Rob Zettle, Ph.D.

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ACT WITH DEPRESSION

• Rob Zettle, Ph.D.
• Wichita State University

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INITIAL ORIENTING EXERCISE
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WORKSHOP OBJECTIVES

• At the end of the session, participants will be
  able to
• 1. Identify and clarify client values salient in
  depression.
• 2. Use a case-conceptualization approach to
  identify core processes and variables that
  contribute to deficits in valued action.
• 3. Select, adapt, and apply ACT-consistent
  interventions that target these same processes in
  order to increase valued living.

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GROUND RULES

• ACT like swimming - is best learned by doing
  it, rather than reading and talking about it.
• Structure of workshop
• Didactic presentations
• Experiential exercises
• All are invited and encouraged to participate.
• None are required to do so.
• May opt to discontinue at any time.

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YOUR LIFE STORY WITH DEPRESSION

• Take 5 minutes and write down at least part of
  your life story with depression.
• Recall a time in the past (or present) when you
  have struggled with depression.
• Describe how it first began, ways in which you
  struggled with it, and the key historical,
  situational, and personal life events that
  contributed to your struggles with depression.

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THE ACT MODEL OF DEPRESSION AND ITS TREATMENT
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The Primary ACT Model of Treatment
Contact with the Present Moment
Values
Acceptance
Psychological Flexibility
Committed Action
Defusion
Self as Context
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RELATED EXPERIENTIAL EXERCISE
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NATURE OF PSYCHOLOGICAL INFLEXIBILILTY

• Being stuck
• Inability to freely choose various ways of
  leading a vital and valued life.
• Dysfunctional persistence
• Cognitive and behavioral rigidity

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CONCEPTUALIZATION OF DEPRESSION

• Depression Both overt behavior and private
  events (thinking and feeling)
• Struggle with feeling the right way
  to feel
• Secondary, reactive emotion
• Dirty pain of unsuccessful
  efforts to control clean pain of dysphoria,
  sorrow, guilt, and
  bereavement.
• Not all cases of depression are usefully treated
  with ACT as the primary intervention (e.g.,
  social skills deficit)

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DEALING WITH SORROW

• TYPES OF SORROW
• 1. Actual Loss of What Once Had
• 2. Projected Loss of What Have Now
• 3. Constructed Loss of What Could Have Had

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ACTUAL LOSS OF WHAT ONCE HAD

• Comparison of Now to a Preloss Past
• Role of rumination Living in a Regretted Past
• Poster child of complicated bereavement
• Grief Bereavement
• Grief Rumination Complicated Bereavement
• Dont they know its the end of the world? It
  ended when I lost your love. Skeeter Davis

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PROJECTED LOSS OF WHAT HAVE NOW

• Comparison of Now to a Bereft Future
• Role of worrying Living in a Dreaded Future
• When I get older, losing my hair many years from
  now, will you still be sending me a Valentine,
  birthday greetings, bottle of wine?
• Will you still need me, will you still feed me,
  when Im 64? The Beatles
• Related exercise

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CONSTRUCTED LOSS OF WHAT COULD HAVE HAD

• Comparison of Actual Now to What Now Might Have
  Been
• Living in a Unfulfilled Present
• You can lose what you never had. Muddy Waters
• I coulda had class. I coulda been a contender.
  I coulda been somebody instead of a bum, which is
  what I am. - Terry Malloy (Marlon Brando) in On
  the Waterfront
• Related exercise

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FUNCTIONS OF DEPRESSION

• Why is depression problematic?
• 1. Clients cant stand feeling that way
  drives experiential control agenda.
• 2. Clients want to be normal suggests
  fusion with self-as-concept.
• 3. Client are prevented for certain activities -
  serves as barrier to committed, valued
  behavior.
• Different forms of depression (e.g., MDD vs. DD
  vs. DDNOS) may serve same function same form may
  serve different functions.

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PRIMARY PATHWAY TO DEPRESSION DYSPHORIA

• Dysphoria as natural, psychologically-healthy,
  and normal mood fluctuation
• Functions
• Adaptive response to unpropitious situations in
  which efforts to pursue a major goal will likely
  result in danger, loss, bodily damage, or wasted
  effort (Neese, 2000)
• Terminates goal seeking helps conserve
  resources

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The Primary ACT Model of Psychopathology
Dominance of the Conceptualized Past and Feared
Future Weak Self-Knowledge
Lack of Values Clarity Dominance of Pliance and
Avoidant Tracking
Experiential Avoidance
Psychological Inflexibility
Inaction, Impulsivity, or Avoidant Persistence
Cognitive Fusion
Attachment to the Conceptualized Self
Several paradigmatic and philosophical
perspectives are available to serve as a
foundational base for applied psychology. Among
these, functional contextualism seems most useful
in adequately meeting the challenge of the human
condition with suffcient scope, depth, and
precision. The basic tenets, truth citerion, and
root metaphor of functional contextualism will
first be defined and contrasted with those of
mechanism, which at least implicitly appears to
be the dominant paradigmatic perspective within
most of applied psychology. This will be
followed by an overview of Relational Frame
Theory (RFT) as a functional contextualistic
account of language and cognition. Finally,
research on the application of RFT through
acceptance and commitment therapy (ACT) and in
work with developmentally delayed populations
will discussed and summarized.
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1. EXPERIENTIAL AVOIDANCE AND RUMINATION

• Rumination Experiential Avoidance
• Attempts to solve the problem of feeling bad
  by figuring it out.
• Exacerbates dysphoria/sorrow into dirty pain
  of clinical depression.
• Effects of Rumination
• Increase in depressed mood
• Reduction in generation of effective solutions,
  confidence in them, and likelihood of
  implementation
• Perpetuation of rumination and perception of its
  insight-value

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The Primary ACT Model of Psychopathology
Dominance of the Conceptualized Past and Feared
Future Weak Self-Knowledge
Lack of Values Clarity Dominance of Pliance and
Avoidant Tracking
Experiential Avoidance
Psychological Inflexibility
Inaction, Impulsivity, or Avoidant Persistence
Cognitive Fusion
Attachment to the Conceptualized Self
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2. RUMINATION AND FUSION

• Fusion Dominance of derived stimulus functions
  over those arising from direct contingencies
• Evaluating Increases self-criticism and
  negative self-referential thoughts
• Reason-giving Asking and answering why?
  increases self-blame
• Story telling Increases arbitrary verbal
  constructions that make sense of evaluating
  and reason-giving

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PRIORITY OF BEING RIGHT

• 1. Life story as reason-giving on a grand
  scale.
• 2. Getting better may be incompatible with a
  life story of being wronged
• (Given the way I was mistreated, I have every
  right to be depressed.)
• (Anyone who had to undergo what Ive had to put
  up with would be depressed.)
• Transgressors not worthy of forgiveness
• 3. Being right more important than getting
  better
• Being right and holding other accountable
  trumps getting better
• Can also extend to holding oneself accountable
  and withholding of forgiveness
• 4. Possible additional function of suicidal
  behavior (revenge, getting even)
• (Theyll be sorry when Im gone.).

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The Primary ACT Model of Psychopathology
Dominance of the Conceptualized Past and Feared
Future Weak Self-Knowledge
Lack of Values Clarity Dominance of Pliance and
Avoidant Tracking
Experiential Avoidance
Psychological Inflexibility
Inaction, Impulsivity, or Avoidant Persistence
Cognitive Fusion
Attachment to the Conceptualized Self
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3. FUSION WITH A FLAWED CONCEPTUALIZED SELF

• Rumination produces increased negative
  self-evaluation.
• Fusion with flawed, conceptualized self.
• Self-worth Life worth
• Precludes contact with a transcendent sense of
  self
• If I (self as context) me (conceptualized
  self), and me worthless, then I
  worthless

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FUSION EXPERIENTIAL AVOIDANCE SUICIDE

• Suicide as the ultimate experiential escape act.
• If life suffering
• No life no suffering
• And no life death,
• Then death no suffering
• Because of fusion with the damaged
• conceptualized self, killing yourself is taken
  
• literally rather than figuratively

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The Primary ACT Model of Psychopathology
Dominance of the Conceptualized Past and Feared
Future Weak Self-Knowledge
Lack of Values Clarity Dominance of Pliance and
Avoidant Tracking
Experiential Avoidance
Psychological Inflexibility
Inaction, Impulsivity, or Avoidant Persistence
Cognitive Fusion
Attachment to the Conceptualized Self
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4. LIVING IN A REGRETTED PAST AND DREADED FUTURE

• Rumination also incompatible with mindfully
  living in the present moment by
• Increased recall of and fusion with previous
  negative life events
• Increased construction of and fusion with a
  pessimistic future

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The Primary ACT Model of Psychopathology
Dominance of the Conceptualized Past and Feared
Future Weak Self-Knowledge
Lack of Values Clarity Dominance of Pliance and
Avoidant Tracking
Experiential Avoidance
Psychological Inflexibility
Inaction, Impulsivity, or Avoidant Persistence
Cognitive Fusion
Attachment to the Conceptualized Self
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5. EXCESSIVE RULE-FOLLOWING

• Obscures values and limits valued living
• Two types of RGB that contribute to psychological
  inflexibility
• Pliance Under the control of socially-mediated
  
• consequences for doing what one is told to do
  and should do.
• Avoidant Tracking Under the control of
  naturally occurring aversive consequences in a
  risky world.

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The Primary ACT Model of Psychopathology
Dominance of the Conceptualized Past and Feared
Future Weak Self-Knowledge
Lack of Values Clarity Dominance of Pliance and
Avoidant Tracking
Experiential Avoidance
Psychological Inflexibility
Inaction, Impulsivity, or Avoidant Persistence
Cognitive Fusion
Attachment to the Conceptualized Self
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6. PURSUIT OF VALUE-INCONGRUENT GOALS

• Through pliance, do what is expected or what one
  is supposed to do
• Feeling dispirited, disengaged from life, and
• unfulfilled as natural consequence of pursuing
• and successfully attaining value-incongruent
• goals.
• Success depression Midlife is when you reach
• the top of the ladder and find that it was
  against
• the wrong wall. -- Joseph Campbell

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6. FAILURE TO PURSUE VALUE-CONGRUENT GOALS

• 1. Avoidant tracking leads to leading a cautious,
  risk-averse approach to living.
• 2. Initial depression may be maintained and
  exacerbated by withdrawal from pursuit of
  value-congruent goals
• (It takes too much effort to do X. Why waste
  my time.
• 3. Complicated by ruminative coping style that
  implicates
• conceptualized self.
• (Whats wrong with me?)

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The Primary ACT Model of Treatment
Contact with the Present Moment
Values
Acceptance
Psychological Flexibility
Committed Action
Defusion
Self as Context
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NATURE OF PSYCHOLOGICAL FLEXIBILITY

• Involves the ability to
• Defuse from problematic private events
• Accept private experience for what it is
• Stay in touch with the present moment
• Differentiate a transcendent self from the
  contents of consciousness
• Make contact with valued life ends, and
• Build committed action in pursuit of such ends

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CASE-CONCEPTUALIZATION APPROACH

• Guided by hexaflex and level of functioning
• Lower Follow same order as hexainflex
• Higher Follow reverse order of hexainflex
• Three major steps
• 1. Values identification and clarification
• 2. Identify variables and processes contributing
  
• to a lack of valued action
• 3. Increase level of value-directed activities

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The Primary ACT Model of Psychopathology
Dominance of the Conceptualized Past and Feared
Future Weak Self-Knowledge
Lack of Values Clarity Dominance of Pliance and
Avoidant Tracking
Experiential Avoidance
Psychological Inflexibility
Inaction, Impulsivity, or Avoidant Persistence
Cognitive Fusion
Attachment to the Conceptualized Self
Several paradigmatic and philosophical
perspectives are available to serve as a
foundational base for applied psychology. Among
these, functional contextualism seems most useful
in adequately meeting the challenge of the human
condition with suffcient scope, depth, and
precision. The basic tenets, truth citerion, and
root metaphor of functional contextualism will
first be defined and contrasted with those of
mechanism, which at least implicitly appears to
be the dominant paradigmatic perspective within
most of applied psychology. This will be
followed by an overview of Relational Frame
Theory (RFT) as a functional contextualistic
account of language and cognition. Finally,
research on the application of RFT through
acceptance and commitment therapy (ACT) and in
work with developmentally delayed populations
will discussed and summarized.
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1. IDENTIFYING AND CLARIFYING VALUES

• Values Verbally construed global desired life
  consequences
• Process, not an outcome
• Distinguishable from goals
• Questions to ask?

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IDENTIFYING VALUING KEY QUESTIONS

• What are your goals in coming to therapy?
• If you no longer struggled with depression, how
  would your life be different?
• What in life is so important to you that you
  would be willing to experience depression to get
  it?
• Whats the worst thing for you about being
  depressed?
• What was it about X that was so depressing to
  you?

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IDENTIFYING VALUING OTHER MEANS

• Follow the suffering
• Lifes joys and misery walk hand-in-hand and
  keep each other company. - Donovan
• Revisiting childhood wishes
• Whose life do you admire?
• What do you want your life to stand for? (eulogy
  exercise)
• Epitaph exercise
• Sweet spot exercise

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CLARIFYING VALUING

• Assess for pliance/counterpliance from multiple
  sources of control
• Societal/cultural What if no one knew?
• Parental What if parents never knew?
• Therapist What if I said X was a waste of
  time?
• Assess for avoidant tracking

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CLARIFYING VALUING

• Magic Pill Metaphor
• Helps clarify distinction between values as a
  process and related goals as an outcome
• Choose between a guaranteed outcome (goal)
  inversely related to process (value) vs.
• commitment to a process (value) with no assured
  outcome (goal)

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MAGIC PILL METAPHOR

• Example
• Magic pill if taken by children cause them to
  see you as a loving, caring parent only if you
  are increasingly mean to them vs.
• Commitment to the process of being a loving,
  caring parent with no guarantee that children
  will ever see you that way

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2. ASSESSING VALUED ACTION

• Level of valued action not equal to overall
  activity level
• Three major questions
• What are you already doing that is
  value-congruent?
• What else could you be doing?
• What is stopping you?

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3. INCREASING VALUED ACTION REFRAMING

• Client may already be engaging in valued action
  that has been overlooked, not counted
• I long to accomplish a great and noble task, but
  it is my chief duty to accomplish humble tasks as
  though they were great and noble. Helen Keller
• Valuing may have been obscured by pliance and
  avoidant tracking.

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INCRREASING VALUED ACTION AUGMENTING

• Formative Augmenting
• Infinite number of ways in which to enact
  values.
• Places small activities (changing a dirty
  diaper) in hierarchical frames with valuing
  (being a caring parent) X is an instance of Y.
• Motivative Augmenting
• Dignifies suffering in service of valuing Would
  you be willing to be depressed to recontact
  sweet spots?

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RELATED EXERCISE

• Form groups of 3
• Rotate following roles through 5 minute
  role-plays each
• Therapist Identify and clarify clients
  values, smallest valued action willing to take,
  and
• associated barriers.
• Depressed client Can be self or client
• Consultant Assist therapist, provide
  observations and feedback

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3. INCREASING VALUED ACTION REMOVING BARRIERS

• Addresses other points on the hexaflex
• Defusion
• Acceptance
• Mindfulness
• Self as context/self as perspective
• Approach in case conceptualization manner

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DEFUSION CHALLENGES

• Rumination in depression instrumental in multiple
  levels of fusion with its byproducts
• Life-story
• Reason-giving
• Automatic thoughts

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DEFUSING THE LIFE STORY WITH DEPRESSION

• Rewrite your life story with depression
• Take the earlier life story written at the start
  of this session and first underline the facts
  (including the presence of sorrow) that it
  contained.
• Take these same facts and weave them into a
  different story about them that does not result
  in struggling with depression.
• If needed, new facts can be introduced.

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DEFUSING AUTOMATIC THOUGHTS

• Taking Inventory Exercise
• Separately list various reactions to depressing
  situations.
• Preface each class or category of experiences
  with I have . . . (the thought that, a feeling
  of, a sensation of, the memory of, etc.) . . .
• Milk, milk, milk Exercise
• Bad cup metaphor

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SHAPING ACCEPTANCE

• Experiential discrimination training
• Tug-of-war with the Sorrow Monster
• Demonstrate multiple ways of both pulling and
  dropping the rope
• Carrying your sorrow
• Repeat prn.

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STRENGTHENING MINDFULNESS

• Experientially shaped by series of exercises
• Raisin exercise
• Walking, performing other daily activities
• Awareness of the breath
• Watching your thoughts
• Indirectly promotes self-as-context Noticing
  noticing
• Vantage point from which clients can commit to
  valued action

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ENHANCING SELF-AS-CONTEXT

• Direct means of strengthening perspective taking
• Chessboard metaphor
• Observer exercise

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FOR FURTHER INFO

• Association for Contextual Behavioral Science
  (ACBS) website www.contextualpsychology.org/acbs
• Value-based dues
• Educational and training materials and info
• New Harbinger website www.newharbinger.com
• Chiles, J. A., Strosahl, K. D. (2005).
  Clinical manual for assessment and treatment of
  suicidal clients. Washington, D.C. American
  Psychiatric Publishing.
• Strosahl, K. D., Robinson, P. (2008). The
  mindfulness and acceptance workbook for
  depression. Oakland, CA New Harbinger.
• Zettle, R. D. (2007). ACT for depression A
  clinicians guide to using acceptance and
  commitment therapy in treating depression.
  Oakland, CA New Harbinger.