MINDFULNESS AND ACCEPTANCE-BASED GROUP THERAPY FOR SOCIAL ANXIETY DISORDER: A Treatment Manual Second Edition* Jan E. Fleming, MD, FRCPC Nancy L. Kocovski, PhD Clinical Associate Associate Professor The Mindfulness Clinic Department of Psychology Toronto, ON, Canada Wilfrid Laurier University [email protected] [email protected] *The first edition (2009) is available at www.actonsocialanxiety.com and at www.contextualscience.org. June, 2014 1 Introduction Background Mindfulness and Acceptance-Based Group Therapy (MAGT) for Social Anxiety Disorder (SAD) is based on Acceptance and Commitment Therapy (ACT: Hayes et al 1999), with additional mindfulness components drawn from Mindfulness-Based Cognitive Therapy (MBCT: Segal et al 2002), which is based in part on Mindfulness-Based Stress Reduction (MBSR: Kabat-Zinn 1990). Pilot work found that MAGT was feasible and acceptable to SAD patients and provided initial support for the effectiveness of the approach (Kocovski, Fleming & Rector, 2009). To further evaluate its effectiveness, we compared MAGT to cognitive behavioral group therapy (CBGT: Heimberg & Becker) and a wait list control group in a randomized controlled trial. MAGT and CBGT were both found to be significantly more effective than the control group, but not significantly different from one another (Kocovski, Fleming, Hawley, Huta & Antony, 2013). The first edition of our treatment manual was used in that trial (Fleming and Kocovski, 2009) and is available at www.actonsocialanxiety.com, and at www.contextualscience.org. Given these promising findings for MAGT and additional research support for mindfulness and acceptance-based approaches for SAD (see the Evidence section of www.actonsocialanxiety.com for details) we wrote The Mindfulness and Acceptance Workbook for Social Anxiety and Shyness (Fleming and Kocovski, 2013) in order to make the approach available to a broader audience. The workbook can be used on its own or as an adjunct to individual or group therapy, as outlined in the second edition of the treatment manual. Second Edition of Mindfulness and Acceptance-Based Group Therapy for Social Anxiety Disorder: A Treatment Manual The second edition of the manual covers the same ACT concepts as the first edition. It differs from the first edition as follows: • It is written to be used in conjunction with The Mindfulness and Acceptance Workbook for Social Anxiety and Shyness. • It presents the mindfulness and acceptance approach in a more user-friendly way, which can be summarized as teaching group participants how to shift from “Safety Mode” to “Vital-Action Mode” (described in detail in the manual). • The number of sessions has been shortened from 12 to 10; however, the manual can be modified to accommodate group programs with fewer or more than 10 sessions. • Updates and additional materials will be available on our website, http://www.actonsocialanxiety.com, and our facebook page, https://www.facebook.com/ACTonSocialAnxiety. Important Note: It is assumed that the therapist using this manual is familiar with the assessment and treatment of social anxiety. Second, it is assumed that the therapist also has basic training in Acceptance and Commitment Therapy. If you are interested in further training, we 2 recommend the official website of the Association for Contextual Behavioral Science (ABCS; www.contextualscience.org) for information about training opportunities. Access to some parts of the website requires membership. Membership to ABCS is values-based; in other words, you pay what you think it is worth and what you can afford. TABLE OF CONTENTS PART I: Therapist Manual ……………………………………………………….......4 Treatment Overview………………………………………………………………......5 Session 1: Safety Mode……………………………………………………………….6 Session 2: Acceptance/Willingness…………………………………………………..21 Session 3: Values and Goals…………………………………………………………38 Session 4: Developing a Different Relationship to Thoughts: Defusion……………53 Session 5: Willingness Switch and Being With Your Anxiety………………………69 Session 6: Taking VITAL Action…………………………………………………....82 Session 7: Taking VITAL Action (continued) and Goal Stepping…………………..97 Session 8: Taking VITAL Action (continued)………………………………….…..111 Session 9: Taking VITAL Action (continued)……………………………………...122 Session 10: Wrapping Up and Stepping Forward………………………………….132 References……………………………………………………………………….....142 PART II: Participant Handouts…………………………………………………….144 3 Part I: Therapist Manual 4 TREATMENT OVERVIEW The group meets for 2 hours, once a week for 10 weeks. There are typically 8-12 members per group and two therapists. Each session is roughly divided into four parts: Mindfulness Exercise: 15 minutes followed by 5 to 10 minutes of discussion (see summary below) Review of Homework: 15 to 30 minutes Session Theme: Introduction of ACT concepts using metaphors and experiential exercises (sessions 1-5) and ACT-consistent exposure, called Taking VITAL Action (sessions 6-10) (55-85 minutes) Homework Assignment: for the upcoming week (5 –10 minutes) Summary of Mindfulness Exercises Session 1: Mindful Eating Session 2: Observing Mountain Session 3: Body Scan Session 4: Mindfulness of breath, sound and thoughts Session 5: Mindful Stretching Session 6: Mindful Seeing, Acceptance of Feelings and Thoughts, Guest House poem Session 7: Imagining VITAL Action Session 8: Cultivating Self-Compassion Session 9: Loving-kindness Session 10: Imagining VITAL Action Note: The following materials are meant to be used as guidelines. Sample transcripts of mindfulness and ACT exercises are meant to be tailored for individual groups. 5 SESSION 1 Safety Mode 6 Session 1 SUMMARY This is the only session that does not begin with a mindfulness exercise or include homework review. OPENING REMARKS: • Welcoming remarks and Housekeeping items are tailored for a specific group and therapist(s) • Session structure - Sessions will generally have 4 parts: 1. mindfulness exercise, 2. homework review, 3. New concept/group exercises, and 4. setting of homework INTRODUCTIONS: • Instruct group members to pair up and introduce themselves to each other (“Say something about what brings you here and what you hope to get out of the group”) for several minutes (you can ring the bell after a couple of minutes and ask people to switch if one member of the pair/trio has not yet spoken) • Each group member then introduces his/her partner to the rest of the group. Note: If there is an uneven number of participants, assign one group of 3 and be sure to identify which group members will introduce each other (e.g. Mary, you’ll introduce Tom, Tom will introduce Joe, and Joe will introduce Mary) SESSION THEME: Introduction to “Safety Mode”: • see below for details • therapist prep-MAWSAS, Chapter 2 MINDFULNESS EXERCISE: Mindful Eating • See Exercise 4.1 Mindful Eating • therapist prep- MAWSAS, pgs 51-55 HOMEWORK: • See “Session 1: Homework” for details 7 SESSION THEME: INTRODUCTION TO SAFETY MODE It is helpful to use a whiteboard when introducing Safety Mode. Sample Script: Now we’re going to walk you through an approach to understanding how social anxiety keeps you from getting the most out of your life. The crux of the problem is something we call “safety mode,” a way of being in social situations that can put up barriers to what is really important to you in your life. We’re going to introduce you to safety mode by using a specific example. So everyone imagine now that you are at a party where there is someone you would really like to meet. It could be a co-worker, a neighbour, someone you’re attracted to or someone you really respect. Does everyone have someone in mind? Now imagine that you notice that person standing alone by the food table, looking lost, and you decide to go over and make small talk with them. If you wouldn’t be anxious in this situation think of a recent situation where you felt anxious and use that as we proceed. Goal in Safety Mode: Safety mode is about staying out of harm’s way, about protecting yourself from social danger. Social danger is what you are afraid might happen in a social situation. So what might be dangerous about this party? What are you afraid might happen? What are your worst fears? (group members share fears such as embarrass self, appear anxious, be judged, etc). Four components of safety mode: Now, in order to keep yourself safe from those outcomes, there are four main things that you probably do: use safety behaviours, focus on social danger, resist anxious feelings, and buy into anxious thoughts. Let’s look at each of those in turn, starting with safety behaviours. 1. Use safety behaviours: These are the things you do to protect yourself from social danger, including outright avoidance or staying away from social situations. Let’s have a show of hands from those of you who would avoid going to the party? In addition to outright 8 avoidance, there are many other types of safety behaviours. These are behaviours that come into play once you are in a social situation. They are geared to minimize your chances of being scrutinized and judged, by hiding your anxiety symptoms, keeping you as inconspicuous as possible, and attempting to control the impression you are making. What are some of the safety behaviours you might use at this party? (group members share safety behaviours such as: hold a glass tightly to hide shaky hands, talk to “safe” people, help out in the kitchen or engage inother helping activities to avoid conversations, keep attention off self by asking lots of questions of others, say as little as possible, carefully plan topics ahead of time, have a few drinks to calm nerves, etc).What are some of the downsides of engaging in safety behaviours? (e.g. don’t fully experience social situations, miss out on fully participating in life.) 2. Focus on Social Danger: This involves paying attention to the things you are most concerned about. Self/internal focus: For some people those are the more visible physical symptoms of anxiety, such as blushing, sweating or trembling. For other people it’s what they’re doing (e.g. moving awkwardly, spilling a drink) or what they’re saying (e.g. something boring). It can be any aspect of yourself that you think will influence how you are coming across to others. External focus: You might also look out for signs that people are scrutinizing you (e.g. staring at you) or disapproving of you (e.g. frowning at you, turning away or appearing to be disinterested). What are the things that you would be paying attention to at this party? (group members share) What might be some pitfalls of paying attention in this way? (elicit responses such as: focus on physical symptoms tends to make them worse; may be less likely to notice positive things like smiles or nods of approval; may not really hear what others are saying and lose track of conversations, etc.) 3. Resist Anxious Feelings: Anxious feelings consist of the basic emotion of fear and the physical sensations that go along with it, such as palpitations and muscle tension (& those we just talked about that you focus on). Most people who are socially anxious are not OK with feeling that way. They not only focus on anxious feelings, but also resist, struggle with, and try to control fear. That’s often where safety behaviours come into play. What about you at this party? Are you okay with feeling anxious, or are you resisting it? (group members share) 4. Buy into Anxious Thoughts: As you imagine yourself at the party what are the thoughts going through your mind? (As group members share thoughts identify types of thoughts for a few of them. Examples are: fortune telling -“You’re going to mess up”, mindreading -“they think I’m weird because I’m not saying anything”, etc.) As you think these thoughts at the party, how are you relating to them? Are you getting caught up in your thoughts, buying into them, and doing what they tell you to do? We call that being fused with your thoughts. Team Interaction: We want to point out something that you may have already noticed - that focusing on danger, resisting anxious feelings, and buying into anxious thoughts all work together like a team to feed your safety behaviors. (Use prior responses from a group member to demonstrate this, similar to the example in MAWSAS, p. 28: “Emily’s attention zooms in on her shaky voice the moment she utters a word during conversations [paying attention to social 9 danger] ; she realizes it’s “just nerves” but doesn’t find this acceptable [resisting anxious feelings] ; her mind jumps in (You sound nervous; they think you’re weird), and she buys into what it’s telling her [fusing with anxious thoughts]; she tries to steady her voice and hides it by speaking softly and slowly [using safety behaviors] ; at times, she gets so wrapped up in struggling with her shaky voice that she loses track of conversations and feels even more embarrassed [costs of keeping safe] .”) Now that we’ve walked you through safety mode, we’re going to move on and mention the alternative, vital-action mode. Vital-Action Mode In contrast to safety mode, the goal in vital-action mode is to live a life that really matters to you. In the remaining sessions of the group, we will teach you the skills necessary for shifting from safety mode to vital-action mode. We will help you get in touch with your values and goals, stay tuned to the present moment, bring acceptance and compassion to difficult feelings, and gain distance from your worries, along with other strategies. We’re going to start that process right now with our first mindfulness exercise. First, the definition we’ll be using: Mindfulness means paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally. From Wherever You Go There You Are by Jon Kabat-Zinn, 1994, Hyperion, New York, page 4. MINDFULNESS EXERCISE: Mindful Eating 10