ACT for PTSD: Comorbidity, Childhood Trauma & Skill Training

By Sonja Batten, Ph.D.

This video is part of our upcoming online course about ACT for PTSD.

Highlights

  • Both PTSD and substance use problems can be considered the result of excessive efforts at avoidance.
  • ACT can be used to treat those two types of problems at the same time.
  • Not all avoidance is problematic.
  • Only the individual can make the changes needed to move life forward in the present.

 

Transcript

And now, I’ll talk about some special issues to keep in mind when working with individuals who have experienced traumatic events from an ACT perspective.

So, first of all, it can be really important to set the groundwork for treatment, helping the person understand not only what’s ahead of them but why it can be useful to focus on trauma, even if it’s hard sometimes.

References

Moran, D. J., Bach, P. A., & Batten, S. V. (2018). Committed action in practice: A clinician’s guide to assessing, planning, and supporting change in your client. New Harbinger Publications.

So, one metaphor that I like to use is if you imagine that off in the distance there’s a mountain that you want to go to. And you can see, off in the distance, this mountain is beautiful. It has whatever characteristics would be meaningful to you. It has flowers or it has majestic beauty or whatever would be meaningful to the individual. And so you can see that thing off in the distance. And that’s your goal. That’s where you want to end up.

References

Moran, D. J., Bach, P. A., & Batten, S. V. (2018). Committed action in practice: A clinician’s guide to assessing, planning, and supporting change in your client. New Harbinger Publications.

But when you look down a little bit, more immediately in front of you, you see that there’s a swamp. And the swamp doesn’t look like anything you want to go into. It’s dark and murky and cold and there’s no way of seeing exactly what’s in it. It smells bad. And if it were just going into the swamp for the sake of going into the swamp, there really wouldn’t be any reason to go in to do that. And what we’re suggesting is that perhaps sometimes there can be merit to going into that swamp, even if you can’t see exactly what’s in front of you and you know it’s not going to be particularly pleasant, if going through the swamp is the only way to get on the other side and get to that mountain that’s your goal.

References

Moran, D. J., Bach, P. A., & Batten, S. V. (2018). Committed action in practice: A clinician’s guide to assessing, planning, and supporting change in your client. New Harbinger Publications.

And as the therapist, you can convey that you’re willing to go into that swamp with them and you wouldn’t leave them stranded there. You’ll be there by their side as they walk through that swamp, encounter whatever is there in order to get to the other side, to the mountain. And the mountain, that’s the values, that’s the goals, that’s what’s important to the individual. And so you’re not just sort of going to, you know, muck around in the trauma for the sake of, connecting to the trauma. But sometimes, it’s important to go into that stuff, not just for its own sake, but in order to get the person to be able to reclaim the life that’s important to them.

References

Moran, D. J., Bach, P. A., & Batten, S. V. (2018). Committed action in practice: A clinician’s guide to assessing, planning, and supporting change in your client. New Harbinger Publications.

And I’ve talked about the importance of exposure-based therapy, and certainly we do exposure in ACT, but we talk about the rationale in a different way when we’re talking about exposure to our ACT clients. The idea is not that we’re going to do imaginal or in vivo exposure in order to reduce symptoms, that we’ll go into it over and over until the symptoms habituate and it’s not so difficult anymore. The idea is that we’re working on increasing psychological flexibility in the presence of trauma triggers because trauma triggers are going to happen throughout life.

References

Moran, D. J., Bach, P. A., & Batten, S. V. (2018). Committed action in practice: A clinician’s guide to assessing, planning, and supporting change in your client. New Harbinger Publications.

And so the idea is that the client will have contact with those trauma triggers, expose themselves to that experience and whatever it brings up, and then we’ll work together on demonstrating psychological flexibility and practicing flexibility, even in the presence of those trauma triggers, so that the person can have the type of life that’s important to them.

References

Moran, D. J., Bach, P. A., & Batten, S. V. (2018). Committed action in practice: A clinician’s guide to assessing, planning, and supporting change in your client. New Harbinger Publications.

One of the things that can be useful is working with people first on grounding skills and crisis survival skills. And as I mentioned before, all avoidance is not bad. We really focus on function and workability. Even though I’ve said that experiential avoidance is part of the model for understanding why people have long-term problems, there are certain types of avoidance that may be useful in the short term.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

And so, for example, I will make sure that people have in their repertoire some smaller, effective, potentially avoidant strategies like grounding skills, being able to get in contact with the sights and sounds of the present moment, especially when trauma triggers are pulling out at the present moment.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

Or crisis survival skills from something like DBT, where the person learns how to put their hands under cold water or warm water or call a friend or, you know, interact with their pet—doing something just to get through the moment that may in some ways be avoidance but it’s avoidance that’s not doing anything to harm the person and that’s focused on getting through the moment in a short-term way without making the situation worse. So, we work on building those sorts of skills.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

There are a number of comorbidities or co-occurring problems that can show up in tandem with PTSD and one of those is substance use disorders. And so, as I described previously, PTSD can be conceptualized as a disorder of avoidance. But there’s also plenty of evidence to suggest that substance use is frequently a form of emotional avoidance as well, especially when the substance use is going on over a period of time and is often used to sort of get through the day or to deal with difficult events.

References

Batten, S. V., & Hayes, S. C. (2005). Acceptance and commitment therapy in the treatment of comorbid substance abuse and post-traumatic stress disorder: A case study. Clinical Case Studies, 4(3), 246–262.
Batten, S. V., DeViva, J. C., Santanello, A. P., Morris, L. J., Benson, P. R., & Mann, M. A. (2009). Acceptance and commitment therapy for comorbid PTSD and substance use disorders. In J. T. Blackledge, J. Ciarrochi, & F. P. Deane (Eds.), Acceptance and commitment therapy: Contemporary theory, research and practice (p. 311–328). Australian Academic Press.

So, we really see it as an advancement in the field to consider both PTSD and substance use disorders as disorders of avoidance. And what this does is really advance the field because it allows us to focus on that consistent functional dimension of avoidance, potentially targeting both problems at the same time, rather than having your substance abuse treatment over on one side and your PTSD treatment over on the other side. And then you’ve got to coordinate between the two different treatments or even more problematically, sort of the older school model that somebody’s got to be clean and sober before they can deal with their trauma, which we know is not particularly effective.

References

Batten, S. V., & Hayes, S. C. (2005). Acceptance and commitment therapy in the treatment of comorbid substance abuse and post-traumatic stress disorder: A case study. Clinical Case Studies, 4(3), 246–262.
Batten, S. V., DeViva, J. C., Santanello, A. P., Morris, L. J., Benson, P. R., & Mann, M. A. (2009). Acceptance and commitment therapy for comorbid PTSD and substance use disorders. In J. T. Blackledge, J. Ciarrochi, & F. P. Deane (Eds.), Acceptance and commitment therapy: Contemporary theory, research and practice (p. 311–328). Australian Academic Press.

There also are issues specific to childhood trauma that we think are important to think about when applying ACT. So, for example, individuals who’ve experienced a significant trauma early in life, especially when they’ve grown up in an invalidating environment, may have an especially difficult time with having a sense of self. And when I talk about a sense of self, I really do it in the way that Kohlenberg and Tsai talk about: as the ability to describe certain experiences as things like, “I see this,” “I feel this,” “I want this.”

References

Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in the treatment of posttraumatic stress disorder. Behavior Modification, 29(1), 95–129.
Kohlenberg, R. J., & Tsai, M. (2012). Functional analytic psychotherapy: Creating intense and curative therapeutic relationships. Springer Science & Business Media.

Oftentimes, trauma survivors who’ve experienced childhood trauma and grew up in an environment that wasn’t supportive of their development go on to have significant problems labeling those experiences just based on their own private sort of responses. And so they’re more under the control of the stimuli around them, the people around them, to label how they’re feeling.

References

Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in the treatment of posttraumatic stress disorder. Behavior Modification, 29(1), 95–129.

So, for individuals with that sort of history, oftentimes, they need more work to help understand that there’s a part of themselves that’s there and that’s consistent, regardless of who’s around them or what’s around them and regardless of the emotions, thoughts, and memories that they’re experiencing and helping them connect to that stable sense of self.

References

Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in the treatment of posttraumatic stress disorder. Behavior Modification, 29(1), 95–129.

So, we’ve found in those cases that incorporating some skills training techniques from dialectical behavior therapy, which is another acceptance and change-based behavioral approach, can really supplement the methods from ACT that are designed to increase willingness. And so that’s really using the emotion regulation and emotion labeling skills from DBT, especially with early childhood trauma survivors.

References

Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in the treatment of posttraumatic stress disorder. Behavior Modification, 29(1), 95–129.

And so, it’s our clinical experience that these methods can complement the techniques of ACT. But we do want to consider some caution when adapting the protocol. We really work on developing distance and differentiation between the sense of self and what the person’s private experiences are, so they can turn from avoidance and inaction and begin participating in a valued life.

References

Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in the treatment of posttraumatic stress disorder. Behavior Modification, 29(1), 95–129.

But for the beginning ACT therapist, it can be difficult to understand. Like, what is the difference between when I say taking a step back from those experiences and gaining perspective from those experiences versus changing those experiences? So, in ACT, we’re not working on having the person change a dysfunctional thought or dispute, you know, an assumption they have about the world. We’re helping the person gain perspective so they can take a step back from them. And it’s important to truly understand that because, otherwise, when you start incorporating some of these more cognitive-behavioral techniques, it can start to become confusing pretty quickly for both the therapist and the client.

References

Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in the treatment of posttraumatic stress disorder. Behavior Modification, 29(1), 95–129.

The guiding principle is adding techniques to ACT. When you do that, you should make sure that each new method is consistent with the conceptualization of the case and if we’re thinking about ACT that the overarching goal is still reducing avoidance and escape strategies and helping the person connect with what’s important to them.

References

Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in the treatment of posttraumatic stress disorder. Behavior Modification, 29(1), 95–129.

So, when we think about then overcoming the obstacles and barriers that are associated with these sorts of experiences, oftentimes, individuals who have PTSD or other trauma-related problems, they come to therapy with the conceptualization that their current problems are caused by the traumatic event. And so if you assume that, like your problems are caused by the trauma you experienced, well, given the fact that we can’t go back in time and change the fact that the trauma happened, then in some ways it seems like, well then, how can you ever recover? Because if the trauma caused how you’re feeling right now and the trauma can’t be changed then how are things ever going to change?

References

Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in the treatment of posttraumatic stress disorder. Behavior Modification, 29(1), 95–129.

And so it can be challenging when you have to introduce then that the client has the responsibility at this point for moving forward—even if they didn’t have the responsibility for what happened to them originally. That can feel really invalidating and sometimes threatening.

References

Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in the treatment of posttraumatic stress disorder. Behavior Modification, 29(1), 95–129.

So, in other words, if the person can improve their life now without erasing the traumatic event from their history, well then, maybe the event itself is not entirely responsible for the current level of distress. Or if the client can get better and is no longer sort of the obvious victim of the event, then somehow that can seem to like minimize the awfulness or the wrongness of the event. And this can be a real stuck point for individuals with trauma histories, especially if this is something they have been living with for quite some time and they were clearly wronged by someone else. And so sometimes you have to directly address this in therapy.

References

Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in the treatment of posttraumatic stress disorder. Behavior Modification, 29(1), 95–129.

We use several metaphors in ACT for illuminating the cost of having what’s going on now be defined by what’s happened in the traumatic experiences of the past.

So, one of those is the legal concept of corpus delicti and that means “the body of the crime.” And so the metaphor we talk about is that if there was a murder, there has to be a body to prove the crime.

References

Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in the treatment of posttraumatic stress disorder. Behavior Modification, 29(1), 95–129.

And so, oftentimes, what can happen is somebody who’s been through a traumatic event—especially one that was caused by someone else—is that they have to continue to be that body to demonstrate that a crime was committed and that if they can stand up and walk away that that may let the person who caused the trauma in some way off the hook for what happened.

References

Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in the treatment of posttraumatic stress disorder. Behavior Modification, 29(1), 95–129.

And so we have to sort of get into that tension of the fact that yes, somebody else may have been responsible for what happened. And are you focused on making that person wrong? Or are you focused on moving your life forward?

And that’s a really tricky, challenging conversation to have and it really has to be had in the context of a trusting therapeutic relationship. But we have several metaphors that we use that help illustrate that the responsibility for recovering from a traumatic event ultimately lies with the client, even if the responsibility for the original traumatic experience does not.

References

Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in the treatment of posttraumatic stress disorder. Behavior Modification, 29(1), 95–129.

Some key points: Both PTSD and substance use problems can be considered to be the result of excessive efforts at avoidance. And so the good news is that ACT can be used to treat those two types of problems at the same time.

And although avoidance is frequently a core clinical problem, not all avoidance is problematic. It really depends on the function and the results of the avoidance.
And finally, although traumatic past may have led to the problems an individual is facing now, only the individual him- or herself can make the changes needed to move life forward in the present.

More ACT for PTSD presentations