ACT As A Brief Intervention Model

1. ACT As A Brief Intervention Model Kirk Strosahl Ph.D. ACBS World Conference Reno, NV mountainconsult@msn.com

2. Why Use Brief Interventions? • Average number of therapy sessions: 4 • Modal number of therapy sessions: 1 • Dose effect studies show most change in therapy happens early (before session 8) • Change beyond session 8 is very time intensive • Rapid response studies show it is common • Some contexts require brief interventions

3. Evolution of Brief, Strategic Change Approaches • Concept of brief therapy pioneered at MRI by Haley, Weakland, Fisch and Watzlavic in the 1960s, became popular in the 1970s during managed care revolution • John Grinder and Richard Bandler provided practical guidelines for the application of some of the hypnotic techniques of Milton Erickson (“The Structure of Magic”) • Several different “schools” of brief strategic intervention have emerged (Brief problem focused therapy, Solution Focused Therapy, Narrative Therapy, Ericksonian Therapy) • Main problem is a suspicion of “outcomes” research

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 • 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”

9. 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

10. Brief Strategic Therapy Challenges Some Cherished Beliefs • That building “rapport” is a pre-requisite to change and takes time • That therapy “drives” behavior change, ergo, the more therapy the better • That one hour sessions are necessary to facilitate change • That long standing problems can only be address with long term therapy • That small changes don’t matter when people have big problems

11. Brief Therapy Challenges Some Cherished Beliefs • That getting the patient to “analyze” the source of problem is a necessary step in change • That the patient’s “story” is clinically accurate and useful • That the medical model (DSM-IV) approach is a clinically useful way to guide treatment • That having a behavioral health problem is “abnormal”

12. Key Brief Intervention Principles • Establish a single point of clinical focus • Pull the patient outside the “frame of reference” • The “problem” is not the problem; the “solution” is the problem • Don’t focus energy on issues that are not going to change • Try to identify what the patient is ready to do

13. Key Brief Intervention Principles • Focus of behaviors that create a positive motivational impact • Have the patient take “ownership” of the change process • Try to re-activate healthy behaviors rather than eliminating unhealthy ones • Encourage limited, specific, concrete change • Get the patient to state a behavioral intention

14. ACT as a Brief Intervention? • Core philosophies are very similar • Both are skeptical of pathology and illness explanations for maladaptive behavior • Both heavily rooted in changing the functions of language • Both emphasize qualitative shifts of awareness and self processing • Both make no assumptions dose-effect

15. ACT Brief Intervention Principles • Normalize and validate “toxic” private events that are the natural results 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

16. 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.

17. 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?