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درمان پذیرش و تعهد برای درمان افسردگی

Acceptance and Commitment Therapy for the Treatment of Depression


*The reference tomanual’ refers to Rob Zettle’s  “Complete ACT  Manual” (for Depression) available in the protocol section of the ACBS website

 

 

Sessions should follow the following format:

  • Brief Update and Mood Check
  • Bridge from Previous Session
  • Set Agenda
  • Review Homework
  • Potential supporting exercises (see below)
  • Final Summary
  • Assign Homework
  • Feedback

 

Session-by-Session Information: Objectives, Possible Strategies, and Suggested Homework Assignments

            Note: The therapist should attempt to move sequentially through the below list of components while recognizing that to maximize the fit to the client’s issues, it may be necessary to alter the exact sequence of components, as well as omit or revisit certain components.  It is to be expected that some of these components would be discussed over multiple sessions.

 

Session 1

  • Objectives:
    • The objective of this session is to induce Creative Hopelessness (Zettle manual p.2) by soliciting goals and failed attempts to achieve those goals as a way of examining the unsuccessful client’s use of control strategies to cope with depression. The therapist should also begin to understand the depression presentation from an ACT perspective (examples of fusion, emotional control strategies, distance from values).
  • Potential supporting exercises:
    • Solicit basic goals from the client
    • Solicit past attempt to accomplish those goals
    • Digging out of the Hole Metaphor (Zettle manual p.4)
    • Introduce the idea of the “unworkable system”
    • Option to move ahead to “control as the problem” (time permitting)
  • Homework:
    • Daily Experiences Diary

 

Session 2

  • Objectives:
    • The objective of this session is to elaborate on the prior session’s conclusion that the client’s depressive state shows limited responsiveness to control strategies. Experiential exercises should be used to further test the efficacy of control strategies. Therapist should introduce the idea that “control is the problem, not the solution.” The therapist should also teach client about the relationship between depressed mood and behavior using examples from the client’s own life, and aim to increase the client’s engagement in activities to engender a sense of mastery or pleasure.
  • Potential supporting exercises:
    • Control as the problem/Control of private events (Zettle manual p.9)
    • Polygraph Metaphor (Zettle manual p.10)
    • Jelly Donut Metaphor (Zettle manual p.10)
    • Tug of War with Monster (Zettle manual p.11)
    • Rationale for behavioral activation (to make life fuller and richer, to interrupt avoidance patterns as opposed to changing thoughts and feelings)
    • Initial behavioral goal setting
    • Option to move ahead to Willingness (time permitting)
  • Homework:
    • Performance of initial identified behavioral goal
    • Daily Willingness Diary (or postpone to session 3 as necessary)

 

Session 3

  • Objectives:
    • The objective of this session is to continue to drawn on the client’s experience to strengthen the recognition that “control is the problem,” and to introduce Willingness to experience depression as an alternative to control. Therapist should also troubleshoot difficulties with behavioral activation, so as to increase the likelihood of the client’s success.
  • Potential supporting exercises:
    • Apparent success of deliberate emotional control
    • Programming of private events: What are the Numbers Exercise? (Zettle manual p.15)
    • Willingness as an alternative to control: Two Scales Metaphor (Zettle manual p.16)
    • Costs of unwillingness: Dirty Distress/Pain revisited (Zettle manual p.17)
    • Box Full of Stuff Metaphor (Zettle manual p.18)
    • Identification of simple behavioral goal requiring Willingness (ACT Practical Guide p.97-99)
  • Homework:
    • Clean Vs. Dirty Distress Diary
    • Performance of identified behavioral goal
    • Daily Willingness Diary (if not completed in Session 2)

 

Session 4

  • Objectives: 
    • The objective of this session is to introduce the idea of Defusion from depressive thoughts and feelings.  The therapist should introduce strategies that enhance defusion and deliteralization in the service of increased Willingness.
  • Potential supporting exercises:
    • Your Mind is not Your Friend Exercise (“and you can’t do without it”) (Zettle manual p.20)
    • Milk, Milk, Milk Exercise (Zettle manual p.21)
    • Passengers on the Bus (Zettle manual p.22)
    • Leaves on a Stream (Mindfulness) (Zettle manual p.24)
    • Identification of simple behavioral goal requiring  Defusion and Willingness
  • Homework:
    • Mindfulness Practice
    • What is Mindfulness Handout
    • Performance of identified behavioral goal

 

Session 5

  • Objectives:
    • The objective of this session is to assess the client’s ability to defuse from depressive thoughts and feelings and to introduce additional practical ways to foster defusion.
  • Potential supporting exercises
    • Undermining reasons as causes: Dishes of Ice Cream Exercise (Zettle manual p.29)
    • “And” versus “but” (Zettle manual p.29)
    • “I’m having the thought that . . .”
    • Mindfulness exercise revisited (Zettle manual p.24)
    • Identification of simple behavioral goal requiring Defusion and Willingness
  • Homework:
    • Reasons as Causes (Zettle manual p.33)
    • Mindfulness Exercise continued (Zettle manual p.24)
    • Performance of identified behavioral goal

 

Session 6

  • Objectives:
    • The objective of this session is to introduce the distinction of the Conceptualized vs. Observing Self.  The Observing Self should be recognized as the perspective from which defusion and mindfulness occur.
  • Potential supporting exercises
    • Mental Polarity Exercise (Zettle manual p.34)
    • Chessboard Analogy (Zettle manual p.36)
    • Observer Exercise (Zettle manual p.37)
    • Identification of simple behavioral goal requiring Defusion and Willingness
  • Homework
    • Mindfulness Exercise continued (Zettle manual p.24)
    • Performance of identified behavioral goal

 

Session 7

  • Objective:
    • The objective of this session is to introduce the importance of values and for the client to understand how “values dignify Willingness.” Client should understand how Willingness is critical for behavioral activation.
  • Potential supporting exercises:
    • Introduction to values (Zettle manual p.42)
    • Valuing as acting versus feeling: Argyle Socks exercise (Zettle manual p.43)
    • Choosing values: Choices vs. Judgments/Decisions (Zettle manual p.44)
    • Identification of values: Funeral Exercise/Tombstone Exercise (Zettle manual p.45-6)
    • Identify a valued action (behavioral goal) to perform this week
  • Homework:
    • Valued Direction Worksheet
    • Mindfulness Exercise continued (Zettle manual p.24)
    • Performance of identified valued action

 

Session 8

  • Objectives:
    • The objective of this session is to help the client continue to identify life domains where he/she is not living fully according to personal values. Client should continue to understand that values are a source of commitment to apply Willingness in the service of behavioral activation and personal goals.
  • Potential supporting exercises:
    • Discuss relationship between goals and values (Zettle manual p.48)
    • Discuss relationship between process and outcome: Skiing Metaphor (Zettle manual p.52)
    • Identify a valued action (behavioral goal) to perform this week
  • Homework
    • Performance of identified valued action

 

Session 9

  • Objectives:
    • The objective to explore the relationship between goals and actions, and to firmly root components of Willingness and Defusion in the service of achieving behavioral goals.
  • Potential supporting exercises
    • Identification of actions steps (smaller goals in the service of the larger ones)
    • Role of choice in committed actions (review choice vs. judgments/decisions): Gardening Metaphor (Zettle manual p.56)
    • Barriers to goals and willingness to accept them: Bubble in the Road Metaphor (Zettle manual p.57)
    • Identify a valued action (behavioral goal) to perform this week
  • Homework:
    • Behavioral Activation (commit to achieving identified smaller goals)
    • Performance of identified valued action

 

Session 10 (and subsequent sessions without impending termination)

Objectives

  • Objectives:
    • Continue to emphasize the components most relevant to specific client issues. Homework should continue to feature Behavioral Activation in the form of making commitments to specific actions that are inspired by the client’s larger goals and values.
  • Possible Strategies:
    • Unwanted Visitor (a.k.a. Joe the Bum Metaphor) (Zettle manual p.62)
    • All-or-nothing nature: Jump Exercise (Zettle manual p.63)
  • Homework:
    • Homework should continue to feature Behavioral Activation in the form of making commitments to specific actions that are inspired by the client’s larger goals and values.

 

Session 11 (one session prior to termination)

  • Objectives:
    • To teach the client to be his or her own therapist. To maximize the likelihood that the client will continue to apply skills learned in therapy after termination. To address client’s concerns about termination, if applicable. To prepare for post-termination setbacks.
  • Possible Strategies:
    • Preparation for Termination
    • FEAR algorithm for identification of barriers (Zettle manual p.67)
    • ACT algorithm for committed action (Zettle manual p.70)
  • Suggested Homework Assignments:
    • Develop a post-treatment plan
    • Record goals for self (i.e., in 1 month, 6 months, 1 year)
    • Behavioral activation

 

Session 12

  • Objectives:
    • To reflect on progress made and client’s continuing goals.
  • Possible Strategies:
    • Two Mountains Metaphor (Zettle manual p.64)
    • Discuss and refine post-treatment plan
    • Termination

 

 

 

References

 

Zettle, R.  Complete ACT Manual. Unpublished.

 

 

 

 

 

 

Appendix

 

Metaphor Description Prompts

 

Argyle Socks exercise (Zettle manual p.43) – An exercise to help the client appreciate the difference between choices and judgments and that it is not necessarily to feel a certain way in order to choose a behavior that supports a value.

 

Box Full of Stuff Metaphor (Zettle manual p.18)

 

Bubble in the Road Metaphor (Zettle manual p. 57) - A metaphor for barriers to goals and willingness to accept them:

 

Chessboard Analogy (Zettle manual p.36) – The idea of the client being at the” level of the chessboard” supports the concept of the observer self.

 

Digging out of the Hole (Zettle p. 4) – The client has fallen down into a hole and has only a shovel

 

Dirty Distress/Pain revisited (Zettle manual p.17) – Clean Distress is a product of living, while Dirty Distress is our response to/reaction to Clean Distress.

 

Dishes of Ice Cream Exercise (Zettle manual p.29) – A preference for an ice cream flavor serves to identify our habits around providing reasons as causes...

 

Funeral Exercise/Tombstone Exercise (Zettle manual p.45-6) - two exercises that facilitate the identification of values and contrast a value-directed life with one driven by avoidance

 

Gardening Metaphor (Zettle manual p.56) – A metaphor about how lack of commitment and continually beginning again undermines our movement in a valued direction.

 

Jelly Donut Metaphor (Zettle manual p.10) -  Patient is asked not to think about delicious jelly donuts as a way of appreciating the limitations of the control agenda.

 

Jump (Zettle manual p.67) – The nature of Willingness requires 100% commitment, but can choose when and where you are going to be willing.

 

Leaves on a Stream (Mindfulness) (Zettle manual p.24) – A metaphor to facilitate mindfulness meditation practice.

 

Mental Polarity Exercise (Zettle manual p.34)

 

Milk, Milk, Milk Exercise (Zettle manual p.21) – Excessive repetition of language decontextualizes the words and reminds us that words as descriptions are qualitatively different from experiences.

 

Observer Exercise (Zettle manual p.37) – The client is asked to share three different memories from different phases of life and in which one, to consider who was noticing how the client was feeling in that moment. Contrast with the conceptualized self.

 

Passengers on the Bus (Zettle manual p.22) – The image of driving a bus full of rowdy passengers remind us of the cost of trying to control distressing private events and the benefits  of choosing to focus on a chosen action.

 

Polygraph Metaphor (Zettle manual p.10) – The idea of being attached to a sensitive instrument that monitors anxiety helps the patient appreciate the limitations of the control agenda.

 

Skiing Metaphor (Zettle manual p.52) – This metaphor reminds the patient that, even as we focus on meeting our behavioral goals, it is the process that is more important than the goal.

 

Tug of War with Monster (Zettle manual p.11) – An endless battle with a monster of distress reveals the hopelessness of the situation and points toward the possibility of a creative alternative.

 

Two Mountains Metaphor (Zettle manual p.64)  – This metaphor involves seeing one’s path up a mountain form the perspective of someone watching from afar on a different mountain.

 

Two Scales Metaphor (Zettle manual p.16) – We have two scales, anxiety/depression and Willingness, but we only have control of the latter.

 

Unwanted Visitor (a.k.a. Joe the Bum Metaphor) (Zettle manual p.62) – This metaphor in which the client is hosting a party reminds us of the costs of being unwilling to experience distressful private events.

 

What are the Numbers Exercise? (Zettle manual p.15) – This exercise helps the patient realize how verbal memory cannot be erased, but can only be added to.

 

Your Mind is not Your Friend Exercise (“and you can’t do without it”) (Zettle manual p.20)

 

 

 

Handouts

 

Daily Experiences Dairy

Daily Willingness Diary

Distress Diary

Reasons as Causes

What is Mindfulness?

 

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