Discuss about the Diagnosed With DSM – V Major Depressive Disorder.
The importance of ACT for treating Major Depressive Disorder
The patient in this case is Mary, a twenty year old university student who sought professional help to resolve her issues. Mary had been diagnosed with DSM – V major depressive disorder. ACT or Acceptance and Commitment Therapy has been recommended for Mary. It is an action oriented approach to counselling. The whole purpose of ACT is to prevent patients from hiding, avoiding or denying their inner emotions. Instead, it is crucial to be able to accept these feelings so as to process them healthily. ACT has 6 main processes – acceptance, cognitive defusion, being present, the self as context, values and committed action. In Mary’s case, the following have been observed:
- Acceptance– This is one of the fundamental principles of ACT. This emphasizes that all negative experiences are a part of one’s existence and one should be able to accept them and embrace them. Avoiding these feelings and experiences would only lead to further problems. Instead, a person should be able to see the silver lining behind each challenging situation. In Mary’s case, there are two examples that can be cited which show that she has been trying to avoid her situation. She mentioned in her sessions that she had been trying to distract herself by watching TV or by drinking. She also mentions that she feels angry with her boyfriend at times and feels like confronting him, yet brushes her anger aside. These are common techniques that people use to defer negative experiences or shift focus from them. Mary would rather distract herself or suffer in silence than confront her issues.
- Cognitive defusion– Cognitive defusion requires an individual to examine his thoughts from an objective point of view; it would involve analysis of inner feelings without pondering too much about them. When asked, Mary mentions that she has been blaming herself for her situation. She feels angry with her situation due to her poor performance in university. Also, she had considered herself to be someone who could cope with anything and had thus disappointed herself. Here, it can be said that Mary had failed to view her situation from an impersonal perspective and ended up blaming herself, which deepened her condition.
- Being present– Mary is simply unable to focus on the present situation and live in the moment. She keeps dwelling about the past and how her boyfriend and friends betrayed her, which is one example of her not being able to let go. She mentions that every time she reflected on what had happened, she felt a gaping hollowness within, which seemed overwhelming.
- Self– Mary is also unable to get in touch with her real self. She claims to feel lost and alone, without anyone to confide in. That shows sign of interdependence; in other words, she feels that she needs someone to get better. Had she been able to get in touch with her real self, she would have been able to focus on her own healing. Another factor preventing her from seeing her “self” in context is her excessive drinking. She mentions drinking frequently to distract herself.
- Values– It is important for every individual to be aware of what they want in life and what they want to achieve. Mary’s inability to pursue her real dream of being a graphic designer is one of the main causes behind her depression. Mary also mentions that she finds her course exhausting and her duties in medical care overwhelming and thus pointless. Mary has still not been able to figure out her main purpose in life, which has contributed to feelings of sadness and despair.
- Commitment to action– Commitment to action means that a person would focus on activities which add value to life. Mary has completely lost interest in her course and tries to avoid classes. She spends most of her time drinking or trying to distract herself. She even mentions ignoring her duties and responsibilities towards patient care and finds no meaning in it anymore.
The main purpose of ACT is to shift focus from the content of a particular experience to its context. In other words, a therapist using ACT would not simply take into account the experience that the patient has undergone but also the greater meaning such an experience would have. In the previous sections, various examples from the session have been listed, all of which are standing in the way of the core processes of ACT. Here are some strategies that could be used:
- Acceptance– A writing acceptance exercise could be used, which had been introduced by Matthieu Villate. Mary would be handed a piece of paper and pen and would be asked to write a sentence. An obstacle would be placed in front of her that prevents her from accessing the paper. She would be informed that the obstacle would remain and that she would have to find a way to write anyhow. The point of this strategy is to show Mary that obstacles and challenges will prevail, however she would have to accept them and work through them. The strategy in this case is to demonstrate to the patient the ill effects of control. Mary must understand that controlling her emotions and feelings would only exacerbate the problem. Instead, she should try to find a healthy outlet for the same. For instance, ACT guided therapy would ensure that she is more flexible in terms of behavioral responses. That would allow her to distance herself from her thoughts and view them objectively. She would also stop fighting her feelings or trying to replace them with distraction. Instead of reducing the significance of her emotions, she would be able to work through them.
- Defusion– The clean pain versus dirty pain strategy will be used to defuse the thoughts of Mary. Clean pain is usually when something hurtful happens. This is common and everyone has faced it at some point or the other. Dirty pain on the other hand is when people begin to dwell on their situation, how wrong it is, how it should not have happened and how everything is bad in their life. Through practice, Mary will come to realize that these thoughts are self generated and self maintained and letting them go would only help her. Another strategy that can be used in this case is the lemon exercise. First, Mary would be asked to visualize a lemon and imagine herself eating it. She is bound to salivate at the thought of it. Next, she would be asked to repeat the same word multiple times for 45 seconds. The main point of this exercise is to break the association with the word. For instance, there might be certain words or items which greatly affect Mary or make her feel twice as sad. This is because her brain associates these with pain or sad memories. The only way to get over this is repetition. With repetition, Mary’s mind would stop associating the word or song or item with the painful memories and it would defuse her thoughts. Slowly, she would realize that these are just thoughts at the end of the day, which can be let go of.
- Values– For this process of ACT, a value direction worksheet will be used. Mary will be provided with a sheet which lists 10 domains, namely work, intimate relationships, parenting, friends, education, self care, family, spirituality and recreation. She will be asked to prioritize them using a scale of 0 (not important) to 2(very important). Mary would gain better insight into what adds value to her life and what does not, putting her life into perspective. For personal growth, it is important to focus on the aspects which would add value and eliminate those that do not.
- Being present– In this aspect, it would be explained to Mary that her situation is like a quicksand situation. This metaphor would be explained to her. The more Mary dwells on her situation and her past, the more she would sink into the quicksand. Instead, it is better for her to accept the situation and focus on herself in the moment. At present, it is important for her to pursue her interests or focus on her studies. Mindful breathing is another strategy that would work in this case. Mindful breathing entails shifting attention from all that is happening around an individual and focusing simply on the physical act of breathing. One purposeful or meaningful breath can help Mary gain clarity and become aware of her being in the present.
- Self– A concept of psychological flexibility will be used to help Mary get in touch with her actual self. ACT recognizes that self compassion is an important facilitator of personal growth. In instances of extreme sadness or stress, it is self compassion which can help a person grow and heal. Self compassion would entail extending patience, kindness and benevolence to oneself. Mary had constantly been blaming herself. Self criticism in difficult times can be potentially damaging; instead, treating herself with kindness is what can help her through the situation.
- Commitment– Now that Mary has been able to identify the aspects of her life which add value, she would be able to commit herself to the action. She should only work on her willingness to do so. The ACT strategy can be used in this case. It is an acronym for “accept, choose and take action.” Once Mary comes to terms with her situation, she should be able to evaluate her options and decide the course of action she wants to commit to.
According to Hayes et al. (2013), the Acceptance and Commitment therapy is one of the useful and beneficial modes of treatment in psychotherapy, since it is largely action oriented. This mode of psychological intervention makes use of mindfulness and acceptance strategies to treat patients suffering from anxiety, depression and chronic pain (Buhrman et al., 2013). Öst (2014) commented that the main purpose of ACT is psychological flexibility. It was initially called comprehensive distancing. The purpose of ACT is to enable an individual to view his or her situation in an objective way. It is important for individuals to realize that adverse situations and challenging life events are common. Yet, blocking emotions and trying to control thoughts would only worsen the situation and is called dirty pain (Marquez-Gonzalez & Baltar, 2017). In such a situation, a person keeps dwelling on past events and is unable to move on from it. Podina and David (2017) argue that the six core processes of ACT (acceptance, defusion, self, present context, values and commitment) are essential components which can help an individual gain personal growth. ACT teaches individuals about the importance of mindfulness and how personal values can help in psychological flexibility.
Hooper and Larson (2015) however argue that ACT can often be counterproductive and that cognitive behavioral therapies would be more effective since they emphasize on modifying negative behavior and thoughts and are much more time effective. Yet, Morris (2018) argues that avoiding one’s emotions or restricting oneself can prove to be far more damaging than trying to accept them. Essentially, ACT states that an individual would have to focus on personal values, aims, goals and emotions in order to heal from negative experiences. Failure to do so could result in mental disorders like severe depression. A-tjak et al. (2015) argues that the exercises and strategies used in ACT are mindfulness and willingness tactics which could be used to relieve patients of depression. It would teach such patients that although there are innumerable obstacles and hurdles, one must learn to work through them. It also helps an individual get detached; in other words, the person would be in a defused state and would not be obsessed with his or her feelings. Pushing aside avoidance strategies and embracing one’s emotions and behavioral responses to challenging situations would be the most effective way to get past the same.
A-tjak, J. G., Davis, M. L., Morina, N., Powers, M. B., Smits, J. A., & Emmelkamp, P. M. (2015). A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems. Psychotherapy and Psychosomatics, 84(1), 30-36.
Buhrman, M., Skoglund, A., Husell, J., Bergström, K., Gordh, T., Hursti, T., ... & Andersson, G. (2013). Guided internet-delivered acceptance and commitment therapy for chronic pain patients: a randomized controlled trial. Behaviour research and therapy, 51(6), 307-315.
Hayes, S. C., Levin, M. E., Plumb-Vilardaga, J., Villatte, J. L., & Pistorello, J. (2013). Acceptance and commitment therapy and contextual behavioral science: Examining the progress of a distinctive model of behavioral and cognitive therapy. Behavior therapy, 44(2), 180-198.
Hooper, N., & Larsson, A. (2015). The research journey of acceptance and commitment therapy (ACT). Springer.
Márquez-González, M., & Baltar, A. L. (2017). Acceptance and Commitment Therapy. Encyclopedia of Geropsychology, 1-9.
MORRIS, E. M. (2018). Acceptance and commitment therapy. In CBT for Psychosis (pp. 95-113). Routledge.
Öst, L. G. (2014). The efficacy of Acceptance and Commitment Therapy: an updated systematic review and meta-analysis. Behaviour research and therapy, 61, 105-121.
Podina, I. R., & David, D. (2017). Acceptance and Commitment Therapy. Cognitive Behavior Therapies: A Guidebook For Practitioners, 177-208.
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