Human suffering pain, stress, life crisis The single most remarkable fact about human existence is how hard it is for humans to be happy. (Hayes, Strosahl, & Wilson, 1999) Riddle?? pain, stress, life crisis
The ACT model of Psychopathology Experiential Avoidance Cognitive Fusion Dominance of the Conceptualized Past and Feared Future Psychological Inflexibility Attachment to the Conceptualized Self Lack of Values Clarity Inaction, Impulsivity, or Avoidant Persistence Riddle?? The Swedish health care system offers more solutions to the with chronic pain and those on long term sick leave than any other system in the world. No where in the world is this problem so great and so costly. ACT Treatment Processes BEING THE POSITIVE REINFORCEMENT: COACH Contact with the Present Moment Acceptance Values Psychological Flexibility Cognitive Defusion Committed Action Self as Context Draws us into the future or past Produces increasing cognitive entanglement Focuses our attention in the wrong places And even claims to BE us Lost love Controll and hold Shut down feelings Be good, take care of others Life feels empty Parents separate Shut down feelings Be good, take care of others
ACT assumption Pain and suffering are universal to all human beings. Languaging rather than the actual condition amplifies suffering Struggling with suffering creates more suffering The dog and the man Pathololgy model of pain ACT assumption
What is Relief? Relief? Pathololgy model of pain When pain was unavoidable it was bearable, when it became avoidable, it became unbearable The best a primary care physician can do for a person with chronic pain is nothing. Nothing is better than anything that is done today. The past is never dead. It s not even past (William Faulkner (1897-1962) SBU: metaanalysis of all pain The best a primary care physician can do for a person with chronic pain is nothing. Nothing is better than anything that is done today.
have real pain/stress Our clients health care provides simple quick fix solutions to complicated human problems that are mostly unsolvable. have real pain/stress Our clients Solutions are the problem have tried to fight their pain/stress health care provides simple quick fix solutions to complicated human problems that are mostly unsolvable. Our clients Our clients have real pain/stress have tried to fight their pain/stress have tried to control their pain/stress
Chronic pain have real pain/stress Our clients have tried to fight their pain/stress have tried to control their pain/stress have tried to ignore their pain/stress About 95% is unexplanable Chronic pain Our clients have real pain/stress have tried to fight their pain/stress have tried to control their pain/stress have tried to ignore their pain/stress have failed About 95% is unexplanable Chronic pain Causal models for chronic pain fail in reliabilty and validity have real pain/stress Our clients have tried to fight their pain/stress have tried to control their pain/stress have tried to ignore their pain/stress have failed just keep on trying
About 95% is unexplanable Chronic pain Causal models for chronic pain fail in reliabilty and validity Humans dont like unexplanable things Bad news is About 95% is unexplanable Chronic pain Causal models for chronic pain fail in reliabilty and validity Humans dont like unexplanable things Humans have a neocortex that generates ideas and solutions for problems whether its useful or not Bad news is From an alien pt of view Humans and their cortexes from an alien point of view Cortexes generate solutions If solutions do not work think harder! Human Suffering is a unsolvable problem Conlusion: Humans are slaves of their cortexes!! Cortexes cannot stop doing this, even when harmful
Bad news is Human Suffering is a unsolvable problem Human Suffering is a unsolvable problem Bad news is How does that make you feel right now??? Human Suffering is a unsolvable problem Human Suffering is a unsolvable problem Human Suffering is a unsolvable problem Bad news is How does that make you feel right now??? CREATIVE HOPELESSNESS Human Suffering is a unsolvable problem Human Suffering is a unsolvable problem Human Suffering is a unsolvable problem Human Suffering is a unsolvable problem
Fundamental questions in life are questions of values CREATIVE HOPELESSNESS Valued directions link together life events
Values Doing a good job at teaching Values Chosen qualities of purposive action Provides context and meaning of exposure Situating Our Approach to Values finding meaning in whatever job I have Doing a good job at teaching Application Theory Science Philosophy of science: Emphasis on context, goals
getting in touch with how I can contribute finding meaning in whatever job I have getting in touch with how I can contribute finding meaning in whatever job I have Doing a good job at teaching Contributing to any collective I am in getting in touch with how I can contribute finding meaning in whatever job I have Doing a good job at teaching Text getting in touch with how I can contribute finding meaning in whatever job I have Doing a good job at teaching
Keeping my body healthy and strong getting fresh air and exercising Text playing with a team Playing soccer Text Playing soccer Work? Text playing with a team Playing soccer getting fresh air and exercising Text playing with a team Playing soccer
practice loving kindness with myself willing to be and loving with myself willing to keep myself when in fear of being rejected being with my partner Elin being with my partner Elin health? willing to keep myself when in fear of being rejected being with my partner Elin willing to be and loving with myself willing to keep myself when in fear of being rejected being with my partner Elin
being in contact and giving myself what I need listening to myself being quiet with myself playing my guitar playing my guitar own time? being quiet with myself playing my guitar Be listening to myself being quiet with myself playing my guitar
Be Health Own time Work Be Be Be Own time Health Work Health Be Be Own time Own time Health Work Health
Be Health give myself what I need Own time Work Contribute Be Health Own time Work Be give myself what I need Be Tired! Own time Own time Health Work Contribute Health Work Be give myself what I need Be give myself what I need Tired! Own time Own time Health Pain! Work Contribute Health Work
Learning theory Negative and Positive Reinforcment Arbitrary & Natural Reinforcment Be Health Tired! Pain! Stressed! give myself what I need Own time Work Contribute YOUR LIFE LINE Be Tired! Stressed! give myself what I need Own time 1 example of an event which you consider a significant loss 1 example of an event which you obtained your dream (reached a major goal). Health Pain! Pain! Work Contribute Event, feeling, how you related to that feeling Valuing is a verb
PROBLEMS KNOWING commercial world tells us what we value Our parents tell us what we value. Our nation tells us what we value. Valued direction is not a goal Valuing is a verb Our learning history tells us what we value. MORE CONFUSION TRYING TO AVOID NEGATIVE FEELINGS OR RETAIN POSITIVE FEELINGS JUST CAUSES MORE SUFFERING feelings are not values judgements are not values thoughts are not values LANGUAGE TRAPS Fusion with conceptualized self: roles, rules Feelings are not causes: I still hurt so I cant explore a new relationship; vs: I feel hurt and I choose not to explore a new relationship. (we must feel a certain way before we can behave according to our values) HOW DO YOU KNOW WHAT YOU VALUE?
The concept of impermanence Any form you consider positively reinforcing will become punishing if you continue persuing it. FORM OR FUNCTION? EXPERIENTIAL Any form you consider punishing may entail positive reinforcment if you look closely. WHAT ATTRACTS YOU TO THE CONCEPT OF VALUING? Valuing = Choosing each and every step is a matter of choice which is a matter of valuing Is it that simple? it is what you choose with your feet, not your mind that reveals what you are valuing It is how we do it that matters
4,5 4,0 3,5 3,0 2,5 2,0 1,5 A BULLI about persistency F(3,75)=62,61; p<,0000 B C N=27 Self rated 1,0 scores on B-E 0,5 Selfrated sc 0,0 Pre Fu 1 Fu 2 Fu 3 TIME ACT AC Bulls-Eye in process research Lundgren, T., Dahl, J., Hayes, S. Evaluation of mediators of change in the treatment of epilepsy with acceptance and commitment therapy, Journal of Behavior Medicine, In press. In a treatment outcome study for persons suffering from epilepsy, pre to follow up changes in seizure reduction and increase in quality of life were mediated through ACT processes such as values attainment, defusion, acceptance and persistency in living a valued life even in the face of difficulties and emotional resistance. Daily activities breakfast avoidance pliance vitality gym meeting lunch
control ol and avoidance cycle: moving down into control ol and avoidance cycle: moving down into struggle and away control ol and control ol and avoidance cycle: moving down into struggle and away from a values-based control ol and avoidance cycle:
Mindy chatter: when I feel pain, reasons, predictions consequences control ol and Entanglement: taking literally, avoidance cycle: mindy solutions that call for moving down into escape, avoidance, making struggle and away deals, losing who you are from a values-based vital life control ol and avoidance cycle: moving down into struggle and away from a values-based vital life Control and avoidance: complying with mindy solutions and buying these thoughts and engaging in the actual behavior they structure Relief:temporary elief, illusions that mindy lutions may work this time Mindy chatter: when I feel pain, reasons, predictions consequences control ol and avoidance cycle: moving down into struggle and away from a values-based vital life Entanglement: taking literally, mindy solutions that call for escape, avoidance, making deals, losing who you are Control and avoidance: complying with mindy solutions and buying these thoughts and engaging in the actual behavior they structure Mindy chatter: when I feel pain, reasons, predictions consequences control ol and avoidance cycle: moving down into struggle and away from a values-based vital life Life Restriction and loss: life skrinks, moment disappears, vitality is lost Relief:temporary elief, illusions that mindy lutions may work this time Mindy chatter: when I feel pain, reasons, predictions consequences control ol and avoidance cycle: moving down into struggle and away from a values-based vital life Entanglement: taking literally, mindy solutions that call for escape, avoidance, making deals, losing who you are Mindy chatter: when I feel pain, reasons, predictions consequences control ol and Entanglement: taking literally, avoidance cycle: mindy solutions that call for moving down into escape, avoidance, making struggle and away deals, losing who you are from a values-based vital life Control and avoidance: complying with mindy solutions and buying these thoughts and engaging in the actual behavior they structure
Tiger metaphor the more you feed the tiger, the hungrier he gets! Life Restriction and loss: life skrinks, moment disappears, vitality is lost Relief:temporary elief, illusions that mindy lutions may work this time Pain Mindy chatter: when I feel pain, reasons, predictions consequences control ol and avoidance cycle: moving down into struggle and away from a values-based vital life Entanglement: taking literally, mindy solutions that call for escape, avoidance, making deals, losing who you are Control and avoidance: complying with mindy solutions and buying these thoughts and engaging in the actual behavior they structure Values: the life directions I choose, what I want my life to be about Tiger metaphor
Commitment and flexibility: choosing to take action consistent with my values, enhancing life flexibility Values: the life directions I choose, what I want my life to be about Acceptance and being : making room for pain in the moment it occurs Values: the life directions I choose, what I want my life to be about Acceptance and being : making room for pain in the moment it occurs Growth and contact with barriers: as I step forward I grow and develop and feel pain Mindfulness and defusion: observing my thoughts as thoughts, taking heed if they are helpful, staying conscous as the observer self, cognitive flexibility Values: the life directions I choose, what I want my life to be about Values: the life directions I choose, what I want my life to be about Commitment and flexibility: choosing to take action consistent with my values, enhancing life flexibility ACT: moving up towards a values based vital life Acceptance and being : making room for pain in the moment it occurs Acceptance and being : making room for pain in the moment it occurs Growth and contact with barriers: as I step forward I grow and develop and feel pain Mindfulness and defusion: observing my thoughts as thoughts, taking heed if they are helpful, staying conscous as the observer self, cognitive flexibility Mindfulness and defusion: observing my thoughts as thoughts, taking heed if they are helpful, staying conscous as the observer self, cognitive flexibility Values: the life directions I choose, what I want my life to be about Acceptance and being : making room for pain in the moment it occurs Growth and contact with barriers: as I step forward I grow and develop and feel pain Mindfulness and defusion: observing my thoughts as thoughts, taking heed if they are helpful, staying conscous as the observer self, cognitive flexibility
Defusion Are you willing to open up and embrace what is here and now? Are you willing to open up and embrace what is here and now? Acceptance Defusion The Guest House (by Rumi) This being human is a guest house Every morning a new arrival A joy, a depression, a meanness some momentary awareness comes as an unexpected visitor. Welcome and entertain them all! Even if they re a crowd of sorrows who violently sweep your house, empty it of its furniture. still treat each guest honorably. He may be clearing you out for some new delight.
Dating game Committed Action does the fish know it s in water? Self as context Committed Action Larger and larger patterns of effective actions linked to chosen values. Willingness to expose oneself to discomfort Your thoughts will always struggle, YOU need to move the chess board where you want to go
Mean QOL Score 44 43 42 41 40 39 38 37 36 Total Quality of Life Pre Post 6-Mo FU ACT MTAU Chronic Pain Dahl, Wilson & Nilsson (2004). Behaviour Therapy, 35, 785-801 20 public health caretakers at risk for developing long-term pain/stress symptoms 10 TAU, 10 ACT protocol, 4 sessions at work-site/ home Baseline=60 days, intervention: 4 1-hr sessions over 30 days, FU 60 days 2 therapists: 1 experienced CBT, 1 nurse Evaluation of an Acceptance based Self-Help manual Average Total # Sick Days 80 70 60 50 40 30 20 10 0 Cumulative Sick Leave ACT TAU BL mo 1 BL mo 3 BL mo 5 Intervention FU mo 2 FU mo 4 FU mo 6 Cohen s d at follow-up = 1.00 Advantages of manual based intervention minimal or no face to face outpatient psychological treatment (considerable savings!) Internet/telephone support helps patient at home. Manual based increases treatment integrity Medical Service Utilization: Physician, Specialist & Physiotherapist Mean Medical Visits 16 14 12 10 8 ACT 6 MTAU 4 2 0 1 Month Pre Post 6 Month FU
RCT Department of Psychology and the Pain Center, University of Uppsala RCT n=100, ACT/Applied Relaxation Project New Zeeland Marie Johnston University of Waikato 2008 RCT trial 6 weeks cross over design (n=11) DV: Acceptance, quality of life, satisfaction with life, depression, anxiety and pain CPAQ, CPVI, QOLI, SWLS, MPQ- SF, CMDI, BAI Evaluation of a Self Help book, 2 hours therapy face to face, 30 minute internet or telephone contact 6 weeks IV: Book and 30 minute telephone support weekly Text
Contact info and references joannedahl.com JoAnne.Dahl@psyk.uu.se www.contextualpsychology.org Dahl & Lundgren, living beyond your pain 2006, New Harbinger Dahl et al ACT and the treatment of chronic pain, 2005, Context Press Results ACT group significantly improved in acceptance of pain, participation in activities, psychological flexibility for avoidance and fusion and depression Conclusions Acceptance based treatment compared to controlled based appears to yield promising long-term results The person with chronic pain may be more interested in getting his/her quality of life back than simply getting rid of the pain.