ACT & MAORI MENTAL HEALTH
Associate Professor Te Kani Kingi
Associate Professor Te Kani Kingi began his talk by detailing some of the early impressions European explorers had of Maori people when they first came into contact. Maori were described as remarkably fit, strong, healthy and vibrant people. However in the following decades this changed rapidly due to land wars, being forced to move from ancestral lands, and introduced diseases. While the challenges facing Maori in terms of health have changed, they are still significant, and one of the most significant health threats is now mental health.
The current health challenges are due to many factors including socio-economic and lifestyle factors, and a loss of cultural patterns that initially led to good health and mental well-being. In terms of mental health, solutions may lay in part to better service provision. This includes appropriate welcoming, assessment and treatment. Cultural assessment is part of this to determine the level of specific cultural practice that should be integrated into the process for each individual.
Associate Professor Te Kani Kingi forwarded five principles for using ACT appropriately with Maori.
- Blending the model "without conflict or compromise"
- Tailoring the delivery to meet the needs of the individual
- "Expressing ACT in ways which make sense to Maori (e.g. the language used in assessment tools, explanations etc)
- Expanded methods - using ACT with other related treatments (e.g. Medication, nutrition etc)
- Using an outcomes based approach, and making sure that the outcome we think is good, is actually good for the person (e.g. Being able to live as an individual may not be the aim for Maori, or the fact that one may be considered, despite some health difficulties, if their whanau relationships are harmonious)
TRAUMA FOCUSED ACT
Caroline Burrows
In this presentation Caroline Burrows outlined TACT, a 10 week manualised group for adult survivors of sexual assault with PTSD symptoms. Each of the 10 sessions were 3.5 hours long. The intervention included psycho-educational and experiential components, and home based practice between sessions, and integrated ACT with trauma research and clinical practice. It does not involve individual disclosure, and clients are involved in individual therapy while doing the group. Caroline stated there is very little research about ACT in this area, and that to her knowledge this is the first ACT based group for this population.
Measures included the MAAS, DASS 21, AAQ-II, and measures of trauma and dissociation. There were also qualitative questions. There were 27 initial participants, no control group, and three measurement points - pre (27), post (24), and follow up (7). Preliminary findings indicate reduction in PTSD and stress symptoms, and increased psychological flexibility.
DERIVED RELATIONS & THE SLOT MACHINE NEAR WIN EFFECT
Dr Anne Macaskill
Here Dr Anne Macaskill detailed an experiment using a relational frame intervention to help change gamblers beliefs about near wins. After the intervention participants began to believe, more accurately, that near wins were not actually near wins, but losses. To put this another way, more could understand that getting 4 out of 5 on the slot machine was not a near win, it was just another loss.
HOW DOES MINDFULNESS AFFECT THE WORDS WE USE?
Judy Pickard
In this presentation Judy Pickard detailed part of her PhD research looking at the relationships between word use, attachment style and mindfulness.
Internal working models can increase bias. Change in our working models requires new experiences, and the ability to be present to these experiences.
Language use has been associated with physical and mental health. In clinical practice we should consider attachment working models as they can influence therapeutic progress. One way to notice this may be through a clients specific word use and phrasing. For example, previous research has shown those with a more dismissive attachment style may have a short narrative about childhood. They may initially say "Our family was all good", then later reveal a history of abuse. They are also less likely to use feeling words, and more likely to say "l can't remember" and "I don't know" etc.
Judy outlined her research using Linguistic Inquiry Word Count (LIWC) to analyse the word use of participants. Participants were interviewed about their parents and upbringing, and the interview were then transcribed. She found mindfulness and secure attachment were associated, and those higher in mindfulness used more sensory and body based words. There was also a negative correlation between mindfulness and use of the word "I" (-.242*). There were many other interesting correlations, but I didn't have time to record it all sorry folks!
ACT TRAINING VIDEOS UNDER THE ANALYTIC MICROSCOPE
Ben Sedley & Associate Professor Anne Weatherall
Here the presenters detailed their study, which sought to understand more about how ACT was done in practice. They used therapy videos from the DVD linked to the book "Learning ACT". Using conversation analysis, they looked at micro level interactions.
They found that ACT therapists included many directives (requests for action) in their work with clients. For example, a therapist might direct a client to repeat a statement they made about an emotion slowly, and then direct them to stay with the emotion. Requests began with phrasing such as "Can I ask.. Could you......" etc. Researchers found that the first time the therapist is directive about a certain point, the wording was more open and inquisitive. Later it became more clearly directive.
COMPASSION FOCUSED ACT
Dr Maria-Elena Lukeides
Compassion focussed therapy, CFT, was developed by Paul Gilbert to help people suffering from shame and a sense of unworthiness. Shame, unworthiness and self-criticism occur across diagnoses, and are often high in depression and anxiety. He felt self-compassion was the best way to heal such deep wounds.
Dr Lukeides presented compassion not as passive, but like a being a fierce caring parent that can "activate the soothing system" of their child. She spoke of compassion and self- compassion having two parts:
- Engagement
- Alleviation
She then linked these two elements to the ACT hexaflex. The ACT hexaflex skills help behavioural flexibility in the face of distress, and can help increase self-compassion.
Compassion involves knowing that we have different selves, and that "How we are is not who we are". Bad things do not happen to people because of who they are, as "Context matters". Factors beyond people's control occur, and those experiences shape who we think we are. As children we struggle to see the wider context we are a part of, so many of our explanations come back on to ourselves, leading to self-blame.
In terms of intervention, Dr Lukeides encouraged talking to clients about a situation where a child is being scolded by a parent or harassed bully. We then ask the client how they feel about that, and what would they want to do. After this, we can then ask how often the client berates themselves in such ways. Then instead, can they they act in a fierce, self-compassionate way toward themselves? We can help by coaching them to use mindful awareness, focus on feelings in the body, breathe, and bring compassion to the emotion, and their experience overall, including the part that is self-critical.
Bring compassion into the work around the hexaflex. If a client is very sad - ask what they need from us as therapists at that moment. Then how can they also give that to themselves? What could they say? Work with people on the tone of voice, facial expression, and body movements of compassion to self.
Dr Lukeides also highlighted the need for us to bring self compassion to ourselves as clinicians. This will then in turn help our flexible wisdom, and we will get better at being flexible and doing what is needed at any given moment in therapy. Overall therapy should be a compassionate place, that applies compassion in varied and appropriate ways as needed.
It is also important to bring self compassion to the parts of us that are not compassionate. Knowing that those harsh parts are trying to help, just in a different, and often less effective way. Flexibility and self-compassion are fundamentally important parts of successful therapy and mental well-being in general, and compassion accounts for more variance than mindfulness alone.
FATIGUE BUSTER
Mary Sawyer
This presentation was also related to compassion, but this time it was more about the clinician developing their own self care. Caregivers need self care. We feel compassion in our body working with people. How do we process this? How do we ensure we do not suffer from compassion fatigue?
After drawing our circles (see the example above), we did a group exercise where we got into three groups. One was the inner critic, while another group got criticised, and the third group watched as the observer. This process helped to see the way the critic plays out in our heads, the impact it can have, and how we could not be as critical to someone else as we are to ourselves.
Mary advocates caring for ourselves as we would for someone we love, through:
- Thoughts and behaviours
- Nutrition
- Exercise
- Being warm, and using gentle touch and a gentle voice (can increase oxytocin and opioids)
- Sleep
- Asking how do we treat ourselves at the start of the day? Before and after sessions? At the end of the day before leaving the office? In the evening?
THE FUTURE OF CBS
Professor Steven Hayes
Behaviourism must tackle the issues of language and cognition. This is the origin of cognitive behavioural science. Professor Hayes stated he and others spent time ensuring the underlying philosophy was sound, and refined radical behaviourism into functional contextualism. There were many people working together from different fields, helping to develop the principles and model over many years. Now there are 154 RCTS on ACT, and 2000 publications overall.
In this keynote address, Professor Hayes outlined 13 future steps for cognitive behavioural science:
- Moving from treatment protocols for syndromes, to process oriented ACT. While a new clinician may need protocols, over time one must move to process oriented work, and overall CBS should go more in this direction.
- Put RFT to broader use. For example in language development and prosocial influence (e.g. reducing objectification and dehumanisation) to help the world in a wider way.
- Scale the concept of psychological flexibility. Take it out to couples, families, towns etc.
- Sorry folks, I missed this one!!
- Nest CBS inside evolutionary science. 8 weeks of meditation alters our genes, as does therapy. CBS and cultural evolutionists need to join together.
- Address what people care about, not just mental health.
- Go to the gate keepers - training centres, schools, churches etc. For example, Chaplains in US military are being trained in motivational interviewing and ACT.
- Help where it is expensive - non effective psychology, health care etc. Professor Hayes talked here about a study of 6 follow up ACT phone calls after colorectal cancer surgery had a major impact on medicine adherence and quality of life.
- Build our own methods, outlets, and standards.
- Build bridges. With all health professions, and beyond.
- Technology and training. There can never be enough therapists. We need to develop things and give them away. One example was a study where an ACT website helped people to stop smoking, and a phone line helped even more. He showed other evidence of online interventions for PTSD.
- Take it to the streets. To the poor, to minorities, to the forgotten. Train the trainers by helping people working with these groups also. For example, people have used ACT in work with Ebola ravaged villages. They helped by coming to an understanding of the values of the group, then working with communities to develop their own new rituals to prevent infection. The Bo district (with this ACT group training) had the lowest infection rates of all districts.
- Speak to the culture world wide. Use blogs and videos and put it out there and help.
What stood out for me in this talk was professor Hayes willingness to question EVERYTHING, including language, psychometrics, the DSM, and current systems in the world. Another stand out was the focus on sharing, not ownership. The focus on serving, not just in the clinic, but on a broad scale, based on a set of scientific principles.
ACT FOR REVOLUTION
While suffering is a normal part of life, there are many forces that make it worse. One example being that marketing brings up the "I'm not good enough" story. There are so many issues in our world, and this talk was not just about humans. With climate change, government corruption, corporate domination, wars and famines our world is in serious danger. Therapy can be very self focused. We need to move beyond to the human condition. The "living condition" must take account of the whole world including animals, plants, the ocean, the air, and humans.
Language use influences our emotional responses and views - e.g. "Asylum seekers" - promotes an us vs. them mentality. We need to see and name the story being told to us, and defuse from cultural narratives such as nationalism, as often such narratives do not help world peace etc. And we must be aware of experiential avoidance.
Individual psychotherapy will be gone in the face of climate change issues if we don't act. We need to become ACTivists, using the knowledge and skills with ourselves, our clients, and taking action in the wider world.
As humans we can be so adaptable, and this is good. BUT avoidance and adaptation means we adapt to problems we should not adapt to including pollution, climate change, and political corruption. In short, active pro-social work is essential.
As one example of how groups can make a difference, 'Idle No More' is a movement of indigenous people in Canada. It stands on a spiritual foundation, and is values based from a collective cultural standpoint. They frame their women as warriors and have the hash tag #warriorup. Such movements are making a difference, for example helping to stop the Keystone XL pipeline.
We need to focus more on our collective values. Not just our individual values. In our work we can focus on people's wider community values, and discuss how to act on these, including such actions as volunteering.
In our wider work in the world, if working with communities, we can focus on Co-Design = Starting from the beginning with a community, identifying the problem together, and facilitating community problem solving.
THE IMPORTANCE OF BODY BASED INTERVENTIONS IN ACT
Professor Steven Hayes, Dr Bakjinder K. Sahdra, Professor Joseph Ciarrochi, Dr Louise Hayes, & Dr Paul Atkins
Here the panel discussed how we are "more than talking heads", and the importance of body focused work in therapy. Children start with movement as the way of learning. We must focus on more than just cognitions, as the body plays a vital role in well being.
Professor Hayes talked about this being part of the reason why we need to link to evolutionary psychology, and why we must we ask about sleep, nutrition, and exercise. He increasingly talks about embodying our cognitive state, asking clients to "Show me your body when your state is at its worst, and then at its best". One will represent being flexible, the other will represent being non-flexible. The body and cognitions are interrelated. People can show us physically what they may not be able to tell us.
We can use metaphors that speak to how the body is and its impact on us - "It's easy to be mindful when the horse we are on is calm, but when the horse is going crazy it is less easy".
There was a question between the panel about whether it is possible to have a purely physical intervention. This seemed to relate to an overarching debate about whether or not RFT itself favours cognition excessively. It appeared that overall, most physical work has a language component, at least to some degree. For example yoga includes instruction. Yoga teachers can use ACT based languaging to help - with perspective, acceptance etc. Further to this, research shows our verbal understanding of why we are doing any kind of physical activity, and the impact the think it may have on us, can change the effect it has on our body. One example was that of hotel cleaners who were told that hotel cleaning was the best exercise there is. This understanding drastically improved their blood markers, including lipids etc.
Professor Hayes recommends that when teaching people physical exercises, do an addition agenda. For example, when working with relaxation skills, instead of trying to take away tension, add the ability to let go and allow the body to be how it is. Instead of doing distraction, say "ADDtraction" - adding attention to something else. In short, use ACT principles in the body work we do - here this means not focusing on reducing symptoms.
There is a growing body of research on sport and ACT, including highly competitive cross fit participants and Olympians. This research shows that ACT can help performance. The data on ACT for pain is better than other interventions and is solid. When working with pain, use experiential exercises. Add other focal points to the pain, rather than trying to take away pain. However, in saying this, research shows that even ACT which focuses on pain reduction still reduces pain.
We should use the body in therapy to enhance experiential learning. You can take all kinds of cognitive based work and make it more physical. One example may be acting out metaphors, or walking during therapy and allowing clients to flexibly make decisions about the direction taken. ACT is not all about talking. Draw, move, change posture, act out avoidance etc. When it comes to body based interventions, any physical activity can be used, if based on ACT principles.
LIVING LIFE FROM THE FEET UP: Creating well-being in the larger context of earth, animal, and humans
Dr Robyn Walser
"Whatever you think, it's worse than you think"
Dr Walser spoke about the planet and its current state. She talked about there being much ignorance about what is going on, and the relationships between things (cause and effect). Recently someone swam over the North Pole - and it was the first time had ever been possible. Many of us are avoiding the environmental crisis, and she showed slides to expose the many issues we face, and the ways this is impacting those who are less fortunate.
The Pope has written a radical message about climate change. The Dalai Lama backed up his calls. And yet mass action has not ensued. Denial is not workable in the long term. This is a moral issue. What is our collective responsibility? Will we take it? In the face of he current planetary challenges we must care with our feet and take action.
This relates to the ACT community as we talk about flexibility. Seeing the situational demands and adapting in a way that actively helps, rather than simply adapting to things getting worse and worse. We can use skills of perspective taking (for animals, future generations etc) to help fuel actions in line with deeply held values. Overall, at this time in history, extreme flexibility and prosocial behaviour is needed. To encourage this we can begin to include social and environmental values and actions in our measures and models.
ACT WITH UNIVERISTY STUDENTS
Dr Jacqueline Pistorelli
Before this presentation began Dr Pistorelli talked us through an experiential exercise where we thought back to our time at university. We recalled our feelings, what was was important to us, and asked 'how did we hide?' Many people reported feeling excited, that social connection was important, and hiding at times through drugs, alcohol, socialising or video games. One current student spoke of fellow students hiding in their phones.
Being a student at university is a unique developmental period with various pressures. We discussed the many stressors students face, and how international students face even greater strain than domestic students. Dr Pistorelli cited her own research of 1000 students that found 25% met diagnostic criteria for a mental health diagnosis. Studies show mental health declines from the start to the end of first year of university.
ACT is a good approach with this population as they are in their head so much, and it can help in part by teaching them ways of being less in this state. Mindfulness can assist with the level of distraction students currently face.
In a study of 3000 students who completed the 7 item AAQ (acceptance and action questionnaire) before starting university, Dr Pistolrelli and colleagues found that pre-existing psychological flexibility was associated with earlier graduation. Another study has found values training increased student GPA. In an Australian study mentioned by an Australian attendee, high AAQ was associated with higher grades.
The research detailed here was a preventative education intervention with a sample of more that 500 first year students. A significant grant that allowed researchers to pay to run a student course that went toward their course credits. They embedded the intervention into a first year experience class. There was a control group class (more didactic and less experiential), and an ACT group class taught by graduate students using the book 'Get of Your Mind and Into Your Life'. The course ran for 8 x 2 hour classes, included videos, and attempted to be fun and interactive.
Findings suggested the intervention was acceptable to students. More distressed students liked ACT the stream better than students who were less distressed. However, as a prophylactic intervention, it was not found to have the intended preventative impact. There was some increase on the AAQ-II after intervention, but not by much. There was some discussion that people may have to need ACT before it can work for them.
PROSOCIAL: The science of working better together
Dr Paul Atkins
ProSocial is an approach formed from The Evolution Institute. It is based on the work of Elinor Ostrom who won a noble prize for identifying 8 principles that have helped groups throughout history evolve and sustain themselves successfully. The principles relate to the concept of the tragedy of the commons, and how groups in history have prevented themselves from falling victim to common pool resource dilemmas. Elinor Ostrom also identified 4 things that disrupt a functioning system - migration in and out of the system, when external helpers don't consult the group, when there is corruption, and when the group seeks outside help excessively.
Groups that co-operate are more likely to survive. A huge percent of human interaction is prosocial, however this is not always the case. When working with groups, we can use the 8 principles, and use the ACT hexaflex alongside them.
Dr Atkins detailed an illustrative study, where egg laying chickens were selected for groups based on individual performance vs. selecting an entire group for their overall performance. The group made up of the most successful individuals, six generations later, were more prone to hurting each other, and were less productive in terms of laying eggs.
Leaders can use the 8 principle to guide thinking and decisions, and groups can use the principles to asses where they are at, and how they can become stronger. ProSocial facilitators work with business teams, and top Australian athletes have been taught this approach after their trainers wanted them to make wiser choices.
The first three principles are about building cooperation, the next three are about managing excessive individualism, and the last two relate to how the group relates to other groups.
So, how do we work with the 8 principles when we are working with a group? To begin with, and to ensure the first principle is well throughout (which is essential), individuals should complete The Choice Point or Matrix models.
The choice point maps on to the 6 parts of the hexaflex. Mindfulness links to being in the centre of the choice point. Practice mindfulness with people to help strengthen this. When using the choice point, start with the long term specific goals / actions they want to take / achieve. Then, move backward to values that relate to these actions. Then brainstorm the away from actions, and move to what underlies these actions. Pull out the values that relate to both toward and away from behaviours.
When working with a group, do individual choice point exercises, then move onto a group based choice point exercise.
What does the group want long term? What are the related values? What are the behaviours we choose instead that are away from? What are the internal barriers / experiences that underlie and drive these behaviours? And what are the values that drive that?
The presenters today stated some pre training may be needed for groups to do this well together, for example discussions about how to have hard conversations also. Often they give material a month beforehand, seek informed consent, and make a group agreements so people know what they are getting into and there are agreed upon guidelines.
After the individual and group choice point exercises, begin working through the 8 principles. This can start with each person rating their group on each of the 8 spokes. This process will then stimulate discussion, and from there the group can begin to make an action. ACT principles can support this whole process, and the action planning phase.
ProSocial facilitators do measures with groups pre and post intervention. Measures include psychological flexibility (AAQ), empathy and group identity.
Go to www.prosocialgroups.org where there is an online course that outlines the process detailed above.
THANKS!!!
I would like to say a huge thank you to all the people who made this conference possible. I had a great time meeting new people and learning. All the best until next time.
Dr. Daniel Farrant
Clinical Psychologist
University Health and Counselling Service, The University of Auckland
d.farrant@auckland.ac.nz
