ACT Treatment for Trauma

By Sonja Batten, Ph.D.

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

Highlights

  • The traditional ACT model has specific nuances for how it’s applied when working with trauma survivors.
  • Each treatment plan must be individualized.
  • Homework facilitates the acquisition and application of ACT skills outside of the therapy room.

 

Transcript

I’m going to go into a little more detail introducing the ACT model of treatment with a focus on trauma. So, as I mentioned, there are several processes that we work on in ACT, regardless of what the presenting problem is.

References

Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (p. 241–269). Springer Science + Business Media.

First of all, acceptance. When we talk about acceptance as it relates to trauma, that can mean acceptance of current experiences, thoughts, feelings, memories, the current situation as well as acceptance of historical events. And acceptance is seen as the antidote to experiential avoidance.

References

Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (p. 241–269). Springer Science + Business Media.

We work on defusion, which is seen as the antidote to the cognitive fusion. So that means being able to take a step back from thoughts about self or others that may not be helpful anymore in the current context.

References

Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (p. 241–269). Springer Science + Business Media.

We work on contact with the present moment. So oftentimes, individuals who’ve experienced a trauma are focused excessively on the past—understandably because of what has happened to them—or worried about the future. And so we work on contact with the present moment, using things like mindfulness and finding ways to stay in the current moment as a way of taking a step away from the focus on the past or the future.

References

Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (p. 241–269). Springer Science + Business Media.

We also work on identifying the self as the context. So the self, some experience of the person’s own self, as a container for thoughts, feelings, memories, bodily sensations, etc.

References

Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (p. 241–269). Springer Science + Business Media.

You know, oftentimes, people who have been through traumatic events come to be defined by those traumas and it becomes part of their identity. And so what we work on doing is not taking those experiences away from the person in any way, but seeing that there’s a broader part of themselves that is the context for holding all of those experiences—but without being defined by them.

References

Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (p. 241–269). Springer Science + Business Media.

We also work on values. So, especially if somebody experienced trauma quite a while ago and they’ve gotten into that cycle where they’re, you know, sort of frequently moving away from things instead of moving toward things, they may have a lack of clarity about their own values and what’s important to them. And so there’s a lot of important work to be done around reclaiming one’s own values.

References

Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (p. 241–269). Springer Science + Business Media.

And often, there’s a connection to the pain of the trauma that helps provide some really important information about what is important to the individual.

References

Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (p. 241–269). Springer Science + Business Media.

Finally, the remaining work of therapy becomes focused on committed action. So, when somebody’s been stuck after a trauma, they may be in a cycle where there’s a lot of inaction or a lot of impulsive choices or avoidance. And so instead what we focus on is making and keeping commitments to actions that are in line with the person’s values. That may be around self-care. It may be around relationships. It could be really in any domain of life, but that’s focused on helping the person move forward, not just move away from their trauma.

References

Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (p. 241–269). Springer Science + Business Media.

And so when we think about structuring trauma treatment, within ACT, there’s no set number of sessions. It really depends on the individual, the severity of their symptoms, how long they’ve been having these problems, the level of comorbidity.

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 we really start with an ACT-based informed consent. And what does that mean? It means not just the regular informed consent, which you would still do around privacy, confidentiality, etc., but also talking a little bit about what makes ACT different from other treatments. And part of that is that the goal of ACT is not necessarily for symptoms to go down, but for your life to improve. And so that means that what we’ll be doing together may sometimes be frustrating because it wouldn’t be as focused on immediate relief because instead there’s perhaps some harder work to do about moving life forward, not just about feeling better in the moment.

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.

You may choose to begin each session with a mindfulness exercise. As I mentioned, there is that attention to focusing on the present moment. And so starting the session with a mindfulness exercise can be really useful—not just for the client but also for the therapist. We’re often running from session to session and so starting with a brief mindfulness can be centering for both people.

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.

With trauma survivors, especially for those who have had an interpersonal violence experience, I generally don’t start with breathing exercises. I generally don’t start with closed eyes mindfulness exercises or even body-focused awareness exercises to start with because they can end up being triggering. So, you may not ever choose to do those with trauma survivors. Or if you do, you would want to make sure that you’ve worked on other coping skills with the individual first.

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 then I also want to point out, just in terms of structuring ACT-based treatment for trauma, that homework or between-session work is really important. You know, we’re really upfront with the client about the fact that whatever we do here in these 50 minutes or this hour can only go so far. What’s going to be more important is in fact what you do between sessions.

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 one way of thinking about structuring that homework process for maximizing that between-session improvement. And again, you don’t have to use the word “homework.” Sometimes, just that word is triggering for some people if they had a bad experience with school. So, you can talk about it in terms of practice or between-session commitments or whatever word you and the client want to use. I’m just using homework for the sake of describing the process here.

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, structuring that, you can even break it down into these steps. So first, the client and the therapist collaboratively identify behavioral targets to be met by the client before the next session or within a specific time period. And then the client and the therapist work together to identify potential barriers to committed action that are likely to arise and could get in the way of accomplishing the target behavior. And they develop strategies to address those behaviors in the service of successful committed action. The client makes a commitment to follow through with the identified behavioral targets. I often recommend writing them down together so that it’s clear what that commitment is.

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 client, in between sessions, either does or doesn’t follow through with the planned behaviors. Really, from an ACT perspective, it doesn’t really matter if the person does or doesn’t follow through because you’re going to gain information either way.

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 the next session, the therapist follows up to determine whether the client successfully accomplished the homework assignment. And if the client followed through, great. Then the therapist works to help make sure that the client is aware and in contact with the natural contingencies of how that behavior turned out.
Or like I said, if the client didn’t follow through or only did so partially, that’s okay, too, because then the therapist helps the client assess what the barriers were and together they make a plan to overcome those barriers in the future. It’s all information. It’s all grist for the mill.

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, some key points. The traditional ACT model has specific nuances for how it is applied when working with trauma survivors. And although there are some specific suggestions for how to apply ACT for treatment of the sequelae of posttraumatic events, each treatment plan really has to be individualized. And homework—or whatever term you want to use—is frequently a component of ACT for trauma treatment in order to facilitate the acquisition and application of ACT skills outside of the therapy room.

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