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Acceptance and Commitment Therapy for People with MS


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Dr Sarah Gillanders and Dr David Gillanders introduce acceptance and commitment therapy for people with MS, a form of cognitive behavioural therapy that focuses on how we live with difficult things. It blends behaviourism, mindfulness, values, compassion and perspective taking.

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Acceptance and Commitment Therapy for People with MS

  1. 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. 2. What do people struggle with when they have MS? • At the beginning… • During a relapse • During remission • Transition… • End of life and afterwards for loved ones
  3. 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. 4. What‟s 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 alternative…
  5. 5. Acceptance • Not – resigned, tolerating, giving in, defeated, not a state or a stage • Acceptare “To take in what is offered” • A choice. • A behaviour, moment to moment….
  6. 6. Values • Compass metaphor • Directions versus destinations • Qualities of action • Available now….
  7. 7. When to use your mind and when to lose your mind… • Amazing problem solvers • A really useful tool • Who‟s using who? • Noticing being hooked into ineffective problem solving
  8. 8. Mindfulness • Bringing flexible attention to the here and now • Noticing the ebb and flow of experience • Giving greater capacity to choose actions
  9. 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. 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. 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 „story‟
  12. 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. 13. MS and Families • MS doesn‟t 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. 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 doesn‟t want additional carers in the house Relationship strain
  15. 15. Outline of sessions • Session 1 and 2: Jane alone – – – – – – – – – 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 – – – – 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. 16. • Session 3: Howard alone – How is Jane‟s MS is impacting on the family? • • • • – – – – – Typical day Practical impact Impact on each individual Impact on relationship What strategies do they use? Workability Current stressors His well-being His goals – Discussed couples work
  17. 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. 18. What private events are they struggling with? Thoughts/beliefs Emotions/feelings Physiological sensations I ought to be able to cope independently I shouldn‟t 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. 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 aren‟t done her way Nipping at each other Friction in the relationship Communication style that is critical and frustrating Disconnection between the couple Low
  20. 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 doesn‟t 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. 21. If this wasn’t 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 – the need for Howard to do a lot Cognitive slowing and memory problems
  22. 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 Doesn‟t ask for things or share thoughts Tell self „this is just how it is‟ I just need to „you make your do the bed you lie in it‟ practical stuff I will do what I think is best I am not in control Other people don‟t want to know about your problems Just does tasks without asking Busy self with practical tasks
  23. 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 „we need to hold it together‟, 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. 24. • Sessions 4-6: Jane and Howard – – – – 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
  25. 25. • Metaphor: Leaves on the stream • Exercise: mindfulness
  26. 26. – 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 – Used this interactional style through the sessions
  27. 27. Both pragmatic and there was evidence of mild cognitive difficulties. We made some practical recommendations, which linked with Jane‟s goal of feeling more involved with household tasks: •To sit together after breakfast •To sit with Jane at her bedside •To discuss correspondence each week and to jointly plan what to address and how •To avoiding nipping •To meal plan together •To be more open about what they need and how they feel Exercise: Sailing boat metaphor
  28. 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. 29. • Better insight into relationship dynamics • More able to pause and step back from conflict and stress and chose a direction and behaviour • Intimacy hadn‟t changed but they were happy with their relationship and neither wanted to address this at this time
  30. 30. • Scores on AAQ-II hadn‟t 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. 31. Ways you might begin to incorporate ACT strategies • Help clients examine what works and what doesn‟t • Help them let go of what is not working, even if they think it should be working • When setting goals – do it with a values perspective
  32. 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 „mental time travelling‟ and gently come back to here and now.
  33. 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. 34. Ways you might begin to incorporate ACT strategies • Instead of modifying thoughts, try renegotiating „the deal‟ you have with them. • Flexible ways of living values in small steps • Slow down, get in the moment, make room and lean in
  35. 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)… • It can be transformative, if you want it to be…..
  36. 36. Next steps • Reading • Other training • Join ACBS: Check out my training page above – forms, diaries, metaphors, audio exercises, slides
  37. 37. Thank you for listening