ACT Psychological Inflexibility Processes Identified: Experiential Avoidance, Conceptual Past/Future, Cognitive Fusion, Attachment to conceptualize self
ACT Psychological Flexibility Processes Engaged: Cognitive Defusion, Acceptance, Presence, self-as-context
Prognostic Ladder Representation of Psychological Flexibility: Low
The scope of awareness is deliberately broad as many biopsychosocial processes are engaged in intentional attention allowing for an arising awareness. Attention is defined by the APA as a state in which cognitive resources are focused on certain aspects of the environment rather than on others and the central nervous system is in a state of readiness to respond to stimuli. Awareness is defined by the APA as perception or knowledge of something. Accurate reportability of something perceived or known is widely used as a behavioral index of conscious awareness. However, it is possible to be aware of something without being explicitly conscious of it. As these definitions clearly define, attention is independent of awareness and awareness is only relative to consciousness. However, from a pragmatic sense, there is not much functional benefit from defining the two separately in the ladder, conscious deliberate attention is engaging in awareness. Exploration of the RFT experience of self forms the basis for awareness in MWPF (I/You, Here/There, Now/Then). Utilizing the RFT definitions of self previously described in the notes section, explicitly bringing attention to the self-as-perspective and exploring the content of self are the relationships and networks is the process we are engaged in. As physical rehabilitation professionals, we may have to emphasize sensorimotor experiences, rather than cognitions and emotions, as our entry point for developing basic levels of awareness despite the often arbitrary and futile nature of the effort. This, in part, is an attempt to meet the expectations of the client attending physical rehabilitation. We attempt to guide individuals to recognize resting muscular activity, the uniqueness of their own structural anatomy, and the ability to influence it. In sensorimotor awareness, there are many realms of exploration of sensorimotor options and experiments which could lead to meaningful action if so desired. Depending on the flexibility and openness of the client to engaging in deliberate psychosocial processes, cognitive awareness, such as knowing we have and observing thoughts, beliefs, memories, judgements, and predictions which influence our sensorimotor behavior and relate to our emotions are guided experiences which could be gradually introduced as the client shows openness to the concepts. Emotional awareness entails knowledge of emotions as experienced in the physical body that there is relationships with thoughts and sensations but also unique physical experience qualities to be noticed. Awareness of values that have been lost or never identified are often vital for individuals to develop true ownership but are more explicitly explored in meaningful action.
Awareness Engagement Process (AEP or Exploring options)
When we engage in awareness processes we explore options. What do we mean by options? We mean to explore variability across biopsychosocial domains: movement variability through exploring ways of moving, ways of holding positions, ways of doing actions; psychological flexibility in noticing what we think we’re doing and respecting emotional and mental cues for our internal congruence; and respecting the needs of the whole person for functional capacity through relationships of extrinsic factors in preparation for meaningful action. In this awareness we will also recognize the things that matter to us, that are valuable and use these as compasses toward a better life and the ability to thrive transdiagnostically.
For the purpose of the MWPF, the “options” revealed to the client and/or the clinician during engagement with Awareness Processes will be label Awareness Engagement Processes (AEP). A client may be prognostically in the awareness phase of the MWPF but the action they are engaging in, relative to that phase, will be defined as AEP.
The forefront of rehabilitation has been symptom modification (eg: modulation/”calming”), whether exercises such as specific exercise, directional preference, manual therapy, dry needling, taping/strapping, any number of modalities, and referral related to pharmacology, and procedures. However, the value of symptom modification in long term outcomes and addressing disability is questionable. In some contexts, symptom modification when combined with functional understanding may have the potential for cognitive defusion, committed action, contacting values, and potentially address thoughts about the conceptualized past and future through expectation violation. However, it also has strong potential to reinforce experiential avoidance, attachment to conceptualized self, decrease presence in the now and in the physical body. It is potentially a risky behavioral path to focus on and has the potential for decreasing likelihood for true ownership, building, or thriving. Symptom modification may overlap with behavior change and processing, but more than likely, it may result in an indirect effect of these two processes. As defined above, the opportunity for cognitive defusion may still present an indirect effect on either, or both, AEP.
The scope and scale of biopsychosocial behavioral change available to humans is broad. The AEP of Behavior change is a client lead process in which a clinician presents activities which are selected in their ability to overlap with multiple psychological flexibility processes. An example of a common first-generation activity found in the early phase of MWPF development is the acts of sitting, standing, or walking. The act of sitting, standing, or walking provides the client an open opportunity to increase sensory, cognitive, and emotional awareness and to explore options within the experiences that arise in the process. Case review of the breadth of behavior change from these guided awareness practices yielded behavior changes across physical, personnel, professional, and social life domains with clients reporting the experience of these 3 awareness acts being their most influential moment in their POC when questioned greater than 6 months after the guided process. Again the individual acts are likely not as important as the AEP, and the transition of simple awareness acts toward multiple life domains is another proposed example to support the theoretical transdiagnostic ability of the MWPF. Behavior change strategies presented in context have the long term potential for increasing true ownership, building, and ultimately thriving prognostic trajectories. Behavior change may include overlap with symptom modification and processing, but this is not the intent, but rather the indirect (“fuzzy”) effect of AEP.
The processing AEP is the broadest in scope and depth with the least amount of “borders”. Processing is the active engagement in the process of awareness and including historical, cognitive and emotional memories. It distinctly does not yield action, but requires engagement in non-action, or being, with self-as-perspective. Processing is engagement in RFT in its broadest perspective, observing the self-as-content and self-as-process. From the ACT flexibility process, it is engaging in self-as-context, attention to the present moment, acceptance, and defusion in the absence of values and action. It could be considered in popular terminology such mindfulness or meditation, however, these include broader observations such as universal connectedness, which are beyond the intent of the MWPF Processing AEP. Prosocial elements such as self in relationships to others and spirituality are engaged, but, the primary intent is engagement in self as an experience. Processing may include overlap with symptom modification and behavior change but once again, this is not the intent, but rather the indirect (“fuzzy”) effect of AEP.