336 -Acceptance and Commitment Therapy for Trauma

 
 
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ACT for Trauma
Objectives

~ One of the primary activities of this protocol is to begin to facilitate in vivo exposure to avoided activities.
~ From an ACT perspective, the goal of exposure is not to experience anxiety reduction, but to increase psychological flexibility in the presence of painful and anxious internal experiences so that engagement in valued activities can be re-established. “Living in the And”
Difference Between ACT and Others
~ All offer the opportunity for people to develop a more helpful relationship with thoughts, feelings, sensations and behaviors.
~ Differences
~ CBT: Change thoughts to impact feelings and behaviors
~ Exposure Therapy/Systematic Desensitization/Stress Innoculation: Decondition stimuli and add new behaviors to control problematic responses
~ Psychodynamic approaches make the unconscious material from the trauma conscious so it can be dealt with
~ ACT does not try to change thoughts, feelings or physiological reactions but instead to help people alter the functions of those things and allow them to make life affirming choices.

Goals of ACT for Trauma
~ Recognizing that trying to escape emotional pain will never work. (Creative hopelessness) and exploring the idea of “making room” for past traumas, acknowledge negative internal experiences and pursuing a meaningful life despite their presence.
~ Understanding that problems come not from the emotional pain itself but from attempts to control or avoid it. Besides potentially making the pain worse, people may spend so much time and energy trying to avoid it that they have none left for pursuing positive things in life.
~ Viewing themselves as separate from their thoughts and feelings. Although these thoughts may feel true, they are only thoughts, not a reflection of what is really true. Learning to “take a step back” from their thoughts and not buy into them as truth. (Emotional reasoning… I feel…therefore it must be…)
Goals of ACT for Trauma
~ Stopping the struggle with thoughts and feelings, and practice being both open and willing to experience thoughts and feelings for what they are.
~ Committing to action toward a rich and meaningful life. Avoiding emotional pain requires a huge amount of energy for people with PTSD. It can consume their lives, keeping them from spending much time or energy on living a meaningful and rewarding life.
6 Core Processes
~ Values: Clarifying what is most important to you
~ Mindfulness: Bringing your awareness to the here-and-now with openness
~ Willingness: Making room for feelings, sensations, and urges
~ Defusion: Recognizing thoughts, images, and memories for what they are – just words and pictures. Allowing them to come and go as they please, without struggling with them
~ Committed Action: Taking action and making goals that are in line with your values, no matter how many times you might get off track or struggle to succeed
~ The Observing Self: Remembering that there is a you across time
Introduction
~ Help people describe what they value and want in a rich and meaningful life.
~ “I hear you saying that in your attempts to get rid of all this pain, you have started to feel numb and distant from your family. Is your family important to you?”
~ It is very common for people to be so overwhelmed by their PTSD symptoms, that some of the things that matter most to them start slipping away (OR in some cases, you may have forgotten what really matters).
~ Helping you live those values out is a big part of what this group is about. Is that something you would like?
Introduction
~ Goals are things that can be achieved in a specific time frame
~ Values are ongoing and shape what goals you set for yourself.
~ For example, if I value my health, then I may set a goal of quitting smoking, running a 5K, or eating 5 fruits and vegetables each day
~ Values may change over time. For instance someone who valued achievement above all else and had a very successful career may begin to value service and philanthropy in retirement
Introduction
~ Card sort and eliminate
~ Values: People, things and experiences
~ The overall goal is to begin creating a greater emotional connection to the values they have selected.
~ Why did you select this value?/Why is it important to you?
~ What would it be like if there were no barriers to living out this value?
Understanding Pain Activity
~ Principles
~ Everyone suffers
~ New way to relate to your PTSD pain, so that it doesn’t control their lives and so they are able to fully engage with what matters in their lives.
~ The goal in this approach isn’t to get rid of the pain completely, but to help people relate to it in a new way.
Understanding Pain Activity
~ Principles
~ Two types of pain
~ Pain of presence (clean pain/inevitable pain): Pain we feel in response to losses, anxiety, traumatic memories, and specific problems
~ Pain of absence (dirty pain) The happiness we miss out on because were are focused on and struggling with the pain of presence. (Experiential avoidance)
~ Example: Cleaning your room
Experiential Avoidance
~ Experiential avoidance is considered a normal human tendency that both patient and therapist are likely to exhibit.
~ From an ACT perspective, experiential avoidance is problematic for several reasons
~ It does not actually get rid of the unwanted thought, emotion, or experience
~ Failed attempts to avoid painful internal experiences can result in an increased sense of failure and perceived “brokenness”
~ Efforts to remove pain take tremendous amounts of energy that interfere with pursuing valued activities and relationships
~ As valued activities decrease, people’s daily life and sense of identity become increasingly defined by their trauma
Understanding Pain cont..
~ When we talk about PTSD pain, we are referring not to specific situations, but experiences of having a memory or image of a past painful experience, and sensations or urges to do something that has caused problems in the past
~ drinking, avoiding places, angry outbursts, negative thoughts about yourself, others, or the world that bother you, and feeling anxious or angry in certain situations
~ Have people list their sources of PTSD pain

Understanding Pain cont..
~ Have people list they ways they have tried to deal with their PTSD pain (Whiteboard list/checklist)
~ Distraction (staying busy, shopping, watching TV)
~ Withdrawing or giving up
~ Thinking (ruminating, dwelling on, fantasizing, blaming)
~ Numbing (substances, self-harm, recklessness, dissociation)
~ Avoidance of anxiety-provoking situations (e.g., not going to particular places, hypervigilant behaviors, exerting excessive control, etc.)
~ What is the main goal of these behaviors? To avoid the pain and anxiety. This is such a natural thing to do!
Understanding Pain cont..
~ Have people list what they miss out on, or ways their strategies for coping with their PTSD pain have kept them from what is meaningful in their lives
~ Which ones cause more problems in the long run?
~ Which ones are ineffective?
~ Which ones keep you from those people things and experiences that make your life rich and meaningful? (cont.)

Understanding Pain cont..
~ Validate difficult emotions that arise when looking at the pain of absence and reinforce willingness to have them.
~ What is it like for you to look at these things? It can often take a lot of effort to avoid or get rid of pain and anxiety, and it can be really difficult to look at how our efforts to avoid pain have gotten in the way of the life we want to live. Your willingness to do this is an important first step towards living the life that you want

Impact of PTSD
~ Write down ways your PTSD has impacted (ball or chart activity)
~ Your behaviors and what you do.
~ How you think about things (your beliefs)
Willingness to Live in the And
~ “Joe the Annoying Uncle” metaphor
~ Imagine that you've decided to have a party and invite all the neighbors over. The sign says “everybody's welcome.“ This includes your annoying Uncle Joe, who is smelly, dirty, loud, and rude.
~ You could decide that even though you said everybody was welcome, in reality Joe is not. But as soon as you do that your focus changes. You have to be at the front door, guarding the house, and keeping Joe out. In the meantime, life goes on, the party is going on, and you are spending all your time guarding the house.
~ Or, you could welcome Uncle Joe to the party. You don't have to like him, or like the way he makes you feel. But result of not being willing to have him there will mean you cannot be with your friends and family doing things you enjoy.
Willingness to Live in the And
~ “Joe the Annoying Uncle” metaphor
~ The more unwilling you are for Joe to be there, the more time you spend trying to keep him out. The problem is that Joe—like your own distressing thoughts and feelings—is really good at finding a way back in.
~ Very quickly, this party can become less and less about doing what matters to you, and more and more about fighting a losing battle and keeping Joe away.
~ Try hard to imagine what it would be like to think; “I don’t want Joe here, but, in the interest of making this party about what I value, I’m going to give up the fight against Joe—and live my life in a way that matters to me with Joe in plain sight.”
Willingness to Live in the And
~ “Joe the Annoying Uncle” metaphor
~ The goal of this activity is to help people see that by choosing a stance of willingness, they can have a more meaningful life.
~ They don’t have to get rid of pain to have a rich and meaningful life.
~ How is PTSD like Uncle Joe?
~ Can people have pain AND have what they want in life?
~ How?
~ What would that look like?
~ How would that help live a rich and meaningful life?
Willingness and Mindfulness
~ Willingness isn’t about just experiencing pain to experience it. It’s being willing to have whatever pain or anxiety is present so that you can pursue what matters to.
~ Go to your kid’s soccer game
~ Drive to…
~ Go hunting
~ Willingness is not about making life easier or avoiding pain it is about choosing how that pain impacts your life—
~ Does it take over and pull you away from what matters? Or do you live a full life even in its presence?
~ Start focusing on the AND, and stop being stuck in “buts.”
~ Instead of saying, “I want to stay at my kid’s event, but I’m scared,” say “I want to stay at my kid’s event AND I’m scared.” The fear doesn’t go away but your fear no longer limits your behavior.
Willingness and Mindfulness
~ You may have been in situations where you felt scared for your life AND you still moved forward because it was important to you. You didn’t say, “I need to do this, but I’m too scared.” You’ve shown the ability to “live in the AND.”
~ Ask group members for other examples of when they were scared but moved forward anyway.
~ Ask the following questions to help identify what thoughts, emotions, physical sensations, and urges people were having at the time and whether they continued on anyway:
~ What was it like?
~ How were you able to move forward anyway?
~ How did you feel about yourself when you were able to do that?
~ Get Off Your Buts activity
Mindfulness
~ When we try to avoid or get rid of PTSD pain and anxiety, we are not acknowledging and experiencing the present moment.
~ PTSD pulls our focus to what might happen in the future or toward thoughts and feelings about what happened in the past.
~ The goal of mindfulness is to
~ Become aware of your present environment, thoughts, feelings, emotions, and physical sensations, rather than thinking about the past or worrying about the future
~ Get better at noticing positive experiences.
~ Be aware of what is going on with you “systems check.”
~ If you are not aware of what you are thinking, feeling, etc. then it is hard to get distance from it and do something healthy with it.
~ To learn how to be nonjudgmental of your thoughts leading to shoulding or emotional reasoning.
Mindfulness
~ 5-Minute Awareness
~ Pre-awareness-walk out of the room, separate everyone. Have them write down as much as they can remember
~ Awareness- Everyone goes back in the room and becomes aware (not writing yet)
~ Post-Awareness- identify what everyone noticed and group by the 5 senses
~ Discuss people’s experiences.
~ If a someone says they felt like they didn’t do it right, help them observe and label that as a thought they are having.
~ Validate any comments about awkwardness or trouble staying focused.
~ Validate resistance by noting that often the last thing that people with PTSD want to do is sit still with their experience because that is when painful thoughts or emotions come up.
~ Point out that the goal is not relaxation, but awareness
Mindfulness
~ Survivors of trauma often cope in two different ways, both of which are counter to mindfulness:
~ Dissociation or Numbing: Shutting down and feeling distant and disconnected from their feelings, daily life, or other people.
~ Hypervigilance: Becoming highly aware of everything around them. It was likely very adaptive to have a high level of awareness in the trauma, since danger really was always just around the corner.
~ Hypervigilance is not the same as mindfulness
~ Questions
~ When you are doing either of these things, how does it affect your ability to engage in important parts of your life?
~ Has hypervigilance ever prevented you from enjoying good moments?
~ What do you think life might be like if you didn’t do these things?
Mindfulness
~ Mindfulness scan
~ Physical feelings and sensations
~ Emotions and feelings
~ Thoughts
~ Validate any difficulties brought up by noting again that this is a totally new approach for many, especially for those with PTSD who often have a great deal of practice at NOT noticing how they are doing inside.
~ It can be difficult at first, and very few people find all mindfulness exercises equally helpful.
Mindfulness
~ A stroll down the road (or through the garden)
~ You notice: a $20 bill, a flower, a puppy, empty beer bottles
~ Some of these things trigger happiness some trigger anger
~ You can choose which ones you pick up and carry with you.
~ Think of your painful thoughts, memories or experiences like those empty beer bottles. You don’t have to pick them up and carry them with you. You can observe them. Note your feeling about it and move on.
~ Think of a painful trauma-related thought, emotion or memory.
~ What does it look like?
~ How big is it?
~ What color is it?
~ How powerful is it?
~ Do you have to pick it up, or can you walk by and notice something else?

Decision Points
Decision Points
Diffusion
~ Saliva Exercise
~ Imagine that I have given you the strange homework assignment of saving up your saliva in a water bottle for the next week. You bring it in and I ask you to drink it. You will the warm, thick, saliva as it enters your mouth and slides down your throat”
~ None of us had to actually drink the saliva, but we were able to produce that disgust and terrible physical sensation. That is because even though all we did was use words and images, our mind gave them an element of realness. The fact that you were able to envision it without seeing it is what we call fusion
~ Imagine what happens when fusion occurs with a less simple or more painful thought. For example, the thoughts “I am a failure” or “things will never get better.” Just like the description of saliva, those can conjure up intense emotions and reactions, even though in reality that are just words. If we take them seriously, they can have a huge impact on us.
Fusion
~ Broken Glasses
~ Use permanent marker or something else to draw lines on inexpensive glasses
~ Have people put them on and discuss how much it limits them. How much they would miss out on. How it reduces their ability to respond to the world around them?
~ If my goal is to be successful but I am fused with the thought that I am a screw up, how will that get in the way?
~ Think of the fused thought of “I am a screw up” as the glasses – You can’t see around, notice other person’s reactions, and you are so caught up in your own thought that you are a screw up that you can’t see anything else

Diffusion
~ I am having the thought/feeling that
~ Silly voices
~ Name your story (the Screw-Up Anthology)
~ Angel and Devil

The Observing Self
~ Fly on the wall
~ Helps people “see” things more objectively
Summary
~ Common Barriers to Recovery
~ F = Fusion
~ E = Exiting the present moment
~ A = Avoidance of discomfort
~ R = Remoteness from values
~ The Antidote to Barriers:
~ D = Defusion
~ A = Acceptance of discomfort
~ R = Reunite with the present through mindfulness
~ E = Embracing values