Supercharging therapy with values

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Supercharging therapy with values
Dr. Joseph Ciarrochi, School of Psychology,
University of Wollongong
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Structure of talk

• Part 1 Theory
• Part II. Behavioral Activation
• Evidence behavioral Activation is effective.
• Part III Values clarification
• Evidence values clarification is effective
• How to work with values

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Part I A Unified Theory
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What happens to peoples dreams?

• The very great majority kill themselves long
  long before their time.
• Live as children grow pale as adolescents show
  a flash of life in love die in their twenties
  and join the poor things that creep angry and
  restless about the earth (OBrian, 1991, p. 526).

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ACT as a Unified framework

• An extremely brief and pictorial description
  of Relational Frame Theory
• Fusion and Avoidance, two key processes that
  play a role in interfering with value-congruent
  living

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How do we lose touch with what we value?Fusion
is the dominance of particular verbal functions
over other potentially available nonverbal and
verbal functions (Hayes et al., 1999).
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Fusion and avoidance. Fusion makes it possible
for our private experiences (the bees above) to
seem like physical threats. It allows us to spend
time avoiding our experiences, just as we would
avoid an outside threat
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Avoidance takes a great deal of energy and is
often inconsistent with other activities, e.g.,
distress provoking valued-activities
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Desire (or values) and fear are two sides of the
same coin. If cant have distress, then you often
must give up what you desire or value
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Acceptance and Commitment Therapy (ACT) and
Behavioural Activation (BA)

• Shared philosophy of science Functional
  Contextualism
• Behaviourist
• Emphasis on functional analysis
• Emphasis on context rather than content
• Shared therapeutic processes
• Activation of behaviour
• Undermining of harmful avoidance behavior
• Mindfulness
• Exposure

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Distinctions between ACT and BA

• ACT is based on a behavioral theory of language.
  Like traditional CBT, ACT views cognition as
  playing a key controlling role in suffering.
  However , ACT and traditional CBT differ in how
  they conceptualize and treat client problems
  (Ciarrochi Bailey, 2008).
• Cognitive Defusion. ACT attempts to change the
  way one interacts with or relates to thoughts by
  creating contexts in which their unhelpful
  functions are diminished.
• Self-as-Context- ACT helps people to contact with
  the sense of self as a locus or perspective
  (e.g., the observer self). This self gives
  clients a place to observe their experience and
  learn to let go of unhelpful self-evaluations.
  They learn that they are not the same as their
  evaluations they are not the same as their pain,
  their depression.

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Distinctions between ACT and BA

• Activities versus values
• ACT tends to emphasize values more than
  traditional BA, which focuses a bit more on
  activity scheduling

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Part II Behavioral Activation
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Study 1 supporting BA aswell-established
treatment for depression (Chambless et al., 1996)

• McLean and Hakstian (1979) JCCP. Behavior therapy
  superior to other therapies at immediate
  follow-up (9 of 10 indices), and marginally
  superior on follow-up (7 of 10 indices)
• Behaviour therapy had lowest dropout (5 compared
  to 26 to 36 for other treatments)

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Study 2 supporting BA aswell-established
treatment for depression (Chambless et al., 1996)

• Jacobson et al. , 1996, (JCCP) compared three
  conditions.
• Conditions
• Behavioural Activation (BA)
• BA automatic thought challenging (ATC)
• BAATC downward arrow/core belief
• Results
• Behavioral activation alone was as effective in
  treating depression as BA combined with cognitive
  interventions.
• Gortner et al. 1999 showed effects held at 2
  year follow-up

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More research supporting behavioural activation

• Dimidjian et al., 2006, JCCP. Study of Major
  Depression
• Compared behavioural activation to Cognitive
  Therapy and Antidepressent medication (ADM)
• BA found to be comparable in efficacy to ADM, and
  more efficacious than CT.
• Differential treatment effects obtained only for
  most severely depressed
• For more severly depressed participants, BA and
  ADM comparable
• Cuijpers et al., 2007 CPR. Meta-analysis
• BA effective (effect size .87) and effects
  fairly consistent across studies

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Is behavioral activation effective for other
disorders, such as anxiety?

• ACT theory posits similar processes fusion and
  avoidance.
• Approximately 50 of individuals with depression
  have a coexistant anxiety disorder ( Kessler et
  al., 1996 Mineka, Watson, and Clark, 1998)
• Anxiety and depression share many symptoms (e.g.,
  difficulties concentrating, restlessness,
  fatigue, and sleep problems.
• Decrease in control and predictability may be
  common in both disorders
• Anxiety and mood disorders may be variable
  manifestations of similar neurobiological
  processes (See Hopko, et al., 2006, for review of
  similarities between anxiety and depression)

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Exposure in the service of activating valued
behaviour
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Is behavioral activation useful in treating
anxiety

• Small study of pure B.A. with PTSD shows B.A. was
  effective (Jakupac, et al., 2006)
• Social anxiety Exposure is as effective as CT
  and full CBT package in treating social anxiety
  (Powers, et al., 2008)
• ACT, with big BA component, is effective in
  treating anxiety (Block, Wulfert, 2000
  Dalrymple herbert, 2007 Forman et al,2007
  Zettle, 2003)

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Part III Values
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What are values?

• Wilson, Sandoz, Kitchens, and Roberts, 2008,
  under review
• 1) Values are ongoing patterns of activity
• Not achievable, cant be completed
• Goals are achievable and serve values

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What are values?

• 2) values are a special class of reinforcer
• Can me distant in time, and occur in tiny
  increments
• Can refer to benefits that , in principle , could
  never contact (e.g., afterlife)

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What are values?

• 3) values are verbal
• Language makes present psychological functions
  without direct operant or classical conditioning
  processes

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What are values?

• Values are a special class of reinforcers
  that are verbally constructed, dynamic, ongoing
  patterns of activity, for which the predominant
  reinforcer is intrinsic in the correspondence
  between the individual behaviour and valued
  behavoural pattern (Wilson, et al., 2008)

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Values, what are they good for?

• Values have tremendous transformational power
• Theoretically, values set up the possibility for
  behaviours to become more reinforcing or
  punishing because of their relation to value
  statements

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Empirical evidence Values work is likely to be
good for the client
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Values affirmation buffers the stress response

• All participants rank order values in terms of
  personal importance
• Trier social stress taskinvolves telling
  subjects they will have to do stressful speech
  task and mental arithmetic.
• Cresswall et al., 2005, Psychological Science

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Values affirmation buffers the stress response

• Affirmation manipulation
• Answer question like Assuming that you have
  sufficient ability, would you prefer to be (a) a
  banker (b) a politician
• Experimental condition. Answered questions
  relating to top-ranked value
• Control. Answers questions relating to fifth
  ranked value

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Salivary cortisol response to stress in the
value-affirmation and control groups
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Pretest and postest self-report stress measure,
as function of self-resources (self-esteem and
optimism)
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Value affirmation improves objective performance

• Cohen et al., 2006, Science
• Theory
• People are motivated to maintain self-integrity
• Negative group characterizations (e.g., black
  stereotypes in U.S.) pose chronic threat to
  self-integrity
• This threat, if too severe, can undermine
  performance

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Value affirmation improves objective performance

• Main study and replication
• Treatment and control condition presented a list
  of values
• Treatment condition indicate most important
  values. Write about why value important to you
• Control condition. Indicate least important value
  and why this value might be important to someone
  else

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Values clarification and tolerance for pain

• Is their benefit to connecting pain-related
  thoughts to actions in a valued direction?
• Paez-Blarrina, M. et al., 2007, Behavior
  Modification Paez-Blarrina et al. ,2008,
  Behaviour Research and Therapy

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Values clarification and tolerance for pain

• Pain task
• Perform cognitive task. If do well, get points,
  which can be exchanged for a reward at the end of
  the task.
• Red asterisk appears on screen.
• If choose finish, then task ends and no shock.
• If continue, more chance for points but also a
  shock. (this is behavioural measure of pain
  tolerance)

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Values clarification and tolerance for pain

• Key Conditions
• ACT-values protocoldepicted pain as a part of
  valued action
• Control-values protocolpain is opposed to valued
  living
• No values protocol

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Values clarification and tolerance for pain

• Findings
• 7/10 ACT-values intervention tolerated maximum
  number of shocks Only 1/10 and 2/10 tolerated in
  the control and untrained condition,
  respectively.
• Pain believability. Do you keep going even when
  you think the task is causing you very much
  pain.
• 9/10 kept going in ACT-values Only 5/10 and 3/10
  kept going in the control and untrained
  conditions respectively
• These differences were significant

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Measuring and using values in therapy
ACT intervention
Survey of Life Principles
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Past research in values

• Values work (Schwartz, et al., Rokeach et al.).
• What is most important to you?
• Are there Universal values?
• Personal strivings (Sheldon, Emmons, Deci).
• What do you strive for
• Why do you strive? Is it for authentic or
  controlled reasons?
• We will call both of these guiding principles
  for ease of reference

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Towards a behavioural approach to values and
goals Recasting Needs

• Both value and striving literature seek to
  identify universal needs that underpin all
  guiding principles
• Need is identified by observing that positive
  psychological consequences result from conditions
  that allow its satisfaction and negative
  consequences accrue in situations that thrwart it
  (deci and ryan, 2001, pg 229)
• Instead of speaking in terms of needs, I will
  speak in terms of categories of reinforcer.

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Towards a behavioural approach to values and
goals type of rule following

• Pliance- rule governed behavior under control of
  apparent speaker-mediated consequences for a
  correspondence between the rule and the relevant
  behavior. (Zettle and Hayes, 1982 Hayes,
  Wilson, and Stroshal, 2001)
• Factors that impact pliance
• ability of speaker to monitor compliance, and
  deliver consequences
• importance of consequences to listener
• others (history, credibility Hayes and zettle)
• Problem with pliance. Excessive pliance, e.g.,
  wanting to be good and please others, can
  dominate over ones direct, personal expeirence of
  what works
• Reinforcers are arbitrary

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Towards a behavioural approach to values and
goals type of rule following

• Tracking- rule governed behavior under control of
  apparent correspondence between the rule and the
  way the world is arranged. (Zettle and Hayes,
  1982)
• Factors that impact tracking
• Listeners history with the rule giver
• Correspondence between the rule and other rules
  or events in the listeners history
• Importance of the consequence implied by the rule
• Extent rule successfully leads to reinforcement,
  avoid punishment
• Speaker does not mediate compliance (e.g., the
  rule could be conveyed by a book and have the
  same effect) (Hayes and Zettle, 1982)

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Recasting Self-Determination Theory in
behavioural terms.
Pliance
Tracking
Deci and Ryban, 2000, psychological science
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The ImPActS intervention model
Importance Important principles are expected to involve tracking ACT can be used to help people discover what principles are or are not important to them.
Pressure ACT can be used to undermine the power of unhelpful, pliance-based principles
Activity ACT can be used to increase the amount of principle-congruent activity and the likelihood of contacting reinforcers
Success ACT can be used to increase peoples success at living principles (e.g., via overcoming barriers and reinforcing commitment)
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Research on values

• The area emphasizes the Importance component of
  the ImPActS model.

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The structure of values (Schwarz)
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Values and behaviour

• ImPActS
• Values importance has predicted more than 15
  different behaviours
• e.g., voting for political party, choosing a
  university course
• Other predicted behaviours delinquency,
  cooperation, competition, consumer purchasing,
  environmental behaviours, religious behaviours
• (See Bardi and Schwartz, 2003)

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Values and well-being

• ImPActS
• The following were positively related to
  subjective well-being
• Achievement Personal success through
  demonstrating competence according to social
  standards. (Successful, capable, ambitious,
  influential)
• Stimulation Excitement, novelty, and challenge
  in life. (Daring, a varied life, an exciting
  life)
• Self-direction Independent thought and
  action-choosing, creating, exploring.
  (Creativity, freedom, independent, curious,
  choosing own goals)
• Sagiv and Schwarz, 2000, Eur. Jn., of Soc. Psyc

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Values and well-being

• ImPActS
• The following were negatively related to
  well-being
• Conformity Restraint of actions, inclinations,
  and impulses likely to upset or harm others and
  violate social expectations or norms.
  (Politeness, obedient, self-discipline, honouring
  parents and elders)
• Security Safety, harmony and stability of
  society, of relationships, and of self. (Family
  security, national security, social order, clean,
  reciprocation of favors)
• Sagiv and Schwarz, 2000, Eur. Jn., of Soc. Psyc

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Values and well-being

• ImPActS
• The researchers failed to find a positive
  association of subjective well-being and
• Universalism Understanding, appreciation,
  tolerance and protection for the welfare of all
  people and for nature. (Broadminded, wisdom,
  social justice, equality, a world at peace, a
  world of beauty, unity with nature, protecting
  the environment)
• Benevolence Preservation and enhancement of the
  welfare of people with whom one is in frequent
  personal contact. (Helpful, honest, forgiving,
  loyal, responsible)
• Seemed inconsistent with the notion that concern
  for others rather than self promotes subjective
  well-being
• A false dichotomy?
• Sagiv and Schwarz, 2000, Eur. Jn., of Soc. Psyc

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Succeeding at what is important to you

• ImPActS
• Congruity between people's values and their
  environment promotes well-being, regardless of
  the particular values to which people ascribe
  importance.
• Power values were negatively associated with
  well-being amongst psychology students, and
  higher satisfaction amongst business
  administration students. The business folks were
  also happier the more they were into achievement
  values.
• Sagiv and Schwarz, 2000, Eur. Jn., of Soc. Psyc

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Succeeding at what is important to you

• ImPActS
• Life satisfaction influenced when satisfied in
  value-congruent domain.
• More specifically, global life satisfaction was
  strongly influenced by social life for
  individuals high in Benevolence values, whereas
  it was strongly influenced by family life for
  individuals high in Conformity values.
• Satisfaction with grades was a stronger predictor
  of global life satisfaction for individuals who
  stress achievement than for those who do not.
• Within-individual variation of day-to-day
  satisfaction is strongly influenced by daily
  success with the most valued domain.
• Oishi, et al., j of personality, 1999

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Personal strivings

• Key Researchers Sheldon, Emmons, Elliot, and
  Others
• Idiographic. People describe their own personal
  strivings and do not select from a set items, as
  in values work
• Emphasis on Self-concordance. To what extent do
  people pursue their goals because the goals fit
  with their underlying interests and values rather
  than because others pressure them to pursue the
  goal.

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Universal needs, or categories of reinforcer

• Competence or effectancepropensity to have an
  effect on the environment as well as to attain
  valued outcomes within it.
• Relatedness -- desire to feel connected to
  others, to love and care, and to be loved and
  care
• Autonomy refers to volitionthe organisimic
  desire to self-organize experience and behavior
  and to have activity be concordant with ones
  integrated sense of self

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Personal strivings key findings

• Self concordance relates to subjective
  well-being across many cultures (Sheldon, 2002
  Sheldon et al., 2004)
• Longitudinal study. Making progress towards
  goals predicted well-being. However, this
  depended on the organismic congruence of the
  goal. That is, goal achievement led to increased
  well-being for those people who pursued goals for
  more autonomous reasons, and those goals that are
  oriented towards more intrinsic outcomes (Sheldon
  and Kasser, 1998)
• This relates to Importance and Pressure in the
  ImPActS model

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Personal strivings Avoidance goals

• Elliot and sheldon (1998) coded goals in terms
  of approach and avoidance
• Approach goals get in good shape, be more gentle
  and humble
• Avoidance goals avoid procrastination, dont be
  lazy
• People with avoidance goals tend to feel less
  competent and in control and experience greater
  reporting of physical symptoms (Elliot and
  Sheldon, 1998)
• Elliot, Sheldon, and Church (1997) had students
  classify goals as approach oriented or avoidance
  oriented. Avoidance striving was deleterious to
  both retrospective and longitudinal well-being

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The survey of life principles (SLP)

• Ciarrochi and Bailey, in press Stefanic and
  Ciarrochi, 2008 Frearson and Ciarrochi, 2008
• The SLP attempts to combine the best parts of the
  values literature and the personal strivings
  literature, and attempts to do so in a way that
  is useful to clinic
• SLP provides people with wide variety of
  principles to choose from. This has the advantage
  of prompting people to think about principles
  they might have not considered for awhile, or
  might have forgotten
• SLP measures extent principle is due to self
  versus other pressure

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The survey of life principles (SLP)

• 53 items, sampled to cover every major domain
  identified in values literature, goals
  literature, and job interests literature.
• Somewhat heavy emphasis on social principles,
  given their clinical relevance.
• Three items related to experiential control
  (e.g., having a stress free life)
• Principles written in a verb form, in keeping
  with the ACT definition of values as being
  ongoing patterns of activity.
• Principles were written to have maximal personal
  relevance (e.g., A world of beauty changed to
  creating beauty)

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The survey of life principles (SLP)

• Items are call principles, because they could
  refer to either values or abstract goals (e.g.,
  being honest might be either value or goal)
• Two open end items for people to write down own
  principles

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Four dimensions of the SLP

1. Importance. The extent a person finds princple to
   be personally imporant
2. Pressure. The extent person feels pressured to
   hold principle. Pressure can come from other
   people, groups, media, society, etc.
3. Activity. Each principle is rated in terms of
   whether the person wanted to put it into play
4. Success. If person wanted to put a principle into
   play, then they rated that principle in terms of
   their level of success.

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SLP Early findings

• First study conducted with 300 University
  Students
• We focused on variables of interest to
  clinicians e.g., measures of emotional
  well-being, psychological well-being, social
  support, and relationship satisfaction
• The next study will be conducted later this year
  with 600 year 12 adolescents. We have been
  conducting a longitudinal study with these
  students for 7 years.
• Includes broad range of measures related to
  social and emotional well-being
• Involves ratings by peers and teachers

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Each SLP global score makes a distinctive
contribution to well-being
Description Low Score Mean High Score
Importance Low scores indicate the person finds few principles to be important 5.81 6.51 7.19
Female 5.90 6.57 7.24
Male 5.57 6.3 7.03
Pressure High scores indicate the person feels pressure from others to hold principles 3.14 4.54 5.98
Activity Low scores indicate that the person is putting reduced number of principles into play 23.63 31.18 38.73
Success Low scores indicate that the person is not succeeding at principles 3.05 3.48 3.91
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SLP Global scores and emotional well being
Global score Positive Affect Sadness Hostility
Importance .10 .08 .11
Pressure -.10 .11 .12
Activity .22 .01 -.09
Success .36 -.34 -.31
Variance explained 23 14 12
p lt .05 plt .01
Note These are the Betas from regression
analysis. All variables were entered
simultaneously, so Beta represents the unique
variance explained by each global score, after
controlling for the other scores
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SLP Global scores and Psychological well-being
Global score Autonomy Relations with others Purpose
Importance -.12 .08 .27
Pressure -.25 -.15 -.12
Activity .11 .04 .14
Success .30 .36 .39
Variance explained 18 18 29
p lt .05 plt .01
Note These are the Betas from regression
analysis. All variables were entered
simultaneously, so Beta represents the unique
variance explained by each global score, after
controlling for the other scores
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Predicting social wellbeing
Global score Romantic relationship satisfaction Social support numbers Social support satisfact.
Global Success .12 .09 .18
Prosocial Import. .24 .07 .12
Having genuine and close friends-success .00 .20 .14
Having relationships involving love and affection-success .41 -.04 .21
Variance explained 32 7 20
p lt .05 plt .01
Note The global score success was the only one
to uniquely predict each of the social
well-beings. However, prediction was much
improved by using the more specific social
principles
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Resisting pressure?
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One needs to look at local as well as global
indices

• Importance of power not related to well-being.
  Indeed , it is related to higher hostility
• Importance of wealth was not related to
  well-being

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Top 10 most important values
1 Having genuine and close friends
2 Being loyal to friends, family, and/or my group
3 Maintaining the safety and security of my loved ones
4 Having relationships involving love and affection
5 Feeling good about myself (experiential control item)
6 Striving to be a better person
7 Experiencing positive mood states (experiential control item)
8 Being Honest
9 Having an enjoyable, leisurely life
10 Being safe from danger
69
Top 10 most pressured values
1 Meeting my obligations
2 Being ambitious and hardworking
3 Being physically fit
4 Showing respect to parents and elders
5 Eating healthy food
6 Being honest
7 Being self-sufficient
8 Striving to be a better person
9 Being competent and effective
10 Being safe from danger
70
Top 10 most successful values
1 Being loyal to friends, family, and/or my group
2 Enjoying food and drink
3 Being safe from danger
4 Having genuine and close friends
5 Being honest
6 Maintaining the safety and security of my loved ones
7 Making sure to repay favors and not be indebted to people
8 Showing respect to parents and elders
9 Having relationships involving love and affection
10 Enjoying music, art, and/or drama
71
Top 10 failures
1 Leading a stress free life (experiential control)
2 Having a sense of accomplishment and making a lasting contribution
3 Promoting justice and caring for the weak
4 Gaining wisdom and a mature understanding of life
5 Being wealthy
6 Being at one with god or the universe
7 Feeling good about myself (experiential control)
8 Striving to be a better person
9 Being physically fit
10 Having an enjoyable, leisurely life
13 Experiencing positive mood states (experiential control)
Note Failure index Importance success.
72
Principle compatibilities and incompatibilities
73

• Principle
• Having genuine and close friends
• Perceived compatibilities
• Being loyal to friends, family, and/or my group
• Having relationships involving love and affection
• Emotion control principles (e.g., Leading a
  stress-free life, feeling good about myself)
• Perceived incompatibilities
• Gaining wisdom and a mature understanding of life
• Artistic principles
• Comment
• Surprising disconnect between many pro-social
  principles (e.g., honesty) and friendship

74

• Principle
• Having relationships involving love and affection
• Perceived Compatibilities
• Having genuine and close friends
• Maintaining the safety and security of my loved
  ones
• Being sexually active
• Being safe from danger
• Perceived incompatibilities
• Sensation seeking principles (Having a life
  filled with adventure)
• Nonsocial activities (Building and repairing
  things working outdoors)
• Comment
• Where are the prosocial virtues? Honesty,
  loyalty, helping others

75

• Principle
• Prosocial Being loyal, honest, maintaining
  security and safety of loved ones, respecting
  parents and elders, helping others
• Perceived Compatibilities
• Being safe from danger
• Resolving disputes
• Showing respect for tradition
• Perceived incompatibilities
• Power (e.g., having influence having authority,
  being in charge)
• Sensation seeking
• Artistic

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• Principle
• Being wealthy
• Perceived Compatibilities
• Power principles
• Sensation seeking principles
• Achievement principles
• Being sexually active being sexually desirable
  (both M and F)
• Emotion control
• Perceived incompatibilities
• Helping others
• Being at one with nature
• Being at one with god
• Being artistic
• Promoting justice and caring for the weak

77

• Principle
• Power having influence of people, having
  authority, being in charge
• Perceived Compatibilities
• Achievement principles (e.g., being ambitious and
  hard working)
• Being sexually desirable
• Perceived incompatibilities
• Being honest
• Respecting parents and elders
• Helping people
• Being at one with nature
• Being at one with god, practicing religion
• Promoting justice and caring for the weak

78
Utilizing the SLP

• Importance ratings
• What do clients value most? What is likely to be
  the subject of therapy
• Values themes. Social. Power. Art? Achievment
• Look out for low global values ratings. Might
  suggest a client has no idea what they value, or
  refuses to acknowledge values
• Likely interventionValues clarification
  (see card sorting task)

79
Utilizing the SLP

• Restricted range of principles
• Clients may endorse very few principles as
  important.
• They may endorse several as important, but state
  that they have not tried to put them into play.
• Finally, they may rate a number of value clusters
  as unimportant
• What are the barriers to putting the values into
  play?
• Likely interventions acceptance, defusion, or
  overcoming practical barriers?

80
Utilizing the SLP

• Dominance of experiential control items
• High importance on experiential control
  dimension
• Nothing inherently wrong with experiential
  control, unless in conflicts with other important
  principles
• Likely interventions Creative hopelessness,
  acceptance

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Utilizing the SLP

• Presence of strong pressure
• Research suggests that pressured principles tend
  not to lead to vital living or well-being
  (Sheldon Kasser, 1995) and tend to be
  associated with hostility and sadness (Stefanic
  Ciarrochi, 2008).
• Danger of contercompliance In reaction to
  pressure, the client refuses to act according to
  the principle, or acts contrary to the principle

82
Utilizing the SLP

• Presence of strong pressure Interventions
• Therapist behaviours acting with humility in
  session, undermining your own authority,
  encouraging clients to not believe anything you
  say
• Remove source of pressure. E.g., imagine nobody
  knew you were living the principle. Would you
  still live it?
• Seek to identify past experience that was vital.
  E.g., sweet spot exercise. Connect their valued
  statements to this vital past

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References

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