ACT like a Pro 2017

 

Ray’s Log

It’s 9.45am on an early autumn Sunday morning, in an otherwise-empty teaching block at the University of Birmingham, on a campus where all the students are asleep, hung-over or – in fact –  still partying.  In a large teaching room, 23 experienced ACT practitioners are already deep into their own persistent, yet unhelpful self-stories, and are exploring how these can get in the way of being the therapists they want to be. The first tears of the day are showing up, with another six hours of advanced theory, practice, close observation and feedback on skills still to come. It’s going to be emotional…

 ..Welcome to ‘ACT Like a Pro’!

This is an account of a two-day advanced ACT skills workshop that we ran in September 2017 as part of the yearly  .  We suspect that some of what we did, and how we did it, is relatively uncommon, so we thought it would be worthwhile to describe both content and process for anyone else wanting to carry out a similar advanced training format. We’re very happy to share materials if you get in touch.

 

BACKGROUND

One of the facilitators, Rich Bennett, had set up ‘Birmingham ACT Week’, a ‘boot camp’ style training event at the University of Birmingham 4 years previously, and now organises it annually.  The rest of us had taught on the programme every year since its inception.  Birmingham ACT week provides a 2-day Introductory / Experiential course, a one-day practical basics workshop, and a two-day Intermediate workshop on consecutive days. In the past, there had been individual, specialist days the following week (e.g. ACT for… Sleep, Psychosis, Health, Grief).

There’s a lot of good ACT training around in the UK these days.  One thing we’d noticed, though, was that was relatively little aimed at the established ACT practitioner who has already done various intermediate and specialist events, and who wants to develop their skills further. Thus was born the idea of an advanced 2-day skills-based course. The title ‘ACT like a Pro’ was borrowed following a conversation between Rich and his supervisor, Rikke Kjelgaard, who runs similar events in Scandinavia (“It’s a f***ing awesome title”: Kjelgaard, 2017)

A WhatsApp group chat, occasional Skype meetings, and a planning session held in a Seville park during the ACBS WorldCon eventually led to the course we delivered.

 

FORMAT

The course ran over 2 days with a total of 19 participants.  Each day started and ended with an hour long plenary session for the whole group.  Each plenary had the same structure, beginning with an experiential exercise, followed by open discussion and reflections on the workshop sessions.

The participants were divided into 4 small groups, who during the two days rotated through four specific ‘workshop’ sessions of about 2 hours length.  Each workshop was run on four occasions by one of the facilitators.

 

PROCESS

Each separate workshop included provision of new learning and in-depth skills practice, based on the Portland Supervision Model .  By rotating roles through the workshops, each participant had at least one opportunity to practice their skills, to present a relevant issue (either their own or roleplaying a client), to be advisor to the person practising their skills, or tracking the key ACT skills being demonstrated. Deviating from the usual model, the workshop facilitator also provided direct feedback and suggestions where useful.

 

CONTENT

Plenary sessions

The four plenary sessions, in which the whole group came together, were used to cover a range of issues, including logistics of the course, group exercises, and reviews of learning.

They aimed to set a context that might help facilitate the learning that participants gained from the workshop.  We also worked on building the ‘stance’ of the course (see below) by video and small group discussion tasks emphasising openness, vulnerability, and compassion, and reflection upon our own self-stories as therapists.

 

Workshop sessions

Here are the descriptions of the four 2-hour workshop sessions (that each small group rotated through) as described in the course programme

FAP-ing up The Matrix – Rich Bennett

It is a widely-held assumption in psychotherapy that both clients and therapists bring their typical patterns of interpersonal interaction with them into the therapy room.  This session will focus on the use of the ACT Matrix to shape in-session behaviours of clients, in the service of strengthening the impact of interpersonal relationships, both inside and outside of the therapeutic relationship.  It will draw on the general principle of the use of the ACT Matrix, as well as principles from Functional Analytic Psychotherapy (FAP).

The aim of the session is to help participants focus on discriminating in-session between helpful and unhelpful interpersonal behaviours, bringing attention to these through the mechanism of functional analysis.

 

Expanding the Power of Present-Moment Focus – Jim Lucas

Just as your clients struggle, it is easy for you to get lost in the hexaflex wondering, “Where do I go next?” or “Have I done enough work on that process?”  You too can get caught up trying to fix, problem-solve, or talk about what to do instead of doing it.  When this happens, you are moving away from experientially-focused learning.  In this session, you will be using and re-using the present-moment to enhance psychological flexibility.  Drawing on the work of Strosahl & Robinson (2015), you’ll get to develop your ACT skills by applying five distinct phases of intervention.  Specifically, to observe, describe, let-be, soften, and expand.  These five sets of skills help you stay on track when attempting to reduce experiential avoidance and rule-governed behaviours.

  

The Self and Perspective Taking – using RFT to Supercharge Self Acceptance – Joe Oliver

Understanding the “self” is like the holy grail of psychology.  And yet, self-as-context is the part of the ACT model practitioners most often shy away from.  However, with a good understanding of “selfing” issues, we can help us unlock any number of thorny, stuck issues that come up in working with clients.  The aim of this session is to equip practitioners with simple, practical skills for understanding and using self-as-context processes. The focus will be on how to move towards self-acceptance through the elegant use of ACT and RFT principles, most notably deictic relations.

 

How We Get In Our Own Way – Ray Owen

ACT and other contextual behavioural approaches emphasise that the therapist is subject to the same processes as the client, and consequently the same potential sources of inflexibility. When these inevitably show up for the therapist during sessions, they may push her/his behaviour in less workable directions.

 This session will invite participants to consider their own recurring sources of inflexible responding in the context of clinical sessions, and focus upon developing greater awareness of their occurrence, openness in responding to them, and engagement in moving towards valued outcomes in therapy, even in their presence.

 

STANCE

From the earliest stages of planning, all four of us were keen to not only pay attention to the content and the mechanisms of teaching, but also to embody a shared, values-based approach.

In particular, we sought to model

  • openness and vulnerability, both in the group exercises and in the disclosures and interactions of the facilitators. The sense of “all in it together” was further reinforced by an open invitation to the pub and meal together on the first evening
  • respect for the skills and experience brought into the room by the participants in this ‘advanced’ workshop. For example, during introductions a tally of “years of experience in healthcare” was taken, demonstrating that there was over 350 years of experience in the room. This experience was to be used, reflected on and enhanced, rather than ignored or dismissed
  • respect and feedback in all directions by the use of “Tootles” (brief, hand-written messages of appreciation that could be given directly to any other participant or facilitator to thank them for something they contributed – sometimes used in ProSocial work)
  • ensuring that the learning in each phase addressed ‘head, heart & hands’ – i.e. comprehension/coherence, direct experience and noticing of our own thoughts and feelings, and practical skill development

 

REFLECTION

The most important question for any enterprise like this is surely, “Did it help?”  We can’t definitively know the answer, but here are our reasons for thinking that maybe it did.

The on-the-day ratings were overwhelmingly positive: participants were asked to rate the event on a 0-5 scale in terms of the quality of the new information provided (head), the experiential exercises (heart), and the skills practice (hands). The results were:

 

Providing new information

(“head”)

Experiential exercises

(“heart”)

Skills practice

(“hands”)

Mean (x/5) 4.8 4.9 4.9

 

Verbal feedback was also very positive, and participants were able to cite specific commitments to what they would do more of, or less of, in order to become more of the therapist they wanted to be.  This event was not set up as a piece of research and had no formal measurement of behavioural change or follow-up.  However, each of us facilitators has heard from multiple participants saying they continue to benefit from that intense but overall very useful weekend.

As four experienced trainers, we all felt that this was something different to our usual training events: not just in terms of the technical ‘level’ of the content, but in terms of the way that awareness, openness, and engagement were manifest throughout.  ACT and other CBS practitioners will (hopefully) tend to bring that to an event, and the way the workshop was set up (the format, the stance, the modelling) further enhanced this.

In terms of hard economics, this is a difficult format to break even on – four facilitators, accommodation with space for four ‘breakout’ groups, catering etc, with only around 20 paying participants. This was only really viable as part of the broader activities of Birmingham ACT Week, some of which involved much larger numbers which could effectively cross-subsidise.  However, we suspect that – as focussed as we could be with only 5 participants per workshop session –  with a slight change to the groupwork setup, participant numbers could be doubled without losing the essential qualities of the skills work, which begins to make this format more financially viable.

One interesting barrier to participation was the reluctance some voiced to identifying themselves as ‘competent’ enough to take part in an ‘Advanced’ skills workshop – there were a lot of nervous emails prior to booking checking out whether they ‘deserved’ to be there.  It may be that some potential participants were lost to their own self-doubt.  We wondered if the name ACT Like a Pro added to this effect, but felt it was not the title per se but the concept of advanced workshops that evoked ‘imposter syndrome’. And yet, several participants also mentioned how nice it was to be in a setting where the core concepts of ACT were familiar to all and didn’t need explaining.

Finally, for myself, delivering the workshop was fun, challenging, affirming, and a bonding experience with fellow practitioners, including my good friends and colleagues Joe, Jim, and Rich.  I want to especially thank Rich for initiating and organising the whole event, and his son who nobly gave up his bed for me, so that I could stay over for the weekend under his Star Wars duvet!

 

Ray Owen (drrayowen@gmail.com)

for

Rich Bennett (r.bennett@bham.ac.uk)

Jim Lucas (jim@openforwards.com)

Joe Oliver (joe.oliver@contextualconsulting.co.uk)

 

 

The ACT of Grieving

The ACT of grieving; when the pain won’t go away, and life seems pointless

Dr Ray Owen, Consultant Clinical Psychologist (Cancer & Palliative Care)

 

Alina’s husband Pete died of prostate cancer 8 months ago. She describes the weeks immediately after his death as a blur. For the last few months, though, she says her life has settled into a constant cycle of sadness and tears, replaying his last weeks in her mind and avoiding activities or people that remind her of him, bringing new waves of pain and loss. Alina says she doesn’t know what she’s for any more, so can’t find the motivation to do anything. And when she thinks of years more of this life, she’s beginning to wonder whether it’s worth carrying on.

 

The nature of the problem

Everyone who works with grief will recognise situations like that of Alina (a fictional person, but based on so many real ones I’ve met). And these problems are familiar enough that we all have our ways of approaching them, making sense of them, trying to help.

Yet this stuff is always difficult, and it’s worth reminding ourselves of some of the reasons why:

  • This emotional pain is intense, is entirely understandable (we might even say ‘deserved’), and we know it’s probably not going away anytime soon
  • So much of an individual’s identity and purpose may have been tied up in the person who died: it becomes hard to see what to aim for in life now
  • And sometimes, our own losses may make our clients’ pain hurt us, or make us feel helpless in the face of their suffering

 

When anyone grieves, it’s not just the emotional pain of grief – the sadness, anger, fear, guilt – it’s how we react to the pain that gets us into more trouble; the withdrawal, the dwelling on the past, the over-busy-mustn’t-let-my-mind-start-thinking, even the use of alcohol or other drugs to numb the pain.

Though any of these might have the desired effect in the short-term, not only will they fail to change things in the longer term, they’ll also make it harder to start moving towards that ‘new life’ that well-meaning friends will increasingly talk about.

What’s more, all of this is takes place against the background of a society that tends to view human suffering as a problem to be fixed, or worse an illness to be medicated. And that grief is some set process or a state to be ‘got over’.

 

Acceptance & Commitment Therapy – a way of helping

Different models of how to support grieving people will address these matters in different ways (or sometimes don’t).

One approach to this – a psychological model called Acceptance and Commitment Therapy (or ‘ACT’, always pronounced as the word, not separate letters) – doesn’t see the pain, the response to the pain, or even the (sometimes unhelpful) actions of other people  as symptoms, complications or pathology; but rather as fundamental to how we humans learn about the world, understand it and react to it. And those ways are both our greatest strengths and our greatest vulnerabilities. So, this approach it isn’t just about grief responses, but all forms of distress and suffering.

ACT is a ‘third-wave’ therapy – at heart it’s a form of behaviour therapy which puts a huge emphasis on acceptance, mindfulness, compassion and values-driven behaviour. In the 20 years or so that it’s been around, there have been thousands of scientific studies of its various parts, and over 150 major treatments trials (randomised controlled trials or RCTs) published in academic journals showing its effectiveness across a surprising range of conditions. These include the usual mental health conditions (anxiety, depression, PTSD, delusions, hearing voices, anger control amongst others), coping with physical health problems (chronic pain, cancer, diabetes, other long term conditions) but also areas that aren’t usually seen as clinical problems, such as dealing with stigma and prejudice, learning new skills or even encouraging use of safety equipment on building sites! All the details are on the main ACT website  www.contextualscience.org .

ACT sees many of our difficulties as arising from our attempts to control, challenge or remove naturally occurring thoughts and feelings, rather than learning how to pursue a fulfilling life even with them present some of the time. And that’s true for all of us, not just those seeking help.

To turn things around, ACT encourages us to be more AWARE, OPEN, and ENGAGED

  • AWARE; able to notice what’s going on both inside our heads, hearts and bodies, and in the world outside us, and develop the ability to return to the here-and-now rather than being lost in the past or future, or ruled by rigid rules and stories about ourselves. ACT overlaps with mindfulness-based approaches in this way.
  • OPEN: responding to those thoughts and feelings with recognition of what they are, rather than letting them control all of our choices and actions. Be willing to experience them, if that’s what it takes to move forward. And develop the ability to ‘let them be’ without taking unhelpful steps to reduce them.
  • ENGAGED: to become clearer about our values – what matters to us, how we want to be in this world (different people value different things – mine include ‘being helpful’, ‘being kind’, ‘being curious’,’being creative’) and then base our actions on those rather than the (understandable) urge to reduce unwanted thoughts and feelings. And finding ways of doing that even when our circumstances have changed – as in bereavement.

 

While those are the changes that ACT promotes, it also puts great emphasis on how that’s done, through

  • Being clear that what is causing difficulty is not illness or pathology, but the natural consequences of how our minds work
  • As such, it applies as much to the therapist as to the client. To model this, ACT therapists will use more self-disclosure than is found in many counselling or therapy models
  • Focussing less on what is absolutely ‘true’ for this client or the world in general, and more on what works to give them a more fulfilling life
  • Actively doing and experiencing things – within sessions and between them- rather than exclusively talking and listening

 

An example

So what would be an ACT approach helping Alina, whom we met at the beginning of this piece?

Well, the first thing to say would be that (hopefully) it would have many things in common with any other caring and effective form of support; not least, showing compassion, respect, a genuine interest in the other’s experience and a willingness to allow their story to be properly heard.

The ACT practitioner might also be spending time on:

  • Helping Alina notice in detail the thoughts and feelings that show up for her, when they do, and what she tends to do next (e.g. avoiding seeing people)
  • Understanding why we naturally react this way, such as the urge to reduce or move away from strong unpleasant feeling (known as ‘experiential avoidance’). Emphasising that it is not a sign of being ‘ill’ or ‘broken’, yet noticing that it might not be working well for her in the long term
  • Encouraging her not to struggle against the thoughts and feelings when they show up, yet neither to get drawn into prolonged rumination and reflection if it doesn’t help
  • Helping her to return to the here-and-now when her mind begins to spiral into her memories, without unhelpful patterns of suppressing thoughts or needing constant distraction
  • Noticing the presence and the impact of rules and beliefs about herself, especially those that define her in terms of being (for example) a wife and a carer
  • Establishing the values that matter most to Alina; look how they have been impacted by her loss and the pain that creates (“inside your pain, you’ll find your values”)
  • Without giving a message of ‘rushing’ or ‘moving on’, look at new ways of living by those values in a life where Pete is no longer around. So, gradually developing a sense of purpose and meaning distinct from the specific roles she has lost while maintaining continuity with the things that mattered most about how she was with Pete (examples for her might have been acting caringly, loyally, honestly)
  • Helping to understand that in moving forward she will be carrying many of her difficult thoughts, memories and feelings with her – life cannot wait until they are all resolved (because they never fully are)
  • Helping her develop any new skills necessary to do these things

And what might I want for Alina at the end of this work? That her memories and feelings relating to Pete – both the wanted and unwanted ones – are still there, but they do not control her as much anymore, and that she is no longer scared of them. And most importantly, that she is beginning to experience a life that has meaning, fulfilment and pleasure in it, even in the presence of her grief.

Of course, Acceptance and Commitment Therapy isn’t the only way to help someone achieve this.

But I’ve certainly found it to be one very powerful way.

 

Taking it further

As with any different model of counselling or therapy, some of those specific approaches will take a bit of learning, but some key parts (e.g. working with Values) needn’t require a massive amount of training.

If you are interested in learning more, then I’d recommend starting with a self-help book written  by Dr Russ Harris (2012)  The Reality Slap – how to find fulfilment when life hurts (Robinson Press). Indeed, that author’s writings and youTube videos are definitely one of the best ways into this field, and his website www.actmindfully.com.au has lots of good stuff on it.

If you prefer to read something more academic, then Hayes, Strosahl & Wilson (2012) Acceptance and Commitment Therapy (2nd edition- Guildford Press) is very thorough and will give you a sound understanding of the principles underlying the approach.

There is a wide range of ACT courses available, many of them listed at the main ACT website www.contextualscience.org .

If you’d like to learn more about ACT specifically for Grief, I’m delivering a 2 hour webinar in April 2017; here’s the link if you’re interested:

https://contextualconsulting.co.uk/workshop/act-for-grief-webinar

 

 

 

Dr Ray Owen, July 2016

What’s this blog for?

Sometimes, there are things that seem worth saying that are longer than a tweet or a Facebook post, and that aren’t really right for an article in a journal or a chapter in a book. I’m thinking that this blog might be a place for those. Time will tell…..