ACT As A Brief Intervention Model

1. ACT As A Brief Intervention Model Kirk Strosahl Ph.D. ACT World Con III www.behavioral-health-integration.com mountainconsult@msn.com

2. Why Brief Interventions? • Average number of therapy sessions: 4-6 • Modal number of sessions: 1 • Dose effect analyses fail to show linear trend between session number and outcome • 50% of therapy gain within first 4-8 sessions • Rapid response literature growing • Increased pressure from payers to complete therapy in fewer sessions • Increasing number of contexts where brief encounters are the norm (i.e., primary care, schools) • New models for delivering behavioral health services, i.e., primary care consultation

3. Toxic Assumptions • That you have to build “rapport” in a particular way to be effective • That therapy “drives” behavior change, ergo, the more therapy the better • The one hour therapy session is the only way to create change • That chronic suffering can only be address with long term therapy • That small changes don’t make a difference when people have big problems • That the patient’s descriptions of symptoms, suffering and causes are scientifically accurate

4. Basic Issues in Brief Intervention • Competing Theories of Human Suffering • Bio-Medical model • Emphasizes pathology, symptoms and syndromes, disease concepts, and a focus on somatic treatment • Less weight attached to person and environment interactions, context for behavior and the role of language in shaping dysfunctional behavior • Many syndromes share the same symptoms and respond to the same treatments • Emphasizes treatment over time

5. Basic Issues in Brief Intervention • Competing Theories of Human Suffering • Stress-coping-vulnerability models • Emphasis on delicate relationship between stress and coping responses • “Symptoms” occur when coping responses are insufficient to manage stress over time • Emphasis on building positive coping responses and/or decreasing stress • Interventions tend to be more situation specific and time limited

6. Basic Issues in Brief Intervention • Competing Theories of Change • Theory of big change (“cure”) • People are “broken” and need to be fixed • Success if defined by the elimination of symptoms and eliminating underlying causes • Treatments tend to be staged and longer • Goal setting often emphasizes large changes in behavioral, cognitive and emotional functioning • Historically has been very ineffective with more complicated patients

7. Basic Issues in Brief Intervention • Competing Theories of Change • Theory of strategic change (function) • From a person-environment perspective, small behavior change can have a domino like effect • Evidence shows that small changes are easier to make than big changes • Focus on using coping skills that work and stopping what doesn’t work • Small change builds “self-efficacy” or the conviction that one can make changes • Basis of many evidence based treatments

8. Basic Issues in Brief Intervention • Competing Theories of Agency • Provider driven change (therapist in charge) • Places patient in subordinate role • Provider assumes more responsibility for solving the patient’s problems • Generally requires longer and more frequent contacts • Runs the risk of engendering dependence, passivity, low motivation for change and non-adherence

9. Basic Issues In Brief Intervention • Competing Theories of Agency • Patient driven change (patient is in charge) • Places patient in co-equal role with provider • Responsibility for behavior change shifted to patient • Emphasis on patient education, basic goal setting with consultation from provider • Change occurs in real life settings, not in the provider’s office • Leads to greater motivation, adherence and better delineation of “boundaries”

10. Basic Brief Intervention Theory • Establish a single entry point • Pull the patient outside the normal frame of reference • The “problem” is not the problem; the “solution” is the problem • Emphasize acceptance of the ongoing stream of experience while behaving differently • Get the patient to “own” the need for and ability to change from negative to positive momentum • Focus on increasing positive behaviors, rather than on eliminating negative behaviors • Encourage limited, specific behavior change

11. ACT Brief Intervention Principles • Normalize and validate “toxic” private events that are the natural sequelae of being alive • Reframe the issue from “whether to” to “how to” experience what is there to be experienced • Emphasize approach toward rather than retreat from response ableness • Use spontaneous contact with mindfulness to help patient see an alternative • Get the patient to “stand for something” • Focus on small, value consistent actions

12. ACT Brief Intervention Strategies • Is there anything in front of you here that you are not big enough to have? • What if the goal were not to feel good, but to feel it good? • Are you having this? Or is it having you? • Looks like the more you try to control this thing, the more uncontrollable it becomes. What about just letting it be what it is? • What would make what you are going through here honorable, legitimate and purposeful? • You don’t have to do this perfectly—just get from point A to point B.

13. ACT Brief Intervention Strategies • What do you think life is trying to teach you here? • Is there anything about how you’re feeling, right here, right now that you would not be willing to feel? • What do you want to stand for here? • What will make you feel like you’ve grown as a human being when this situation is done? • It sounds like your mind is telling you to do things that your experience says doesn’t work. • If you were free to choose how to respond here, what would you like to do? • Is there anything standing in the way of you and what you want to be about here?

14. Video and Exercise: Patient With Multiple Family Stresses/Depression • Two Teams: • One: Focus on content level, client level of analysis, insight into causes, the client’s story, “therapist bait” • Two: Focus on function of symptoms, core ACT processes and ACT relationship factors • Debrief: Was this ACT consistent? Not? Mixed? • Other intervention strategies you might use?