Demystifying ACT: A Practical Guide for Therapists

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ACT for PTSD: Key Initial Concepts

By Sonja Batten, Ph.D.

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

Highlights

  • The experience of a potentially traumatic event is common during most people’s lives.
  • Only a small number of people will develop PTSD.
  • ACT views an individual’s experience of trauma within their current and historical context.
 

Transcript

Hello everyone. Thanks so much for joining me today. My name is Sonja Batten. I’m a clinical psychologist and the lead for Flexible Edge Solutions. I’ve been practicing acceptance and commitment therapy for over 25 years now. And I’m a past president and fellow of the Association for Contextual Behavioral Science and a peer-reviewed ACT trainer. And I’m excited to begin this course with you around using acceptance and commitment therapy for posttraumatic problems in living.

In today’s videos, I’m going to talk to you about using acceptance and commitment therapy (or ACT) for posttraumatic problems in living, working with individuals who have experienced traumatic events. I’ll use the shorthand, oftentimes, of the term PTSD, or posttraumatic stress disorder, but I want to make clear that not all individuals who experience a trauma will have PTSD. And in fact, that’s one of the beautiful things about working with ACT. That we don’t have to be focused on any given diagnosis. So, when I talk about using ACT for PTSD, that’s sort of a shorthand. Really what I mean is using ACT with individuals who have gone through a traumatic event and who are still experiencing challenges in their life as a result of that traumatic event.

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.

That said, I will start off by just giving a little bit of background around PTSD, or posttraumatic stress disorder. In PTSD, a person experiences a potentially traumatic event followed by more than 30 days of reexperiencing symptoms, avoidant symptoms, negative changes to cognitions, and mood and arousal symptoms…

References

National Center for PTSD. (n.d.). VA.gov | Veterans Affairs. https://www.ptsd.va.gov/

And let me talk a little bit about what those are. Reexperiencing symptoms are what they sound like. They’re symptoms where a person is being triggered and reexperiencing something that reminds them or is related to the trauma. So, that could be an intrusive memory. It could be a nightmare. It could be an image that comes to mind about the trauma. Those are the reexperiencing symptoms.

References

National Center for PTSD. (n.d.). VA.gov | Veterans Affairs. https://www.ptsd.va.gov/

Then, for the avoidant symptoms, those are things where the person tries hard not to think or feel or remember things about the event. And so that may be emotional numbing. It may be a lack of willingness to go someplace that reminds them of the trauma or have conversations about the trauma.

References

National Center for PTSD. (n.d.). VA.gov | Veterans Affairs. https://www.ptsd.va.gov/

Negative changes to cognitions and mood are what they sound like. So, that could be depression, down mood, anxiety, negative thoughts about self, others, or the world. And then arousal symptoms, which are things like trouble sleeping, exaggerated startle response, things like that.

References

National Center for PTSD. (n.d.). VA.gov | Veterans Affairs. https://www.ptsd.va.gov/

And it’s really normal if somebody experiences a potentially traumatic event to have some combination of those symptoms in the immediate aftermath of the event. What we’re talking about when we’re talking about PTSD is having those symptoms in a way that leads to a significant disruption in life activities after more than 30 days.

References

National Center for PTSD. (n.d.). VA.gov | Veterans Affairs. https://www.ptsd.va.gov/

So, what are the types of traumatic stressors or potentially traumatic events—as I call them—that can lead to PTSD? Well, it’s a whole variety of things. It could be being in warfare or combat. It could be a basic motor vehicle accident. It could be something that was experienced in childhood, like child abuse, whether physical abuse or sexual abuse…

References

King, L. A., King, D. W., Fairbank, J. A., Keane, T. M., & Adams, G. A. (1998). Resilience-recovery factors in post-traumatic stress disorder among female and male Vietnam veterans: Hardiness, postwar social support, and additional stressful life events. Journal of Personality and Social Psychology, 74(2), 420–434.

It could be natural disasters, floods, hurricanes, tornados. It could be sexual trauma or domestic violence or another kind of physical assault, basically anything where the person is experiencing an event that makes them fear for their own safety or bodily integrity.

References

King, L. A., King, D. W., Fairbank, J. A., Keane, T. M., & Adams, G. A. (1998). Resilience-recovery factors in post-traumatic stress disorder among female and male Vietnam veterans: Hardiness, postwar social support, and additional stressful life events. Journal of Personality and Social Psychology, 74(2), 420–434.

There are some risk factors that help us understand why it is that some people go on to develop long-term problems and some people don’t. One of those is the severity of the traumatic event. How long did it go on? How violent was the experience? Another thing that we know can affect the response is whether or not the person had social support after the event. If the person is not in a supportive environment and does not receive social support after experiencing the trauma, that can lead to longer-term problems, additional life stressors. So, if the person, goes through a natural disaster and then has no money and loses their home and loses their job, those additional life stressors all add up, as do other adverse childhood events.

*References *

Brewin C. R. (2001). A cognitive neuroscience account of posttraumatic stress disorder and its treatment. Behaviour Research and Therapy, 39(4), 373–393.
National Center for PTSD. (n.d.). VA.gov | Veterans Affairs. https://www.ptsd.va.gov/

So, in addition to the index trauma, if the person has a number of other negative childhood events, that can contribute to longer-term problems.
Also, lower socioeconomic status, education, and then just in general prior traumatic exposure. So, the number of traumas that someone is exposed to over their lifetime does tend to have a cumulative effect. And then gender also can be a risk factor. So, we know that although men are more likely to experience potentially traumatic events, women are more likely to go on to develop PTSD. And there are a number of reasons that may be the case both in terms of cultural expression of symptoms as well as, potentially, biology.

References

Brewin C. R. (2001). A cognitive neuroscience account of posttraumatic stress disorder and its treatment. Behaviour Research and Therapy, 39(4), 373–393.
National Center for PTSD. (n.d.). VA.gov | Veterans Affairs. https://www.ptsd.va.gov/

And so when we look at these posttraumatic problems in living from an ACT perspective, we’re not as interested in the diagnosis per se. We’re really interested in looking at the behavior in context. And when I say behavior in context, I mean both observable behaviors like whether the person is avoiding driving a car after being in a car accident, but also non-observable behaviors, things that we can only know by the self-report of the individual like intrusive images or trouble sleeping or, negative thoughts and worries. So, we’re interested in behavior at large, both what can be observed by someone else and what can only be observed by the individual.

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’re also interested in the function of behaviors, not the topography or how they look on the outside. For example, if somebody tells me that they’re exercising 6 times a week, that could mean multiple things. It could have the function of being a coping strategy. Oftentimes, we’ll tell people after they experience a potentially traumatic event that they should be trying really hard to maintain routines with sleeping, eating, exercising. It could be that somebody who’s exercising 6 times a week, that’s an effective and healthy coping strategy. On the other hand, it could be an avoidant strategy because the person has a history of interpersonal violence and a lot of shame around their body, so they exercise 6 times a week because they’re not willing to experience their body the way it is. So Again, we’re looking at the function of a behavior in context, not just how it looks on the outside.

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.

As I mentioned, we’re also interested in both distal and proximal variables. So, we’re interested in variables that may go back a long time, may go back to childhood, and understanding somebody’s family of origin or other experiences during childhood as well as the proximal variables about current social support. Is the person employed? Are they having financial stressors?

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 all of this is interconnected. It’s interconnected within the person’s sort of internal experience, you know, as a unique individual, in terms of their family system, in terms of their work environment, in terms of their culture. All of this is interconnected and so we have to look at these experiences on a very individual basis. Even if there are certain targets that we can look at to try to understand because the literature tells us they’re relevant for a number of people, we have to truly try to understand those things on an individual basis because it’s going to be different for every unique person.

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, the model upon which ACT, or acceptance and commitment therapy, is based: it’s a behavioral approach to treatment. It builds on the cognitive-behavioral models that have been in existence for several decades and we’re going to go into much more detail over the course of this course. But just to give a really simple overview, the model can be described as having 6 primary areas of focus.

Reference

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. Guilford Press.
The Association for Contextual Behavioral Science. (n.d.). https://contextualscience.org/

Acceptance, defusion, contact with the present moment, self as context, values, and committed action. And this is often represented with a 6-sided hexagon that has lines that connect all of those different processes together.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. Guilford Press.
The Association for Contextual Behavioral Science. (n.d.). https://contextualscience.org/

All of those processes, when we work on them together, are designed to move the person towards psychological flexibility. And that’s the ability for the person to be able to interact effectively in their environment—even in the presence of a variety of different internal and external experiences.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. Guilford Press.
The Association for Contextual Behavioral Science. (n.d.). https://contextualscience.org/

In successful ACT treatment, the therapist and client work together using these 6 processes for the purpose of enhancing psychological flexibility and improving the client’s life. And it’s important to note that although there are these 6 processes and they can be used flexibly and you can go back and forth between them, you don’t just sort of jump from 1 process to another based on your whim or what you feel like doing that day as a therapist. You have to start the work with a functional analysis.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. Guilford Press.
The Association for Contextual Behavioral Science. (n.d.). https://contextualscience.org/

Remember when I talked about looking at the function of behavior, not just the form of the behavior? So, we do a functional analysis to truly understand the function of the client’s current problems. We want to understand both the internal influences and the environmental influences on the client’s behavior…

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. Guilford Press.
The Association for Contextual Behavioral Science. (n.d.). https://contextualscience.org/

…and then understand how is that ineffective behavior being reinforced or strengthened in their current environment, how is effective behavior being punished or weakened, and how all of those things are currently working together in a way that the person’s life is not currently full of the things that he or she values. Because in ACT, it’s all based on that individual’s values and what is important to him or her.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. Guilford Press.
The Association for Contextual Behavioral Science. (n.d.). https://contextualscience.org/

So, from an ACT perspective, there are several potential processes that are probably candidates for contributing to a client’s ineffective behavior. And we use our awareness of those processes to generate hypotheses and guide the development of a fundamental case conceptualization and treatment plan that is individualized to that unique client.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. Guilford Press.
The Association for Contextual Behavioral Science. (n.d.). https://contextualscience.org/

So, the key points. First of all, the experience of a potentially traumatic event is common at some point during most people’s lives, including all of us participating in this course. Many people are affected in some way by the experience, but only a smaller number will develop posttraumatic stress disorder, or PTSD. And acceptance and commitment therapy is a behavioral psychotherapy approach that views an individual’s experience of trauma within their current and historical context.

More ACT for PTSD presentations