Supercharging therapy with values Dr. Joseph Ciarrochi, School of Psychology, University of...

Supercharging therapy with valuesSupercharging therapy with values

Dr. Joseph Ciarrochi, School of Psychology, University of Wollongong

Structure of talkStructure of talk

• Part 1 Theory

• Part II. Behavioral Activation– Evidence behavioral Activation is effective.

• Part III: Values clarification– Evidence values clarification is effective– How to work with values

Part I: A Unified TheoryPart I: A Unified Theory

What happens to people’s dreams?

What happens to people’s dreams?

• “The very great majority kill themselves long long before their time.

• Live as children; grow pale as adolescents; show a flash of life in love; die in their twenties and join the poor things that creep angry and restless about the earth” (O’Brian, 1991, p. 526).

ACT as a Unified frameworkACT as a Unified framework

An extremely brief and pictorial description of Relational Frame Theory

Fusion and Avoidance, two key processes that play a role in interfering with value-congruent living

How do we lose touch with what we value?Fusion is the dominance of particular verbal functions over other potentially available nonverbal and verbal functions (Hayes et al., 1999).

How do we lose touch with what we value?Fusion is the dominance of particular verbal functions over other potentially available nonverbal and verbal functions (Hayes et al., 1999).

Fusion and avoidance. Fusion makes it possible for our private experiences (the bees above) to seem like physical threats. It allows us to spend time avoiding our experiences, just as we would avoid an outside threat

Fusion and avoidance. Fusion makes it possible for our private experiences (the bees above) to seem like physical threats. It allows us to spend time avoiding our experiences, just as we would avoid an outside threat

Avoidance takes a great deal of energy and is often inconsistent with other activities, e.g., distress provoking valued-activities

Avoidance takes a great deal of energy and is often inconsistent with other activities, e.g., distress provoking valued-activities

Desire (or values) and fear are two sides of the same coin. If can’t have distress, then you often must give up what you desire or value

Desire (or values) and fear are two sides of the same coin. If can’t have distress, then you often must give up what you desire or value

Acceptance and Commitment Therapy (ACT) and Behavioural Activation (BA)Acceptance and Commitment Therapy

(ACT) and Behavioural Activation (BA)

• Shared philosophy of science: Functional Contextualism– Behaviourist

– Emphasis on functional analysis

– Emphasis on context rather than content

• Shared therapeutic processes

– Activation of behaviour

– Undermining of harmful avoidance behavior

– Mindfulness

– Exposure

Distinctions between ACT and BA


• ACT is based on a behavioral theory of language. Like traditional CBT, ACT views cognition as playing a key controlling role in suffering. However , ACT and traditional CBT differ in how they conceptualize and treat client problems (Ciarrochi & Bailey, 2008).

• Cognitive Defusion. ACT attempts to change the way one interacts with or relates to thoughts by creating contexts in which their unhelpful functions are diminished.

• Self-as-Context- ACT helps people to contact with the sense of self as a locus or perspective (e.g., the “observer” self). This self gives clients a place to observe their experience and learn to let go of unhelpful self-evaluations. They learn that they are not the same as their evaluations; they are not the same as their pain, their depression.



• Activities versus values

• ACT tends to emphasize values more than traditional BA, which focuses a bit more on activity scheduling

Part II: Behavioral ActivationPart II: Behavioral Activation

Study 1 supporting BA as“well-established” treatment for depression (Chambless et al., 1996)


• McLean and Hakstian (1979) JCCP. Behavior therapy superior to other therapies at immediate follow-up (9 of 10 indices), and marginally superior on follow-up (7 of 10 indices)

• Behaviour therapy had lowest dropout (5% compared to 26% to 36% for other treatments)



• Jacobson et al. , 1996, (JCCP) compared three conditions.

• Conditions– Behavioural Activation (BA)

– BA + automatic thought challenging (ATC)

– BA+ATC+ downward arrow/core belief

• Results– Behavioral activation alone was as effective in treating depression

as BA combined with cognitive interventions.

– Gortner et al. 1999 showed effects held at 2 year follow-up

More research supporting behavioural activationMore research supporting behavioural activation

Dimidjian et al., 2006, JCCP. Study of Major Depression

• Compared behavioural activation to Cognitive Therapy and Antidepressent medication (ADM)

• BA found to be comparable in efficacy to ADM, and more efficacious than CT.

• Differential treatment effects obtained only for most severely depressed

• For more severly depressed participants, BA and ADM comparable

Cuijpers et al., 2007 CPR. Meta-analysis

• BA effective (effect size =.87) and effects fairly consistent across studies

Is behavioral activation effective for other disorders, such as anxiety?

Is behavioral activation effective for other disorders, such as anxiety?

• ACT theory posits similar processes: fusion and avoidance.• Approximately 50% of individuals with depression have a

coexistant anxiety disorder ( Kessler et al., 1996; Mineka, Watson, and Clark, 1998)

• Anxiety and depression share many symptoms (e.g., difficulties concentrating, restlessness, fatigue, and sleep problems.

• Decrease in control and predictability may be common in both disorders

• Anxiety and mood disorders may be variable manifestations of similar neurobiological processes (See Hopko, et al., 2006, for review of similarities between anxiety and depression)

Exposure in the service of activating valued behaviourExposure in the service of activating valued behaviour

Is behavioral activation useful in treating anxiety

Is behavioral activation useful in treating anxiety

• Small study of pure B.A. with PTSD shows B.A. was effective (Jakupac, et al., 2006)

• Social anxiety: Exposure is as effective as CT and full CBT package in treating social anxiety (Powers, et al., 2008)

• ACT, with big BA component, is effective in treating anxiety (Block, & Wulfert, 2000;

Dalrymple & herbert, 2007; Forman et al,2007; Zettle, 2003)

Part III: ValuesPart III: Values

What are values?What are values?

• Wilson, Sandoz, Kitchens, and Roberts, 2008, under review

• 1) Values are ongoing patterns of activity– Not achievable, can’t be completed– Goals are achievable and serve values


• 2) values are a special class of reinforcer– Can me distant in time, and occur in tiny increments

– Can refer to benefits that , in principle , could never contact (e.g., afterlife)


• 3) values are verbal– Language makes present psychological

functions without direct operant or classical conditioning processes


Values are a special class of reinforcers that are verbally constructed, dynamic, ongoing patterns of activity, for which the predominant reinforcer is intrinsic in the correspondence between the individual behaviour and valued behavoural pattern (Wilson, et al., 2008)

Values, what are they good for?

Values, what are they good for?

• Values have tremendous transformational power

• Theoretically, values set up the possibility for behaviours to become more reinforcing or punishing because of their relation to value statements

Empirical evidence: Values work is likely to be good for the client

Empirical evidence: Values work is likely to be good for the client

Values affirmation buffers the stress response


•All participants rank order values in terms of personal importance•Trier social stress task—involves telling subjects they will have to do stressful speech task and mental arithmetic.

Cresswall et al., 2005, Psychological Science



Affirmation manipulation•Answer question like: Assuming that you have sufficient ability, would you prefer to be (a) a banker (b) a politician•Experimental condition. Answered questions relating to top-ranked value•Control. Answers questions relating to fifth ranked value

Salivary cortisol response to stress in the value-affirmation and control groups

Salivary cortisol response to stress in the value-affirmation and control groups

Pretest and postest self-report stress measure, as function of self-resources (self-esteem and optimism)

Pretest and postest self-report stress measure, as function of self-resources (self-esteem and optimism)

Value affirmation improves objective performance


• Cohen et al., 2006, Science

• Theory

1. People are motivated to maintain self-integrity

2. Negative group characterizations (e.g., black stereotypes in U.S.) pose chronic threat to self-integrity

3. This threat, if too severe, can undermine performance



• Main study and replication

• Treatment and control condition presented a list of values

• Treatment condition: indicate most important values. Write about why value important to you

• Control condition. Indicate least important value and why this value might be important to someone else

Values clarification and tolerance for pain


Is their benefit to connecting pain-related thoughts to actions in a valued direction?

Paez-Blarrina, M. et al., 2007, Behavior Modification; Paez-Blarrina et al. ,2008, Behaviour Research and Therapy



Pain task

1.Perform cognitive task. If do well, get points, which can be exchanged for a reward at the end of the task.

2.Red asterisk appears on screen.

1. If choose “finish”, then task ends and no shock.

2. If continue, more chance for points but also a shock. (this is behavioural measure of pain tolerance)



Key Conditions•ACT-values protocol—depicted pain as a part of valued action•Control-values protocol—pain is opposed to valued living•No values protocol



Findings

•7/10 ACT-values intervention tolerated maximum number of shocks; Only 1/10 and 2/10 tolerated in the control and untrained condition, respectively.

•Pain believability. Do you keep going even when you think the task is causing you “very much pain.”

•9/10 kept going in ACT-values; Only 5/10 and 3/10 kept going in the control and untrained conditions respectively

•These differences were significant

Measuring and using values in therapy

Measuring and using values in therapy

ACT intervention Survey of Life Principles

Past research in valuesPast research in values

• Values work (Schwartz, et al., Rokeach et al.).

– What is most important to you?

– Are there Universal values?

• Personal strivings (Sheldon, Emmons, Deci).

– What do you strive for

– Why do you strive? Is it for authentic or controlled reasons?

• We will call both of these “guiding principles” for ease of reference

Towards a behavioural approach to values and goals: Recasting Needs

Towards a behavioural approach to values and goals: Recasting Needs

• Both value and striving literature seek to identify universal needs that underpin all guiding principles

• Need is identified by observing that positive psychological consequences result from conditions that allow its satisfaction and negative consequences accrue in situations that thrwart it (deci and ryan, 2001, pg 229)

• Instead of speaking in terms of “needs”, I will speak in terms of categories of reinforcer.

Towards a behavioural approach to values and goals: type of rule following


• Pliance- rule governed behavior under control of apparent speaker-mediated consequences for a correspondence between the rule and the relevant behavior. (Zettle and Hayes, 1982; Hayes, Wilson, and Stroshal, 2001)

• Factors that impact pliance

– ability of speaker to monitor compliance, and deliver consequences

– importance of consequences to listener

– others (history, credibility; Hayes and zettle)

• Problem with pliance. Excessive pliance, e.g., wanting to “be good” and please others, can dominate over ones direct, personal expeirence of what works

• Reinforcers are arbitrary



• Tracking- rule governed behavior under control of apparent correspondence between the rule and the way the world is arranged. (Zettle and Hayes, 1982)

• Factors that impact tracking

– Listeners history with the rule giver

– Correspondence between the rule and other rules or events in the listener’s history

– Importance of the consequence implied by the rule

– Extent rule successfully leads to reinforcement, avoid punishment

• Speaker does not mediate compliance (e.g., the rule could be conveyed by a book and have the same effect); (Hayes and Zettle, 1982)

Recasting Self-Determination Theory in behavioural terms.

Recasting Self-Determination Theory in behavioural terms.

Deci and Ryban, 2000, psychological science

Pliance Tracking

The ImPActS intervention modelThe ImPActS intervention model

Importance Important principles are expected to involve tracking

ACT can be used to help people discover what principles are or are not important to them.

Pressure ACT can be used to undermine the power of unhelpful, pliance-based principles

Activity ACT can be used to increase the amount of principle-congruent activity and the likelihood of contacting reinforcers

Success ACT can be used to increase people’s success at living principles (e.g., via overcoming barriers and reinforcing commitment)

Research on valuesResearch on values

• The area emphasizes the Importance component of the ImPActS model.

The structure of values (Schwarz)The structure of values (Schwarz)

Values and behaviourValues and behaviour

• ImPActS• Values importance has predicted more than 15

different behaviours• e.g., voting for political party, choosing a

university course• Other predicted behaviours: delinquency,

cooperation, competition, consumer purchasing, environmental behaviours, religious behaviours

(See Bardi and Schwartz, 2003)

Values and well-beingValues and well-being

• ImPActS

• The following were positively related to subjective well-being

– Achievement: Personal success through demonstrating competence according to social standards. (Successful, capable, ambitious, influential)

– Stimulation: Excitement, novelty, and challenge in life. (Daring, a varied life, an exciting life)

– Self-direction: Independent thought and action-choosing, creating, exploring. (Creativity, freedom, independent, curious, choosing own goals)

• Sagiv and Schwarz, 2000, Eur. Jn., of Soc. Psyc


• ImPActS

• The following were negatively related to well-being

– Conformity: Restraint of actions, inclinations, and impulses likely to upset or harm others and violate social expectations or norms. (Politeness, obedient, self-discipline, honouring parents and elders)

– Security: Safety, harmony and stability of society, of relationships, and of self. (Family security, national security, social order, clean, reciprocation of favors)

– Sagiv and Schwarz, 2000, Eur. Jn., of Soc. Psyc


• ImPActS

• The researchers failed to find a positive association of subjective well-being and

– Universalism: Understanding, appreciation, tolerance and protection for the welfare of all people and for nature. (Broadminded, wisdom, social justice, equality, a world at peace, a world of beauty, unity with nature, protecting the environment)

– Benevolence: Preservation and enhancement of the welfare of people with whom one is in frequent personal contact. (Helpful, honest, forgiving, loyal, responsible)

• Seemed inconsistent with the notion that concern for others rather than self promotes subjective well-being

• A false dichotomy?• Sagiv and Schwarz, 2000, Eur. Jn., of Soc. Psyc

Succeeding at what is important to you

Succeeding at what is important to you

• ImPActS

• Congruity between people's values and their environment promotes well-being, regardless of the particular values to which people ascribe importance.

• Power values were negatively associated with well-being amongst psychology students, and higher satisfaction amongst business administration students. The business folks were also happier the more they were into achievement values.

• Sagiv and Schwarz, 2000, Eur. Jn., of Soc. Psyc

Succeeding at what is important to youSucceeding at what is important to you

• ImPActS

• Life satisfaction influenced when satisfied in value-congruent domain.

• More specifically, global life satisfaction was strongly influenced by social life for individuals high in Benevolence values, whereas it was strongly influenced by family life for individuals high in Conformity values.

• Satisfaction with grades was a stronger predictor of global life satisfaction for individuals who stress achievement than for those who do not.

• Within-individual variation of day-to-day satisfaction is strongly influenced by daily success with the most valued domain.

• Oishi, et al., j of personality, 1999

Personal strivingsPersonal strivings

• Key Researchers: Sheldon, Emmons, Elliot, and Others

• Idiographic. People describe their own personal strivings and do not select from a set items, as in values work

• Emphasis on Self-concordance. To what extent do people pursue their goals because the goals fit with their underlying interests and values rather than because others pressure them to pursue the goal.

Universal “needs, “ or categories of reinforcer

Universal “needs, “ or categories of reinforcer

• Competence or “effectance—propensity to have an effect on the environment as well as to attain valued outcomes within it.

• Relatedness -- desire to feel connected to others, to love and care, and to be loved and care

• Autonomy refers to volition—the organisimic desire to self-organize experience and behavior and to have activity be concordant with one’s integrated sense of self

Personal strivings: key findingsPersonal strivings: key findings

• Self concordance relates to subjective well-being across many cultures (Sheldon, 2002; Sheldon et al., 2004)

• Longitudinal study. Making progress towards goals predicted well-being. However, this depended on the “organismic congruence” of the goal. That is, goal achievement led to increased well-being for those people who pursued goals for more autonomous reasons, and those goals that are oriented towards more intrinsic outcomes (Sheldon and Kasser, 1998)

• This relates to Importance and Pressure in the ImPActS model

Personal strivings: Avoidance goalsPersonal strivings: Avoidance goals

• Elliot and sheldon (1998) coded goals in terms of approach and avoidance

– Approach goals: get in good shape, be more gentle and humble

– Avoidance goals: avoid procrastination, don’t be lazy

• People with avoidance goals tend to feel less competent and in control and experience greater reporting of physical symptoms (Elliot and Sheldon, 1998)

• Elliot, Sheldon, and Church (1997) had students classify goals as approach oriented or avoidance oriented. Avoidance striving was deleterious to both retrospective and longitudinal well-being

The survey of life principles (SLP) The survey of life principles (SLP)

• Ciarrochi and Bailey, in press; Stefanic and Ciarrochi, 2008; Frearson and Ciarrochi, 2008

• The SLP attempts to combine the best parts of the values literature and the personal strivings literature, and attempts to do so in a way that is useful to clinic

• SLP provides people with wide variety of principles to choose from. This has the advantage of prompting people to think about principles they might have not considered for awhile, or might have forgotten

• SLP measures extent principle is due to self versus other pressure

The survey of life principles (SLP)The survey of life principles (SLP)

• 53 items, sampled to cover every major domain identified in values literature, goals literature, and job interests literature.

– Somewhat heavy emphasis on social principles, given their clinical relevance.

– Three items related to experiential control (e.g., “having a stress free life”)

• Principles written in a verb form, in keeping with the ACT definition of values as being “ongoing patterns of activity.”

• Principles were written to have maximal personal relevance (e.g., “A world of beauty” changed to “creating beauty”)

The survey of life principles (SLP)The survey of life principles (SLP)

• Items are call “principles”, because they could refer to either values or abstract goals (e.g., “being honest” might be either value or goal)

• Two open end items for people to write down own principles

Four dimensions of the SLPFour dimensions of the SLP

1) Importance. The extent a person finds princple to be personally imporant

2) Pressure. The extent person feels pressured to hold principle. Pressure can come from other people, groups, media, society, etc.

3) Activity. Each principle is rated in terms of whether the person wanted to put it into play

4) Success. If person wanted to put a principle into play, then they rated that principle in terms of their level of success.

SLP: Early findingsSLP: Early findings

• First study conducted with 300 University Students– We focused on variables of interest to clinicians: e.g.,

measures of emotional well-being, psychological well-being, social support, and relationship satisfaction

• The next study will be conducted later this year with 600 year 12 adolescents. We have been conducting a longitudinal study with these students for 7 years.– Includes broad range of measures related to social and

emotional well-being

– Involves ratings by peers and teachers

Each SLP global score makes a distinctive contribution to well-being

Each SLP global score makes a distinctive contribution to well-being

Description Low Score Mean High ScoreImportance Low scores indicate the

person finds few principles to be important

5.81 6.51 7.19

Female 5.90 6.57 7.24 Male 5.57 6.3 7.03Pressure High scores indicate the

person feels pressure from others to hold principles

3.14 4.54 5.98

Activity Low scores indicate that the person is putting reduced number of principles into play

23.63 31.18 38.73

Success Low scores indicate that the person is not succeeding at principles

3.05 3.48 3.91

SLP Global scores and emotional well being

SLP Global scores and emotional well being

Global score Positive Affect Sadness Hostility

Importance .10 .08 .11

Pressure -.10 .11* .12*

Activity .22** .01 -.09

Success .36** -.34** -.31**

Variance explained

23% 14% 12%

*p < .05; ** p< .01

Note: These are the Betas from regression analysis. All variables were entered simultaneously, so Beta represents the unique variance explained by each global score, after controlling for the other scores

SLP Global scores and Psychological well-being

SLP Global scores and Psychological well-being

Global score Autonomy Relations with others

Purpose

Importance -.12* .08 .27**

Pressure -.25** -.15** -.12*

Activity .11 .04 .14**

Success .30** .36** .39**

Variance explained

18% 18% 29%

*p < .05; ** p< .01

Note: These are the Betas from regression analysis. All variables were entered simultaneously, so Beta represents the unique variance explained by each global score, after controlling for the other scores

Predicting social wellbeingPredicting social wellbeing

Global score Romantic relationship satisfaction

Social support numbers

Social support satisfact.

Global Success .12 .09 .18*

Prosocial Import. .24** .07 .12*

Having genuine and close friends-success

.00 .20** .14*

Having relationships involving love and affection-success

.41** -.04 .21**

Variance explained 32% 7% 20%

*p < .05; ** p< .01

Note: The global score “success” was the only one to uniquely predict each of the social well-beings. However, prediction was much improved by using the more specific social principles

Resisting pressure?Resisting pressure?

One needs to look at local as well as global indices

One needs to look at local as well as global indices

• Importance of power not related to well-being. Indeed , it is related to higher hostility

• Importance of wealth was not related to well-being

Top 10 most important valuesTop 10 most important values

1 Having genuine and close friends

2 Being loyal to friends, family, and/or my group

3 Maintaining the safety and security of my loved ones

4 Having relationships involving love and affection

5 Feeling good about myself (experiential control item)

6 Striving to be a better person

7 Experiencing positive mood states (experiential control item)

8 Being Honest

9 Having an enjoyable, leisurely life

10 Being safe from danger

Top 10 most pressured valuesTop 10 most pressured values

1 Meeting my obligations

2 Being ambitious and hardworking

3 Being physically fit

4 Showing respect to parents and elders

5 Eating healthy food

6 Being honest

7 Being self-sufficient


9 Being competent and effective


Top 10 most successful valuesTop 10 most successful values

1 Being loyal to friends, family, and/or my group

2 Enjoying food and drink


4 Having genuine and close friends

5 Being honest

6 Maintaining the safety and security of my loved ones

7 Making sure to repay favors and not be indebted to people

8 Showing respect to parents and elders

9 Having relationships involving love and affection

10 Enjoying music, art, and/or drama

Top 10 failuresTop 10 failures1 Leading a stress free life (experiential control)

2 Having a sense of accomplishment and making a lasting contribution

3 Promoting justice and caring for the weak

4 Gaining wisdom and a mature understanding of life

5 Being wealthy

6 Being at one with god or the universe

7 Feeling good about myself (experiential control)


9 Being physically fit

10 Having an enjoyable, leisurely life

13 Experiencing positive mood states (experiential control)

Note: Failure index= Importance – success.

Principle compatibilities and incompatibilities

Principle compatibilities and incompatibilities

Principle

• Having genuine and close friends

Perceived compatibilities

• Being loyal to friends, family, and/or my group

• Having relationships involving love and affection

• Emotion control principles (e.g., Leading a stress-free life, feeling good about myself)

Perceived incompatibilities

• Gaining wisdom and a mature understanding of life

• Artistic principles

Comment

• Surprising disconnect between many pro-social principles (e.g., honesty) and friendship

Principle

• Having relationships involving love and affection

Perceived Compatibilities

• Having genuine and close friends

• Maintaining the safety and security of my loved ones

• Being sexually active

• Being safe from danger


• Sensation seeking principles (Having a life filled with adventure)

• Nonsocial activities (Building and repairing things; working outdoors)

Comment

• Where are the prosocial virtues? Honesty, loyalty, helping others

Principle

• Prosocial : Being loyal, honest, maintaining security and safety of loved ones, respecting parents and elders, helping others


• Being safe from danger

• Resolving disputes

• Showing respect for tradition


• Power (e.g., having influence; having authority, being in charge)

• Sensation seeking

• Artistic

Principle

Being wealthy

Perceived Compatibilities• Power principles• Sensation seeking principles• Achievement principles• Being sexually active; being sexually desirable (both M and F)• Emotion control


• Helping others

• Being at one with nature

• Being at one with god

• Being artistic

• Promoting justice and caring for the weak

Principle

Power: having influence of people, having authority, being in charge


• Achievement principles (e.g., being ambitious and hard working)

• Being sexually desirable


• Being honest

• Respecting parents and elders

• Helping people

• Being at one with nature

• Being at one with god, practicing religion

• Promoting justice and caring for the weak

Utilizing the SLPUtilizing the SLP

Importance ratings

1. What do clients value most? What is likely to be the subject of therapy

2. Values themes. Social. Power. Art? Achievment

3. Look out for low global values ratings. Might suggest a client has no idea what they value, or refuses to acknowledge values

Likely intervention:Values clarification (see card sorting task)


Restricted range of principles• Clients may endorse very few principles as

important.

• They may endorse several as important, but state that they have not tried to put them into play.

• Finally, they may rate a number of value clusters as unimportant

• What are the barriers to putting the values into play?

Likely interventions: acceptance, defusion, or overcoming practical barriers?


Dominance of experiential control items

• High importance on experiential control dimension

• Nothing inherently wrong with experiential control, unless in conflicts with other important principles

Likely interventions: Creative hopelessness, acceptance


Presence of strong pressure

• Research suggests that pressured principles tend not to lead to vital living or well-being (Sheldon & Kasser, 1995) and tend to be associated with hostility and sadness (Stefanic & Ciarrochi, 2008).

• Danger of contercompliance: In reaction to pressure, the client refuses to act according to the principle, or acts contrary to the principle


Presence of strong pressure: Interventions

• Therapist behaviours: acting with humility in session, undermining your own authority, encouraging clients to not believe anything you say

• Remove source of pressure. E.g., imagine nobody knew you were living the principle. Would you still live it?

• Seek to identify past experience that was vital. E.g., sweet spot exercise. Connect their valued statements to this vital past

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