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

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

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

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

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

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

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

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

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”

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

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

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.

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?

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?