Podcast: Apply ACT Principles to Your Daily Life

Jenn talks to Dr. Jason Krompinger about the benefits of acceptance and commitment therapy (ACT). Jason discusses the six psychological processes that are targeted in ACT and gives insight into how we can all become more mentally flexible and better adapt to whatever life throws our way.

Jason Krompinger, PhD, is a clinical psychologist with expertise in treating OCD and related disorders. He serves as director of Psychological Services at McLean’s Obsessive Compulsive Disorder Institute. In his role at the OCD Institute, he serves as the director of the training program, supervising students, post-doctoral fellows, and early career psychologists in the delivery of empirically based interventions. Dr. Krompinger also works alongside the OCDI’s Office of Clinical Assessment and Research (OCAR) in order to better understand factors that interfere with patients’ ability to access treatment.

Relevant Content

Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Hi, folks. Good morning, good afternoon, good evening to you, and thank you for joining us wherever you’re joining us from, and whatever time you’re joining us today for our chat titled, “Apply ACT Principles to Your Daily Life.”

I’m Jenn Kearney, and I’m a digital communications manager for McLean Hospital, and I am joined today by Dr. Jason Krompinger. So, acceptance and commitment therapy, or ACT, can be really useful, but at the surface level, it can seem really difficult.

Its approach isn’t really how we typically think about or address problems, but it’s shown to be really beneficial to a lot of people. Okay, so, how are we supposed to get the psychological flexibility benefit of ACT if we’re hardwired to think differently?

And that is why I’m joined by Jason today, because Dr. Krompinger is going to talk all about ACT, how it’s effective beyond treating OCD, and how we can all become a little bit more mentally flexible thanks to adding it to our daily lives.

So, if you are unfamiliar with Dr. Krompinger, you are going to be very pleasantly surprised over the next hour-ish. Jason Krompinger, PhD, is a clinical psychologist with expertise in treating OCD and related disorders, and he serves as the director of psychological services and clinical research at McLean’s Obsessive Compulsive Disorder Institute.

So, Jason, hi, and thank you for joining today. It’s nice to see you again.

Jason: Thank you. You too!

Jenn: I want to get started just by asking flat out, what exactly is ACT, and what are the benefits of it?

Jason: Yeah, so, like you’ve kind of laid out already, ACT is acceptance and commitment therapy is what it stands for, and it’s a psychological intervention that has been shown to be effective for actually a variety of conditions.

So, in a nutshell, the way I think about what ACT really is, it’s about helping people better move towards what’s meaningful and important to them, kind of irrespective of what shows up internally.

So, we all have all kinds of difficult internal experiences, whether you have a diagnosed psychological problem or not. We all have thoughts that we don’t necessarily like to have, we all have difficult feelings, and sensations, and memories that can be really powerful, and really feel like they have a really strong impact on our lives, and our behavior, and the choices that we make.

And ACT is essentially about helping us to develop a way of responding to all those inner experiences, such that we are continuing to live and engage with life in a way that fits with what we care about, with our, we’ll use the word values a lot in ACT, even though those kinds of experiences can kind of make it feel like we can’t.

So, like you mentioned the term psychological flexibility, that’s sort of the core process that is being addressed in ACT, is that. Oftentimes, what it can feel like when we have difficult thoughts, feelings, et cetera, is that we have kind of one option, one way of responding to them.

And it could mean that, if we feel a certain way, we kind of have to isolate, or we have to ruminate on whatever the thought is that we had, or the situation that we’re in, or we need to engage in some coping strategy that may not be terribly useful, like self-medicating, or risky behavior, or whatever the case might be.

And in the moment, again, it can just feel like that’s the only sort of path that we can go down. That’s we’ve sort of learned to do. Being psychologically flexible means that we’re, we see that there’s a broad repertoire of different paths that we can take in response to the experiences that show up.

ACT, in a way, is sort of like helping to shine a light, a little spotlight on all those other directions that we can go in. One last way of describing it, I like to think about it, is, you’re developing a new relationship with your inner experiences.

So, I think what we often are geared to do is think of them as little enemies that we have to sort of battle, like our demons, and that we have to eradicate somehow. And that kind of setup can be fairly problematic, at least for some people.

So, a new relationship is kind of cultivated by way of being more flexible in the face of those experiences. That’s kind of the overview. It’s been, just to say a little bit more, it’s been shown, like I said, to be beneficial for all kinds of different conditions.

So, it’s useful in tandem with exposure and response prevention for OCD, it’s useful for mood disorders, useful for psychotic disorders, substance abuse and alcohol use disorders, even experiences like psychosis have been shown to be kind of better able to be managed by the use of ACT, the incorporation of ACT strategies.

So, it’s really kind of a wide variety of conditions that it’s been shown to be effective for.

Jenn: My understanding is that ACT targets six of our psychological processes. And there, and tell me if I miss one of these, it’s acceptance, defusion, values, committed action, self-as-context, and then contact with the present moment, right?

Jason: You got it.

Jenn: Awesome. Good thing my notes, good thing my notes pulled through!

Jason: Me, too!

Jenn: Can you provide a little bit of context into how ACT actually targets these processes?

Jason: Yeah, so I guess I’ll, how about I just, I don’t want to, I could talk forever about any one of them, I guess, but how about, I can just kind of say a few things about each one, if that-

Jenn: Yeah, just rapid fire.

Jason: Yeah, yeah, yeah, relatively rapid fire. So, you know, with acceptance, acceptance is this idea that we are allowing for the experiences that we have.

So, like I was kind of saying before, I think that a lot of things can contribute to this, but we can see our feelings as these, our bad feelings at least, or we can even just me saying that there are certain feelings that we sort of categorize as good and categorize as bad, and we want the good feelings, and we don’t want to have the bad feelings.

And why, of course, everybody feels this way, why wouldn’t you feel this way? The problem is that when we try to not have certain feelings, what happens is that, ironically, we are going to have them more and more, and they become more powerful and more weighty.

And we sort of teach ourselves that those experiences are our enemies, therefore, we experience them like they’re our enemies. So, when we have a sadness and we don’t want to feel sad, it makes the experience all the worse.

Or if we’re anxious and we’re not, if I was telling myself going into this webinar, “Don’t be anxious!” that’s a terrible thing for me to tell myself, because I would just feel way worse just in doing it.

So, acceptance is about allowing for the fact that they exist. It’s not necessarily about, you don’t have to like them, but simply coexisting with them because they’re there. That applies to difficult feelings that applies to difficult sensations, memories, thoughts, the whole gamut.

Defusion is a way of, is essentially a way of relating to the thoughts that we have. And the spirit of it is that we are learning that thoughts are just thoughts, as opposed to something that can feel very, very important and meaningful to us.

So, we have, the way that human beings work is that we have this really significant relationship with the words in our head, such that they are pretty meaningful to us. So, we use language all the time, constantly.

I’m using it right now, you’re using it, we’re thinking in terms of words and language. And the vast majority of the time, that’s actually pretty useful to engage with our thoughts, and have our thoughts help dictate our choices, and figure out what we do next, et cetera.

But there are certain circumstances where having particular thoughts, or at least buying into the certain thoughts that we have doesn’t actually lead us to something useful, it doesn’t actually pay off for us, it doesn’t actually improve our lives.

So for example, I could have a thought that I suck, or I’m a terrible person. I should feel very guilty. And I could, what that thought could tell me to do is kind of ruminate on that thought, or distance myself from those that I care about, or distance myself from my job, or whatever the case might be.

That’s not terribly useful. That’s not really, buying into the thought in the way that I do like that doesn’t move me forward. Defusion gives us a strategy where we can practice seeing those kinds of thoughts, like that I suck, or that I’m useless, as simply thoughts.

They’re just simply just phenomena of the brain that we can choose how to respond to them. It isn’t necessarily that we have to treat them like they’re the honest truth, the gospel truth, and that we have no other choice.

The values, kind of mentioned this already, but values in a nutshell is identifying who and what is important to you. So, you know, everybody has things that they care about.

And even when you say that you feel like you don’t have things that you care about, oftentimes, the fact that you are distressed by feeling like you don’t have things that you care about means that you care about things, if that makes any sense.

So, whether it’s family, whether it’s being independent, whether it’s contributing to the world in some way, health, safety, all that sort of stuff, you have all these gut things that we care about. And there are times in which when we respond to our inner experiences by trying to get rid of them, that actually tends to move us away from what we care about.

So, clarifying what those values are is really important in ACT, because like I said, one of the main purposes is to practice being able to move towards them in a more consistent and substantial way.

So, related to that, committed action refers to literally the act of moving towards your values, so engaging in behaviors that are consistent with what you care about in the face of whatever inner experiences you have.

A common phrase that we’ll throw around in ACT kinds of discussions and therapy sessions is, what kind of person do you want to be? You’ve got your brain that’s screaming at you to tell you to, you know, in OCD, it could be to run away from this thing that’s anxiety provoking to you, or do some kind of obsessive, a compulsion or a ritual to eliminate this experience somehow.

But oftentimes, engaging in those behaviors has moved the person further and further away from what they actually care about. So, the question of, “Well, we have this trigger, we have this thing that’s so distressing, but how do we want to behave amidst this trigger?” That’s what committed action is referring to. Self-as-context is kind of a fun one.

So... Having a self is cool, but it’s also a little bit complicated, because it gives us all these rules. If you’ve ever said something like, “I’m not the kind of person that would do that,” sometimes, that could be really useful, to look at yourself in that way.

I feel like for me, I don’t know, I’m not the kind of person that’ll probably skydive, I was actually saying this to somebody earlier today, I don’t think I’m the kind of person that would skydive. I just, I don’t think I am.

And that might be fine, that might be totally functional for me to think about myself in that way. But it’s kind of interesting how having a self, a certain perspective on a self can create all these rules for what we can and can’t do that aren’t really rules.

We can break them whenever we want. But I think we can sort of pigeonhole ourselves if we’re not careful about how we see a self.

So, self-as-context is this idea of understanding that, well, just because you have these certain thoughts about what yourself is doesn’t mean you necessarily need to adhere to those rules. We can redefine what a self is. Your self isn’t necessarily your thoughts about yourself, it isn’t necessarily the emotions that you have or the sensations that you have.

Your self can be sort of like the holder of all that, the container, or the context as we say, kind of the observer of all those different thoughts, all those different experiences that we have.

And putting yourself in those kinds of shoes where you see yourself as more the context can put you in a position to be more flexible amidst whatever it is that shows up, because you’re not as constrained by those rules.

“Oh, it doesn’t matter. I can kind of do whatever, even if I’m, if my brain is telling me that I’m not the kind of person to do X, I can still do X, even though I have those kinds of rules,” if you see yourself as more the container, as opposed to being those thoughts, literally. So, that’s kind of that idea. And then present moment is getting practice with, with experiences as they are.

So... Couple ways of looking at this. Oftentimes, what we can do is be in situations where there’s something very distressing to us, and the narrative that we craft around that distressing thing combined with the distressing thing itself makes it way more challenging to deal with than the actual experience as it is.

So, imagine if I told you, and if I told you, you know, when you went to the gym, don’t, I hope, “Okay, go to the gym, workout, but try not to feel sore. Don’t feel sore afterwards, ‘cause that’s a problem if you feel sore.”

If went to the gym, worked out, and felt sore, it’d be bad enough that you felt sore, but you’d also had this whole narrative around it, that I helped create, that said, “Oh, this is bad. This is a threat.” And that would feel much more, you’d be much more distressed because of that.

So, present moment is kind of like cutting through all that narrative and saying, “Well, I don’t want it getting into the story of what it is, just, what is it exactly?” So, I have a pain in my leg, or I have these sensations of soreness in my leg.

I can just co-exist, and be with that, and be in contact with that, rather than this whole story that I’ve attached to it, because that doesn’t actually help me, to get wrapped up in that story.

That’s kind of what present moment is sort of encouraging us to be, more connected to what’s actually happening, as opposed to what our brains are telling us is happening. So, I think I hit all six with that.

Jenn: Yeah, you did, you nailed it. In your years of experience, have you found that some processes are more challenging for folks to master than others, or are they more case-dependent?

Jason: I mean, I think it’s case-dependent, but I think just anecdotally at least, the whole idea of acceptance is, I think, pretty challenging. This idea that we’re supposed to practice, I was using the word co-exist, with experiences that can be quite painful is a tall order.

It could be, or it could be just very, again, very challenging for anybody to wrap their head around, because that experience does feel very threatening, or it does feel very, very much like something that kind of, if I could eliminate this thing, I sort of would.

The problem is that most people, or a lot of people that we work with at least, have already exhausted lots of efforts to try to not have that feeling, and it hasn’t really worked for them. They’re kind of left with it still, you know, one way or another.

So, and that’s when we start opening the door towards acceptance, and saying, “Well, what if we didn’t work so hard to try to get rid of these experiences that you’re having, and tried to get to the point where we can better have them?”

So, we’ll, the ACT people will say things like, “Treatment isn’t necessarily about feeling better,” it’s about feeling better, like practicing learning how to feel things in a better way, which is I think, again, it’s kind of like, it was one thing just for me to sit here and say it, it’s another thing to actually practice it.

And I think that’s, some people out there are having struggles with the idea of acceptance in particular, and that’s, you’re not alone at all. And it’s normal. It’s part of the process, to really have some difficulty wrapping your mind around it, but people do get there, for sure.

Jenn: And one thing I know is a lot of folks that have self-doubt will try to accept the thoughts that they’re having, but also, are trying to dismiss them at the same time, as, you know, you’re in a, basically, a mental battle with yourself.

So, when it comes to accepting our thoughts, do you have any suggestions about accepting uncomfortable thoughts without allowing our brain to always acknowledge them as being true?

Jason: Yeah, so, just one thing that I’ll say about, that is a good point you made about kind of what happens when we try to accept.

With any of these approaches within the ACT framework, we need to be paying attention to the functions of them, why we’re implementing them, what our intention is. The point is to better co-exist and be more flexible with all these experiences.

What can happen, especially if you’ve kind of trained yourself to, you, over the years, have been trained to think of things a certain way, is that you can take something like defusion, you can hear what I’m saying and say, “Okay, I’m going to work on having my thoughts, on taking my thoughts less seriously.”

And you can sort of use that as a new way to try to get rid of the thoughts, if that make sense. Like, “Well, as long as, as long as I remind myself to take it not seriously, or to remind myself that it’s not true, or something like that, then I’m doing defusion.” But that’s not really what kind of defusion is.

That’s I think more, that’s more grappling with a thought, and that’s more sort of like we’re trying to not have these kinds of inner experiences. So, paying attention to the intention behind it, and having this approach of, “I’m going to sort of be with it” is a good attitude, I think, to have.

But as far as specific ways of doing that, one thing to do is to literally change how you respond to certain, let’s just, I mean, we’re talking about thoughts specifically, certain difficult thoughts. So... Just pick, I mean, I said “I suck” before, but I wanted to pick a different one.

But... Yeah, something like, “I’m not good enough.” Let’s just say that’s a thought that, a lot of people have that thought. And typically, again, what somebody might do is just, if nothing else, just kind of start, be a little bit zoned out in what they’re doing, and just start grappling with that a little bit.

And it’s like trying to, “Am I really good? Am I not good enough? What are all the ways that I am good enough? What are all the ways that I’m not good enough?” You know, try to talk yourself out of that. Like, “Well, that can’t be true. My brain is just lying to me.”

And then of course, you marshal all this evidence that says that your brain’s lying, but then your brain comes back and says, “Well, how do you know for sure? Maybe you really aren’t good enough!” And there’s all that kind of struggle. And that could be the typical response to that thought.

I’d say one simple thing to do is, when you notice a thought like that, just write it down. Just literally write it down on a piece of paper, or just have it on a computer screen, and see it there in ink and paper.

In doing that, it might seem like a really simple thing, but in doing that, you’re showing yourself, “I could have that thought,” and that’s actually a pretty literal step towards acknowledging for yourself that it doesn’t have to be this enemy that I try to grapple with and get rid of, I can just literally write down and be with it. Here it is, sitting down on a piece of paper.

I can put it up on the wall behind me, and have it hang out with me while I do my work, you know, while I talk to my loved ones, while I watch my TV show, or whatever it is. That is I think a concrete kind of thing that we do to try to start to promote the idea of defusion from thoughts when they show up.

Jenn: A lot of what you’re saying sounds to me like mindfulness practices. Is there actually a difference between the two, between ACT and just being mindful? And if so, what are the differences?

Jason: ACT, I think mindful is a core process within the treatment of ACT. So, I think in order to do any of these things that I’m talking about, there’s a certain amount of mindfulness that’s involved. So, we talk about mindfulness as being aware. I really see mindfulness as just being, having awareness of what’s happening in the current moment.

So, if we’re going to practice acceptance, or the self-as-context idea, or defusion, all that, we have to have an awareness of how we tend to interact with ourselves, and that’s where mindfulness, I think, is really useful.

If we have no idea how we react, typically, to difficult emotions, or how we’re responding to thoughts, or how we’re thinking about these kind of rules that can show up in the case of having a strong sense of this is kind of, this sense of self, then it’s hard to sort of intervene.

So, mindfulness is kind of woven into the fabric of ACT. Think of ACT as more like a, more of a protocol, of a sort of, I don’t want to call it protocol, because it’s not quite as structured as that, but more of a treatment intervention. And mindfulness is sort of like a process that can help connect with the different aspects of the treatment.

Jenn: One thing that I’m sure a lot of folks tuning in are curious about is, can anybody benefit from ACT? And if the answer to that is yes, what kind of impact does ACT practices have on our everyday lives?

Jason: Yeah. Like I was saying at the beginning, it’s, I think we’ve seen that those, I haven’t done these studies for sure, but there have been plenty of, hundreds of studies done to show that ACT is useful for a variety of psychological conditions.

I don’t know that I would say that it’s, it’s not indicated for really sort of anything. If you’re somebody who tends to struggle with inner experiences and has not found a way to adequately deal with them and do what’s important to you, in a way that that kind of fits within the context of your life, then I think ACT can be useful.

I think that’s really where it’s most useful, is that... I think what I really like about it is that it helps us acknowledge our humanity. And what I mean by that is, All of us, like I was saying, I probably said this already a couple times, but just, all of us have stuff.

You know, all of us have stuff that shows up, obviously, to different extents, and the specific content can vary, but we all have our kind of challenging internal experiences. We all have stress in our lives.

We all have things that make us anxious, things that make us sad, et cetera. And, you know, if... And I think that what you can often see, I don’t want to trash society as a whole, but I think oftentimes, the message that we get sent is that you’re supposed to not have that stuff, live an anxiety-free life.

You see positive affirmation posters. You see, “Get rid of negativity,” and all that, all that kind of stuff. You know, “This is my anxiety buster tip,” all this kind of stuff to get rid of your anxiety, get rid of your stress once and for all, and I don’t know how helpful that is! Sorry, if anybody out there is a huge proponent of that.

Look, I will honestly say, if it works for you, cool, do it. And I mean that honestly. But for a lot of people, I don’t know how helpful that is. It propagates this idea that we need to vilify certain experiences, when, you know, having, again, having these experiences is human.

So, I think the ACT framework is useful just in seeing that, “Hey, I can have whatever thought and feeling I have, and learn to be with it, and learn to have it in a way that doesn’t dictate to me the courses of action that I take,” and that can really sort of translate into benefits.

So, I think that just, helping us think differently about these kind of thoughts and feelings is a major way that it’s useful to anybody.

Jenn: So, if folks are interested in starting the journey of ACT, do they need to work with a licensed professional to start implementing this, or can they just start this journey on their own at home, now?

Jason: Certainly, I would not tell anybody not to begin to investigate. If any of this sounds interesting to somebody, there are plenty of really, really good books out there that are intended for the layperson to start to address these concepts that I’m bringing up.

One that we, the one that we actually kind of have most of our patients at the OCDI read in the early stages of treatment is called “The Happiness Trap,” by Russ Harris. It’s a really good one. It’s a really easy read. So, it’s kind of very clearly written.

There’s actually an illustrated version of it, if you happen to, if you’re kind of in a position in your life where just reading stuff feels overwhelming, it’s actually, that’s cool, too. So, absolutely start to kind of poke around in that space.

There are other, if you look, they’ve got them on Amazon, or whatever, there’s plenty of good ACT books out there. Patricia Zurita Ona writes some good ACT stuff, and Jill Stoddard does, too.

But I would say if you’re going to actually do ACT, you should work with somebody with actual ACT training, who’s licensed, because one issue is that, kind of like we were alluding to a few minutes ago, ACT is something, like any treatment, really, that can be easily misused.

And I think that you can sort of take some of these approaches, and just, again, convert them into new ways of trying to get rid of our experience. Like, I mean, again, defusing from thoughts, or, I’m going to accept my, “Yeah, I’m going to practice accepting my feelings with the hope that they actually go away.”

So, you have to really be working with somebody, I think, skilled to navigate those kinds of challenges. Those examples, by the way, I just said are very, very common.

So, if you’re, if anybody’s watching and is involved in ACT, and then finds themselves going down those paths, yeah, again, a very common kind of struggle. But you want to be working with somebody who’s pretty familiar with the concepts to make sure that you’re kind of, you’re kept on the right track.

Jenn: It seems like from what you’re saying, really, anybody can benefit from ACT, but are there types of patients that are the best candidates for incorporating ACT into their treatment regimens?

Jason: I don’t know for sure if there’s a particular population that benefits the most. I will say that... So, there are particular interventions under the CBT umbrella that, you know, pre-ACT, or even irrespective of ACT, focus on getting better at dealing with feelings, right?

Well, I guess to some extent, all of them do. But what I’m thinking about specifically are the exposure-based approaches. So, most anxiety disorders have an exposure-based, or are indicated for an exposure-based treatment approach, where you practice facing what you fear, basically.

And not only facing what you fear, but practicing resisting what you would normally do to take care of that fear. So, OCD is a very kind of clear example of this, where, in OCD work, what often happens in your existing treatment is that you’re working on deliberately facing what it is that causes anxiety, and not doing your compulsive rituals.

So, just to, I’ll use intrusive thoughts as an example. You can have somebody who has lots of fears that if they’re standing by a subway platform, that they’re going to push somebody into the oncoming train.

So, what they do is they, I mean, first of all, they avoid the subway platform. But if they were on a subway platform, they’d be doing all kinds of mental gymnastics in their head to try to not have that thought, or stay away from people, and certainly not come close to the edge, or come close, within close proximity of anybody, because they are paralyzed with fear that they’re going to act on this kind of an impulse.

So, what we do to help that person is actually, it’s called exposure, and we directly face those scenarios. So, you deliberately have thoughts, “Maybe I’m going to push this person in front of the subway.” You deliberately stand on the subway platform, you deliberately stand in close proximity.

And it’d be very, very scary, but the idea is that over time, when you do that, you learn that, “Okay, well, just because I’ve had this thought that tells me I’m going to do it doesn’t mean I’m actually going to have to do it,” or, “Just because I have this feeling I’m going to do something, doesn’t mean I actually do it.”

ACT, these principles that I’ve been talking about, are very compatible with an exposure-based approach, because in a nutshell, what ACT is about is having whatever experience you have and not letting it dictate what it is that you do.

So, I just find that, I don’t know if it’s the best, but I just find that weaving in ACT principles to exposure-based work is very, very compatible.

I’m not saying you have to be working with somebody who knows ACT to benefit from exposure therapy, but I think increasingly, you’ll find a lot of people who sort of hold themselves out to the public as exposure-based therapists, for anxiety disorders, or OCD, or whatever the case might be, are going to talk about ACT too, and that’s cool.

That’s awesome. I think that’s been a great development over the past five to 10 years or so.

Jenn: I know you do a ton of work with OCD patients. For those of us who have a diagnosis of OCD, can you do ACT without ERP, or do they have to occur together in order to be effective?

Jason: I just don’t think ACT is very different than ERP, is the thing. Yeah, I don’t, that’s the thing. I think I was on another webinar, maybe a year ago at this point, I don’t know if it was. It was a long time ago. But, you know, it’s, again, they are very compatible.

So, I think that what’s good about ERP, not to kind of turn this into an ERP kind of talk, but ERP is a little bit more structured, where, compared to ACT, and it’s targeting very, very specific problems, very specific obsessions and compulsions.

So, certainly, I think, you know, if you have OCD, you’d want to be going to, if you had a choice at least, you’d be going to someone who kind of specialized in ERP. And if they incorporate ACT stuff, again, like I said before, then that’s fantastic.

It’s not that ACT by itself couldn’t be useful, but I don’t know that we know yet that ACT by itself is as effective as ERP by itself. I mean, there’s some preliminary data that suggests perhaps, but I think it’s, mostly what we’ve found is that a good approach on the psychotherapeutic side of things is to have both ERP and ACT at the same time.

So, and if you could choose one, I think ERP is sort of the gold standard. But if you’re doing ACT, just ACT, and you have OCD, you’re certainly not doing any harm. You’re definitely on the right track, again, as far as how to begin to develop this new relationship with your inner experiences.

But at some point, it’s going to be that you’re doing exposure anyway, when you sort of, when you sort of start to go down the ACT path, as someone with OCD. So, I think it’s beneficial to have somebody who knows that, that ERP approach.

Jenn: So, for folks who are trying to grapple with having uncomfortable or alarming thoughts, how often do we need to have them before it’s considered a problem?

Jason: It’s when it’s, it’s when you can’t do the kinds of things that you want to be doing in your life.

That’s kind of the biggest thing, is that when your relationship with those kinds of difficult thoughts is such that, for any number of reasons, you can’t work, you can’t be with your family, you can’t babysit, you can’t go enjoy the good weather outside, you can’t pursue any other, you know, relationships, social stuff, whatever it is, you know, anything that’s meaningful to you, I think that’s a major indicator that this has become a problem for you, and you should seek some help.

In fact, I’ll, I’ll actually cut myself off there for once. I’ll stick with that as an answer.

Jenn: Perfect. We had someone write in saying, “I imagine we all have a hard time truly accepting things that we do not like about ourselves.”

Jason: Totally. Yeah, I agree.

Jenn: And for them, when they acknowledge things they’re not proud of, it takes an emotional toll on them, which, again, they’re not alone in this. Do you have any suggestions around turning revelations into action and not getting caught up in the habit of judging ourselves?

Jason: Yeah, for sure. So, you know, these revelations that we have absolutely can be very painful. And so yes, I totally agree. To acknowledge aspects of ourselves, or aspects of our personhood that aren’t our favorite things can certainly invite pain. What I want you to do is just notice then what that pulls for you to do.

Because what happens is that, you know, we recognize this stuff, and then oftentimes, whether it’s the shame, and the guilt, or whatever the case might be, it pulls for us to actually do things that, ironically enough, just kind of keep us in that spot of not doing what’s meaningful to us, and not kind of moving forward in our lives, whether it’s ruminating on things, whether it’s avoiding, whether it’s isolating, that sort of thing.

So, what I... I think what I go back to, as a starting point for people, is when that stuff shows up, and when you’re grappling with all that, and when you’re noticing that shame, asking yourself very simply, “Well, the person that I’d like to be, amidst all this, does what with this?”

And if you’re saying things like self-flagellation, it’s like, “Well, is that, how useful has that been for you, in your life?” You know, I mean, I understand the pull for that. You know, we all have that I think kind of self-critical part of our brains, some of us louder than others.

And maybe for some of us, that’s been really useful to have a self-critical part of the brain, it’s really helped. But in a lot of cases, when we talk about this kind of thing that we’re talking about, guilt, and shame, and trying to accept ourselves, the self-criticism, self-flagellation, it might feel appropriate, but it’s not necessarily functional.

It’s not actually going to translate to any benefits. So, the practice in that case is recognizing what the kind of person you would like to be does in this situation, what that moves you towards, and practicing doing that.

So, “I feel really guilty and shameful, I don’t want to see anybody, but does the person that I want to be spend time with my family, spend time, I’m going to do it.” It’s going to be difficult, yes, of course. I’m going to allow for the fact that it’s difficult, but as you practice it, it can get easier over time.

Jenn: Can you talk a little bit about folks who may be encountering challenges with what they value versus what they can’t control? And I think a good example of this would be parents who are working the graveyard shift who can’t see their kids, but value their families.

Jason: Totally. Yeah, absolutely. You know, those people working the graveyard shift, they are demonstrating committed action, I think, right there.

Their brains might, I’ve heard this from people that are moms, especially who, who work, and feel as though, because they’re working so much, they’re not able to spend as much time with their kids, even if I’m working from home, and their kids are right there.

Just like, “I’ve got to pay attention to this, I can’t,” and they feel like bad moms. They’re not bad moms. The reason why they’re doing the thing is to create a better life for their kids.

So, I think it’s about recognizing the narrative that shows up, again, where your, our brains want to tell us this story about, “Oh, see, you’re selfish. You don’t care. You’d rather work than see your kid, or you’d rather, you know, you’re sacrificing all of this to, you’re sacrifice all this time with your kid for your job for some reason.”

But in reality, that, what you’re doing is that you’re engaging in all these efforts so as to better their life. And even if you engaging that effort is, it’s about them, but it is, even if it’s about you to some extent, where it’s like, “No, I want to further my career, I want to kind of, you know, move forward and up the trajectory of my professional life,” and that makes you happy, that’s still not selfish, because that has impact for them, too.

That has implication for your kids, as well. So, it’s about sort of, again, this whole questioning the narrative a little bit, where we can go with what, the first thing our brains tell us, and just kind of bite into that, and see where that goes.

But if that’s causing trouble, if that’s sort of like, “Well, I’m just increasingly guilty and shameful for doing, for doing things like working my fingers to the bone,” then it’s about recognizing that I don’t have to go with that initial narrative. There are other ways that I can respond to this that are perhaps more useful for me.

Jenn: Do you think that kids can benefit from ACT? And if so, what processes would you recommend?

Jason: Yeah, totally, kids can benefit from ACT. I think that it, yeah, I don’t work as much with kids these days. I used to back, in the initial part of my training, I did way more with kids. But I think that, you know, we were talking about mindfulness as a basic process of ACT.

I think, you know, teaching kids to be mindful, doing the basic mindful meditations, you know, focusing on your breath, noticing your thoughts, that’s something that I think is increasingly done in schools, actually, these days.

I think that’s awesome, that’s super cool. But then I’m going to, I guess I’m a broken record at this point, but then again, it’s back to this thing about feelings. I think that we as parents, we as people that have contact with kids, teachers, educators, whoever it is, can do our part to essentially demonstrate this attitude, like, “It’s okay to feel. It’s okay to feel however it is that you’re feeling.”

And that’s not necessarily specific to ACT, but I think that’s just an important kind of core concept that I think, again, like I said before, ACT helps us think about and acknowledge the humanity, and I think it’s really important that kids absolutely recognize that there’s no such thing as a wrong feeling.

You can feel however it is that you feel. And of course, there are certain behaviors that aren’t acceptable, but all thoughts and all feelings are acceptable, and doing what we can to I think model that for our kids is very useful.

So, if they’re, you know, if somebody’s, if a kid comes up and says, “I’m hungry,” after, you know, 30 minutes after lunch, you don’t say, “You’re not hungry. No, you’re not,” or something like that.

It’s like, “Okay, yeah, I understand you feel that way, but dinner’s in three hours,” whatever the case might be. So, there’s simple interactions like that, I think can be kind of useful.

Jenn: If there are couples tuning in that may not need couples therapy, but recognize they could do a little bit better when it comes to communicating, are there any parts of ACT that could specifically be applied to reducing stress in romantic relationships?

Jason: Yeah, I think there’s a book called “ACT for Two,” or “The ACT Matrix for Two,” by Benji Schoendorff, which, there’s going to be show notes, I guess we can put, we can put all these things in the description.

But, yeah, there are a bunch of I think studies that have been done using ACT for couples. And, you know, I won’t be able to exhaustively review it all, but I think that, the answer is yes, that I think, yeah, it can be useful in the context of a couples treatment.

And one specific way of thinking about it is, it gets back to this awareness thing I was kind of talking about a little before with mindfulness, where you start to notice how, as a couple, you can engage in both behaviors that move toward, you can become aware of behaviors that move you towards what’s actually important to you as a couple.

But also, you can engage, you can notice behaviors that move you, are more about trying to get rid of these inner experiences. So, for example, your spouse may say something that frustrates you, and your brain can tell you this whole story about “Well, they just are always doing that on purpose, and they don’t respect me, and all that.”

And then you feel all frustrated, and sad, and anxious about that. So, you respond by kind of lashing out, but that behavior was more about trying to address the feelings that you had, as opposed to actually moving towards what was meaningful to you in the relationship.

So, you know, ACT, I think, approaches can help us better recognize those kinds of experiences, but then respond in a way that is actually moving the relationship in the direction that you want it to go in, you know, acknowledging the hurtfulness of the comment in a more composed way, rather than in a lashing out kind of way.

So, yes, there’s certainly room for these kinds of approaches in couples work.

Jenn: We’ve had a few folks write in asking if you would please speak a little bit more to the values aspect of ACT.

Jason: Yeah, sure. So, the... Well, if the question is what is a value exactly, again, where you’d start is, who or what do you care about? Just, I mean even, if you’re listening to me right now, just think about that.

So, I think, who do you care about tends to be a little bit easier. So it’s like, “Okay, I care about my family. I care about my friends. I care about my spouse. I care about my children. I care about my coworkers,” all that sort of stuff.

But then, what do you care about is like, it’s like, what are my guiding lights in my life? What are my characteristics, my ways of being that I want to be really, really important to me? I care about humility. I care about honesty. I care about independence. I care about ambition. I care about kindness.

You know, I care about, again, physical health, whatever the case might be. These are just core ideals to you that are kind of incontroversial, they’re not, they’re sort of incontrovertible. It’s not that these are things that we’re always acting in accordance with.

In fact, there may be many times that we’re not necessarily acting in accordance with any of these things. I can certainly think of that for myself. But just because we’re not acting in accordance with those values doesn’t mean they don’t exist.

So, you know, and you can kind of go through all kinds of different domains in ACT, where it’s like, personal domain, and professional domain, and et cetera. But those are the kinds of things that we’re talking about when we talk about values.

So, you spend time clarifying what those are so that then, you can think about, “Okay, so, yes, I am going to work on being with these feelings, and having a different relationship for these feelings, but why, to what end?”

So, if my life isn’t about trying to control and get rid of stuff that I don’t like, what is it about? And the answer that ACT provides is, well, it’s about moving towards values. It’s about, so instead of trying to just push all these kinds of things away, it’s about moving towards what you care about.

Another sort of way that I think values is really important is in thinking about, just back to this idea of developing a new relationship with our difficult inner experiences.

What I’ll say to a lot of folks who have OCD is, especially when it’s OCD around harm, they are afraid that certain thoughts that they’re going to have can create harm to people that they care about, or they’re going to act on some impulse to harm, I’ll say to them, I’ll say to them, “Yeah, I can take away all your anxiety about harm coming to your loved ones. There’s only one thing you need to do, just don’t care about them, at all.”

And most people will look at me like I’m an idiot, and say, “Okay, no, I’m not going to do that.” Cool. My point is that simply by caring about someone, you’re going to have anxiety about them. That’s just a reality of life, and the way the world works, is that... Them’s the breaks.

It’s like, on the one side of things, there’s everything that you care about, and then tied right into it is bad, quote, unquote, bad feelings, difficult feelings. So, why would we vilify that?

Why would we try to get rid, trying to get rid of that, you know, and trying to control that while we care about these things, it didn’t really, it doesn’t really make a lot of sense.

So, I think that that’s one way to sort of bring in values to try to develop this new perspective on emotions, where, again, they’re not these enemies that we have to eliminate, they’re just a by-product of the fact that there are things that are really meaningful to us.

And the, it very much is the case that the existence of that anxiety is indication of the extent that we care. So, there’s a couple ways that we think about values.

Jenn: So, you’ve talked about working with patients to help identify their values, but how do you work with them after they’ve identified their values in order for them to stay committed to the behaviors that they’re changing?

Jason: Yeah. So, what you can do is, first of all, specify, it gets back to this question of the person that I want to be. What does the person that I want to be do?

You could literally make a list with somebody and say, “Okay, what are different value-oriented behaviors that I’d like to be doing more of, especially when I’m feeling anxious, depressed, whatever the case might be, that I do, I don’t do very much of at all?”

And just kind of create whatever, you know, create a list of those things, and create a plan to be engaging in more of those kinds of actions amidst whatever the experience is.

And at the same time, making a list also of behaviors that we might tend to do that are not so much about moving towards values, and that are more about trying to control our inner experiences.

We call those towards and away moves, so, towards moves being the ones that move us towards what’s meaningful to us, and away that are more about trying to get rid of our bad feelings.

So, you can then very kind of concretely make a behavioral plan. ACT is, if I didn’t say this already, I probably didn’t is kind of a behavioral treatment, and you can create these behavioral plans wherein you’re identifying specific actions that you and your therapist kind of collaborate on and agree that are consistent with what you care about, and you want to be engaging with more.

Jenn: How would you respond to somebody who’s really invested in feeling their emotions and may feel like approaching it this way is either challenging or invalidating their experience with the emotions they’re having?

Jason: Yeah, the last thing that ACT, that I think ACT should be is invalidating. It should be the opposite. It should be that you’re actually honoring the experience that you have.

So, that’s, I think when I was saying, talking before about working with somebody who knows ACT, one way that you can kind of misuse ACT is this idea that, “Oh, all thoughts and feelings are meaningless. So, who cares about thoughts and feelings? It’s just about acting towards your values.” And that’s not really quite, that doesn’t quite capture it.

I think the approach is always that, whatever my brain, whatever my body gives me, whatever my brain gives me is okay to have, and I need, I can welcome it, I can connect with it, I can coexist with it. It just, it’s just that it doesn’t have to control the choices that I make if those choices that I make in response to it don’t help me, aren’t actually useful for me.

That’s it. The subtext is not that they are meaningless, because, that they shouldn’t have any impact on our behavior because they’re meaningless. They’re, again, like I was saying before, they’re often very important.

They indicate the existence of what we care about most deeply in our lives. You know, our emotions that we have are information.

They tell us about things, they tell us about needs that are unmet, whether it’s, we need to feel more safe, we need to feel, if it’s sadness, we need to feel more connected to others, if we have shame, then we have things that we need to address. It’s all useful stuff for us.

Again, it just comes down to this question of if our relationship to those feelings is such that we do things that just get in our way, or again, don’t move us towards what we care about, then there are other directions that we can take. Like we were saying at the beginning, ACT is about increasing your behavioral repertoire amidst those experiences.

Jenn: Can you offer some examples of defusion?

Jason: Yeah, sure. So, ACT actually has some kind of funny little tricks to initially practice defusion. So, I mean, this isn’t really a trick, but I mentioned before this idea of, you have a difficult thought, you write it down.

That’s an act towards defusion. But what you’ll read in some books are things like having a thought and saying it in a funny voice, or kind of drawing it on a, drawing it in bubble letters on a piece of paper, in a kind of kaleidoscopic, kind of weird way.

You can practice singing along to the thought, just to, you know, like, I suck so much You know, whatever it is, or, I’m so worthless Just as a way, again, to demonstrate to yourself that, “Okay, I can have different responses to this thought. I don’t have to treat it like it’s this solemn, really important thing.”

I just, I do want to say though, I want to be just careful with that stuff, because that’s kind of a means to an end.

You do that to initially start to change your relationship, but you don’t, the idea of ACT isn’t to use those approaches literally every single time that you have a thought, it’s about sending your brain this message that I can sort of respond differently.

So, over time, people that get really good at ACT stuff, they don’t have to go through that whole process. When they have a thought that’s not helpful to them, they kind of just shrug their shoulders at it and move on.

And that’s ultimately where we want to get, but I think those specific kinds of interventions can sort of help grease the wheel, kind of grease the skids towards getting there.

Jenn: And it also helps, too, if you’re adding a little bit of color or humor to it. It helps you realize what thoughts you should take seriously, and which ones you should take a little less seriously.

Jason: Yeah, totally, I agree.

Jenn: So, for folks, in order to incorporate ACT into their daily lives, do they actually need to master each of these processes before moving onto the next? Or is it like, it’s graduated?

Jason: I hope not. No, I don’t think, mastering is not, this is a... This is something that I think is a lifelong journey, this whole ACT thing, in the same way that I think any kind of wellness approach is kind of a lifelong journey. It’s like, when you...

If you decide that you are physically not in the shape that you want to be in, so, you do the thing where, you know, you check your nutrition, you change your diet, you exercise, you kind of change your lifestyle, all that sort of stuff.

And you do all that, and then six months later, a year later or whatever, you’re physically fit. You’re not done. It’s not like, “Okay, cool, am I good? Now, I can just start eating cheeseburgers again?” No, it’s kind of a, it’s kind of a lifelong sort of a thing.

So, that’s kind of how I think about, like I said, about ACT, and I think about, really, lots of different kinds of psychological interventions, is that, kind of build it into the context of your life.

And I do think that you can get to the point where it becomes more second nature, like I was saying before with the defusion stuff, where if you kind of practice it, you practice taking that approach enough, it just kind of, you kind of more by default take your, excuse me, take your thoughts a little bit less seriously when they show up.

Or you just kind of have a different response to them, or by default, when difficult emotions show up, you start to get curious about those emotions, as opposed to just reacting to them. That can certainly happen over time. But I really hesitate to use the word master. I think that, I don’t know if anybody’s really, truly mastered it.

Jenn: If folks are looking to incorporate ACT into their day-to-day, is there one of these six processes they should start with, or does the order not matter? And is there one that you’d suggest starting with over another?

Jason: I think that it’s, I don’t know if there are any data to back this up, but anecdotally, I’ll say that it’s kind of, like you were asking before about difficult processes, and one of them was the acceptance piece that I was thinking.

So, it’s hard, I think, to start with that one, you know? Especially if you haven’t done anything in the realm of defusing from thoughts.

So, you know, if you’re in this kind of position where you believe and buy into every single thought that you have, and then you’re trying to accept your emotions, but your brain’s telling you that this emotion is really caustic, and terrible, and you have to get rid of it, and you’re buying into that, it’s kind of hard to, you’re not going to be able to accept it terribly well.

So, I think one really very basic thing to start with is just the practice of taking thoughts a little bit less seriously when they show up, and seeing them as, kind of having this attitude of, “Oh, that’s interesting.” One phrase that we’ll say a lot is, “Thanks, brain. Okay, brain, cool. I see you’re giving me that thought right now. That’s interesting.”

And starting to develop that kind of attitude is I think a decent place to start. But even before that, it’s just the awareness stuff. Can I just start to pay attention to how I respond to these different experiences that I have?

And that kind of applies to really any psychological intervention, certainly ACT. But you know, developing that awareness, and then starting to take thoughts a little bit less seriously, I think, is a good place to start.

Jenn: Someone joining us is curious if you’re able to comment on the use of ACT in psychedelic-assisted psychotherapy.

Jason: No, no, sorry. I don’t think I know enough about, I do know that psychedelic-assisted therapy is increasingly showing some potential for particular conditions, but I just, I don’t, I don’t know that I can say anything about how useful it might be in conjunction with ACT yet. That sounds cool, but sorry, I don’t really know anything.

Jenn: It’s all good. This is what happens when it’s an ask me anything style session. Could you speak a little bit about the self-as-context?

Jason: Self-as-context? Is that what you said?

Jenn: Yeah.

Jason: Okay, yeah. So, my favorite metaphor to use for self-as-context is this idea that, so, this might sound really cheesy, but I still like it. It’s like our thoughts are birds, our feelings are clouds, our sensations and memories are like the sun and the stars.

But we, the self, we are the sky. We are the container of all that. So, all of this different stuff can sort of show up, but that self is something that is sort of indestructible, untouchable. We kind of walk around with those experiences, but we are not actually those experiences.

I think that if, like I was saying before, sometimes, if we get too caught up in this idea that we are those thoughts and feelings, or just have too much of a sense of, this is who I am.

I have this autobiography in my mind of, this is what I am, this is my self, then when that stuff gets threatened in some way, or if we start having thoughts that we don’t like, for example, I feel like then it’s like, “Well, what does that mean about me as a person?” And that creates all kinds of I think distress for certain people, could be problematic.

So, this idea of seeing your self-as-context, and as more the container of it, I think puts you in a position to have a little bit of distance from all that stuff, and say, “Hey, I can have all that stuff. I don’t have to buy into it like it’s part of me fundamentally. I can, again, choose my responses when it sort of shows up. And I’m more just, I’m like the observer. I’m the eyes behind my mind, kind of a thing.”

And yeah, again, for people that are amenable to that, I think it could be a really useful way of looking at life, and themselves. There are some people that really have a prescribed way of looking at themselves, and it works, by the way.

Like, “I’m a firefighter,” or “I’m a military person,” or “I’m a,” whatever. You know, and if it works for you, cool. I’m not vilifying this idea of having an autobiography of yourself that you really kind of stick to, but it’s when that limits you in a way that doesn’t help.

You know, I had, when I was growing up as a kid, I didn’t, I had this narrative that I, I was interested in psychology, but I had this whole thing where it was like, “There’s no way I’m ever going to be a psychologist. I don’t, I’m mumbly, I’m quiet, I don’t really say, you know, I don’t speak clearly.” And my family also was kind of a little bit like, “Ah, I don’t know about that!”

So, I had this kind of idea, this definition in my mind, that that really wasn’t going to be for me. But then over the years, I was just so drawn to it that I had to bust through those rules and say, “Well, I’m going to try it anyway.”

I don’t know, somehow, I just did. So, that’s kind of one way that I think self can be unnecessarily constraining, and self-as-context gives us another option.

Jenn: If it’s any consolation, I told my parents when I was younger, I was going to be a writer for “Saturday Night Live,” so-

Jason: I think you said that before, yeah, that’s fantastic.

Jenn: So, let me tell ya, it’s-

Jason: There’s still hope! There’s still hope, Jenn.

Jenn: Maybe, we’ll see. I’m still young. Is there a way to mentally prioritize our values in order to help us fulfill what we construe to be our main values? And an example would be taking care of ourselves to make sure that we can take care of our kids.

Jason: Yeah. Yeah, I mean, to me, those aren’t different. I mean, to me, the value there is that you care about, you care about your family, you care about those that are close to you. So, you taking care of yourself is a committed action that is in the service of that value.

You know, you’re no good to your family if you haven’t taken care of yourself. That’s what we all kind of wrap, the whole, the great metaphor, the oxygen mask on the airplane metaphor, put yours on before somebody else’s.

So, yeah, I mean, I don’t know this idea of main value, maybe for some people, that there is a bit of a hierarchy to values. I think for a lot, it can just sort of feel pretty similar, they all feel pretty important. But I think it’s something to explore a little bit, within the context of therapy, for sure.

And, you know, if you, if for you, it feels like, “Yeah, there are certain things that I just care about the most,” then address those first, and say, “Okay, well I’m going to arrange my treatment, or I’m going to start to address my life such that I’m doing more behaviors that are in support of those main, those important values that I’ve decided are the most important for me.”

And then kind of see how things shake out from there. I wonder, if you start to do that, then you notice that the behaviors that are in support of the main value are actually also in support of all these other values, too. But it varies by person.

Jenn: I know we are creeping into the last minutes of our time together, so I wanted to ask you one last question. Any additional words of wisdom you’d want to share about ACT with us?

Jason: I think that the main thing that I want people to kind of take away from this is that we don’t have to respond to our brains like they are our masters, or anything like that. It’s a weird thing to think about.

I think what’s so cool that being human is we have this consciousness thing, and we can see that we’re thinking about stuff. I think that’s awesome.

So, you know, in the same way that we are not our heartbeats, and we are not our, the way that our lungs expand and contract, and we are not our muscles, we are also not our thoughts, and we don’t have to treat them differently just because they are our thoughts.

They are just an epiphenomena of being human. And I think ACT is about sort of harnessing that ability to see that and create some distance from that so that we can actually engage in what’s important to us, what’s meaningful to us, and not get so wrapped up in what’s going on, what’s going on inside, and trying to find the right feelings, and the right kinds of thoughts.

So, one last thing I’ll say is that this is a challenge. You know, this is not something that comes naturally to, really, I think anybody.

So, if you have, if you’re engaging with this kinds of treatment and you’re having trouble with it, or just, it’s taking time to really wrap your mind around it, it makes a lot of sense. I think for a lot of people, that’s the case, and that’s okay, just keep at it.

Jenn: It’s really comforting, though, to hear that an expert is saying it’s going to take a while, and it’s going to be multiple iterations, but eventually, you’ll get the hang of it. Dr. Krompinger, this was so fun.

I have learned so much, and I love talking about this stuff, and you’re just a great resource. So, thank you for taking some time to hang with me and talk all about ACT, and implementing it into our everyday lives. If you are joining us for the session, this actually concludes it.

So, until next time, be nice to one another, but most importantly, be nice to yourself. Thanks again, and have a great day!

Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

- - -

The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

© 2022 McLean Hospital. All Rights Reserved.