Acceptance & Commitment Therapy for physical health problems

1. ACT for Health
Edinburgh
October 2014
Dr Ray Owen
Clinical Psychologist
drrayowen@gmail.com

2. Aims for the day
►Consider how core ACT processes relate to
working with people who have physical health
problems
►Look at specific problems related to Health, and
useful ACT-based techniques
 E.g. living with uncertainty, altered sense of self, carer
burden, tolerating physical treatment, healthy behaviour
change
►Reflect on own experience as clinician
►Reflect on own experience as human being
►Feedback suggests more experiences, technique
and clinical reflection, less literature survey
 All at contextualscience.org

3. To begin with…

4. Physical health
►Acute
 e.g. cancer with curative intent, recovery from
injury
►Long-term / chronic
 e.g. chronic pain, bowel disorders, neurological
disorders, lung problems
►Palliative
 e.g. advanced cancer, late-stage MND
►Health Behaviour Change

5. TThhee AACCTT MMooddeell ooff PPssyycchhooppaatthhoollooggyy
Dominance of
Conceptualised
Past & Future
Psychological
inflexibility
Experiential
avoidance
Cognitive Fusion
Attachment to the
conceptualised self
Lack of Values
Clarity,
dominance of
pliance and
avoidant tracking
Inaction,
impulsivity or
avoidant
persistence

6. STUCK
UNFULFILLE
D
Experiential
avoidance:
basing your actions
on avoiding feeling
bad
Fusion: getting
tangled up in
thoughts
Loss of contact with
present moment :
getting caught up in the
past & the future
Inflexible sense of self:
getting stuck in an unhelpful 'story'
about yourself
Loss of contact
with Values: not
recognising what
matters to you in life
Lack of
committed
action: not acting
effectively to live
your life the way
you want to

7. Think of a client…

8. The PPoossiittiivvee PPssyycchhoollooggiiccaall
PPrroocceesssseess AACCTT SSeeeekkss ttoo SSttrreennggtthheenn
Being in the
present moment /
mindfulness
Psychological
Flexibility
Acceptance /
Willingness
Defusion
Self as
Context
Values
Committed
Action

9. MOVING
FORWARD:
MORE
FULFILLED
Acceptance /
willingness to
experience:
allowing whatever
shows up just to be
there.
Defusion: treating
thoughts as
thoughts (not
realities)
Present moment awareness
/ mindfulness: living in the
Here-and-Now
Observing self / flexible
perspective-taking: adopting a
more flexible sense of self
Awareness of
Values: recognising
what matters to you in
life
Committed action:
doing the things that
matter to you, even
when it's difficult

10. Think of a client…

11. STUCK
UNFULFILLE
D
Experiential
avoidance:
basing your actions
on avoiding feeling
bad
Fusion: getting
tangled up in
thoughts
Loss of contact with
present moment :
getting caught up in the
past & the future
Inflexible sense of self:
getting stuck in an unhelpful 'story'
about yourself
Loss of contact
with Values: not
recognising what
matters to you in life
Lack of
committed
action: not acting
effectively to live
your life the way
you want to

12. Fusion and Avoidance
►On the buses
►“Why does my mind hurt me that way?”
►Living with an uncertain future
►Thoughts we should pay attention to
►What kind of feelings are we avoiding?

13. Using the basics
►Another trip on the bus..
►Not just an explanatory metaphor
 Ongoing tool
►A landslide blocking the road

14. While we’re on the bus…
► Minds say unhelpful things
► Take a minute..
 Notice a passenger
 What are they saying
 What form they take
 Where’s that coming from
 What is the function of that passenger speaking up
► Actual
► ‘intended’
► Mind is not usually our enemy
► So why say these things?
► Doing its job(s)
 The stay alive machine (can become the EA machine)
 The Problem-solving machine (can become the worry-engine)
 The Learn From Experience machine (can become the dwell on the past
machine

15. Default assumption
►My mind is not ‘out to get me’
►It’s mostly trying to help by doing one of its jobs
►Most of the time it’s pretty good at that
►Sometimes in trying to be ‘helpful’ (protect you
from harm, from social victimisation, isolation etc
etc) its suggestions end up being unhelpful
►Recognising this makes it easier to use ‘Thanks,
mind’
►Why this helps in Health

16. Uncertainty
►Back to your client
 How does uncertainty show up
 Potential impact on life
 Interaction with core processes
►?especially here-and-now, committed action?

17. Many paths
►More of a raft than a walk
►Originally used with denial-like behaviours
►BBeenneeffiittss
 DDeeffuussiioonn ffrroomm tthhoouugghhttss aabboouutt pprrooggnnoossiiss
 OObbsseerrvviinngg sseellff
 AAcccceeppttaannccee ooff ffeeeelliinnggss tthhaatt aarriissee
 AAbbiilliittyy ttoo ffooccuuss oonn VVaalluueess--ddrriivveenn ccoommmmiitttteedd
aaccttiioonn ((nnoott bbeeiinngg ffrroozzeenn iinn ffaaccee ooff uunncceerrttaaiinnttyy))

18. But what about the thoughts we
SHOULD attend to?
►“I’m sure that lump wasn’t here last week..”
►In ACT, we’re interested in the behaviour in context
 Behaviour here includes internal behaviour eg thoughts
 Need to know context and function
►‘Defuse and move on’ vs ‘pay attention to and act
upon’
 nb anyway more able to evaluate and act from defused
position
►Old vs New thoughts
►Risk-related

19. Approaches other than classic
defusion
►Safe review period (if still here by… then I’ll..)
►Checking out with others
►If new, evaluation / challenge
►Looking at impact
►Worry Time

20. Avoiding feeling bad
►Emotions
►Physical sensations – emotion related
►Physical sensations – health related
 When distinct, when overlap
 When is it safe to accept?
►E.g. aching in fibromyalgia vs crushing chest pain in heart
disease
 In a war vs living with the enemy
 Narrowing lives in battle with symptom
 For highly intrusive symptoms, look at ACT for chronic
pain literature (Vowles, McCracken, Dahl)

21. STUCK
UNFULFILLE
D
Experiential
avoidance:
basing your actions
on avoiding feeling
bad
Fusion: getting
tangled up in
thoughts
Loss of contact with
present moment :
getting caught up in the
past & the future
Inflexible sense of self:
getting stuck in an unhelpful 'story'
about yourself
Loss of contact
with Values: not
recognising what
matters to you in life
Lack of
committed
action: not acting
effectively to live
your life the way
you want to

22. The self
►Over-attachment to the conceptualised self
►Self-as-content, self-as-process, self-as-context
►Flexible perspective-taking
►Development of key relational frames
►What’s your mind telling you right now?

23. How your (conceptualised) Self gets
in the way..
►Stuck in a story
 ‘still the person I used to be’
►Someone who never gives up
►The strong one
►Carer
 ‘lost the person I used to be’
►‘shadow of my old self’
►No use any more
►That was the real me
 Adjustment
►I’m a burden

24. Versions
► Version 1
► Version 1.1
► ...Version 1.5
► …Version 1.6
► Version 2.0
► …Version 2.1
► Version 2.1.1
► Version 2.1.2
► ..Version 2.2
► ..Version 2.3
► Version 3.0
► Version 4.0
► Version 4.0.4
► Version 4.1
► Version 4.4
► etc
► Alpha
► Beta
► Cupcake
► Donut
► Eclair
►
►
►
► Froyo
► Gingerbread
► Honeycomb
► Ice cream sandwich
►
► Jelly Bean
► KitKat

25. I THEN, I NOW.. For you
► characteristics ► At primary
► Young adult ► Now
school
► Psychological
► Physical
► Social
► A personality trait
► An ambition
► A friendship
► A talent
► ‘positive’ or
‘negative’

26. I THEN, I NOW.. For client
(nb. tailored appropriately for their history)
► Young adult ► Pre-illness ► characteristics ► Now
► Psychological
► Physical
► Social
► A personality trait
► An ambition
► A friendship
► A talent
► ‘positive’ or
‘negative’

27. Old me new me exercise
►Elicits ‘stories’ about self
►Allows us to notice balance of them
►How firmly held?
 Can challenge if appropriate (new thought / insight)
►Doing the exercise is act of defusion
►Mourn the past, accept the present
►Are they fixed (e.g. ‘less sociable’)
►Reinforces transitions over time
 ‘this too will pass’

28. STUCK
UNFULFILLE
D
Experiential
avoidance:
basing your actions
on avoiding feeling
bad
Fusion: getting
tangled up in
thoughts
Loss of contact with
present moment :
getting caught up in the
past & the future
Inflexible sense of self:
getting stuck in an unhelpful 'story'
about yourself
Loss of contact
with Values: not
recognising what
matters to you in life
Lack of
committed
action: not acting
effectively to live
your life the way
you want to

29. ►Doing treatment
►Hopelessness
►Carer burden
►Making a choice
 Values & Goals

30. Treatment
►Originally from cancer treatments (chemotherapy
& radiotherapy), however..
►‘doing’ not ‘having’
►“Why did you choose to have treatment?”
 “no choice”
 What hoping to achieve
 “not dying” vs “what do with more/better quality life”
 Acknowledge cost of having
 Price you are willing to pay in order to increase your
chances of … e.g. being close to your children
 Fast initial way into Values (often session 1)
 Emphasises active role vs victim story

31. CHOICE POINT
AWAY FROM
VALUES
TOWARDS VALUES
HOOKS, e.g.
Urge to avoid
discomfort
Desire for
short-term
gains
Old habits
Hooked by
thoughts
Stuck in a story
etc
HELPERS, e.g.
Awareness of
Values
Skills:
-Present moment
awareness
-Defusion
-Acceptance
-Flexible perspective
taking
Effective goal-setting
etc
Adapted from Ciarrochi, Bailey & Harris 2013

32. Finally..
►The same core processes of ACT apply in living
well with physical health problems as with any
other adversity
►Same interventions can work
►Some tailored/tweaked/specific ones too
►True whether aiming to
 Make healthy behaviour change
 Cope with an more acute health crisis ‘facing the storm’
 or live a fulfilling life despite chronic health problem,
where aim is ‘living with the enemy’

33. ►Please leave feedback on this event
►At
www.surveymonkey.com/s/H33JMPT