ACT As A Brief Intervention Model Kirk Strosahl Ph.D. ACBS World Conference Reno, NV

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 2

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 3

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 –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 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

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 10

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” 11

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 12

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 13

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

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

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?