Intro to CBT - ACT (Part 1)

Acceptance and Commitment Therapy (ACT)

Action-oriented approach and related to CBT

• Clients learn to stop avoiding, denying, and struggling with their inner emotions

  • Instead accept these feelings

• Developed in the 1980s by Steven Hayes

• A strength-based approach rather than psychopathology based.

Goal of ACT

• Live a values based life

• Psychological flexibility

The ACT Model 

• Hexaflex components (clockwise)

  • Contact with the present moment

  • Values

  • Committed action

  • Self as context

  • Defusion

  • Acceptance

• Goal (center): psychological flexibility 

Two Groups of the ACT Model

• Acceptance and mindfulness processes

• Commitment and behavior change processes

Acceptance and Mindfulness Processes

• Contact with the present moment

• (Radical) Acceptance

• Defusion

• Self as context

Commitment and Behavior Change Processes

• Contact with the present moment

• Values

• Committed action

• Self as context

ACT Hexaflex - Forman and Herbert

• Aims to increase psychological acceptance of subjective experiences (e.g., thoughts and feelings) and decrease experiential avoidance

• Increase psychological awareness of the present moment

• Teaches patients to defuse from subjective experiences, particularly thoughts

• Decrease focus on and attachment to the conceptualized self

• Values clarification

• Committed Action

Creative Hopelessness

The buy-in to acceptance (and ultimately ACT)

• You’ve tried just about everything to feel better, get rid of negative emotions, etc...

• “Gold medal” effort

• Could simply “try harder.” But how likely is that to work?

• What if your experience is valid? What if it won’t work because it can’t work

  • Man in the Hole Metaphor

• Tug of war with a monster metaphor (letting go of the rope)

Control as the Problem (Man in the Hole)

Why do we keep trying to dig our way out of holes?

•  It works elsewhere

• It seems to work for others

• You are told it should work for you

• It often does work in the short run and in some types of situations

The implications of creative hopelessness:

• Cognitive and behavioral strategies designed to control our internal experience are unlikely to be effective

• Control strategies are limiting

Experiential Avoidance (EA) 

The unwillingness to remain in contact with distressing internal experiences along with the attempts to control or avoid distressing internal experiences.

• Has been associated with a range of psychopathological symptoms across a range of clinical presentations of anxiety and fear.

Acceptance as the Alternative

• The negative reinforcement cycle of experience avoidance

• We have limited control over our internal experiences

• Chocolate cake metaphor: the more you try to not think about chocolate cake, the more you are going to think about it.

• Polygraph control metaphor: becoming more anxious when told to just relax because of the pressure from polygraph and gun.

Acceptance as the Alternative - Are You Willing?

• Not because you want or like it

• Not because you’ve given up hope it will get any better

• But instead, to openly allow the momentary pain to end the long-term suffering?

• The hidden choices

• Give up “direct control” of your thoughts and emotions to gain control of your life

• Allow yourself to experience all emotions so you can also experience “good emotions

Acceptance of Difficult Content 

Giving up the control agenda means:

1) accepting the inevitability of distress

 2 ) a willingness to experience that distress in the service of living a valued life

Psychological Acceptance 

• The ability and willingness to endure/tolerate aversive internal experiences

• Learning to accept the presence of uncomfortable internal experiences

• Engaging in behaviors even when they produce internal discomfort

Willingness

The behavioral manifestation of distress tolerance

What does Willingness Look Like?

• Is a choice

  • Not a feeling

  • Not a belief

• Is an action

  • Doing, not trying

  • A jump, not a step

• Is always in the service of our goals/values and recovery

  • Not resignation

  • Not touching the stove for the sake of touching the stove

Can Willingness Alter the Frequency/Intensity of Internal Experiences?

Short answer: Yes

• In the long-term, in an overall average kind of way

• But, “rogue waves” and inability to ever take away all negative feelings

We can tell clients this directly, but...

• “trying to pick up the rope”

Distress Tolerance Skills

• Psychological Acceptance

• Uncoupling

  • Converting “but” language into “and” language

• Willingness

  • Transforming “only if” statements to “even if” statements

  • Pattern smashing

• Dealing with Dirty Distress

But/And Example

I would eat all my meals and snacks today but I am afraid of gaining weight

• I will eat all my meals and snacks today and I am afraid of gaining weight

Even if, Only if - Example

I will get go to the social event only if I don’t feel too tired or depressed

• I will get go to the social event even if I feel tired and depressed.

Dirty Distress

Additional feelings about your feelings

• (e.g. irritated about being sad - “I shouldn’t feel sad – I should just get on with it”).

Clean Distress

Experiencing the pure distress in the present moment

• (“I’m sad, this is unpleasant”; “I am in pain”)

Cognitive Defusion - Getting Distance

The idea of observing and separating from internal experiences.

• First part of defusion in ACT

• Recognizing that an internal experience is an internal experience

  • e.g. labeling and describing thoughts as thoughts, emotions as emotions, etc.

• Learning to looking at internal experiences, rather than from internal experiences

Cognitive Fusion 

Believing the literal contents of the mind, so one becomes fused with the thoughts

• Disentangling people from their minds is one of the main aims of ACT

• The opposite of fusion is defusion

Cognitive Defusion Exercises

• Observe, Describe, Balance

• Learning to get distance from and Label Thoughts, Feelings, and Physical Sensations

• Balancing Inner and Outer Wisdom

Definitions for Cognitive Defusion

• The act of focusing the mind in the present moment

• The ability to bring one’s complete attention to present experiences

• The ability to observe and experience rather than evaluate and change internal experiences (thoughts, emotions, urges, hunger, fullness)

Cognitive Defusion - Leaves on a Stream Metaphor

• You as the leave

• Mud, filth and debris as thoughts, sensations, events, and feelings

• Riverstream as the distress

• Can drift downstream with mud, filth and debris or can stand in the riverbank and watch them go by

Contact with the Present Moment

A state of full, open, and non-judgmental awareness of your current experience, both internal (thoughts, feelings) and external (sights, sounds, sensations).

• Goal: To be fully engaged in what is happening right now, rather than being lost in rumination about the past or worry about the future.

• Cues: worry about the future, rumination about the past

Defusion and Present Moment Awareness

• How they work together

• By using defusion techniques, you create the mental space to make "contact with the present moment" more fully.

• Defusion helps you stop being swept away by your thoughts, and contact with the present is the result—a direct, sensory experience of the here and now.

Mindful Awareness Skills

• Observe, Describe, Balance: Increasing awareness of emotions, physical sensations, and thoughts.

• Shifting attention to the present moment

• Mindful Decision Making

Mindful Decision-Making

Awareness of immediate experiences

• Internal: thoughts, feelings, desires, hunger, cravings

• External: sounds, sights, smells