In many ways, this—persistent inaction, impulsivity, or avoidance—might be the problematic domain that is most obvious to clients and influences them to seek help. This domain usually includes the obvious problems other people can see too. Now we are talking about the “symptoms” that are often measured in psychopathology studies and are addressed in the empirically supported treatments. When performing functional analy- ses on troublesome behavior, the B part of the ABC functional analysis is the clinically relevant behavior being addressed in this portion of the case conceptualization.
The clinical question in this domain might sound like this: “What is the client doing too much of or too little of, or doing in the inappropriate contexts?” During case conceptualization, the therapist is developing an understanding about what the person is doing in the service of experiential avoidance. Notice what the people in the follow- ing vignettes are doing too much of or too little of, or are doing inappropriately, and then notice the experiential avoidance and inflexible verbal behavior supporting the problem:
A woman who is unwilling to have thoughts and feelings about contami-
nation may impulsively wash her hands a few times an hour with bleach in order to avoid those private events.
A man diagnosed with a mood disorder may be persistently inactive
because whenever he attempts to live toward his valued ends, aversive private events arrive. He has thoughts of difficulty and feelings of failure, and in the service of experiential avoidance, he develops a repertoire of inflexibly avoiding these private events. He decides to sleep in, miss work, and refuse social interaction, then sets up an agenda that keeps him from these aversive events. By doing so, he sabotages a value- directed lifestyle.
A young woman participates in a relationship with her abusive girl-
friend. She claims, “I am dedicated to her, even if this is a star-crossed relationship.”
In treating each case, we would first discuss with the client what behavioral goals might be most prudent for treatment, and then select the behavioral measure that might correspond with clinical improvement.
In chapter 1, we commented that the domain of committed action is where the rubber meets the road in psychological flexibility. This is where people are doing what they care about. Persistent inaction, impulsivity, and avoidance are where the rubber isn’t meeting the road or where people are just spinning their wheels erratically. When using the Inflexahex Case-Conceptualization Worksheet, the persistent inaction, impul- sivity, or avoidance section will be dedicated to recording the infrequent, excessive, or inappropriate responses that prevent the client from flexibly approaching his valued directions. Notice that with ACT case conceptualization, the concern is with changing the client’s overt behavior, not changing the form of the client’s covert behavior. With OCD, ACT therapists are interested in making the client’s repertoire more broad and flexible, which can include reducing the number of times he washes and increasing the number of public places he goes. The ACT therapist is not interested in making his obsessive thoughts less frequent or more rational. The ACT approach with a person in an abusive relationship is not to reduce the number of times the client says, “But I love him and he really needs me,” nor is it to make her statement more rational. Rather, the approach is to get the client to notice that thought and to change her overt dependent behaviors that continually put her in harm’s way.
The section of the case conceptualization that considers inaction, impulsivity, and avoidance will include the ABC Functional Analysis Sheet (see appendix A) or Event Logs (see appendix C), and may include measures of clinically relevant behavioral dimensions (frequency, intensity, and so on) as well as other standardized assessments. Be mindful that inaction may be especially difficult to assess during therapy because it is based on what the client doesn’t do. Oftentimes the empirically supported treatments will focus on ameliorating the concerns rated in this domain of the inflexahex. In this regard, it is prudent to measure “psychopathology” change for ACT clients in terms related to valued living rather than with symptom reduction per se. Bach and Hayes (2002) measured change in latency to rehospitalization and reduction in believability of psychotic events for people diagnosed with psychosis disorders treated with ACT. For people with type 2 diabetes given ACT therapy, Gregg (2004) measured improve- ments in self-management behavior and blood glucose levels. ACT outcome studies will include measures that may hint at an eliminative agenda. ACT for smoking cessation measures the reduction of cigarette consumption, and ACT for depression is interested in change in Beck Depression Inventory-II (BDI-II; Beck et al., 1996) scores. Influencing clients to do less of what they do too much of, or do more of what they do too little of, can be an ACT goal.
And at the same time, ACT is explicitly about helping clients develop broader and more flexible repertoires. The clinical direction engenders committed action toward vital living. Selecting a valued direction and maintaining that course is critical to the ACT approach. If clinical measures show a reduction in the number of cigarettes per
Conceptualizing Functionally 103
day, a lowering of the BDI-II scores, or better maintenance of blood glucose levels in the service of valued living, then those measures are part and parcel part of our ACT treat- ment. Third-wave behavior therapy thoroughly embraces measuring inaction, impulsiv- ity, or behavioral avoidance, and utilizing evidence-based interventions to treat those concerns.