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ACT With The Challenging Patient. Kirk Strosahl Ph.D. Steven Hayes Ph.D. ABCT November, 2007. What Constitutes A Challenging Patient? The Presentation. A pattern of behavior that is:

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act with the challenging patient

ACT With The Challenging Patient

Kirk Strosahl Ph.D.

Steven Hayes Ph.D.

ABCT November, 2007

what constitutes a challenging patient the presentation
What Constitutes A Challenging Patient? The Presentation
  • A pattern of behavior that is:
    • Pervasive (dysfunctional behavior becomes the dominant response to almost any stress, setback or emotional flare-up)
    • Persistent (dysfunctional behavior occurs across time despite negatively consequences)
    • Resistant (difficult to extinguish in the response hierarchy because of its over-learned nature)
    • Distress producing in the context of reduced self efficacy and low motivation
three main polarities in therapy
Three Main Polarities In Therapy
  • Acceptance—Fusion polarity contains defusion, willingness, acceptance
    • This undermines emotional avoidance
  • Choose mindfully---automatic pilot polarity contains self experience, evaluation/reason giving and valuing
    • This undermines fusion with rules, hidden evaluations, reason giving and attachment to the self story
  • Take action-avoidance of action polarity contains willingness, value based goal setting to create exposure to vitality producing life moments
    • This undermines behavioral avoidance
even more simply think of these as core response styles
Even More Simply, Think Of These As Core Response Styles
  • Accepting Versus Rejecting Stance Toward Unwanted Experience
    • Willing versus struggling posture with all forms of personal experience
    • Accepting both positives and negatives as necessary & healthy
  • Chosen Versus Automatic Behavior Style
    • Balance between present moment experience & absorption in self process
    • Ability to take perspective, identify values and pick responses
  • Taking Action Versus Avoiding Action Style
    • Willingness to put self in harms way based upon values
    • Ability to persist with value based commitments and change strategies based upon results
a simple case conceptualization framework
A Simple Case Conceptualization Framework
  • Does this patient exhibit . . .
    • An accepting or rejecting posture toward unwanted and possibly painful experiences?
    • A mindful, chosen daily lifestyle or a rule driven, automatic style of responding?
    • An approach based goal oriented or a withdrawal, avoidance oriented way of dealing with problems?
  • You can place any patient somewhere on each of these three continuums
    • This can help you begin to identify treatment goals and ACT strategies that might be useful
a case example
A Case Example
  • Patient with long hx of meth addiction, now recovered; severely depressed & dropping commitments
  • Two Groups:
    • 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
what is a challenging patient
What Is A Challenging Patient?
  • Low levels of acceptance for distressing content; high levels of emotional avoidance and self numbing behaviors
  • Automatic rule following responses that are insensitive to real world results and contingencies; absorption in rigid forms of self experience
  • Severe restriction in approach based, value oriented responses; excessive behavioral avoidance
what constitutes a challenging patient therapist behaviors
What Constitutes A Challenging Patient? Therapist Behaviors
  • Therapist is doing all of the work in session
  • Therapist lectures, moralizes and cajoles
  • Therapist uses “resistance” generating strategies (directives vs. eliciting)
  • Therapist subtly blames patient
  • I can’t help you if you don’t want to help yourself
what constitutes a challenging patient stalled therapy process
What Constitutes A Challenging Patient? Stalled Therapy Process
  • Help seeking and help rejecting
  • “Yes, but . . .”
  • Lots of ventilating in session (emotion focused coping) but little change out of session
  • Non-adherence to out of session practice
  • No showing appointments
  • This really isn’t helping me!
personal qualities of the effective therapist
Personal Qualities of the Effective Therapist
  • Models an open, honest, accepting approach to problems and uses patient driven change
  • Communicates genuine caring and concern
  • Creates a “collaborative set” with the patient
  • Understands the difficulty of changing a well entrenched behavior or set of beliefs
  • Believes in patient’s ability to create a better life
  • Willing to incorporate crises into treatment
personal qualities of the effective therapist1
Personal qualities of the effective therapist
  • Understands we are “in this stew together”
  • There, but for the grace of god, go I
  • Open to what works, not what ought to work
  • Instinctive mistrust of “insight & understanding”
  • Does not promote culturally sanctioned solutions
  • Believes in the patient’s ability to choose
  • Does not promote personal agenda of what the patient “ought to do”
components of act with the challenging patient
Components of ACT with the challenging patient
  • Contain high risk behavior (alcohol, self destructive behavior, )
    • Reframe the function of the behavior
    • Neutralize the reinforcement field
    • Study rather than judge the behavior
    • Emphasize “response ability” rather than blame
    • Develop a crisis and case management “frame”
    • Use behavior as “grist” for the therapeutic mill
    • Connect the patient with the “cost” of escape and avoidance in terms of valued life goals
components of act with the challenging patient1
Components Of ACT with the challenging patient
  • Attack the workability of the behavior
    • Get patient to invest in the “story”
    • Destabilize confidence in the “story”
    • Institute workability as the yardstick
    • Use creative hopelessness to release the patient from control strategies
    • Encourage stopping what doesn’t work before looking for what does work
components of act with the challenging patient2
Components of ACT with the challenging patient
  • Substitute acceptance and willingness for emotional and behavioral avoidance
    • Introduce relationship of willingness, suffering and workability
    • Distinguish decision and choice
    • Work on components of FEAR
    • Find small ways to practice willingness
    • Use any life challenge as opportunity to explore two alternatives: acceptance (willingness) vs.. control (struggle)
components of act with the challenging patient3
Components of ACT with the challenging patient
  • Institute committed action and behavior change
    • What do you want your life to stand for?
    • Who would be made right if you got better?
    • Address sense of victimization: pain vs.. trauma
    • Address confidence the feeling vs. confidence the action
    • Relate sense of right & wrong with forgiveness
    • Emphasize committed action as a process, not an outcome (titrate to fit clients readiness)
case example and exercise
Case Example and Exercise
  • Woman with hx of chronic suicidality in personal crisis and currently suicidal
  • Two Groups:
    • 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 points you might have selected?
dealing with downers
Dealing With Downers
  • In groups of 4
    • Take 2 of the downer statements and develop 3 ACT consistent responses originating in three different core processes
    • How would you respond to these show stopping comments, so that you could
      • Avoid being on the defensive such that you had to push the client away
      • Be real in how you respond
      • Return “serve” to the client in a positive way
suggested readings
Suggested Readings

Hayes, S. & Strosahl, K. (2004). A practical guide to Acceptance and Commitment Therapy. New York: Springer Science + Media Press.

Chiles, J. & Strosahl, K. (2005) Manual for the assessment and treatment of suicidal patients. Washington DC: American Psychiatric Publishing