The ACT therapist would also do well to consider the humanistic approach to case con- ceptualization and evaluation. Rogers (1951) warns that there can be “a degree of loss of personhood as the individual acquires the belief that only an expert can accurately evaluate him, and that therefore the measure of his personal worth lies in the hands of another” (p. 224). The ACT approach acknowledges the ubiquity of suffering and the vulnerability of all people—including so-called experts—to problems in living. Seeing the pervasiveness of human suffering and that all people can fall into language traps, the ACT therapist radically accepts the client’s clinical concerns and also attempts to reduce the imbalance of power between the two people in the therapy room by making sure the treatment plan and therapy unfold as a collaborative process.
The human relationship between the therapist and client is ever present in ACT. As noted throughout the ACT literature, we are all “swimming in the same soup.” We all benefit from our shared language, and also collectively and individually feel its bite. Oftentimes the ACT therapist will dispense with the clipboard and pen during the first meeting and sit next to, rather than across from, the client in an effort to level the playing field. This of course is a matter of style and must be used judiciously with each therapist-client dyad. The drawback of such an approach is that the interview data are not recorded immediately, and yet one might ask if, on balance, the presession assess- ments and questionnaires might do the job of that first question-and-answer session and allow the therapist-client interaction to unfold more naturally during the first session. In addition, the postsession notes for the first few sessions might also require more diligence
and time if the intake is done with a more humanistic approach. We might also consider that a collaborative therapeutic relationship is given a better chance to thrive when the clinician joins the client in such a way. And from a functional contextual point of view, we can consider that in the context of therapy, we are going to begin to tear down some walls and unwrite some of the “rules of engagement” (see chapter 2 for more on functional contextualism).
The humanistic tradition rejects diagnoses outside of their utility as descriptions, and Rogers (1951) explains that “psychological diagnosis as usually understood is unnec- essary for psychotherapy and may actually be detrimental to the therapeutic process” (p. 220). Functional contextualism also rejects categorical diagnosis with additional reasons. Categorizing or pigeonholing a collection of “symptoms” based on the topography or obvious form of the behavior does very little to address why the person exhibits those behavioral symptoms. In other words, the categorical approach ignores the function of “symptoms.”
Hayes, Wilson, Gifford, Follette, and Strosahl (1996) suggest that the categorical nosology used by the DSM is inadequate. In addition, the currently popular DSM diag- noses lack treatment utility (Kupfer, First, & Reiger, 2002; Hayes et al., 1987; Persons, 1989). These authors instead suggest a dimensional approach to clinically relevant behavior. In other words, just because a therapist properly assesses a group of symp- toms that cohere under a DSM category, that diagnosis does not necessarily lead to appropriate treatment unless a functional analysis of the signs and symptoms is con- ducted (see chapter 3 for an explanation of functional analysis). In many ways, the atheoretical approach of the DSM creates a theoretical and etiological vacuum that case conceptualization aims to fill.
The typical client-centered therapist’s attitude toward case conceptualization appears quite similar to the functional contextual approach: hold it lightly. Humanistic authors Goldman and Greenberg (1992) agree that “knowledge of certain nosological categories or syndromes can be helpful to experiential therapists but that they are best conceived of as descriptions of patterns of functioning rather than of types of people” (p. 404). ACT practitioners would agree for similar humanistic and additional, scientific reasons.
A humanistic therapy approach, with its emphasis on empathy, can also imbue the case-conceptualization process with value. Some authors (Kuyken, 2006; Eells, 1997) suggest that the process of case conceptualization “normalizes” the clinical concern and may lead to greater empathy from the clinician. The ACT stance fosters greater empathy because the therapist does not entertain the assumption that people can achieve an ongoing state of complete “healthy normality.” In fact, the ACT/RFT literature (Hayes, Barnes-Holmes, et al., 2001; Hayes et al., 1999) suggests that normal language pro- cesses have important useful effects and also have detrimental effects on valued living. Discussing the myth of “healthy normality” during the development of the relationship and the development of the case conceptualization may help the clinician embrace the client and the “problem” with greater empathy. Normalizing symptoms is not only a part of case conceptualization. It can also serve as a psychoeducational intervention on its own because it often decreases client distress (which is more of an unintended effect in
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ACT, but likely welcomed by the client this early in therapy). The client’s concerns are seen as a natural outcome of historical and external events rather than as something inherently “wrong with” her. An empathic orientation can foster the client-therapist relationship, and the quality of the relationship has been linked to positive outcomes in therapy (Wright & Davis, 1994). In addition, a focus on the relationship as an impor- tant therapeutic factor has a firm place in clinical behavior analysis (Callaghan, Naugle, & Follette, 1996; Kohlenberg, B. S., 2000; Kohlenberg, R. J., & Tsai, 1991).