FACT KIRK D. STROSAHL, PhD Kirk@Mtnviewconsulting.com PATRICIA J. ROBINSON, PhD Patti@Mtnviewconsulting.com Objectives Introduction of ACT, theory, evidence Self-assess FACT competencies Learn competencies Brief intervention Assessment Conceptualization and planning Intervention Practice FACT interventions 2 Psychological Flexibility is contacting the present moment more fully as a conscious human being, as it is, not as what it says it is, and based on what the situation affords, changing or persisting in behavior in the service of chosen values. The ACT Question Given a distinction between you and the things you are struggling with and trying to change, are you willing to experience those things, fully and without defense, as it is and not as it says it is, and do what takes you in the direction of your chosen values in this time and situation? Core Concepts of Psychological Flexibility Mindfulness Paying attention with flexibility, openness and curiosity Away Experiential Exercise Behavioral moves away Noticing Behavioral moves toward Toward Values Staying focused on chosen life directions Internal away moves What matters? Who matters? 6 Kirk Strosahl & Patti Robinson 1
Why Be Brief? We want to... Be helpful To many people when they ask for help Particularly underserved 7 Do Brief Interventions Work? In Primary Care Behavioral Health model (Robinson & Reiter, 2007, 2015), YES! Clinically significant patient improvement (Bryan et al., 2009; Bryan et al., 2010; Cigrang et al., 2006) With 2 or more sessions, reduced symptoms, improved functioning and social integration (Bryan et. al. 2010) More severely impaired patients at pre-treatment improved faster than patients with less severity (Bryan et al., 2012) Reduced symptoms and improved functioning, high levels of satisfaction with BHCs, no gender differences (Angantyr, A.R., & Norden, T., 2015) Changes robust and stable during a two year follow up period (Ray-Sannarud et. al., 2012) 9 FACT, A PSYCHOTHERAPY THAT HELPS THE PATIENT... Focus on unworkable results of avoidance Accept the presence of distressing, unwanted, private experiences Choose a life path based in personal values Take actions which propel him/her down that path 10 CORE FACT ASSUMPTIONS A brief therapy is one that can achieve its goals before the client s natural tendency to drop out is realized The change process begins during the first visit Talking in rapid change terms is likely to induce rapid change Clients with long-standing problems are just as likely to experience rapid change as those with time limited problems! FACT Therapist Stance Assume that the first visit may be the last visit Instruct self and client that dramatic, powerful change is possible in one visit Know that you cannot rescue clients from the challenge of growth Workability, not reasonableness, is the issue Turn strong feelings into therapeutic opportunities; including your own (it humanizes you) Don t argue or persuade; your opinions and beliefs are not the issue You are are in the same boat. Never protect yourself by moving one up on a client. 11 Kirk Strosahl & Patti Robinson 2
FACT MANTRA Treat every session as if it s the last! Evolution of ACT Psychological Flexibility Model The original 6 Points FACT The refined 3 Pillars The Now Attention & Intention ACT Five Facet Model 13 14 Core Processes / Points Be Present FIVE FACET MODEL: IN THIS MOMENT BOOK Be Present Accept Defuse Psychological Flexibility Connect with Values Act on Values Acceptance Defuse Psychological flexibility Connect with Values Act on Values Perspective Taking Robinson, Gould & Strosahl, 2010. Real Behavior Change in Primary Care (Adapted from Hayes, Strosahl & Wilson, 2004). Perspective Taking Pay Attention From Points to Pillars Acceptance Defuse Be Present Psychological flexibility Connect with Values Act on Values To acknowledge the interconnectedness of the six points To better support in the moment conceptualization To better teach the model to our clients Perspective Taking ACT with Intention Kirk Strosahl & Patti Robinson 3
Open Aware Engaged OPEN: ACCEPTANCE AND DEFUSION Be Present Acceptance of, rather than controlling... Acceptance Defuse Healthy Mind And Body Connect with Values Act on Values Private experiences (thoughts, feelings, memories, sensations) Personal history Attitudes/behavior of others Realizing how our mind works Perspective Taking Recognizing while not reacting to the content of our mind 20 AWARE: PRESENT MOMENT AWARENESS AND PERSPECTIVE TAKING Present Moment Awareness requires... Flexible attention / focus, or ability to effectively shift of focus attention Ability to be aware of and use ongoing stream of private experience Perspective Taking requires... Sense of continuity of consciousness Ability to step back and become an observer of events Ability to imagine the point of view of someone else Values are... ENGAGED: VALUES AND COMMITTED ACTION Verbally constructed, provide intrinsic motivation and reinforcement Principles of living that organize behavior over time Committed Actions... Are specific behaviors that reflect values Are done in the presence of unpleasant private or public events 21 22 Focused Acceptance and Commitment Therapy Competency Assessment Tool F A C T C A T RADICAL CHANGE: FACT FLOW ASSESSMENT Build Expectancy for Rapid Change Rating Scale Questions Love, Work, Play and Health Target Problem Analysis Flexibility Profile Pre-Training Assessment 1 = low 2 = adequate 3 = exceptional Set learning goals. FRAME AND REFRAME CONCEPTUALIZATION INTERVENTION Focusing Questions Reframing Four Square Analysis Bull s Eye, Life Path, FACT Visit Worksheet 23 24 Kirk Strosahl & Patti Robinson 4
Build Expectancy: THE FIRST 2 MINUTES Hi: My name and discipline My Job: To help you solve problems in living that happen to all of us In this visit: Get a snapshot of your life and see what s working and not working; work together to come up with a plan to make your life better. After today: You may find that you got what you came for and don t need to come back; or you might return to learn more. Assessment: Today and at every visit, to plan ways to make the most of our time together, to make every session count. 25 A STREAMLINED ASSESSMENT Problem Severity, Confidence and Helpfulness Assessment Questions Love, Work, Play and Health (life context interview) Target Problem Analysis (Three Ts) Flexibility Profile (strengths & skill deficits) 26 FACT: VISIT RATING SCALE LOVE, WORK, PLAY AND HEALTH Assessment Questions 1 How big of a problem is this for you? On a scale of 0 = not a problem and 10 = a very big problem, how would you rate it? 2 How confident are you that you will follow through with our plan? Use a scale where 0 = no confidence and 10 = very confident. 3 How helpful was this visit? Use a scale where 0 = not helpful and 10 = very helpful. LOVE WORK PLAY HEALTH Where do you live? With whom? How long have you been there? Are things okay at your home? Do you have loving relationships with your family or friends? Do you work? Study? If yes, what is your work? Do you enjoy it? If no, are you looking for work? If no, how do your support yourself? What do you do for fun? For relaxation? For connecting with people in your neighborhood or community? Do you use tobacco products, alcohol, illegal drugs? Do you exercise on a regular basis for your health? Do you eat well? Sleep well? 27 28 THREE Ts AND WORKABILITY QUESTIONS TIME TRIGGER TRAJECTORY WORKABILITY When did this start? How often does it happen? What happens immediately before / after the problem? Why do you think it is a problem now? Is there anything--a situation or a person--that seems to set it off? What s this problem been like over time? Have there been times when it was less of a concern? Have there been times when it was more of a concern? Do you see any other pattern with the problem? What have you tried (to address the problem)? How has that worked in the short run? In the long run or in the sense of being consistent with what really matters to you? TEAMS (Private Experience) Emotions Associations Memories Thoughts Sensations 29 30 Kirk Strosahl & Patti Robinson 5
Associations TEAMS What comes up for the client? For you? The broth in the soup The thickener is stress; chronic stress = very thick Brain is hot; restless May be nonverbal or verbal or both; may operate outside of awareness Key element in flexible responding May be improved by brain training exercises Observe Skills Describe Skills Detach Skills Thoughts Emotions Associations Memories Sensations 31 32 WORKABILITY...the transition between the assessment and intervention phase of a session... FACT/ACT UNITY Pillars of Psychological Flexibility OPEN Able to accept distressing material without struggle Behavior is shaped by direct results rather than rigid rules AWARE Able to experience the present moment Able to take perspective on Self and self-story ENGAGED Strong connection with values Able to sustain valueconsistent action 33 34 FLEXIBILITY PROFILE EXERCISE RADICAL CHANGE: FACT FLOW OPEN AWARE ENGAGED Strengths Strengths Strengths Skill Deficits Skill Deficits Skill Deficits ASSESSMENT FRAME AND REFRAME CONCEPTUALIZATION INTERVENTION Build Expectancy for Rapid Change Rating Scale Questions Love, Work, Play and Health Target Problem Analysis Flexibility Profile Focusing Questions Reframing Four Square Analysis Bull s Eye, Life Path, FACT Visit Worksheet 35 36 Kirk Strosahl & Patti Robinson 6
REDEFINE THE PROBLEM Do I know the answers to the Focus Questions? Can I reframe? 37 FRAME AND REFRAME Frame: Focus Questions 1. What are you looking for? 2. What have you tried? 3. How has it worked? 4. What has it cost you? 5. What type of life would you choose if you could choose? Reframe 1. Helps client question the accuracy and usefulness of their existing system of beliefs 2. Redefines the problem in a new way that the client hasn t thought of before (simplifies or shifts perspective) 3. May be a saying, story, analogy, or metaphor enhancing client hopefulness 4. Creates a positive intentional path for the client to follow 38 FACT: REFRAME STRATEGIES REFRAMING Go to 30,000 feet and portray the problem in terms of a bigger life path the client is following Focus the discussion on the positive, value based intentions of the client, rather than on what is not working Describe the necessity of the problem in teaching the client about self or life ( you are in the perfect position ) State your confidence that the client is about to learn something important and will do things differently Validate emotions and behaviors Understand and acknowledge function of the problem Connect pain and values Create new relationship to symptoms (importance, usefulness) Modify function and create meta-cognitive shift 39 40 REFRAME REEL REFRAMING DEPRESSION Your Job Two lines of 3 facing each other Line A; Line B (switch out role of being therapist; when your line is not the therapist line, notice your TEAMS and time / 4 minutes) Problems Depression Anxiety Anger Relationship problem Stress Alcohol abuse Line A: One of the 3 agrees to step forward and role play a depressed patient. The depressed patient faces the line of therapists in Line B and says: I am getting worse and sometimes I don t even get out of bed some days; that s not like me. Line B: One of the 3 decides to reframe and indicates this by stepping forward closer to the depressed patient... And offers a reframe. The exercise continues for 12 minutes; group discusses 3-5 minutes 41 42 Kirk Strosahl & Patti Robinson 7
REFRAMING ANXIETY Line B: One of the 3 agrees to step forward and role play an anxious patient. The anxious patient faces the line of therapists in Line A and says: I get so nervous when I have to talk at meetings. I actually start to tremble and my voice shakes and I know other people think there is something wrong with me. If I could, I d quit my job. Line A: One of the 3 decides to reframe and indicates this by stepping forward closer to the anxious patient... And offers a reframe. The conversation continues for 3-5 minutes; group discusses 3-5 minutes REFRAMING ANGER Line A: One of the 3 agrees to step forward and role play an angry patient. The angry patient faces the line of therapists in Line B and says: I work out 2 hours in the morning, I work 8 hours at a job I don t like, I work out 2 more hours and I go home to an empty house and pray that I don t punch another hole in the wall. I ve lost all control since my wife left and took my son. Line B: One of the 3 decides to reframe and indicates this by stepping forward closer to the angry patient... And offers a reframe. The conversation continues for 3-5 minutes; group discusses 3-5 minutes 43 44 REFRAMING ALCOHOL ABUSE Line B: One of the 3 agrees to step forward and role play a college student who abuses alcohol. The patient faces the line of therapists in Line A and says: I ve got a problem. You know I m here because I have to be, but I do know I have a problem. I don t get it. I don t know why I drink like I do. It s crazy. I don t drink all week, but come Saturday, I start and I keep it going until Sunday morning. Lots of bad things have happened and I have regrets, but I don t seem to have much control. Line A: One of the 3 decides to reframe and indicates this by stepping forward closer to the anxious patient... And offers a reframe. The conversation continues for 3-5 minutes; group discusses 3-5 minutes. FACT: CHANGE CONVERSATIONS Best reframes and interventions may come in the form of questions What would you like to do differently? How does that work for you? Is it giving you what you want in life? Who can support you? AVOID ASKING WHY? Create positive valence Would this tell you things are improving? Think small, accumulate positives (move one notch up the scale) Frame it as an experiment Would you be willing to try this just to see what happens? Anticipate that it won t be done perfectly and that perfection doesn t matter 45 46 RADICAL CHANGE: FACT FLOW CONCEPTUALIZE AND INTERVENE ASSESSMENT FRAME AND REFRAME CONCEPTUALIZATION INTERVENTION Build Expectancy for Rapid Change Rating Scale Questions Love, Work, Play and Health Target Problem Analysis Flexibility Profile Focusing Questions Reframing Four Square Analysis Bull s Eye, Life Path, FACT Visit Worksheet Conceptualization Foursquare Analysis Intervention FACT Dancing Bulls Eye FACT Visit Worksheet Life Path 47 48 Kirk Strosahl & Patti Robinson 8
BEHAVIOR FOUR SQUARE ANALYSIS Simple way to describe client strengths and weaknesses and to focus therapeutic interventions Creates distinction between target behaviors and mental processes that enable (or disable) them Often, planning a target behavior will also require work on a mental process that is functioning as a barrier to that behavior FOUR SQUARE ANALYSIS Potential Uses of Conceptualization Tool: As intervention tool with patient (on white board) As a standard part of all visits (See FACT Visit Worksheet) Clinician review of visit not ending in strong behavior change plan To structure consultation, supervision 49 50 FOUR SQUARE EXERCISE WORKABILITY NOT WORKING MORE WORKABLE PUBLIC PRIVATE REAL BC Quick Guide Organized by 6 processes Descriptions of several interventions for each process All interventions can be done in 5-10 minutes Intended to support rapid learning Easy to share with medical colleagues Many amenable to team-based support of change over time 51 52 BULL S EYE PLANNING TOOL FACT DANCING Value Action Steps 1. 2. 53 54 Kirk Strosahl & Patti Robinson 9
FACT DANCING OPEN AWARE ENGAGED If stuck, be curious, If confused, go to When possible, promote model acceptance, notice present/look at different connection between values the mind perspectives and action Support openness and Promote flexible, voluntary Move toward identifying curiosity about previously and purposeful attention to ongoing and qualities of avoided inner experiences the now action meaningful in the here and now Attend to thinking as an Support mindfulness and Construct concrete ongoing process, rather noticing the continuity of behavior change exercises than the world structured consciousness by it Figure 7.2 Pillars of Psychological Flexibility and suggested therapeutic actions. FACT VISIT WORKSHEET Puts it all together Love, Work, Play, Health Assessment Bulls Eye (values clarification, connection) Problem (Time, Triggers, Trajectory) Four Square: Conceptualization Behavior Change Plan Rating Questions: Confidence and Helpfulness 55 56 Why learn how to do ACT? Provider Burn-out Insidious changes in attitudes, moods and behaviors that have consequences on personal and professional life. Emotional Exhaustion Depersonalization Personal Accomplishment Signs/Symptoms of Burnout: over - eating/drinking/working isolation, depression, anxiety relationship problems at work/home More Control What do you want to control, avoid or get rid of and how are you trying to do that? Your LIFE PATH More Meaning What type of life would you choose if you could choose? 58 LIFE PATH QUESTIONS LIFE PATH CLASS PROTOCOLS 1. Draw an arrow above the line to indicate where you are on your life path currently and in which direction you re moving? 2. What, if any, are the costs and benefits of pursuing control? 3. What behaviors would tell you that you re moving toward more meaning in life? 4. When you get stuck, how can you help yourself to keep moving toward more meaning? 5. Who or what helps you move in the direction of more meaning? 59 Class 1 Meet others and discuss your answers to questions about your life path. Homework: Notice when the war starts and what you do. Just try to observe... Class 2 Learn to step back and have a different perspective on your suffering. Homework: Plan to do a valued activity and practice accepting a barrier that s likely to come up when doing the activity. Class 3 Learn to make public commitments and learn to learn from direct experience. Homework: Continue to make intentional choices, pursue valued directions, practice self-compassion, and learn from your direct experience. Client / patient may repeat series. 60 Kirk Strosahl & Patti Robinson 10
Focused Acceptance and Commitment Therapy Competency Assessment Tool F A C T C A T Resources Post-Training Assessment 1 = low 2 = adequate 3 = exceptional Set learning goals for future. 61 Association for Contextual Behavioral Science http://www.contextualpsychology.org/ http://www.newharbingeronline.com/real-behavior-change-in-primarycare.html 62 Resources FACT PRESENT MOMENT BOOKS Lots of downloads: BehavioralConsultationandPrimaryCare.com 63 64 Coming Soon 2016 2 nd Edition Kirk Strosahl & Patti Robinson 11