Hello and welcome, I'm Shereen Khan, Senior Director of Workforce and Organizational Development at Thresholds, Illinois' oldest and largest provider of community mental health services and social work expert for SMI Advisor. I am pleased that you are joining us for today's SMI Advisor webinar, Introduction to Acceptance and Commitment Therapy for Serious Mental Illness. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Now I'd like to introduce you to the faculty for today's webinar, Dr. Jennifer Patterson. Dr. Patterson has a mission to offer evidence-based psychotherapy to help others live full and abundant lives. She is the founder of JPI Psychological Solutions in Mokena, Illinois, and specializes in treating obsessive-compulsive behaviors, anxiety, and depression. At JPI, she uses acceptance and commitment therapy and other third-wave models to assist clients with increasing quality of life. Dr. Patterson is an ACT, acceptance and commitment therapy is also known as ACT trainer, and has led over 500 ACT workshops across the U.S. and internationally. She has served as vice president of the Chicago chapter for the Association for Contextual Behavioral Sciences. Dr. Patterson was a featured psychologist on the learning channel TLC and former co-author for Psychology Today's blog, When More Isn't Enough. Dr. Patterson received both her master's and doctoral degrees from the Illinois School of Professional Psychology. She is a formally trained ACT clinician and is very skilled in mindful-based therapies and empirically supported treatments. Dr. Patterson, thank you so much for leading today's webinar. Thank you so much, Shireen, and welcome. Just a quick disclosure, I have no financial relationships or commercial interests or conflict of interest to report. So we are going to get right into the learning objectives for today. So we're going to be looking at serious mental illness, but not just serious mental illness as a whole, which can include schizophrenia, schizoaffective, bipolar, TBI, trauma. But primarily we're going to be focusing on the symptoms of psychosis, which is the primary symptom that shows up in, you know, what are all of these serious mental illnesses. So for the learning objectives, I'm going to be able to summarize the current state of evidence for ACT treatment with psychosis. I'm also going to describe how to utilize acceptance approaches with avoidant problems to strengthen a client's ability to cope with their distressing experiences and give a few demonstrations of clinical techniques for increasing psychological flexibility. So if you're brand new to acceptance and commitment therapy, I also like to say that it is pronounced as one word, ACT and not A-C-T, but that ACT is not just short for acceptance and commitment therapy. The ACT acronym also nicely captures the three core steps or themes of this approach. So one of the things that we want to think about when we think about that word accept, what does that mean? So now we're not suggesting that an individual who is experiencing symptoms related to psychosis that they have to like it or want it, obviously they don't, but acceptance means that they're willing to lean into it and notice their discomforting experience in a more open and mindful accepting way. So acceptance from the ACT model doesn't mean one has to like or want it. It just means that I'm willing to have what is showing up here and now. We're also going to talk about how we're going to help clients choose directions for their lives by identifying and focusing on values. Values is a very large piece to the ACT model. It's really what promotes willingness for behavior modification, willingness for individuals to look at, well, how can I cope with these symptoms and assisting clients in taking steps toward action that are in line with their values. So what is ACT? We want to think about ACT as a form of third wave experiential behavioral psychotherapy. What does that mean? Well, you want to think about the first wave as Pavlov and Watson, classical conditioning. The second wave, you want to think about it as being more of the cognitive revolution, thinking about Al Ellis or Aaron Beck. The third wave, which also encompasses dialectical behavioral therapy, functional analytic psychotherapy, any of the mindfulness-based cognitive therapies. So about 30 years ago, ACT came onto the scene. It's only been widely disseminated in mainstream psychology within the last 15 to 20 years. But 30 years ago was the first randomized control trial that was done utilizing ACT for pain. Now, this form of third wave behavioral psychotherapy focuses primarily on acceptance and willingness to have. That's why the first lever of A is acceptance. How is this different from the second wave? If you are trained in more of a CBT second wave education, CBT typically emphasizes the direct challenging of thoughts. So if somebody has a thought, I am an idiot, I'm a loser, I am sick, as an ACT clinician, we don't want to ask whether there's evidence for or against that thought. And we certainly don't want to try to restructure the thought. This is where ACT is slightly different from the second wave approach. Instead, we want to help clients to see their thoughts simply as thoughts and that no response is ever truly required. We want to help clients learn to change their relationship with their thoughts and with their private internal experiences, rather than trying to focus on getting rid of the thoughts or diminishing the thoughts or changing the content of the thoughts. Because over the last 30 years, we found that getting involved in that kind of elimination agenda creates more suffering for individuals. So ACT is very experiential. It's not just talking with our clients, it's actually having them embrace the art and science of engaging in different experiential exercises to help clients on all different levels of severity of mental illness, and also on a difference in terms of the spectrum and of intellectual functioning. So we want to engage clients in the process of acceptance and commitment therapy, and we use that via metaphors, analogies, experiential exercises. Why we use metaphors in ACT is to firstly disrupt, unravel, and deliteralize the verbal content that our beliefs and self-talk is present with. So we're going to use a lot of metaphors. I'm going to show you in a little bit how that's done. In doing so, what research has taught us is that when people can get out of their minds and into their lives, that they're no longer struggling with the things that they can no longer control. What they're doing is they're focusing on overt behavior, behavior in life context. And from that perspective, ACT focuses on the individual's behavior and the context in which it occurs. What we mean by that, behavior is not seen as right nor wrong. It's seen as healthy or unhealthy, or in ACT terms, successful or unsuccessful. So the question becomes, what is workability? And that's a fundamental question that ACT therapists are consistently thinking about. Is this client's behavior working for them? Is it working for them in this context? And what does workability mean for this particular client? And that always comes down to a person's values and desired outcome. So that's probably one of the main points I would like you to take away from this slide, that successful working of an individual's behavior according to their values is really what we're looking at as an outcome goal from the ACT model. So psychological pain from this perspective is seen as normal. ACT emphasizes the acceptance of psychological experience and contextual experiences as not being right or wrong, but as, is this healthy in this context? So for example, somebody is going through the grief process because they've just lost a significant person in their lives, or they've lost a beloved pet, or there's some financial setback or some health crisis. Is it abnormal for people to be anxious, to be afraid, to cry, to be sad, to be hurt? Absolutely not. So this becomes a foundation for when we look at how people treat their internal pain. Most people are programmed to want to escape it, avoid it, make it go away, especially when we're talking about individuals that deal with psychosis, because it is scary, because it is painful, because it is disruptive. But how many times have you worked with individuals in this elimination agenda, trying to get rid of their own experience, whether it be a symptom related to their serious mental health or not, right? That that doesn't work long term, it may work in the short term, and that's where we find people hammering down drugs and alcohol, spending hours on end in front of video games, going to the refrigerator and eating everything that's in it, sleeping for 24 to 48 hours. But that's how people tend to try to get rid of things that they cannot. So Eric is not afraid to examine the question, why is this hard? Why is this hard for me to accept what is happening to myself? And if I choose to change the relationship I'm having with my own experience, what does that mean for me? Act does not view these questions as vague, Act does not dismiss them. As a matter of fact, the Act community embraces the experiential, spiritual, and paradoxical elements that other clinical traditions have long forgotten about. So the idea here is, maybe we can turn away from the elimination agenda, maybe we can turn toward our own personal pain and suffering and see it in a different way. See it as not necessarily that I'm crazy, or I'm abnormal, or there's something seriously wrong with me, or I'm broken, right? You've probably heard that countless times from your clients. What's the point? I'm not normal. We're shifting that paradigm, we're looking at, yes, you are experiencing your symptoms, your symptoms can be frightening, but they are actually separate than who you are as an entire person. And so by moving clients in the direction of accepting inevitable pain that shows up will help reduce their suffering, because suffering comes from repeated attempts to get rid of things that we cannot control. So the current state of the Act evidence. As of February 2021, there are approximately 447 randomized control trials of Act published. These are Act for pain management, Act for psychosis, Act for depression, for stress management, for anxiety, for OCD, for weight loss, for substance abuse, and the list goes on. So I invite you, after this short seminar, if you're interested, each of the studies along with the details of them can be found at the following link. We've also reached a new milestone. As of February 2021, Act is now part of more than 150 meta-analyses and systematic reviews. And Act alone was shown, and the core processes of the Act were shown, to increase what is known as psychological flexibility. In other words, increase quality of life. According to the American Psychological Association, the best research supported psychological treatments that are considered evidence-based, Act is on that list. And psychosis, in particular, is shown to have modest research support. So again, for today's seminar, we're going to be focusing on psychosis. There are a total of six randomized control trials that have evaluated the efficacy of Act with people with psychosis. The initial randomized control trial focused on inpatient readmission rates, and RCTs involving outpatients have focused on either depression following psychosis or ongoing positive symptoms. The findings of these trials indicate that Act and the Act approaches can help reduce the impact of psychotic symptoms, but particularly in the process of reducing believability. And this can have an enormous impact on emotional functioning. So one of the earlier Act for psychosis randomized control trials examined the impact of acceptance-based treatment that teaches patients to accept, to move toward, to lean in unavoidable private events and to identify and focus on actions toward valued goals rather than focusing on what's happening in the internal world. And the ability to do that is via the use of something known as diffusion, diffusion techniques. And that is the ability for somebody to learn how to look at their thoughts rather than looking from their thoughts. So when clients can start to notice their thoughts that can diffuse from other unhelpful cognitions and look at thoughts rather than treating them as either the full truth or they're false, just noticing them. 80 patients, inpatient participants with positive psychotic symptoms were randomly assigned to treatment as usual or to four sessions of Act plus treatment as usual. Compared with a treatment as usual control group, participants in the Act group had half the rate of rehospitalization over a follow-up period of four months. Now, whilst the Act participants did show initially a higher reporting of symptoms, what's interesting about this is they reported and rated them as less believable. And that's primarily looking at this process of mindful diffusion. A previous report explored the impact of brief four-session Act and looking at interventions such as mindfulness, acceptance, and diffusion. The presence that extended that to a follow-up period of one year and a sample, again, of 80 inpatients with psychosis, those in the Act condition showed reduced hospitalizations, again, after a follow-up period of one year. Two previously published randomized trials of Act for symptoms of psychosis have found evidence for decreased believability of symptoms and a decreased hospitalization. So, if you're noting that there is a correlation between decreased believability and rehospitalization, among other types of outcomes, and using the combined data set from these trials, the impact of Act on the mediating role of symptom believability were examined and been shown to be highly effective. This present study explored the active therapeutic processes of Act and understanding of therapy as reported by individuals experiencing psychosis. This study investigated the Act processes of mindfulness, diffusion, acceptance, and values. And from individuals, a client's perspective, they were found to improve an understanding and values, increasing meaning of life, and reduction of struggling with depressive, or excuse me, distressing associated symptoms. So, if we put this all together, not just the follow-up of rehospitalization has decreased, but individuals now are reporting that they are more able to focus on life-enhancing thoughts, things that are important to them, values, and are taking steps toward committed action, engaging in those values, you know, while having, you know, passive psychosis symptoms, being able to notice them, being able to diffuse from them, and being able to move forward in the things that they care about. So, this current study shows that Act may be feasible and acceptable for inpatients, that psychotic disorders for intensive care setting should be tested for future effectiveness and implementation in continuation of trials. A randomized controlled trial of acceptance and commitment for psychosis. This is a trial that has looked at creating the study protocol. If successful, this will be the most definitive trial to date for Act for people living with psychosis. So, this protocol is developed by a group of researchers, not only to identify problems arising from conducting RCTs with psychosis, but also to report the results yielded by research. So, looking at the processes of the Act model, but not just that, looking at how the previous RCTs have been applied for ACT with psychosis. So that's increasing the empirical support that ACT is showing to be an evidence based treatment for the treatment of psychosis. So results from a 2018 systematic review of ACT for psychosis, it does appear to be a promising approach to the treatment of psychotic symptoms. And that it can help reduce rehospitalization rates, we saw that. And it can have an impact on psychological inflexibility of people experiencing psychosis. It has the potential to be considered an effective treatment, even in briefer forms, such as four sessions, as we saw, was the typical ACT protocol. Of course, there's always going to be limitations of research, right? So the limitations, larger randomized control trials are required to give this research area more robust evidence based. The ethnicity of participants is heavily skewed toward Caucasian. So for future research should seek to recruit more ethically diverse populations. And evidence on sustainable change and its underlying mechanisms in the individual's daily lives remains limited. And today, there's no evidence for ACT in the use of acute florid hallucinations. So the ACT stance on disorders, it's usually based on the notion that control and elimination of pain is not possible. If you think about the individuals that you've worked with, the clients that you've worked with over the years, right? Is it possible for them to eliminate their private painful experiences, especially when we're talking about the symptoms of psychosis? And, you know, what have they done to try to get rid of that? What had landed them in rehospitalizations? The attempts to get rid of painful private experiences is seen as the underpinning of severe chronic mental health issues. It's not painful thoughts and emotions themselves that are necessarily causing the problem. It's what people are doing. What control strategies are your clients, your patients engaging in that are not working and exacerbating the symptoms of psychosis? Likely hammering down drugs, alcohol, right? Perhaps sleeping, perhaps disengaging, perhaps not following post-treatment plans. So when these control agendas do not work, right, and in fact, they make the pain worse, the cycle begins a cycle of suffering. I don't like what I have. I don't like what I'm experiencing. And then there's an evaluation of that if an individual is experiencing hallucinations and delusions. And then on top of that, they're evaluating their own experience. I'm crazy. I'm sick. I can't hold down a job because I'm a schizophrenic. If they're experiencing those, you know, symptoms, and they're evaluating them, you can imagine that yes, there's a repertoire of elimination and eliminative behaviors that are going to be thus that creates more suffering. The ACT model posits that people who are distressed and disabled by psychotic symptoms are likely to be living in aversive escape-based contexts for their behavior. It is theorized that these contexts are largely verbally regulated. And what we mean by that is thought loops, right? We have the experience, we have individuals with the experience of psychosis, and then they're evaluating their experience. And it's typically in a very bullying, negative, punitive manner, where they're literally bullying their own experience. So of course, people are going to be pulled into doing what's known as experiential avoidant behavior, trying to get rid of, trying to control, trying to diminish, trying not to have their psychotic symptoms. So the ACT stands with distressing psychosis, right? We're going to focus on the impact of symptoms, not symptoms per se, that might be radically different, especially if you come from a medical program, or you come more from a second wave cognitive approach. What we're finding is that is not the solution, it may be a band-aid for a short amount of time, but even with medication, or medication resistant individuals, we still want to focus on symptom impact. How is this and what you're doing with your symptoms, creating more issues for you? So not necessarily symptoms per se. Exploring the effects of cognitive fusion and experiential avoidance, right? That's what we want to do. We want to notice what are you doing when you have these symptoms? How is what you're doing creating more suffering for you? So we want to look at the experience in the case of voices, or the feared outcomes of it, delusions, right? These are typically targets for avoidant behavior and control agendas. But we want to be asking the questions, how is that helping? Or how is that creating more of a problem? From this perspective, negative symptoms may be considered a possible outcome of chronic avoidance. We see that time and time again, in the research, not just with psychosis, not just with serious mental illness, with depression, with anxiety. Because again, oftentimes, the avoidant repertoire that individuals are using has something to do with the continuation of negative symptoms. So we want to emphasize an acceptance. And again, not an acceptance, because you like it or want it, but an acceptance because it is present. And this is your experience. And how can we learn to work with our experience in a different way that we've done in the past, rather than maybe something from a first or second wave approach would be disputation. Focusing on moving things forward. The X stance is that we're working with people in the here and now, we're working with them on assisting with how do we live your life with what is going on for you right here, right now. Oftentimes, and again, it's not with just with individuals that have serious mental illness. Right? It's with people that have depression, anxiety, or people that may not have a diagnosis at all. Right? I'll do X when I feel better. And usually X is something that is extremely important to the person. I'll find a job when I'm no longer sick. I'll reach out to loved ones when I'm no longer feeling horrible about myself. We want to move away because that's just feeding into an act inconsistent elimination agenda that we have to start living life after we get rid of what it is that we're experiencing in the here and now. So move focusing on moving things forward. So when we do this, what we're targeting is increasing the quality of life of individuals. Right? So what we do initially, when we start working with clients, right, we're more focused on how the symptoms are impacting, right, not how the symptoms are being shown on a intake form. And the reason why we're looking at that is we're trying to measure something known as psychological inflexibility. What does that mean? In the act definition, it means clients need to get rid of negative private experiences. This is best achieved by experiential avoidant behaviors. And experiential avoidant behaviors is the core problem most clients face. From the ACT lens, psychological problems and psychological inflexibility is due to a lack of behavioral flexibility due to a lack of behavioral effectiveness. Now from the ACT lens, regardless of the diagnosis, regardless of whether it's schizophrenia or schizoaffective or bipolar, ACT clinicians never view clients as broken. And in the areas of acceptance and diffusion, we always believe that every single human being regardless of that diagnostic label has the basic psychological resources in terms of making choice. Okay, of course, I'm, you know, not what's not included in here is other types of severe mental illness like catatonia, or if we're talking about intractable. But when we do have someone coming in, we do see them as a fully capable, non-broken, and when we mean capable, we mean capable in making choice. Now we understand that certain contexts are going to thwart clients abilities to move forward, right, or certain increases in intensity, acute presentations of psychosis. But what we're talking about here is that when a client walks in, whether it's into the hospital, into your private practice, into an emergency room facilitating, what we want to do is we want to see this person as being capable of making choice. Choice becomes a big word when we talk about the ACT model. So psychological flexibility is measured in terms of six core processes that are interconnected, and maintain psychological and flexible behaviors. So that is experiential avoidance, fusion, disconnection from values or what matters most, persistent inaction, impulsivity or avoidance, lost in a remembered past or imagined future, and lost in the story. So real quickly, I'll go around what is what does, you know, this mean, experiential avoidance, again, this is behaviorally and or internally. So overt or covert behavior, what are people doing to get rid of painful private experiences? What are they doing to get rid of the voices in their head? What are they doing to get rid of the strong beliefs that they are somehow non-human or that they're broken? What are they doing to get rid of their pain? And you're going to see this in both an internal and external way. What does the client fuse to? In other words, when a delusion shows up, or when voices show up, are they listening to them in such a way that there is a high level of believability? Now they have the thought, you are crazy, nobody loves you, you are sick, you should go kill yourself. The level of fusion, that means a higher level of believability, they're taking that thought literally. And then lost in the story. What that means is not only are they taking that thought in that particular moment as being literal, but they're also taking who they are as a broken person, literally. So it's not just the thoughts, it's I am a horribly sick psychotic person. That's why I can't live according to my values. So the persistent, excuse me, inaction, impulsivity or avoidance, that's just it. If you've got these kinds of cognitive thought processes going on, and they're believing them, of course, they're going to be inactive, impulsive or avoided. And this just pulls people further away from what they care about. And all of this is not necessarily happening because of things that are showing up in the here and now. Most often, you pay particular attention to what it is people are saying, it has to do with some regretted, or past transgression, or feared, imagined future. So how do we apply that to psychosis? We want to first understand how do clients make sense of their experience? Are they fused to voices? Are they fused to their thoughts? What type of atypical beliefs are going on? We want to be starting to think about the question, what does recovery mean to the client? Right, oftentimes, recovery is going to come in the form of I just want to get rid of my symptoms. It's going to be about symptom reduction. But again, from the ACT point of view, this is not the goal. The goal is to help clients learn to live with and become liberated from the struggle of psychosis. I'll say that again, learning to live with and becoming liberated from the struggle with psychosis. So we have something known as the inflexihex. Right, if I were to be sitting with a new client, and they came in, maybe they had just gotten done with inpatient and they're coming to see me on an outpatient basis, right? I'm going to sit there, I'm going to ask them, you know, what it is that is going on in their life? How are you feeling today? What will you be doing today? What has gone on in your life? Where did you just come from? Right? And what I'm listening for by just having this, this sort of open, you know, question, open ending questions, I'm listening for words, statements, evaluations, that's going to indicate to me, where the client is stuck in terms of the psychologically inflexible process, right? So if we talk about, you know, client, John Smith, you know, maybe he is suppressing his voices, he's telling me that, you know, I just when the voices show up, I just try not to think of them. And I think I'm trying to think of other things. How does that work for you? Well, it doesn't work unless I'm sitting in front of the TV and watching TV all day long, because that way I can just try to focus on the TV. Well, but does that ever really work? Well, no, because the voices are still there. And then the voices are telling me I'm sick, psycho, broken, and I'll never be normal. Right? Then I might have another thought that says, I should go kill myself. Right? And sometimes I believe that because I am broken. So I can't handle all of this. So what do I do? I Yeah, at the end of the day, I'm tired. I'm tired of fighting with my mind. And I do I drink, you know, a fifth of vodka, or, you know, I hammer down drugs. And what is the point? Anyways, I don't know why I'm here. I really don't care. So you can gain a lot from just listening to clients from this, you know, psychologically inflexible, inflex a hex model, this is more of our, you know, sort of moment to moment conceptualization of what's happening for a client. So when my act be helpful, right? Well, the more psychologically inflexible we see our clients, when they're stuck, when they're having a hard time moving forward, or even having a hard time imagining a life beyond their illness, right? utilizing it to support recovery, utilizing it to support relationships, right? One of common questions I get is what about insight? How do you help clients with, you know, psychotic symptoms with poor insight, right? And that's where this idea of purposeful attention, mindfulness, meditation, contacting the present moment, right? And from the ACT model, some of the techniques and exercises have been geared more towards individuals that come into treatment with less insight and awareness. This is a process, we're helping to build that process. And once we start that momentum of building the process, right, then we want to keep that going with the client. So what we're moving in the direction of is psychological flexibility, that is the outcome. From the ACT lens, when people say what is the desired outcome from ACT, it is psychological flexibility. Note that there's nothing that says symptom reduction. It's not that that isn't important. I don't want to miss, you know, represent it's that it's not the main goal. It's not the focus of treatment. The focus of treatment is increasing psychological flexibility. And what does that mean? From the ACT definition, contacting the present moment fully, as a conscious historical human being, based on what the situation affords, changing or persisting in behavior in the service of chosen values. So right, we're helping clients see themselves not as their history and not as their thoughts about the feared future, seeing that they are a capable person insofar as choice, that they can make choice in their life. And they can decide to choose to change or persistent behavior in line with what's important to them. So the key elements of therapy, of course, just like any other treatment, modality, informed consent. But we want to normalize psychotic symptoms and introduce observing private events as experiences. So things like, I am noticing, I'm having the voices tell me, right, we want to bring that right into the treatment. So it sounds to me like you are aware that there are voices that are telling you that you are no good. We want to have the separation between themselves and their experience. So we want to broaden that contrast between having experiences and responding to them, helping them see that there's a difference between experiencing and action. So being able to contact that sense of self, that perspective that I am a human being who has experiences of voices, I am a human being who has, you know, symptoms of psychosis. Explore unworkable coping strategies, what is it that they're doing to try to get rid of, diminish, you know, make go away, avoid. And we want to start suggesting that perhaps what you've been doing has led to further re-hospitalizations, right? And maybe there's a different way to approach your own experience. There's an alternative to this. And then placing acceptance in the context of valued life domains. I can't express this enough. We're not just telling people, hey, you need to accept what it is you're experiencing. That's not it at all. Most people are going to ask why accept? Well, because by not, you're not living the kind of life that you want to be living. You've told me that you want to be gainfully employed. You told me that you want to fall in love. You told me that you'd like to reconnect with your social support group. You know, but what is getting in the way of that? So each session follows a similar structure, which includes warm up exercises, mindfulness exercises, discussion of the session activity from the previous week, discussion of the process and planning out of session activity. So it is very structured just like a CBT session would be. And the six core processes that we want to hone in on when working with psychosis or severe mental illness. We want to help clarify values and goals. Autonomy and meaningful direction in recovery. What is it that you want to get out of this life? Learning to be present. How to feel and be in the here and now. Learning to live with thoughts and voices as an experience and not who you are. And decreasing the believability. Diffusing from the noise is what we call it. Identifying and letting go of the struggle. And really helping clients to define who I am. If I'm not my thoughts, if I'm not my voices, then who I am becomes a big question. So in other words, what we're doing is we're learning to help clients how to live in the now. Finding choice in each moment and that they are a hundred percent capable of making choice. Sticking with doing with what they care about. Noticing when the mind is helpful and when it isn't. Accepting what you cannot change and being compassionate with yourself. So one of the first things that I typically ask clients when they come in is what do you want your life to be about? What are three things you like to do? Who and what are important to you? And in various stages of a person's mental illness, they may see things like I don't know, I don't care, what do you think I should care about? That's to be expected. We want to help clarify for our clients what is important to them. So some of the ways that we do that, right, is how our minds can lead us to struggle when trying to do things we care about. It's oftentimes the problem that pulls us away from moving in a direction that we want to move in. So I'd like you to identify a direction you would like to go. Your values, pick one. And let's imagine that this is you in your bus and you're the driver of the bus and you want to go places and you want to do things and you want to see what's important to you. And let's imagine that the passengers that are in the bus, right, those are all the scary thoughts, the scary voices, right, and they say things like you're an idiot, you're sick, you're psychotic, stop it, stop the bus, don't do that, you'll fail. And your typical response, which is normal for all of us when we're dealing with pain, I can't handle this. And so you do what you've always done, right? But what if there's a different way? What if we identify a direction you want to go, your value, right, we've identified the passengers on the bus as not being who you are but your experience, your thoughts, your feelings, your memories, your sensations. And what if you can still be in control of driving the bus while they are passengers, right? I don't like this. No, of course you don't. And I can still choose to be the driver. Learning to be present, to become aware of, experience, and consider the value and challenge of being present with one's internal experiences. So how we may do that, some example activities. Occasionally your thoughts, voices, emotions seem to come out of nowhere and oftentimes they're clearly connected to something in our surroundings or clearly connected to something we care about. So I may choose to play three minutes of music and just ask the client to notice their experience. Other types of mindfulness exercises, getting present, mindfulness of the breath and body, all different types of experiential exercises that we can bring into, again, the interaction, the experience of in our sessions. That is what ACT therapists are leading the client to do, is to experience what it's like to be present in the moment. Diffusing from the noise, right? The purpose here is to use language tools, metaphors, and experiential exercises to create a separation between the client and the client's conceptualized experience. I love this bumper sticker. You don't have to believe everything you think and that is true and that is the idea that we want to impart to our clients, that you don't have to believe everything that you think, right? One of the classic diffusion exercises we use is called the lemon, lemon, lemon and simply put, if you say that word, if you do this with me, it's kind of a silly activity but if you think about, you know, your experience with a lemon, right? The last time you inadvertently licked a lemon, last time you smelled a lemon or you had some lemon, you know, meringue pie, right? We all know what lemon tastes like and when we think about a lemon, sometimes that could evoke, right, a visceral experience, just like for clients with hallucination. It may seem so real but this is based on Titchener's repetition, right? If we say that word lemon out loud, really fast, I'll do it for 20 seconds, let's go. Lemon, lemon, lemon, lemon, lemon, lemon, lemon, lemon, lemon, lemon, lemon, lemon, lemon, lemon, lemon, lemon. Okay, not by 20 seconds but I think you get the point. We teach clients to do that. You know, let's take the context of your thoughts and not in a way to defuse or excuse me, to avoid it. In a way to give some space between the experience and the client. So again, we're not using this as an elimination technique where we're helping clients to get that separation. Can you notice this painful voice? You know, not as just being separate but also as just kind of words, right? And words start as sounds. Help it break it down. De-literalize some of the painful, powerful thoughts that they're having that they tend to believe in. If you start to de-literalize them, then chances are they're reducing the believability and they're choosing not to respond. Acceptance. This is to experience the control we have over our external world. What we do with our arms, our hands, our feet, and our mouths. The lack of control we have over our internal world and the resulting problems from trying to control what we can't. We oftentimes use the tug-of-war analogy. Imagine that your symptoms are like a monster and it makes sense. The logical thing to do is to get caught up in this war in your mind. Oftentimes people will say it does seem like there's a war going on. I'm a prisoner of it. And you do everything that you can do to try to make it go away but what happens? You find yourself in that war and everything else that you care about that's going on in life, you're not paying attention to. So the idea here is to drop the rope. You're choosing to drop the rope. It's choice. By doing that, it doesn't make the monster go away. But then you have choice to turn around and pay attention to something that is more important. We want to think about ways in which to help clients learn to accept what is in their control and what isn't. I put up a picture of a mannequin here. Sometimes I have mannequins in the office. A mannequin, we can't change their face. We can't change our face. We can't change what we look like all the time. But the things that we have control over are style. The things that we put on our body. The things that we wrap around our body. Learning the difference between things we can control and things that we can't control. Then the defining of who I am. This is to help clients make contact with the evaluation and reason-given properties of their own story. How I may use this is I might start setting up a checkerboard. I'll ask the client the question, if you're putting these checkers out, red pieces, the black pieces, do they represent different voices in your head? Do they represent different beliefs? Do they represent different painful experiences? They may be saying, yes, this is so-and-so tells me I'm an idiot. This is the thought that the world is out to get me. This is I should just go kill myself. Then after we're done looking at it, it's a diffused mindfulness acceptance activity. I ask the client, is it possible to see yourself, not as all of the different checkers on the board, your experience, rather the board itself. Who you are as a person is always experiencing experiences, but you don't become those. Again, there's different ways to bring that in. The final thing that we want to do is helping clients commit to a course of action. That's what it boils down to. ACT has largely been considered an exposure-based model. It is, because at the end of the day, that's what we're asking for. We're asking for clients to start engaging in meaningful life directions. That can be very simple. Depending on the presentation of your client, what are they struggling with? Are they willing to notice what they're being influenced by? Any unhelpful self-descriptions? Any unhelpful voices? Can they center their awareness on the here and now and accept what's showing up without trying to control it? Noticing that I'm not my thoughts and then doing what it is that you want to do. Do you want to wake up earlier today? Do you want to go and apply for a job? Do you want to wake up today? Do you want to go tell that person that you haven't spoke with in a long time that you love them? This is all because of what this individual cares about. That is Introduction to Acceptance and Commitment Therapy. For useful resources, I encourage you to go for act4psychosis.com. If you are brand new to learning about ACT, I highly suggest you look at joining the contextualscience.org. Other helpful resources, bibliography, and we will take questions. We have about eight minutes to take questions now. Thank you so much, Dr. Patterson, for such an interesting presentation. Right before we shift into Q&A, I just want to take a moment and let you know that SMI Advisor is accessible from your mobile device. You can use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating scales, and even submit questions directly to our team of experts. Upload the app now at smiadvisor.org. Okay, so we have several questions, which is always great. I just want to start off by asking kind of a procedural question for ACT. Does ACT need to be done in total? Do you have to go through all six different areas of psychological flexibility, for example, or can you pull pieces of it? Or does the client have to know that you're doing ACT and here's all the components? That's a wonderful question, and it's a flexible answer. I think according to, you know, the psychological sophistication, savviness, awareness of your client is going to determine how much you do in terms of explaining the different domains. You don't necessarily have to. It doesn't say anything that you have to, but you may choose to with certain clients. And, you know, yes, you know, all the protocols and research has been based on a culmination or connection of the six domains. However, there are and have been some studies that are looking at components such as values, diffusion, and mindfulness. So you can feasibly, if you have especially time limit with an individual. One of the processes from the core model that shows to be most effective is this discussion of values. And that comes from research of clinicians doing bedside hospice work with individuals that are in the last moments of their life. And that's where that question of who and what is important to you, because nine out of ten times people are in hospice are going to say spending more time with friends and family. So that's the idea of even though you're, you know, feeling, your body is feeling and your mind still may be present, you can still generate thoughts about what it is that you care about. So we find that even if you don't have the time to talk about other processes, values, diffusion, and mindfulness are often good ones to stay with. Okay, great. Thank you. And follow up with that. So in the six areas of the hexaflex, do you approach them for each individual as they're needing to focus on each of those the same amount? Or is there a way to assess before you really go in which area they might struggle with and then increase the interventions around, say, you know, self as context over fusion or something? Yes, that's a great question. So if you go to the Association for Contextual Behavioral Sciences.org, and if you choose not to become a member, that's fine. You can still peruse and you can look to see that there are all different types of assessment questionnaires that are geared towards finding which point a client may be more stuck in. So yes. And then you may choose to spend more time in your treatment on, let's say, developing insight and awareness versus values, or maybe developing diffusion skills versus self as context. So to answer your question, yes, and you can find that at the ACBS website. Awesome. And is that also a place that people can receive additional training on acceptance and commitment therapy? Is that where you would recommend? That question also came up. Yes, absolutely. So you will have to become a member to get access to that and all of the protocols and all the research, but it is a values- based membership. There are suggested rates for donation, but I highly recommend if you are someone who is really interested in learning more about ACT to become a member of the ACT community. Awesome. And then the last question, which you knew would be coming, but I think just a little bit more elaboration on the insight piece. So we have several around that. So not even if there's just a lack of insight, but for people who maybe externalize their problems rather than think about them coming from internal suffering and struggling. Can you maybe just talk a little bit more about how to approach this model with people who really aren't aware of what's going on with their own processes? That's a great question, Paula. Yes. So how we typically start with individuals that are lacking awareness is we start with the values piece. So I'm pretty much going to keep coming back to the values piece because regardless of level of insight or awareness, everybody has a set of values that just may not be clear. And some of the questions that you can find on the website are geared towards people that have lower insight awareness, but they're nonetheless gearing towards helping them think about what's important to them. Once you can help them identify what's important, then you can systematically work through how their behavior may be interfering, so more of that sort of externalization, how it may be interfering with what is important to them. So if they identify that there's a parental figure or a best friend or a former boss that's important and they want to maybe reach out, then we want to systematically help them understand, well, this importance and what you did maybe that wasn't in line with that value or in line with leading this valued behavior. How can you step back and maybe sort of see the interaction between the two? And we use a lot of work with externalizing thoughts and feelings, things like physicalizing, taking certain thoughts and feelings and asking them to imagine if it had a physical feature. And then that may be a starting point for a whole other discussion that may lead to values. So there are a lot, if you go to the ACBS website, there are protocols there for ACT for Psychosis, and there are all different types of experiential exercises that will help someone that has a lack of awareness and insight. Awesome. Thank you so much, Dr. Patterson. That's all the time we have today for questions. If you do have follow-up questions, I know we didn't get to them all, but for any other topic related to evidence-based care for serious mental illness, our clinical experts are now available for online consultations. So any mental health clinician can submit a question and receive a response from one of our SMI experts. Consultations are free and confidential. SMI Advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We encourage you to explore the resources available on the Mental Health Addiction and Prevention TTCs, as well as the National Center of Excellence for Eating Disorders and the Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health through the opioid epidemic. Thank you so much for joining us on this exciting topic, and until next time, take care. Thank you for participating in today's free course from SMI Advisor. We know that you may have additional questions on this topic, and SMI Advisor is here to help. Education is only one of the free resources that SMI Advisor offers. Let's briefly review all SMI Advisor has to offer on this topic and many others. We'll start at the SMI Advisor website and show you how you can use our free and evidence-based resources. SMI Advisor's mission is to advance the use of a person-centered approach to care that ensures people who have serious mental illness find the treatment and support they need. We offer several services specifically for clinicians. This includes access to education, consultations, and more. These services help you make evidence-based treatment decisions. Click on consult request and submit questions to our national experts on bipolar disorder, major depression, and schizophrenia. Receive guidance within one business day. It only takes two minutes to submit a question, and it is completely confidential and free to use. This service is available to all mental health clinicians, peer specialists, and mental health administrators. Ask us about psychopharmacology, recovery supports, patient and family engagement, comorbidities, and more. You can visit our online knowledge base to find hundreds of evidence-based answers and resources on serious mental illness. All content in our knowledge base is reviewed by our team of national experts from the American Psychiatric Association, Harvard, Emory, NAMI, University of Texas at Austin, and more. Browse by key topics or search for a specific keyword in the search bar. Access our free education catalog to find more than 100 free courses on topics related to serious mental You can search the education catalog by topic, format, or credit type to find courses that fit your needs. SMI Advisor also offers live webinars each month that let you learn about evidence-based practices and participate in live Q&A with faculty. Check out our education catalog often to find new courses and earn continuing education credits. Thank you for your interest in SMI Advisor. Access our free education, consultations, and more on smiadvisor.org at any time.

Introduction to Acceptance and Commitment Therapy for Serious Mental Illness

webinar

Dr. Jennifer Patterson

SMI Advisor

evidence-based care

psychotic symptoms

psychological flexibility

valued life

six core processes

reducing rehospitalization rates