IMPROVING PSYCHOLOGICAL FLEXIBILITY THROUGH MINDFULNESS BASED BEHAVIORAL THERAPIES

Transcription

1 University of North Carolina at Chapel Hill School of Social Work Clinical Lecture Series presents IMPROVING PSYCHOLOGICAL FLEXIBILITY THROUGH MINDFULNESS BASED BEHAVIORAL THERAPIES Tyler Beach, MSW, LCSW September 20, 2010

2 GOALS OF THIS TALK How Cognitive Behavioral Therapy has changed BRIEF Description and Two of the newer therapies Mindfulness Based Cognitive Therapy (MBCT) Dialectical Behavior Therapy (DBT) LONGER Description of another: Acceptance and Commitment Therapy (ACT) Techniques from each you can take with you If you don t identify as behaviorist, strategies to integrate these techniques into your practice

3 LIMITATIONS OF THIS TALK 1. Don t have time to discuss in-depth the theory or practice of any of therapies presented. Each is quite complex 2. More than three of these therapies: Metacognitive Therapy Functional Analytic Therapy Behavioral Activation

4 PART I: WHAT 3 RD WAVE BUILDS OFF 1 st wave Behaviorism: Emphasis on direct change strategies of overt behavior Observable behavior is goal Focus was on operant and classical conditioning principles with little emphasis on thoughts and feelings 2 nd wave: Introduction of Cognitive Strategies (Beck and Ellis) Inclusion of thought patterns and feelings states Goal of identifying, categorizing, and correcting thought distortions

5 WHAT DOES THIRD WAVE BEHAVIORISM MEAN? (THE FANCY DEFINITION) Grounded in an empirical, principle-focused approach, the third wave of behavioral and cognitive therapy is particularly sensitive to the context and functions of psychological phenomena, not just their form, and thus tends to emphasize contextual and experiential change strategies in addition of direct and didactic ones. These treatments tend to seek the construction of broad, flexible, and effective repertoires over an eliminative approach Reformulates and synthesizes previous generations of behavior and cognitive therapy and carries them forward into domains previously addressed by other traditions, in hopes of improving both understanding and outcomes (Hayes, 2004 p. 6).

6 SAID IN A DIFFERENT WAY? The new behavior therapies carry forward the behavior therapy tradition, but they: 1) abandon a sole commitment to first order change 2) adopt more contextualistic assumptoms 3) adopt more experiential and indirect change strategies in addition to direct strategies 4) Considerably broaden the focus of change (Hayes, 2004 p. 6).

7 WHAT IS PSYCHOLOGICAL FLEXIBILITY? The ability to adapt to a situation with awareness, openness, and focus and to take effective action, guided by your values (Harris, 2008 p. 35) Mental phenomenon (Private Experience) not taken literally, and therefore not as seriously. Thoughts and emotions more contextualized. Emphasis on non-judgment and curiosity. De-emphasis on avoidance strategies. Emphasis on approaching and accepting. Behavior guided by chosen values vs. reaction to mental phenomenon.

8 WHAT IS PSYCHOLOGICAL FLEXIBILITY? Psychological Flexibility = 1) Acceptance to whatever comes up in the mind 2) Decreased reactivity to private experience 3) An approach or accept stance towards private experience vs. avoidance (a significant part of this is decreasing Experiential Avoidance Tendencies) + + Mindfulness and acceptance are tailor made to increase psychological flexibility given this definition!!

9 OLDER TRADITIONS REVISITED Incorporation from older traditions Return to more experiential approaches and techniques Emphasis on non-judgmental and personal values Less direct emphasis on symptoms and increased self-acceptance Paradox of Change change tends to happen as by product of acceptance New translations of Contemplative Psychological Processes Origin: Gestalt and body-focused therapies Existential Tradition Humanistic Tradition Eastern Traditions

10 PART II: Nuts and Bolts Mindfulness-Based Cognitive Therapy Dialectical Behavior Therapy then Acceptance and Commitment Therapy More time with this one, and more examples

11 MINDFULNESS-BASED COGNITIVE THERAPY (MBCT) Theory-driven, psychological intervention designed to reduce relapse in recurrent major depression (Segal et al, 2004, p. 46) Incorporates Mindfulness Based Stress Reduction (MBSR) training developed by Jon Kabat-Zinn (Kabat-Zinn, 1990) 8 weeks skills class with extensive homework Blends Mindfulness Based Stress Reduction (MBSR) developed by Kabat-Zin with cognitive de-fusion and acceptance strategies Manualized treatment

12 MBCT THEORY (cont.) Vulnerability to relapse and recurrence of depression arises from repeated associations between depressed mood and patterns of negative, self-critical, and hopeless thinking during episodes of major depression, leading to changes at cognitive and neuronal levels Specifically, in recovered depressed patients, the thinking activated by dysphoria should be similar to the negative thinking patterns previously present in a depressive episode (Teasdale, 1988, 1997).

13 MBCT THEORY (cont.) States of mild to moderate bad mood are more likely to turn into recurrence than just be blips on the radar when associations are fused with Could be considered similar to PTSD response. Brain literally changes to accommodate past experience.

14 MBCT THEORY (cont.) Examples: To help explain to my patients: Someone who has visited Hell has had that direct experience and will have memories of it. Going to be very scared if they have any associations that raise the possibility that they might be going back there. Buying into the fear actually increases the likelihood they will remain in hell. Common clinical example: A client begins to experience dysphoria related to the flu, but incorrectly attributes this to relapse. Usually relieved when they get sick!!

15 MBCT vs. CBT Recognized that although the explicit emphasis in CBT is on changing thought content, CBT also leads implicitly to changes in patients relationships to their negative thoughts and feelings... Instead of viewing thoughts as absolutely true or as descriptive of important self-attributes, patients are able to see negative thoughts and feelings as passing events in the mind that are not necessarily valid reflections of reality or central aspects of the self (Segal, 2004 p 51). MBCT therefore takes a direct approach to contextualizing private experience vs. direct thought change since they see this as the main benefit of direct CBT.

16 MBCT EXERCISE Three Minute Breathing Space (3MBS) 3 Steps to this Practice Awareness stepping out of automatic pilot, recognize and acknowledge your current experience (no judgment) Gathering bringing attention to sensations of the breath in a particular place in the body Expanding the attention into the body as a whole, using particular sensations of the breath as an anchor, while opening to the range of experience being perceived. (Segal et al., 2002)

17 DIALECTICAL BEHAVIOR THERAPY Developed by Marsha Linehan to treat complex, multi-symptomatic women with self-harming and suicidal behavior. Trained as CBT therapist Initially attempted change-focused CBT model, but treatment ultimately unsuccessful Attributed this to 1) chronic invalidating environments many of these patients grew up in people were always telling them to think differently 2) many of these patients problems were not immediately changeable/solvable (Linehan, 1993)

18 DBT (cont.) Took a step back and realized that she had mastered technology of change but had little in her skill set to assist clients in accepting current reality and bearing current pain. Took a year sabbatical to learn technologies of acceptance, and studied under two different Zen teachers to learn mindfulness acceptance strategies. Reformulated her treatment to balance acceptance vs. change strategies.

19 ACCEPTANCE STRATEGIES Analogy with physical burn victims: Burn victims need to bear their current pain before they can receive their treatment (debriding) In some ways, BPD clients are emotionally burnt. Therefore, they teed acceptance strategies to help them tolerate their pain long enough to allow long term change-based strategies to take effect. Rationale 1) Pain and distress are an unchangeable part of life and inability to accept this fact leads to increased pain. 2) Acceptance is a part of attempts for longer term change. (Linehan, 1993)

20 ACCEPTANCE STRATEGIES (cont.) When used in DBT? Core Mindfulness module, particularly with regard to non-judgmental awareness. Distress Tolerance module, more in-depth application developed for situations in which change is not an option, or when further intervention would make things worse divided into Acceptance and Distraction Strategies My two cents: Distraction strategies are fabulous for folks with excruciating pain, but can be overused and overemphasized by patients who would benefit much more from Acceptance Strategies Example from my old job: Eating Disorders Facility

21 ACCEPTANCE STRATEGIES Suffering = Pain x Non-acceptance of Pain Suffering, therefore, is: optional, and can be reduced to pain through acceptance strategies. Borrows heavily from Buddhist idea of Dukkha (suffering) and that direct experience and acceptance is way out. Suffering is usually intolerable. Pain is usually tolerable.

22 HOW CAN ONE LEARN TO ACCEPT? 1 st Step Judgmental Thinking Become aware of Judgments (cognitive strategies) Judgments automatically distort reality & increase suffering Judgments = shortcuts towards expressing preferences and predicting consequences Can be useful until they become over-generalized and taken literally Practice non-judgmental and more objective stance towards thoughts, feelings, and situations Become a Scientist to your experiences. Clues that judgments are at work: shoulds, shouldn t, bad, good are present. Help clients become more objective by replacing above words with effective and ineffective

23 HOW CAN ONE LEARN TO ACCEPT? 2nd Step WILLINGNESS VS. WILLFULNESS Willingness Accepting what is, together with responding to what is, in an effective and appropriate way. It is doing what works. It is doing what is needed in the current situation or moment. Willfulness Is imposing one s will on reality trying to fix everything, or refusing to do what is needed. It is doing the opposite of what works (Linehan, 1993, p. 103). Provides language for clients to identify which end of the dialectic they are currently on.

24 HOW CAN ONE LEARN TO ACCEPT? 2nd Step Reality Acceptance Strategies DBT provides guidelines for increasing acceptance of current reality. Awareness of the positions of the body. Awareness of connection to the universe. Awareness of making tea or coffee. Awareness while washing the dishes. Awareness of washing clothes. Etc. (Linehan, 1993 p. 102) Goal = let go of cognitive and emotional fight that tends to happen during periods of crisis and intense judgment, and focus on more neutral parts of reality. Provides distance and time to focus Encourages refining of attentional processes Life is BIGGER than painful mental phenomenon

25 ACCEPTANCE & COMMITMENT THERAPY ACT Assumptions Suffering is a normal part of human life. Result of language processes (Relational Frame Theory) and cognition Destructive Normality Normal psychological processes are often destructive Our Social and Verbal community teaches us to resist suffering. (Merwin, 2007 lecture) Does not encourage thought challenging because (ACT posits) it increases verbal entanglement and therefore increases avoidance. Unlike traditional CBT model, psychological event and behavioral urge co-occur in a context, versus linearly. (Merwin, 2007 lecture)

26 ACT (cont.) There is a dark side of humans ability to think the way we do and have a sophisticated language system. (2007 Merwin lecture) Literality we respond to words and mental pictures about events as actual events Words tend to dominate over experience. You can literally develop a phobia simply by being told a story!! Tend to attempt to avoid negative, private experience the same way we would negative, external experience Avoidance causes us to behaviorally restrict (i.e., do less, experience less) Now two types of pain happening: 1. Pain related to negative experience 2. Pain related to loss of opportunities

27 ACT (cont.) Once we have a thought and feeling, they are off the table to change because they have already happened. Now have 3 options. 1. Believe them, 2. Avoid them through symptom use or intellectualization, or 3. Contextualize them, and move forward with what we really want. Many of our problems are not about our actual thoughts or feelings but Our relationship to them Attempts to get rid of them

28 ACT AGENDA VS. OLD AGENDA Confronting the Control Agenda ACT posits that it is usually efforts to control uncomfortable, private experience that are the problem, and not the experiences themselves. Detailed Conversation with clients about what skills they have been using to try and reduce certain private experience Assess effectiveness. Sometimes they are effective, but important to look at what cost? back to behavioral restriction and loss of opportunity & not living according to values

29 ACT EXPERIENTIAL ACTIVITY Control Experiential Exercise Imagine a big grey cat sitting on the stage next to me. He has long hair and a red collar. Take another few seconds to really form a solid image in your head. Now I want you to use all of your mental skills to think about whatever you want EXCEPT the cat for the next minute.

30 RESULTS OF THE EXPERIMENT How Well Does Controlling Private Experience Really Work? How many of you thought about the cat during this exercise? For those of you who did not, you might want to ask yourself how you knew you didn t think about??? Idea here is that many times the things we try to avoid, we actually keep around either directly or by having some sort of construct somewhere in our psychological process (in order to overtly avoid it). And if we are overtly successful, chances are we were because we were employing avoidance strategies!! So, the thing we avoid literally hangs around more.

31 SIX CLINICAL METHODS OF ACT 1) Cognitive Defusion In literal terms, it means the opposite of fusing (joining) with your thoughts, images, and past De-fusion is the process (not the actual technique) of taking a step back from our mental phenomenon Several Techniques to Encourage Defusion Using language system Typical thought: I am a jackass Defusion: I am having the thought that I am a jackass Ridiculous Voice Practice tuning the I have a jackass to the birthday song

32 SIX CLINICAL METHODS OF ACT 2) Self as Context (Observing Self) One of three types of self The conceptualized self: all the beliefs, ideas, memories we have about our self that construct the I of us. Self-as-awareness: the ongoing noticing of our current experience, the present moment. Observing Self (self as context): The space where noticing happens. The viewer or witness not changeable.

33 SIX CLINICAL METHODS OF ACT The Slit lamp metaphor You re in a pitch black room with a slit lamp. You open the slit, and a beam of light shoots out and shows a part of the room. Whatever is being shown is the conceptualized self. The beam of light is the ongoing practice of noticing (self-asawareness). As the light moves, new parts of the room come into focus. Yet regardless of where the light shines, the source of where the light, the lamp, is always the same and unchangeable (2009, Harris, p. 174)

34 SIX CLINICAL METHODS OF ACT 3) Values: Finding out Values RIP Exercise Return to Existential Tradition He was such a kind and open person

35 SIX CLINICAL METHODS OF ACT 4) Committed Action taking action based on values vs. impulses Useful start slowly at first then expand this Again living according to values an existential construct Life as a journey metaphor: It Shouldn t Be This Hard!! Love Connection = a Valued Life, well-lived Loss Joy Fear Pain

36 SIX CLINICAL METHODS OF ACT 5) Contact with Present Moment (connection) Being psychologically present, consciously connecting with and engaging with whatever is happening in this moment It also means consciously paying attention to our here-andnow experience instead of drifting off into our thoughts or operating on automatic pilot (Harris, 2009, p. 9).

37 SIX CLINICAL METHODS OF ACT 6) Acceptance (expansion) Making room and allowing negative, private experience in more fully. Quick Sand Metaphor: Our experience with negative private experiences is quite similar to being trapped in quick sand. When we are caught in quick sand, our initial instinct is fight as hard as we can to get out. What we know is that the more we fight and move, we create air pockets under ourselves which has the effect of entrapping us more. The more effective method is to attempt to relax, lay backwards so that the back of our head begins to touch the quick sand. That way, we bring more of our body into contact with the quicksand and we are more likely to rise to the top. Back to the idea of the Paradox of Change

38 INTEGRATING INTO YOUR PRACTICE How can informing your practice with these strategies be useful? Can offer more accessible way of describing and teaching mindfulness skills (some people put off by other descriptions). Great for left-brained clients!!! When client with history of chronic depression experiences beginning of dysphoria (aka learning not to fall into a potentially optional hole ). When a client is in intense psychological pain, or is in a crisis that is not easily changed or resolved. Self or identity questions.

39 INTEGRATING INTO YOUR PRACTICE (cont.) Indirect way of addressing a clients resistance to a certain issue. When a client is really stuck. ACT especially has a vast number of available metaphors to describe ways we get stuck and how to get out. Super (internally) critical client who is fused with negative self talk. Clients who are focused on changing everything about who they are and desiring having high self-esteem.

40 Any Questions? Tyler Beach, MSW, LCSW (919)

41 Recommended Readings on Dialectical Behavioral Therapy Skills Training Manual for Treating Borderline Personality Disorder by Marsha Linehan

42 Recommended Readings on Acceptance and Commitment Therapy Embracing your Demons by Russ Harris (pdf available for free online) Get out of your Mind and into your Life by Stephen Hayes The Happiness Trap and ACT made Simple by Russ Harris Learning ACT by Jason Luoma and Stephen Hayes

43 Recommended Readings on Mindfulness-Based Cognitive Therapy The Mindful Way through Depression by Mark Williams, John Teasdale, Zindel Segal, and Jon Kabat-Zinn Mindfulness-Based Cognitive Therapy for Depression: A New Approach to Preventing Relapse by Zindel Segal, John Teasdale, and Mark Williams

44 References Merwin, Rhonda (2007, November 27 (multi-date)). ACT Lecture Series. ACT Lecture Series. Lecture conducted from DUMC, Durham. Crane, R. (2008). Mindfulness-Based Cognitive Therapy: Distinctive Features (CBT Distinctive Features) (1 ed.). New York: Routledge. M.D., R. H. (2009). ACT Made Simple: An Easy-to-Read Primer on Acceptance and Commitment Therapy (Professional). Oakland, CA: New Harbinger Pub. Harris, R. (2008). The Happiness Trap: How to Stop Struggling and Start Living. Boston: Trumpeter (n.d.). Embracing Your Demons. Retrieved , 2010, from _A_Non-technical_Overview_of_ACT.pdf

45 References Hayes, S., Follette, V., & Linehan, M. (2004). Mindfulness and Acceptance: Expanding the Cognitive-Behavioral Tradition (1 ed.). New York: The Guilford Press. Linehan, M. (1993a). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: The Guilford Press (1993b). Skills Training Manual for Treating Borderline Personality Disorder. New York: The Guilford Press. Segal, Z. V., Teasdale, J. D., & Williams, J. M. (2001). Mindfulness-Based Cognitive Therapy for Depression: A New Approach to Preventing Relapse (1st ed.). New York: The Guilford Press. APA.