Acceptance and Commitment Therapy for PTSD Veteran
Transcript Of Acceptance and Commitment Therapy for PTSD Veteran
Acceptance and Commitment Therapy for PTSD
Veteran Manual
Regan Settles, Ph.D. Beth Morris, Ph.D. Kristi Bratkovich, Ph.D.
Acknowledgements
Portions of this manual were adapted from or influenced by the following sources: Follette, V.M., & Pistorello, J. (2007). Finding Life Beyond Trauma: Using A cceptance and
Commitment Therapy to Heal Post-Traumatic Stress and Trauma-Related Problems. Oakland, CA: New Harbinger Publications. Harris, R. (2009). A CT Made Simple: A n easy-to-read Primer on Acceptance and Commitment Therapy. Oakland, CA: New Harbinger Publications. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). A cceptance and commitment therapy: an experiential approach to behavior change. New York: Guilford Press. Hayes, S. C., & Strosahl, K. D. (Eds.). (2005). A practical guide to acceptance and commitment therapy. New York: Springer Science. Hayes, S.C., & Smith, S. (2005) Get of Y our Mind and Into your Life. Oakland, CA: New Harbinger. Juariscio, A., Shaw, J., Forman, E., Timko, C.A., Herbert, J., Butryn, M., & Lowe, M. (2010) The WE-ACT Group: Weight and Eating Applications of Acceptance-Based Treatments. Unpublished Manual. Kabat-Zinn, J. (1994). W herever you go, there you are: Mindfulness Meditation in Everyday Life. New York: Hyperion. Stahl, B., & Goldstein, E. (2010). A Mindfulness-Based Stress Reduction Workbook. Oakland, CA: New Harbinger. Walser, R.D. & Westrup, D. (2007). A cceptance and Commitment Therapy for the Treatment of Post Traumatic Stress Disorder and Trauma-related Problems. Oakland, CA: New Harbinger Publications. Portions of session 10 were also adapted from sources on Dr. Russ Harris’ website: www.thehappinesstrap.com The authors would also like to thank Chase Bailey, Ph.D. for his assistance early versions of this manual.” This work was supported by a clinical educator grant from the VA South Central Mental Illness Research, Education and Clinical Center (MIRECC)
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Group Guidelines
Confidentiality Everything you discuss in group is confidential with two exceptions: (1) If you report any plans to hurt yourself or someone else and (2) If you report any abuse. In both of these cases, group leaders are legally required to break your confidentiality to protect you and/or others While your group leaders are bound to confidentiality, group members are not. By participating in this group, we ask you to keep this a safe space by keeping everything that your fellow group members discuss private.
Respect We are all unique people and will have different points of view. Please respect others who think differently than you do. Please also respect that people process their trauma at different paces.
Be on time We have a lot to discuss in this group! If you are more than five minutes late, please enter quietly to avoid disruption. Please also be aware that we may not be able to catch you up on missed content.
Missing sessions If you miss more than two weeks of the group, we will ask you to discontinue and start again during another group. This is because missing more than two sessions will result in you not receiving adequate exposure to the group content.
Staying on Topic Most people have numerous problems going on in their lives. While we view all of this as important, our focus in this group is on posttraumatic stress symptoms. If we redirect you during group, it is not because what you are saying is wrong. Instead, it is because we have limited time and want to make sure that we focus on the purpose of the group. You may also bring something up that is on topic and important, but that we cannot fully address as a group. In these instances, you may asked to address the topic with an individual therapist or group leader outside of the group session.
Homework If you only come to group and do nothing in between sessions, this group will have limited effectiveness. For this reason, we will be giving you weekly assignments to complete between sessions. This homework serves two purposes. First, it helps you apply the things you are learning in group to your specific struggles. Second, it gives you experience using the group material in the real world. If you are struggling with any of the assignments, please bring this up to group leaders as soon as possible so that we can help you identify and overcome barriers.
Open-mindedness During this group we will ask you to think in new ways and at times participate in activities that seem different to you. It is normal to feel confused at times or wonder if this will be helpful to you. Please keep an open mind throughout the group.
4
Session 1 Overview
What is ACT The overall idea of Acceptance and Commitment Therapy, or ACT, is that trying to avoid the pain of PTSD comes at a cost: that cost is the ability to really engage in a life that is meaningful to YOU. The core idea of this group is that we can learn new ways to live with pain, while making more room for the important things in our lives.
Goals of the Group Overcome the pull to avoid your painful memories and anxiety Learn skills to help you live a life that matters to you, despite the presence of PTSD Learn skills to relate to your trauma a new way, so it has less power over your actions
Pain of Presence and Absence Pain is inevitable and unavoidable. We can think of the inevitable presence of pain in life as “clean pain.” When we put a lot of focus and effort into avoiding or getting rid of the pain of presence, we can miss out on important things in life. This is the pain of absence, which can be thought of as “dirty pain” or avoidable pain. By reducing the pain of absence, ACT helps us reconnect with what we find most meaningful and important.
Tug-of-War Monster Activity: My Take Home Points
5
Session 1: The Pain of PTSD Worksheet
Column 1: What are the sources of my PTSD Pain? (“clean pain”)
Column 2: How have I have tried to get rid of PTSD pain?
Column 3: What am I missing out on when I do that? How does this interfere with the life I want? (“dirty pain”)
Common sources of PTSD Pain: Feelings (e.g., anxiety, anger) Sensations (e.g., shaky, tense) Urges (e.g., to leave a crowded
place, to use substances) Thoughts (e.g., about the trauma) Memories (e.g., of what happened) Images/Sounds
Common ways we try to get rid of PTSD Pain: Distraction (e.g., videogames, working overtime) Withdrawing or giving up (e.g., isolating, stopping
activities) Thinking (e.g., ruminating, dwelling on, fantasizing,
blaming) Numbing (e.g., with substances, self-harm, recklessness) Controlling (e.g., only sitting in a particular place,
always being the driver) Avoiding people, places, things Constantly checking for danger
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Session 1 Home work
Finish completing your Pain of PTSD worksheet. Consider bigger sources of pain that you struggle with as well as day to day things that come up for you. See if you can identify any patterns in how you tend to try to get rid of pain/anxiety, and assess the potential personal cost of those efforts.
Complete the PTSD Beliefs and Behaviors worksheet. Use the completed example as a guide.
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Session 1 Homework: PTSD Beliefs and Behaviors Worksheet
Directions: PTSD can impact how we think about things (our beliefs) and what we do (our behaviors). Consider how your PTSD has affected your beliefs about yourself, other people, and the world in the following areas. Answer the following questions by writing how PTSD has affected your beliefs in each area. Next, write how this belief has affected your behavior (i.e., led you to do something differently). Write about the impact of these behaviors on you living the life you want to live. Be as specific as possible. Use the completed example on the following page as a guide. 1. How has PTSD affected your sense of safety?
2. How has PTSD affected your ability to be intimate with others or comfortable with yourself?
3. How has PTSD affected your ability to trust yourself or others?
4.How has PTSD affected your confidence in yourself and in other people?
Questions to help you identify ways that your beliefs may have impacted your beliefs and behaviors: Are there places you won’t go or things you won’t do? What are you afraid will happen in those places? Are there any ways in which you tend to “check out,” give up, or numb yourself? Do you try to control scary situations? For example, do you scan dangerous environments? Check your doors at night a lot? Ask family to call in frequently? Do you look for signs of being hurt by others? Do you isolate? Are there ways you try to punish yourself?
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Session 1 Homework: PTSD Beliefs and Behaviors Worksheet Completed example
1. How has PTSD affected your sense of safety?
I believe I must always be on guard. This leads to me checking my doors a lot at night and constantly scanning my environment. This leaves me feeling safer but I also can’t always enjoy myself when I am out because I am on guard. I am afraid that if I go out in a crowd, I will get anxious and lose control. This keeps me from going to important events with my family. It also decreases my confidence in myself. I am scared that my daughter will get hurt. To manage my fear, I make her check in with me constantly. This annoys her and causes tension in our relationship. It also makes me constantly anxious when she is gone. 2. How has PTSD affected your ability to be intimate with others or comfortable with yourself?
I don’t believe that civilians can understand me. I cope by not spending time with them. This has hurt my relationship with my family and left me with few friends.
I don’t want to get close to people because I’m afraid they might get hurt. I cope by isolating. This has left me feeling lonely.
3. How has PTSD affected your ability to trust yourself or others?
I am afraid that if I express my emotions, I will lose control. This keeps me bottling a lot of things inside.
I don’t think I can trust anyone. I keep everyone distant and I don’t have many relationships.
4. How has PTSD affected your confidence in yourself and in other people?
I believe that I am damaged and unlovable because of my trauma. This leads me to push people away before they get too close. Again, I stay emotionally safe but I am lonely. I believe that I don’t deserve to be happy because other people have died. I cope with this by not letting myself enjoy any good things in life. I am miserable because of it. I believe that other people are always working against me. I cope with this by keeping them at a distance. This has made me feel lonely and angry a lot.
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Session 2 Overview
Reminder: It is a natural part of being human to try and avoid pain. With PTSD, the pull to try and avoid painful or scary memories, thoughts, emotions, and physical sensations is strong. One of our goals in this group is to help you overcome the pull of avoidance.
Joe the Annoying Uncle: My Take Home Points:
10
Veteran Manual
Regan Settles, Ph.D. Beth Morris, Ph.D. Kristi Bratkovich, Ph.D.
Acknowledgements
Portions of this manual were adapted from or influenced by the following sources: Follette, V.M., & Pistorello, J. (2007). Finding Life Beyond Trauma: Using A cceptance and
Commitment Therapy to Heal Post-Traumatic Stress and Trauma-Related Problems. Oakland, CA: New Harbinger Publications. Harris, R. (2009). A CT Made Simple: A n easy-to-read Primer on Acceptance and Commitment Therapy. Oakland, CA: New Harbinger Publications. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). A cceptance and commitment therapy: an experiential approach to behavior change. New York: Guilford Press. Hayes, S. C., & Strosahl, K. D. (Eds.). (2005). A practical guide to acceptance and commitment therapy. New York: Springer Science. Hayes, S.C., & Smith, S. (2005) Get of Y our Mind and Into your Life. Oakland, CA: New Harbinger. Juariscio, A., Shaw, J., Forman, E., Timko, C.A., Herbert, J., Butryn, M., & Lowe, M. (2010) The WE-ACT Group: Weight and Eating Applications of Acceptance-Based Treatments. Unpublished Manual. Kabat-Zinn, J. (1994). W herever you go, there you are: Mindfulness Meditation in Everyday Life. New York: Hyperion. Stahl, B., & Goldstein, E. (2010). A Mindfulness-Based Stress Reduction Workbook. Oakland, CA: New Harbinger. Walser, R.D. & Westrup, D. (2007). A cceptance and Commitment Therapy for the Treatment of Post Traumatic Stress Disorder and Trauma-related Problems. Oakland, CA: New Harbinger Publications. Portions of session 10 were also adapted from sources on Dr. Russ Harris’ website: www.thehappinesstrap.com The authors would also like to thank Chase Bailey, Ph.D. for his assistance early versions of this manual.” This work was supported by a clinical educator grant from the VA South Central Mental Illness Research, Education and Clinical Center (MIRECC)
3
Group Guidelines
Confidentiality Everything you discuss in group is confidential with two exceptions: (1) If you report any plans to hurt yourself or someone else and (2) If you report any abuse. In both of these cases, group leaders are legally required to break your confidentiality to protect you and/or others While your group leaders are bound to confidentiality, group members are not. By participating in this group, we ask you to keep this a safe space by keeping everything that your fellow group members discuss private.
Respect We are all unique people and will have different points of view. Please respect others who think differently than you do. Please also respect that people process their trauma at different paces.
Be on time We have a lot to discuss in this group! If you are more than five minutes late, please enter quietly to avoid disruption. Please also be aware that we may not be able to catch you up on missed content.
Missing sessions If you miss more than two weeks of the group, we will ask you to discontinue and start again during another group. This is because missing more than two sessions will result in you not receiving adequate exposure to the group content.
Staying on Topic Most people have numerous problems going on in their lives. While we view all of this as important, our focus in this group is on posttraumatic stress symptoms. If we redirect you during group, it is not because what you are saying is wrong. Instead, it is because we have limited time and want to make sure that we focus on the purpose of the group. You may also bring something up that is on topic and important, but that we cannot fully address as a group. In these instances, you may asked to address the topic with an individual therapist or group leader outside of the group session.
Homework If you only come to group and do nothing in between sessions, this group will have limited effectiveness. For this reason, we will be giving you weekly assignments to complete between sessions. This homework serves two purposes. First, it helps you apply the things you are learning in group to your specific struggles. Second, it gives you experience using the group material in the real world. If you are struggling with any of the assignments, please bring this up to group leaders as soon as possible so that we can help you identify and overcome barriers.
Open-mindedness During this group we will ask you to think in new ways and at times participate in activities that seem different to you. It is normal to feel confused at times or wonder if this will be helpful to you. Please keep an open mind throughout the group.
4
Session 1 Overview
What is ACT The overall idea of Acceptance and Commitment Therapy, or ACT, is that trying to avoid the pain of PTSD comes at a cost: that cost is the ability to really engage in a life that is meaningful to YOU. The core idea of this group is that we can learn new ways to live with pain, while making more room for the important things in our lives.
Goals of the Group Overcome the pull to avoid your painful memories and anxiety Learn skills to help you live a life that matters to you, despite the presence of PTSD Learn skills to relate to your trauma a new way, so it has less power over your actions
Pain of Presence and Absence Pain is inevitable and unavoidable. We can think of the inevitable presence of pain in life as “clean pain.” When we put a lot of focus and effort into avoiding or getting rid of the pain of presence, we can miss out on important things in life. This is the pain of absence, which can be thought of as “dirty pain” or avoidable pain. By reducing the pain of absence, ACT helps us reconnect with what we find most meaningful and important.
Tug-of-War Monster Activity: My Take Home Points
5
Session 1: The Pain of PTSD Worksheet
Column 1: What are the sources of my PTSD Pain? (“clean pain”)
Column 2: How have I have tried to get rid of PTSD pain?
Column 3: What am I missing out on when I do that? How does this interfere with the life I want? (“dirty pain”)
Common sources of PTSD Pain: Feelings (e.g., anxiety, anger) Sensations (e.g., shaky, tense) Urges (e.g., to leave a crowded
place, to use substances) Thoughts (e.g., about the trauma) Memories (e.g., of what happened) Images/Sounds
Common ways we try to get rid of PTSD Pain: Distraction (e.g., videogames, working overtime) Withdrawing or giving up (e.g., isolating, stopping
activities) Thinking (e.g., ruminating, dwelling on, fantasizing,
blaming) Numbing (e.g., with substances, self-harm, recklessness) Controlling (e.g., only sitting in a particular place,
always being the driver) Avoiding people, places, things Constantly checking for danger
6
Session 1 Home work
Finish completing your Pain of PTSD worksheet. Consider bigger sources of pain that you struggle with as well as day to day things that come up for you. See if you can identify any patterns in how you tend to try to get rid of pain/anxiety, and assess the potential personal cost of those efforts.
Complete the PTSD Beliefs and Behaviors worksheet. Use the completed example as a guide.
7
Session 1 Homework: PTSD Beliefs and Behaviors Worksheet
Directions: PTSD can impact how we think about things (our beliefs) and what we do (our behaviors). Consider how your PTSD has affected your beliefs about yourself, other people, and the world in the following areas. Answer the following questions by writing how PTSD has affected your beliefs in each area. Next, write how this belief has affected your behavior (i.e., led you to do something differently). Write about the impact of these behaviors on you living the life you want to live. Be as specific as possible. Use the completed example on the following page as a guide. 1. How has PTSD affected your sense of safety?
2. How has PTSD affected your ability to be intimate with others or comfortable with yourself?
3. How has PTSD affected your ability to trust yourself or others?
4.How has PTSD affected your confidence in yourself and in other people?
Questions to help you identify ways that your beliefs may have impacted your beliefs and behaviors: Are there places you won’t go or things you won’t do? What are you afraid will happen in those places? Are there any ways in which you tend to “check out,” give up, or numb yourself? Do you try to control scary situations? For example, do you scan dangerous environments? Check your doors at night a lot? Ask family to call in frequently? Do you look for signs of being hurt by others? Do you isolate? Are there ways you try to punish yourself?
8
Session 1 Homework: PTSD Beliefs and Behaviors Worksheet Completed example
1. How has PTSD affected your sense of safety?
I believe I must always be on guard. This leads to me checking my doors a lot at night and constantly scanning my environment. This leaves me feeling safer but I also can’t always enjoy myself when I am out because I am on guard. I am afraid that if I go out in a crowd, I will get anxious and lose control. This keeps me from going to important events with my family. It also decreases my confidence in myself. I am scared that my daughter will get hurt. To manage my fear, I make her check in with me constantly. This annoys her and causes tension in our relationship. It also makes me constantly anxious when she is gone. 2. How has PTSD affected your ability to be intimate with others or comfortable with yourself?
I don’t believe that civilians can understand me. I cope by not spending time with them. This has hurt my relationship with my family and left me with few friends.
I don’t want to get close to people because I’m afraid they might get hurt. I cope by isolating. This has left me feeling lonely.
3. How has PTSD affected your ability to trust yourself or others?
I am afraid that if I express my emotions, I will lose control. This keeps me bottling a lot of things inside.
I don’t think I can trust anyone. I keep everyone distant and I don’t have many relationships.
4. How has PTSD affected your confidence in yourself and in other people?
I believe that I am damaged and unlovable because of my trauma. This leads me to push people away before they get too close. Again, I stay emotionally safe but I am lonely. I believe that I don’t deserve to be happy because other people have died. I cope with this by not letting myself enjoy any good things in life. I am miserable because of it. I believe that other people are always working against me. I cope with this by keeping them at a distance. This has made me feel lonely and angry a lot.
9
Session 2 Overview
Reminder: It is a natural part of being human to try and avoid pain. With PTSD, the pull to try and avoid painful or scary memories, thoughts, emotions, and physical sensations is strong. One of our goals in this group is to help you overcome the pull of avoidance.
Joe the Annoying Uncle: My Take Home Points:
10