ACT

DEPRESSION
Rob Zettle, Ph.D.
Wichita State University

EXERCISIOS
INICIALES

OBJECTIVOS
At the end of the session, participants
will be able to:
1. Identificar and clarificar valores de la
depression.
2. Identify el proceso y la esencia de
por que los valores pierden su poder y
no podemos cambiar.
3. Aplicar las tecnicas apropiadas que
daran a nuetra vida mas valor y
sentido.

RULES
ACT Es como nadar Se aprende
haciandolo,
Structure de la presentacion:
Didactic y Experiencial:

La historia de tu
DEPRESSION
Durante 5 minutos por favor escriba
la historia de su depresion:
Cuando y por que empezo,
Como la sufre, ( sus sintomas)
Eventos que la han mantenido

El MODELO DE
ACT
CONTRA LA
DEPRESION

The Primary ACT Model of Treatment

Contact with the
Present Moment

Values

Acceptanc
e
Psychologi
cal
Flexibility

Committed
Action

Defusion

Self as Context

EXERCISIO

EL ORIGEN DE INFLEXIBILIDAD
PSYCHOLOGICAL
Estancado, sin poder personal
Inhabilitado para hacer cambios y asi
poder escojer varios caminos que
nos lleven a vivir una vida valiosa y
productiva.
Persistencia Difuncional
Rigidez Cognitiva y conductual

QUE ES LA DEPRESSION
Depresin = Tanto la conducta manifiesta y eventos privados
(pensar y sentir)
= Una lucha contra las sensaciones y la manera
correcta de sentir.
= Secundaria, emocin reactiva
= Dolor de esfuerzos infructuosos para controlar el
dolor que causa la disforia, la tristeza, la culpa, y el duelo.
No todos los casos de depresin son tratados tilmente con
ACT como la intervencin primaria (por ejemplo, dficit de
habilidades sociales)

TRABAJAR CON TIPOS

DE SUFRIMIENTO
TYPES OF SORROW:
1. Actual Loss of What Once Had
2. Projected Loss of What Have Now
3. Constructed Loss of What Could Have
Had

ACTUAL LOSS OF WHAT

ONCE HAD
Comparison of Now to a Preloss Past
Role of rumination: Living in a
Regretted Past
Poster child of complicated
bereavement
Grief = Bereavement
Grief + Rumination = Complicated
Bereavement

PROJECTED LOSS OF
WHAT HAVE NOW
Comparison of Now to a Bereft Future
Role of worrying: Living in a Dreaded
Future
When I get older, losing my hair
many years from now, will you still
be sending me a Valentine, birthday
greetings, bottle of wine?
Will you still need me, will you still
feed me, when Im 64? The
Beatles

CONSTRUCTED LOSS OF
WHAT COULD HAVE
HAD
Comparison of Actual Now to What
Now Might Have Been
Living in a Unfulfilled Present
You can lose what you never had.
Muddy Waters
I coulda had class. I coulda been a
contender. I coulda been somebody
instead of a bum, which is what I
am. - Terry Malloy (Marlon Brando)
in On the Waterfront

FUNCTIONS OF
DEPRESSION
Why is depression problematic?
1. Clients cant stand feeling that
way drives experiential control
agenda.
2. Clients want to be normal
suggests fusion with self-asconcept.
3. Client are prevented for certain
activities - serves as barrier to
committed, valued behavior.
Different forms of depression (e.g.,
MDD vs. DD vs. DDNOS) may serve

PRIMARY PATHWAY TO
DEPRESSION: DYSPHORIA
Dysphoria as natural,
psychologically-healthy, and
normal mood fluctuation
Functions:
Adaptive response to unpropitious
situations in which efforts to
pursue a major goal will likely
result in danger, loss, bodily
damage, or wasted effort (Neese,
2000)

The Primary ACT Model of Psychopathology

Dominance of the
Conceptualized Past and Feared Future
Weak Self-Knowledge
Lack of Values Clarity;
Dominance of Pliance
and Avoidant Tracking

Experiential
Avoidance
Psycholog
ical
Inflexibilit
y

Inaction,
Impulsivity, or
Avoidant
Persistence

Cognitive
Fusion

Attachment to the
Conceptualized Self

discussed and summarized.

1. EXPERIENTIAL
AVOIDANCE AND
RUMINATION
Rumination = Experiential Avoidance
Attempts to solve the problem of feeling bad
by figuring it out.
Exacerbates dysphoria/sorrow into dirty pain
of clinical depression.
Effects of Rumination:
Increase in depressed mood
Reduction in generation of effective solutions,
confidence in them, and likelihood of
implementation
Perpetuation of rumination and perception of its
insight-value

The Primary ACT Model of Psychopathology

Dominance of the
Conceptualized Past and Feared Future
Weak Self-Knowledge
Lack of Values Clarity;
Dominance of Pliance
and Avoidant Tracking

Experiential
Avoidance

Psycholog
ical
Inflexibilit
y
Inaction,
Impulsivity, or
Avoidant
Persistence

Cognitive
Fusion

Attachment to the
Conceptualized Self

2. RUMINATION AND
FUSION
Fusion = Dominance of derived stimulus
functions over those arising from direct
contingencies
Evaluating: Increases self-criticism and
negative self-referential thoughts
Reason-giving: Asking and answering why?
increases self-blame
Story telling: Increases arbitrary verbal
constructions that make sense of
evaluating and reason-giving

PRIORITY OF BEING
RIGHT
1.

Life story as reason-giving on a grand scale.

2.

Getting better may be incompatible with a life story of

being wronged
(Given the way I was mistreated, I have every right to be
depressed.)
(Anyone who had to undergo what Ive had to put up with
would be depressed.)
Transgressors not worthy of forgiveness

3.

Being right more important than getting better

Being right and holding other accountable trumps getting
better
Can also extend to holding oneself accountable and
withholding of forgiveness

4.

Possible additional function of suicidal behavior (revenge,

getting even)
(Theyll be sorry when Im gone.).

The Primary ACT Model of Psychopathology

Dominance of the
Conceptualized Past and Feared Future
Weak Self-Knowledge
Lack of Values Clarity;
Dominance of Pliance
and Avoidant Tracking

Experiential
Avoidance

Psycholog
ical
Inflexibilit
y
Inaction,
Impulsivity, or
Avoidant
Persistence

Cognitive
Fusion
Attachment to the
Conceptualized Self

3. FUSION WITH A
FLAWED
CONCEPTUALIZED SELF
Rumination produces increased
negative self-evaluation.
Fusion with flawed, conceptualized
self.
Self-worth = Life worth
Precludes contact with a transcendent
sense of self:
If I (self as context) = me
(conceptualized self), and me =

FUSION + EXPERIENTIAL
AVOIDANCE = SUICIDE
Suicide as the ultimate experiential
escape act.
If life = suffering
No life = no suffering
And no life = death,
Then death = no suffering
Because of fusion with the damaged
conceptualized self, killing yourself
is taken

The Primary ACT Model of Psychopathology

Dominance of the
Conceptualized Past and Feared Future;
Weak Self-Knowledge
Lack of Values Clarity;
Dominance of Pliance
and Avoidant Tracking

Experiential
Avoidance

Psycholog
ical
Inflexibilit
y
Inaction,
Impulsivity, or
Avoidant
Persistence

Cognitive
Fusion

Attachment to the
Conceptualized Self

4. LIVING IN A
REGRETTED PAST AND
DREADED FUTURE
Rumination also incompatible with
mindfully living in the present
moment by:
Increased recall of and fusion with
previous negative life events
Increased construction of and fusion
with a pessimistic future

The Primary ACT Model of Psychopathology

Dominance of the
Conceptualized Past and Feared Future;
Weak Self-Knowledge
Lack of Values Clarity;
Dominance of Pliance
and Avoidant Tracking

Experiential
Avoidance

Psycholog
ical
Inflexibilit
y
Inaction,
Impulsivity, or
Avoidant
Persistence

Cognitive
Fusion

Attachment to the
Conceptualized Self

5. EXCESSIVE RULEFOLLOWING
Obscures values and limits valued
living
Two types of RGB that contribute to
psychological inflexibility:
Pliance Under the control of
socially-mediated
consequences for doing what one
is told to do and should do.
Avoidant Tracking Under the
control of naturally occurring

The Primary ACT Model of Psychopathology

Dominance of the
Conceptualized Past and Feared Future;
Weak Self-Knowledge
Lack of Values Clarity;
Dominance of Pliance
and Avoidant Tracking

Experiential
Avoidance

Psycholog
ical
Inflexibilit
y
Inaction,
Impulsivity, or
Avoidant
Persistence

Cognitive
Fusion

Attachment to the
Conceptualized Self

6. PURSUIT OF VALUEINCONGRUENT GOALS

Through pliance, do what is expected or
what one is supposed to do
Feeling dispirited, disengaged from life, and
unfulfilled as natural consequence of
pursuing
and successfully attaining valueincongruent
goals.
Success depression: Midlife is when you
reach

6. FAILURE TO PURSUE
VALUE-CONGRUENT
GOALS

1.Avoidant tracking leads to leading a

cautious, risk-averse approach to living.
2.Initial depression may be maintained and
exacerbated by withdrawal from pursuit
of value-congruent goals
(It takes too much effort to do X. Why
waste my time.
3.Complicated by ruminative coping style
that implicates
conceptualized self.
(Whats wrong with me?)

The Primary ACT Model of Treatment

Contact with the
Present Moment

Values

Acceptanc
e
Psychologi
cal
Flexibility

Committed
Action

Defusion

Self as Context

NATURE OF
PSYCHOLOGICAL
FLEXIBILITY
Involves the ability to:
Defuse from problematic private
events
Accept private experience for what
it is
Stay in touch with the present
moment
Differentiate a transcendent self
from the contents of

CASECONCEPTUALIZATION
APPROACH

Guided by hexaflex and level of

functioning
Lower: Follow same order as
hexainflex
Higher: Follow reverse order of
hexainflex
Three major steps:
1. Values identification and
clarification
2. Identify variables and processes

The Primary ACT Model of Psychopathology

Dominance of the
Conceptualized Past and Feared Future
Weak Self-Knowledge
Lack of Values Clarity;
Dominance of Pliance
and Avoidant Tracking

Experiential
Avoidance
Psycholog
ical
Inflexibilit
y

Inaction,
Impulsivity, or
Avoidant
Persistence

Cognitive
Fusion

Attachment to the
Conceptualized Self

discussed and summarized.

1. IDENTIFYING AND
CLARIFYING VALUES
Values = Verbally construed global
desired life consequences
Process, not an outcome
Distinguishable from goals
Questions to ask?

IDENTIFYING VALUING:
KEY QUESTIONS
What are your goals in coming to
therapy?
If you no longer struggled with
depression, how would your life be
different?
What in life is so important to you
that you would be willing to
experience depression to get it?
Whats the worst thing for you about
being depressed?

IDENTIFYING VALUING:
OTHER MEANS
Follow the suffering
Lifes joys and misery walk hand-inhand and keep each other company.
- Donovan
Revisiting childhood wishes
Whose life do you admire?
What do you want your life to stand
for? (eulogy exercise)
Epitaph exercise

CLARIFYING VALUING
Assess for pliance/counterpliance
from multiple sources of control:
Societal/cultural: What if no one
knew?
Parental: What if parents never
knew?
Therapist: What if I said X was a
waste of time?
Assess for avoidant tracking

CLARIFYING VALUING
Magic Pill Metaphor
Helps clarify distinction between
values as a process and related goals
as an outcome
Choose between a guaranteed
outcome (goal) inversely related to
process (value) vs.
commitment to a process (value)
with no assured outcome (goal)

MAGIC PILL METAPHOR

Example:
Magic pill if taken by children cause
them to see you as a loving, caring
parent only if you are increasingly
mean to them vs.
Commitment to the process of being
a loving, caring parent with no
guarantee that children will ever see
you that way

2. ASSESSING VALUED
ACTION
Level of valued action not equal to
overall activity level
Three major questions:
What are you already doing that is
value-congruent?
What else could you be doing?
What is stopping you?

3. INCREASING VALUED
ACTION: REFRAMING
Client may already be engaging in
valued action that has been
overlooked, not counted
I long to accomplish a great and
noble task, but it is my chief duty to
accomplish humble tasks as though
they were great and noble. Helen
Keller
Valuing may have been obscured by
pliance and avoidant tracking.

INCRREASING VALUED
ACTION: AUGMENTING
Formative Augmenting:
Infinite number of ways in which to
enact values.
Places small activities (changing a
dirty diaper) in hierarchical frames
with valuing (being a caring parent):
X is an instance of Y.
Motivative Augmenting:
Dignifies suffering in service of
valuing: Would you be willing to be

RELATED EXERCISE
Form groups of 3
Rotate following roles through 5
minute role-plays each:
Therapist Identify and clarify
clients values, smallest valued
action willing to take, and
associated barriers.
Depressed client Can be self or
client
Consultant Assist therapist,

3. INCREASING VALUED
ACTION: REMOVING
BARRIERS
Addresses other points on the hexaflex
Defusion
Acceptance
Mindfulness
Self as context/self as perspective
Approach in case conceptualization
manner

DEFUSION
CHALLENGES
Rumination in depression
instrumental in multiple levels of
fusion with its byproducts:
Life-story
Reason-giving
Automatic thoughts

DEFUSING THE LIFE

STORY WITH
DEPRESSION

Rewrite your life story with

depression
Take the earlier life story written at
the start of this session and first
underline the facts (including the
presence of sorrow) that it
contained.
Take these same facts and weave
them into a different story about
them that does not result in

DEFUSING AUTOMATIC
THOUGHTS
Taking Inventory Exercise
Separately list various reactions to
depressing situations.
Preface each class or category of
experiences with I have . . . (the
thought that, a feeling of, a
sensation of, the memory of,
etc.) . . .
Milk, milk, milk Exercise
Bad cup metaphor

SHAPING ACCEPTANCE
Experiential discrimination training:
Tug-of-war with the Sorrow Monster
Demonstrate multiple ways of
both pulling and dropping the rope
Carrying your sorrow
Repeat prn.

STRENGTHENING
MINDFULNESS
Experientially shaped by series of
exercises:
Raisin exercise
Walking, performing other daily
activities
Awareness of the breath
Watching your thoughts
Indirectly promotes self-as-context:
Noticing noticing

ENHANCING SELF-ASCONTEXT
Direct means of strengthening
perspective taking:
Chessboard metaphor
Observer exercise

FOR FURTHER INFO

Association for Contextual Behavioral Science (ACBS) website

www.contextualpsychology.org/acbs
Value-based dues
Educational and training materials and info
New Harbinger website: www.newharbinger.com
Chiles, J. A., & Strosahl, K. D. (2005). Clinical manual for
assessment and treatment of suicidal clients. Washington,
D.C.: American Psychiatric Publishing.
Strosahl, K. D., & Robinson, P. (2008). The mindfulness and
acceptance workbook for depression. Oakland, CA: New
Harbinger.
Zettle, R. D. (2007). ACT for depression: A clinicians guide to
using acceptance and commitment therapy in treating
depression. Oakland, CA: New Harbinger.