This document summarizes a presentation on Acceptance and Commitment Therapy (ACT) for people with Multiple Sclerosis (MS). ACT focuses on increasing psychological flexibility to live according to one's values despite difficult thoughts, feelings, and physical symptoms. The presentation discusses how people with MS commonly struggle and respond unhelpfully by avoiding, controlling, or fighting their experiences. It then outlines the six core processes of ACT (acceptance, defusion, contact with the present moment, self-as-context, values, and committed action) to build psychological flexibility. A case example is provided of applying ACT in couples therapy with a woman with MS and her husband to improve their communication and relationship.
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Acceptance and Commitment Therapy for People with MS
1. Acceptance and Commitment
Therapy for People with MS
MS Trust Annual Conference 4th November 2013
Dr Sarah Gillanders
Dr David Gillanders
MS Specialist Clinical
Neuropsychologist
Doctoral Programme in Clinical
Psychology
NHS Lothian (Edinburgh)
University of Edinburgh
2. What do people struggle with
when they have MS?
⢠At the beginningâŚ
⢠During a relapse
⢠During remission
⢠TransitionâŚ
⢠End of life and
afterwards for loved
ones
3. And what do they tend to do in
response to these struggles?
⢠Figure it out /
problem solve
⢠Control / get rid /
reduce
⢠Fight it
⢠Avoid it / hide
4. Whatâs the cost?
⢠These are the natural logical things to do
and sometimes they are helpful
⢠But sometimes these efforts can make life
harder
⢠A real alternativeâŚ
5. Acceptance
⢠Not â resigned, tolerating, giving in,
defeated, not a state or a stage
⢠Acceptare âTo take in what is offeredâ
⢠A choice.
⢠A behaviour, moment to momentâŚ.
7. When to use your mind and
when to lose your mindâŚ
⢠Amazing problem solvers
⢠A really useful tool
⢠Whoâs using who?
⢠Noticing being hooked into ineffective
problem solving
8. Mindfulness
⢠Bringing flexible attention to the here and
now
⢠Noticing the ebb and
flow of experience
⢠Giving greater capacity
to choose actions
9. Acceptance and Commitment
Therapy
⢠ACT is a form of cognitive behavioural
therapy that focuses on how we live with
difficult things
⢠Blends behaviourism, mindfulness, values,
compassion and perspective taking.
⢠Uses eyes closed exercises, meditation
strategies, metaphors
10. Goals of ACT
⢠The main goal of ACT is workability
⢠By increasing psychological flexibility
⢠The ability to be present to here and now
and to change or persist with behaviour
when doing so serves valued ends.
11. The ACT Model of Inflexibility
Dominance of
Past & Future
Lack of clarity or
contact with
Values
Experiential
avoidance
Psychological
inflexibility
Inaction,
impulsivity or
avoidant
persistence
Cognitive Fusion
Attachment to the
self âstoryâ
12. The Positive Psychological Processes ACT Seeks
to Strengthen
Being in the
present moment
Acceptance /
Willingness
Psychological
Flexibility
Clarity &
Contact with
Values
Committed
Actions
Defusion
Flexible Self
13. MS and Families
⢠MS doesnât only affect the individual
⢠We can combine ACT with a couples
orientation
⢠This can help the couple / family to
respond more flexibly to the challenges of
MS
14. A Case example: Jane and Howard
⢠62 year old female, transitioned to secondary
progressive MS ~12 months ago
Wheelchair dependent, no functional use of
upper limbs
Married to husband for 35 years
He has chronic health problems
He doesnât want additional carers in the house
Relationship strain
15. Outline of sessions
⢠Session 1 and 2: Jane alone
â
â
â
â
â
â
â
â
â
History of MS and current stage of illness
Main presenting symptoms: biopsychosocial understanding
Current stressors
Psychological history (childhood onwards)
Family structure
Typical day
Goals for intervention
Discussion about potential intervention
Measures: AAQ-II, HADS
â
â
â
â
What problem(s) would she like help with?
Thoughts, feelings, physiological sensations and urges
What has she tried to deal with these problems?
Did they work?
16. ⢠Session 3: Howard alone
â How is Janeâs MS is impacting on the family?
â˘
â˘
â˘
â˘
â
â
â
â
â
Typical day
Practical impact
Impact on each individual
Impact on relationship
What strategies do they use?
Workability
Current stressors
His well-being
His goals
â Discussed couples work
17. ACT Case Formulation Template
Self-reported complaints
Jane
Howard
Both
Frustrated by MS
Feels disempowered
Wants more involvement
with household tasks
Lack of intimacy with her
husband
Would like greater
connection with family
Lost role as a grandmother
Trauma from childhood
abuse
Feels overwhelmed by
caring
Wants to be supportive but
feels the need to keep on
top of things
Own chronic health
problems
Poor communication
18. What private events are they struggling with?
Thoughts/beliefs
Emotions/feelings
Physiological sensations
I ought to be able to cope
independently
I shouldnât need to depend
on others
I am a burden
Sad
Loss
Disempowered
Tension
I ought to be caring for my
husband
Disappointed
Loss of role as wife
Jane
Howard
I have to cope
Burden
Responsibility
Stress
Both
We are a patient and
carer, not a husband and
wife
Resignation
Disconnected
Lonely
Exacerbation of bowel
condition
19. What do they typically do (or have done in the past) when these private events
come up?
What they do
What they
hope will
happen
Actual shortterm
consequences
Actual longterm
consequences
Workability
Doesn't tell
people what she
wants or how
she feels
Feel less of a
burden
Avoid upsetting
others
Feels able to
cope alone
Avoids
emotional
conversations
Avoids feeling
like a burden
Feels alone and
isolated
Misunderstood
Needs not met
Disconnected
from those
around her
Low
Comments on
what husband is
doing around
the house
Become more
involved in
running the
house
Regain previous
role
Feel more
empowered
Husband feels
undermined
Irritated that
things arenât
done her way
Nipping at each
other
Friction in the
relationship
Communication
style that is
critical and
frustrating
Disconnection
between the
couple
Low
20. What do they typically do (or have done in the past) when these private events
come up?
What they do
What they
hope will
happen
Actual shortterm
consequences
Actual longterm
consequences
Workability
Focus on
practical tasks
Keep on top of
caring and
household tasks
Completes tasks
in his own way
Friction between
couple
Jane doesnât
feel involved
Allows them to
avoid dealing
with emotional
issues (health
problems,
relationship
strain)
Medium
Go about
individual
activities
Not add to each
others stress
Avoids
confronting
difficulties
Feel that not
burdening each
other
Avoids
confronting
difficulties
Lonely
Disconnected
Problems
continue
unaddressed
Low
21. If this wasnât such a struggle for them how would life be different, what could they
do?
Valued life area
Specific goals
What gets in the way
Better communication
To sit together after breakfast
Make joint decisions
Prior communication style
Feeling too busy
Feeling that a burden
Greater intimacy
To sit together
To listen, be patient and to care
To hold hands
Furniture
Feeling disconnected
Time
To feel more connected
to children
To speak to children about MS
To answer their questions openly
in the future
Belief that ought to deal
with problems alone
Private person
Shared roles as
housekeepers
To discuss household tasks each
week
To read through correspondence
and answer jointly
Time â the need for
Howard to do a lot
Cognitive slowing and
memory problems
22. What ACT processes underpin or drive the unworkable strategies?
Experiental
avoidance
Cognitive
fusion
Dominance of
conceptualised
past or future
Attachment
to the
conceptual
self
Lack of
contact
with values
Avoidance /
Inaction
Withdraw
I am to
I am not the
blame for my person I used to
symptoms
be
This is how
relationships
turn out
I must deal
with things
alone
I must hold
everything
together
I am
vulnerable
You need
deal with
things alone
Focus is on
practical
tasks
Doesnât ask
for things or
share
thoughts
Tell self âthis
is just how it
isâ
I just need to âyou make your
do the
bed you lie in itâ
practical
stuff
I will do what
I think is
best
I am not in
control
Other people
donât want to
know about
your
problems
Just does
tasks without
asking
Busy self with
practical
tasks
23. How much creative hopelessness needs to be emphasised with this couple?
Both aware that there are problems with their current strategies, but Howard in particular
finds it difficult to generate alternative solutions
A sense that âwe need to hold it togetherâ, that they are vulnerable and fearful of change
What aspects of their context may undermine or support the work?
Small care package contributing to carer strain
Both have chronic health problems and mild cognitive impairments
Jane: childhood abuse and a sense of needing to cope alone
24. ⢠Sessions 4-6: Jane and Howard
â
â
â
â
Better communication
Examined current communication style
Considered workability
Discussed what was driving their communication style (history, a
desire to be effective, frustration etc)
Metaphor: Passengers on the bus
26. â We spoke about their values: how they would like to
communicate with one another and what qualities
they would like to bring to their relationship. They both
said to listen more, to be attentive and to be calm
â Used this interactional style through the sessions
27. Both pragmatic and there was evidence of mild cognitive
difficulties. We made some practical recommendations, which
linked with Janeâs goal of feeling more involved with household
tasks:
â˘To sit together after breakfast
â˘To sit with Jane at her bedside
â˘To discuss correspondence each week and to jointly plan
what to address and how
â˘To avoiding nipping
â˘To meal plan together
â˘To be more open about what they need and how they feel
Exercise: Sailing boat metaphor
28. Outcome
⢠Communication had improved
⢠Jane less frustrated by MS
⢠Felt that their relationship was much stronger
⢠Both felt happier
⢠Both remain quite private people
29. ⢠Better insight into relationship dynamics
⢠More able to pause and step back from conflict
and stress and chose a direction and behaviour
⢠Intimacy hadnât changed but they were happy
with their relationship and neither wanted to
address this at this time
30. ⢠Scores on AAQ-II hadnât changed significantly. Although
Jane reported a number of improvements, she still felt
troubled and controlled by memories from her childhood
June 2013
October 2013
AAQ-II
34/49
39/49
HADS Anxiety
13 (moderate)
9 (mild)
HADS
Depression
9 (mild)
6 (normal)
⢠Conclusion: remains at risk of mood deteriorating if
unaddressed
⢠Plan: individual sessions to help her live more flexibly
with the past
31. Ways you might begin to
incorporate ACT strategies
⢠Help clients examine what works and what
doesnât
⢠Help them let go of what is not working,
even if they think it should be working
⢠When setting goals â do it with a values
perspective
32. Ways you might begin to
incorporate ACT strategies
⢠Use the word willingness instead of
acceptance
⢠Think of willing as a choice in each
moment
⢠Notice âmental time travellingâ and gently
come back to here and now.
33. Ways you might begin to
incorporate ACT strategies
⢠Cultivate the present moment
⢠Appreciation for small and simple things
⢠Develop a sense of when to use the mind
and when to lose the mind
34. Ways you might begin to
incorporate ACT strategies
⢠Instead of modifying thoughts, try
renegotiating âthe dealâ you have with
them.
⢠Flexible ways of living values in small
steps
⢠Slow down, get in the moment, make room
and lean in
35. ACT applies to all of us
⢠The same language traps apply to all of us
⢠We can use willingness, mindfulness,
values and commitment to be more
present in our work (and at home)âŚ
⢠It can be transformative, if you want it to
beâŚ..
36. Next steps
⢠Reading
⢠Other training
⢠Join ACBS: www.contextualscience.org
Check out my training page above â forms,
diaries, metaphors, audio exercises, slides
37. Thank you for listening
sarah.gillanders@nhslothian.scot.nhs.uk
david.gillanders@ed.ac.uk
Hinweis der Redaktion
In this slide, greater intimacy and feeling more connected with the adult children are typically phrased as values. The other two are a little more goal like â they can be achieved. The shared role as housekeepers one is really about successfully managing their role as housekeepers. This is not necessarily something you need to change but people may think of values in terms of family, relationships, citizenship, parenting, spirituality so they may ask you to clarify or explain why these are values in the left column.