Your Personal Work

• Look at your problem situation from this angle
• What is showing up in the situation that is
  pushing my hot buttons?
• Write down any thoughts, feelings, memories,
  physical sensations that come along for the ride
• Up to now, how willing have you been to enter
  into this situation and deal with it somehow?
• What would you have to be willing to accept to
  allow you to stay in the situation and deal?
• Have you been accepting this stuff or have you
  been avoiding it?

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The Role of Fusion

• Basically, problems with acceptance and
  willingness originate in fusion
• Fusion with rules about the dangerous nature of
  private experience (negative feelings are bad for
  you traumatic memories create more trauma to
  establish health, you must be able to control
  these events)
• Taken literally, rules make it impossible to
  participate in direct experience because of its
  perceived toxicity
• Thus, you must experientially and behaviorally
  avoid participating, but this doesnt work either

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Defusion and Acceptance

• Basically, defusion strategies are designed to. .
  
• Create a space between thought and thinker
• Undermine the clients 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

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Principles of Defusion and Experiential Exercises

• Principle 1 Find metaphors that structure
  seeing the process of mental activity for what
  it is
• Phishing
• Sunglasses
• Two computers metaphor
• Alien
• Im having the thought that. ..
• Who am I talking to right now?

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Principles of Defusion and Experiential Exercises

• Principle 2. Notice the automatic nature of
  mental events and their ease of programming
• No pain, no gain
• What are the numbers?
• Blah, Blah, Blah

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Principles of Defusion and Experiential Exercises

• Principle 3. Notice their paradoxical nature when
  you try to control them
• Blondes have more
• Red Volkswagen
• Try really hard to be spontaneous

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Principles of Defusion and Experiential Exercises

• Principle 4. Create a context that weakens the
  the illusion of literality
• Reactive Mind and Wise Mind
• Milk, milk, milk
• There are four of us in here
• Thank your mind for that thought
• Funny voices

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Principles of Defusion and Experiential Exercises

• Principle 5. Notice their limitations and
  attachments
• Tell me how to walk
• Sunrise-Sunset
• Get off your buts

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Principles of Defusion and Experiential Exercises

• Principle 6. Reveal how these operations are
  hidden within language
• Observe a person
• Study an object, evaluate an object
• Kaleidoscope

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Your Personal Work

• We are going to do an experiential exercise
  called railroad crossing
• Prime yourself with the private events that you
  find unacceptable in your hot button situation
  (i.e., read them to yourself several times, so
  you can bring them up when the time comes)
• We are going to practice putting these events on
  railroad cars one by one and observe them cross
  your vision
• If you get pulled out of the exercise by some
  other mental event, put that on a railroad car
• We are going to do this for 10 minutes or so

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Choose Mindfully-Mindless Choosing Polarity

• Being mindful that reactive mind leads to living
  in the past or future, not the present
  (attachment to conceptualized self)
• Being mindful that reactive mind traps you in an
  illusory process of sense making and story
  telling (description-evaluation)
• Using wise mind to offset the mindless rule
  following of reactive mind (do what works, not
  what ought to work)
• Getting in the present moment allows you to see
  the world the way it actually is (Mindfulness
  exercises)
• Using wise mind to reveal your true values
  (values work exercises) and the course you are
  on (Bulls Eye)
• Using wise mind to respond flexibly in the
  present moment (workability)

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Addressing Obstacles Posed by the Conceptualized
Self

• In ACT, we talk about each patient having a
  story that can function like a lockbox
• Heres who I am and how I came to be that way and
  why nothing can ever change my reality
• The key is to get the client to lose confidence
  in the sanctity and unquestioned truth of the
  story
• Autobiography re-write exercise
• Self story wheel
• Time line
• DONT argue about how rational the story is
  let the experiential exercise show that each
  story is arbitrary and there are endless possible
  stories

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Two Forms of Self Experience Comprise Wise Mind

• Present Moment Awareness
• Being in the moment and absorbing what is there
  without mental interference (observer self)
• This is an attention skill that can be learned
• Simple Awareness
• The you that is aware of the present moment
• The you that is your consciousness
• The you that has always been there
• This is not a skill but rather is a result of
  sustained present moment awareness that is a skill

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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?
• Im 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

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Simple Awareness

• A transcendent sense of self that is bigger
  than all of the products of consciousness
• Contact with this space can have life changing
  impacts
• Various ACT exercises make the point
• Chessboard metaphor
• Leaves on a stream
• The you that you call you
• Various meditation and mindfulness exercises

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Your Personal Work

• Loving Kindness Meditation
• We are going to have you think about all aspects
  of your problem situation (your history with it,
  your resentments, your attachments, your fears,
  hopes, etc.)
• We want you to meditate on this situation with
  soft eyes and inject into it the four right
  paths, done one at a time
• Compassion
• Temperance
• Prudence
• Justice
• We will practice this meditation for about 15
  minutes

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Role of Values

• Values are seldom talked about in relation to
  mindful action they are normally thought of as
  the top end of committed action
• Important to distinguish values from valued
  actions
• Valued actions ARE the twin of commitment
• In ACT, values perform a number of important
  purposes
• Contact with values organizes present moment
  experience
• Values allow the clients to parse contingencies
  in the present situation (i.e., you cant know
  whether something is working unless there is an
  existing framework for knowing what working is)

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Workability, Vitality and Values

• The pathway to vitality is basically engaging in
  actions that resonate with personal values
• Workability is the ACT term for the extent to
  which actions are or are not consistent with
  values. It is the yardstick for measuring how
  therapy is working.
• Workability can be assessed situation ally.
• How did it work for you to get drunk last night
  when your wife got angry at you?
• Workability can also be assessed globally.
• How do you feel your life is working right now in
  terms of giving you a sense of vitality purpose
  and meaning?
• Workability is a good place to go to when you get
  stuck in session!

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Clinically Important Properties of Values

• Values are a product of wise mind and thus can be
  suppressed, but not eliminated, by certain
  activities of reactive mind
• Fusion with a toxic self story
• Excessive pliance
• Excessive behavioral control through reason
  giving
• Not based upon reasons, but rather represent
  starting assumptions (I stand for X) and cannot
  be intellectually derived
• Cannot be obtained by any single achievement and
  thus exerts continuous behavioral control (there
  is always more west to go)
• Values function as the fuel for committed
  action

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What Freud Said!

• The foundation of freedom from neurosis is the
  successful pursuit of three main objectives in
  living
• Work
• Love
• Play
• Consider this Freud was the ultimate
  contextualist!

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Areas for ACT Values Assessment

• Work/career/community usefulness
• Love/intimate relationships
• Family/parenting
• Friends/social connectedness
• Personal growth
• Health and hygiene
• Spirituality

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ACT Value Clarification Strategies

• Many techniques, but the core approach
• Use the common sense language of free choice
• Ask what they really want
• Shape the answer by
• distinguishing values from goals
• confronting pliance and avoidance
• being completely and sincerely supportive
• Funeral Exercise is the most often used ACT
  strategy

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Your Personal Work

• Bulls Eye Exercise
• Think about the area of living that is being
  pulled for in your hot button situation
• Sometimes, only one or two areas of personal
  valuing are impacted by a painful situation
• Complete the bulls eye values exercise in the
  area (s) involved (health, work/play,
  relationships)
• Rate how on target you think you are in this hot
  button situation. How do you feel about this?
• What behaviors are consistent? Inconsistent?

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Take Action-Avoid Action Polarity

• Commit to voting with your feet, in accordance
  with your values (valued actions)
• Take action knowing that it will trigger
  distressing content and commit to continuing to
  act (willingness the overt behavior)
• Committed actions are choices that are made with
  reasons, but not for reasons (choosing versus
  deciding)
• Committed acts are qualities no matter how small
  or large as you want them to be (like jumping)
• Committed action triggers a process that never
  ends until you do (journey metaphors)
• Re-attaching to the self story is the main
  barrier to following the path of committed action
  (who would be made right if you got healthy)

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Role of Committed Action

• ACT is ultimately an old school behavior
  therapy this is all about finding more effective
  ways of behaving in the world
• All of our prior work is for naught if the client
  does not engage in ever widening patterns of
  workability
• Acceptance for acceptances sake diminishes the
  work
• Mindfulness that does not lead to valued action
  is called MBCT!

70
Clinical Aspects of Committed Action

• Actions which are consistent with ones
  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.

71
Clinical Use of Choice

• Choice is one of the trickier concepts in ACT and
  is not always understood and can generate
  resistance.
• Think of choice as a for the sake of which
  behavior. It occurs as an act of free will.
  (Diving on a hand grenade to protect other people
  from being hurt)
• However, choices are ongoing behavioral
  processes, not outcomes. You have to choose over
  and over again (a good example is recovery from
  addiction)
• You dont HAVE to choose a particular act over
  any other actyou get to pick. It is OK to let a
  client choose NOT to change!
• Reframe reason giving as choice making.
• Dont use choosing as a way of brow beating the
  client!

72
Principles for Promoting Committed Action

• Think small and accumulate positives
• Focus on the qualitative aspect of committing
  to an action
• Jump from a paper, book, chair
• Small committed actions can stimulate large
  amounts of distressing content
• Eye contact exercise
• Goals are the process by which the process
  becomes the goal (vitality is in the seeking, not
  the acquisition)
• Swamp metaphor, hiking metaphor, skiing metaphor

73
Addressing Barriers to Committed Action

• Are skills deficits going to be an issue?
• If so, provide skills training
• Being righteous rather than being real
• Corpus Delecti no body, no crime
• Forgiveness to give the grace that came before
• Fish hook metaphor
• Being response-able and responsible
• Choose each step exercise
• Inhale broken commitments, name them honestly
• Hop A Long Cassidy metaphor

74
ACT with Children Data

• High levels of EA mediate the relationship
  between childhood abuse and poor outcomes in
  adulthood, including psychological distress and
  substance abuse (Marx Sloan, 2002 Simons,
  Ducette, Kirby, Stahler, Shipley, 2003)
• Children with anxiety disorders more likely to
  propose avoidance solutions to ambiguous
  scenarios than diagnosis-free and externalizing
  children (Barrett et.al., 1996)

75
ACT Strategies with Children Teens

• Use less logical and literal methods (metaphors,
  paradox, experiential exercises)
• Children as young as 3-6 yrs. Prefer and
  demonstrate greater compliance with metaphorical
  vs. literal language during progressive muscle
  relaxation (Heffner, Greco, Eifer, 2003)
• Less instructive quality of metaphor and paradox
  invites less rebellion from teens

76
ACT Strategies with Children and Teens

• Dominance of literal language is less established
  in teens than adults (shorter hs of living in
  their minds)
• Capacity for abstract thinking emerges
• Teens are ready to question rules
• Teens may be particularly receptive to learning
  strategies that increase psychological
  flexibility
• Opportunity for PREVENTION (rather than
  remediation) of maladaptive rule following,
  fusion, and experiential control

77
Suggestions

• Allow metaphors to develop out of context of
  treatment
• Use props, artwork, games, visual aides
• Include parents, teachers, and peers/sibs
  whenever possible and appropriate (Morris
  Grecco, 2002 Murrell, Coyne, Wilson, 2004)

78
Suggestions

• Use with Behavioral Parent Training
• All ages, particularly with adolescence with
  their parents
• Boost impact of behavioral family therapy/ parent
  training with children with multiple behavior
  disorders

79
Apply ACT to One of Your Difficult Cases

• Create an ACT formulation of the clients
  problem.
• Which polarity is likely to be the best point of
  entry?
• Think of one or two strategies you could use.
• What challenges might you run into when you try
  these strategies?
• How can you model what you want your client to
  learn?
• Discuss this case with your partner

80
Your Personal Work

• Time to stand up and be counted! Go back to your
  bulls eye exercise, to the last page.
• Are you willing to once again expose yourself to
  this situation?
• Are you committed to accepting what shows up for
  you in that situation?
• Are you willing to carry the four noble truths
  along with you?
• Will you commit to a specific action or set of
  actions that are consistent with your values?