wrestling with a gooey monster: act for ocd in children

Wrestling with Wrestling with a Gooey Monster: a Gooey Monster: ACT for OCD in ACT for OCD in

ChildrenChildren

Wrestling with Wrestling with a Gooey Monster: a Gooey Monster: ACT for OCD in ACT for OCD in

ChildrenChildren

Koke Saavedra, Psy.D.Koke Saavedra, Psy.D.Licensed Clinical PsychologistLicensed Clinical Psychologist

California, USACalifornia, USA

ACBS Worldcon XIIMinneapolis – June 2014

Hi there!

• Presenter…

• Would you say hi?

2ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

Workshop Overview


OCD… Functional- Contextually Speaking I

OCD is a psychological context characterized by lack of mindfulness:Fusion with catastrophic/anxious cognition –> child believes thoughts literally (context of literality) Experiential Avoidance: Avoidant relationship to unpleasant body sensation/emotion (‘anxiety’) No self-as-perspective & disorientation to valued endsAttention & action narrowly focused on control or moving away from unwanted psychological content

ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D.

4

OCD… Functional- Contextually Speaking II

The psychological context of OCD controls actions narrowly at the service of moving away from unpleasant experience:Acting on Fusion since thoughts are experienced literally, child acts mindlessly to directly suppress cognition and/or avoid its literal, feared consequencesAction at the service of Experiential Avoidance child acts mindlessly to move away from unwanted body, emotional experience & the situations that may elicit them


5

OCD… Functionally- Contextually Speaking III

The psychological context of OCD controls actions narrowly at the service of control (moving away): No self-as-perspective & disorientation to chosen

valued ends child’s actions are mindlessly oriented toward moving away regardless of valued life consequences

Attention & action narrowly focused on control of literal, unwanted psychological event child acts automatically to move away from unwanted psych. content

Action is negatively reinforced as well as a by ‘avoidant tracking’ and pliance (doing the right ‘problem solving’ thing)


6

.

Another Way of Saying the Same Thing – The Behavioral Context of OCD or Living for

Control

ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D. 7

A Metaphor: A Child’s Actions

in the Context of OCD - The Child is living as if chased by scary monsters (made of myriad thoughts & feelings)… and so, naturally, his life is put at the service of avoiding and moving away from these scary monsters- The price the child pays is his life as well as the monsters becoming more present and scary, as well as over time new monsters joining the gang, such as thoughts & feelings of being weird, worthless, hopeless, etc.


8

• ACT is non-evaluative & truly non-directive child valued ends and not control of content guide intervention

• Focus on strengths, oriented to learning to live a valued life• ACT by its nature is best done thought child-friendly

means: playful, creative, hands-on focus on activities; role plays, art, drama, music, poetry; metaphors and experiential exercises

• Flexibility: Easily adaptable to developmental levels/needs – e.g. values clarification exercises for various ages/preferences

• Non-literality of ACT undermines young people’s tendencies to comply (or resist) in content-based (literal) contexts

• No diagnosis/illness, problem is unworkability of behavior: Whole child-centered and valued action-focused

A Word on ACT & the Context of Childhood OCD I


9

A Word on ACT & the Context of Childhood

OCD II– Involvement of parents parents/family are key contextual

variables of OCD and so ACT aims to change parents behavior so they promote actions at the service of valued living and undermine unworkable control

– Remembering & practicing is important (can be supported by parents) and is driven by child’s chosen valued ends

– Attention in children requires adapting length and content of exercises/sessions

– Children are sensory oriented and love art, movement; use lots of metaphors, exercises & make it creative, fun


The ACT Path Out of OCD

ACT works by changing context not content willingness

– Defusion: from a context in which thoughts are literal to mindfulness of thoughts

– Acceptance: from a context of experiential control to mindfulness of bodily experience

– From narrow, control-focused attention & autopilot action to self-as-context and flexible, intentional action at the service of effectively actualizing chosen valued ends


.

Living Well in the Context of OCD – ACT Promotes Psychological Flexibility, i.e., Helps the Child

Develop a Flexible Action Repertoire in the Presence of Unwanted Thoughts & Feelings to Sustain Long Term Valued

Living


Self asContext

Contact with the Present Moment

Defusion

Acceptance

Committed Action

Values

Psychological Psychological FlexibilityFlexibility

.

The ACT QuestionThe ACT Question: : How to promote action How to promote action

that instead of that instead of promoting movement promoting movement

away from the away from the monsters, helps the monsters, helps the

child move towards the child move towards the life they love, no matter life they love, no matter what the monsters do?what the monsters do?

This Road is

Your Valued

Life

Unwanted experience must be faced Unwanted experience must be faced to walk our chosen valued pathto walk our chosen valued path

– – willingness to contact the monsters willingness to contact the monsters is a requirement to valued livingis a requirement to valued living

Mary had a little…ACT claims that ‘monsters’ (psych. pain) are unavoidable, given human language-based, conditioned, learning… and, even more, that struggling to control them is the problem & a

main source of human suffering!

.

Living at the service of:•Not experiencing unwanted

thoughts or feelings•Acting compulsively & ineffectively

to control imagined futures •Disregarding what is truly loved

and the actual long term life consequences of my actions

Some of the costs I pay:• Further suffering: Unwanted

thoughts turning into obsessions, chronic unwanted feelings

• Neglect/avoid valued relationships & activities & time spent

struggling, engaged in meaningless actions

•Health/stress & wellbeing costs•Other life constriction

1. Set My Valued Directions in Significant

Life/Relationship Contexts: Family; friends; play;

school/learning; community; fun & activities; health.

2. Take Freely Chosen Valued Actions in Those Contexts: Is wrestling with & moving away from the monster

working? Is it moving you towards the life & relationships that you

love?

3. Work with the Barriers in those Contexts: Are you willing

to contact the monsters for the purpose of living a chosen, effective

valued life?

14

ACBS XII Minneapolis 2014 - Koke Saavedra, Psy.D.

– Aware: of your present moment experience as it is, not as it says it is – are you willing to embrace the monsters & let them be?

– Choose: in contact with your freely chosen valued directions – become clear about what you really value in life

– Take Action: that works and actualizes the life you love – instead of struggling with the monsters

ACT: Stop Struggling with Monsters & Start Living Your Chosen Life


ACT for OCD in Kids: Wrestling with a Gooey

Monster -> Focus on Values & Valued Action

o Values Exercises for Children-> Art-Based Perspective-taking & Observing Workability of Control-Focused Actions

o Drawing the Scary Monster & Youo What Does the Monster Do? What Do You Do?

-> Promoting Willingness, Mindfulness & Valued Action

o Wrestling with a Gooey Monster Metaphoro Acceptance & Defusion Exercises

-> Exposure: Willingness & Committed Action

-> Focus on Values & Valued Action o Values Exercises for Children

-> Art-Based Perspective-taking & Observing Workability of Control-Focused Actions

o Drawing the Scary Monster & Youo What Does the Monster Do? What Do You Do?

-> Promoting Willingness, Mindfulness & Valued Action

o Wrestling with a Gooey Monster Metaphoro Acceptance & Defusion Exercises

-> Exposure: Willingness & Committed Action


ACT Assessment: Some helpful baseline

measures

• ACT assessment is intervention – wrap it up with the process of therapy

• Assess using drawings and art – it’s not standardized and it works better!

• Bull’s Eye values assessment - adapted for kids• Identify avoided content & avoidant actions – basic

psych flexibility processes • Daily Compulsions Tally [weekly]• White Bear Thought Suppression Inventory – for

kids


17

ACT Treatment: Oriented Squarely Towards Valued

Action

• Values are directions… like going “West” • Values are not goals – they orient us to

the process of living, not to its outcomes• Values are not feelings – we are what we

do• Our values are a compass that orient us

– & like a lighthouse guide us through storms

18

Drawing by Joseph Ciarrochi & David Mercer

Assessment: What you love & who’s getting in

the way?Adapted from Rikard Wicksell

• Hey, let’s talk about what you love…• Are you doing these things?• Catching the monsters and naming

them…

Use a dry erase or paper board, or just a sheet of paper


19

Values for Kids: The Chocolate Box & The Poison Bottle

Source: Amy Murrell & Kelly Wilson

20

What do you love? What do you want in your life?


.

Values Exercise: What really matters to you?

Values are not goals or things you can have, or feelings, they are your chosen life directions, the compass tat guides your actions now

Bull’s Eye is a creation of Tobias Lundgren & Joanne Dahl

Significant Area of life ____________ Values _____________ Actions ____________

Awareness of Values:The Chocolate Box & The Poison Bottle

ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D. & Amy Jenks, Psy.D.

22

Source: Amy Murrell

Art-based Perspective-taking as Assessment &

Intervention• Would you draw you with the scary monster?

• Coloring your feelings: What do you feel? Where do you feel it?

• Thought Bubbles: What does the monster say or tell you that don’t want to hear or that scares you?

• How scared are you of the monster? How much do you believe it? (0 to 10)

• Does the monster stop you from doing things you love?

Can you see how all six basic ACT processes are being assessed in the OCD context?


23

The Case of Tim: Wrestling with a “Gooey

Monster”

10 year old with intrusive thoughts about his parents dying in an accident. Calling parents from schools about 12 times per day. School performance, social life and participation in his favorite activities collapsed.


ACBS XII Minneapolis 2014 Koke Saavedra, Psy.D. & Amy Jenks, Psy.D.

25

Tim – Week 1 out of 8

The Case of Tracy & The “that-was-wrong-say-sorry”

Monster

• Six year-old girl who was afraid of being wrong and would compulsively apologize each time she had the thought that she had done something wrong. She would apologize to the point she was damaging her relationships and was developing


27

Tracy’s drawing # 1 here

Observing Workability of the Struggle with the

Monster(Creative Hopefulness)

• What Does the Monster Do? What Do You Do? & How does it work?

• Help child observe the actual consequences (including values cost) of the following behaviors: (1) believe thoughts & believe the monster is dangerous

(2) try to suppress or not to think thoughts (3) try to avoid feelings & sensations(4) avoid people, activities & situations(5) seek reassurance and other control behaviors


Monster Diary: What I Do & Get When the Monster

Visits(Creative Hopefulness)

• When? Where? With whom?• What did the monster say & what did it make

you feel? • What did you do? Make sure to note the

following: believed monster; tried to suppress or struggle with thoughts; tried to avoid feelings; avoided activities or situations; other control-oriented behaviors

• What is the life cost in terms of what you love?


Metaphor: Wrestling with a Gooey Monster

Isn’t what you are doing like wrestling with a monster made of goo?

What happens if you wrestle with a gooey monster to try to get away from it? If you don’t want it you’ve got it? Is that what is happening to you?

Does it work to wrestle with a monster made of goo? Does it work for you to do what you are doing?

What does your experience tell you? Can you trust what you see rather than what you think?


Promoting Willingness & Practicing Mindfulness

• Wrestling with a gooey monster• Quicksand metaphor• Chinese finger traps• Tug of war with the monster

31

Drawing by Joseph Ciarrochi


Committed Action: What Do I Want to Do Instead?

You are learning to live the life you want even when the monster shows

up•Have child identify one or two truly valued actions they are willing to engage in that they have avoided as a result of the OCD – e.g., playing soccer or playing with friends during the break


Committed Action is Learning to Move with Barriers: Befriending the Scary

Monster

Sometimes a life well lived feels like walking through a swamp… we can learn to keep moving and keep

living the life we love

oWorks? Is what you are doing how you want to live?oWilling? Can you welcome the monster inside your backpack so you can keep doing what you love? Can you let the monster be there & roar?oMindfulness skills (self-as-context, defusion, acceptance, attention to now) help dissolve barriers to chosen action

Source: Georg Eifert & John Forsyth.

Defusion: Undermining the Context of Literality

• Your Mind is Like a Pop-Corn Machine• …and the greatest witch/wizard in the

world – imagine your favorite food (Dumbledore: “In my not so humble opinion, words are the most extraordinary source of magic”)

• …and you don’t control it: “Try not to think for a minute…”


Try Not to Think of a White Kiwi

See what happens when you try to control your

thoughts? Is this what happens when you try not to hear what the monster says?


[email protected] 36

Putting your thoughts on clouds… and thanking the

monster for those thoughts


.

Sing it out loud with the monster!

38

[email protected] 39


More Mindfulness Exercises: Turning Monsters into Friends• Still Quiet Place (Amy Saltzman –

www.stillquietplace.com)

• Body Scan for Kids & Watching your breath• Painting or sculpting your thoughts & feelings• Parade of Thoughts• “I’m your mind, let’s talk? & talking to the TV in

the living room • Walking with your mind • The Ridiculus Curse - dress up the monster or

have it talk in the voice of a silly character • Cartoon or a puppet show: “Me and my monster”


Making Mindfulness Child-Friendly

– Attention in children is different than in teenagers or adults - shorten & simplify sessions & exercises

– Children are less verbal and more sensory oriented - use more art, movement & activities - avoid being literal

– Involve parents/primary caregivers in therapy & train teachers when possible

– Make it fun, playful, non-judgmental, develop a nurturing, caring relationship – don’t rush to intervene and follow the child’s preferences


Monsters in the Bus


Exposure as Willingness & Committed Action

An opportunity to practice mindfulness & behavioral skills while moving towards a valued life

Have child select a valued direction & identify an immediate action that will move child in that chosen direction (e.g., join football game during break time)Help client face psychological barriers (‘monsters’) with new mindfulness & behavioral skillsExpand this work throughout treatmentDeveloping committed action (exposure) hierarchies


Valued Living Practice

• Making it work pointers• Involving parents• Involving schools• A focus on chosen valued

action not on control of experience


45


Tim - Last Week of Treatment

“Your steps tell you where you’ve been, not where you are going…”

46

That’s all

folks!

That’s all

folks!

. ACBS XII Minneapolis - June 2014 Koke Saavedra, Psy.D.

BIBLIOGRAPHY•Hayes, Strosahl, & Wilson (2012). Acceptance & Commitment Therapy: The Process & Practice of Mindful Change. Gilford.•Coyne, McHugh, & Martinez (2011). ACT: Advances and applications with children, adolescents, and families. Child & Adolescent Psychiatric Clinics of North America, 20(2), 397-399.•Laurie Greco & Steven Hayes (Eds.) (2008). Acceptance and mindfulness treatments for children and adolescents: A practitioner’s guide. New Harbinger.•Rikard Wicksell – in ACT in Action DVD Series (New Harbinger) •Steven Hayes & Kirk Strosahl (Eds.) (2004) A Practical Guide to ACT. New York: Springer.•Dahl & Lundgren (2004). Living Beyond Your Pain. New Harbinger.•Wicksell, Olsson, & Hayes (2011). Mediators of change in ACT for pediatric chronic pain. Pain, 152 , 2792–2801.

•.

wrestling with a gooey monster: act for ocd in children

Documents

control acbs

childrenkoke saavedra

behavioral context of

child pays

service of control

directive child valued

scary monsters

california ocd functional