Focused Acceptance and Commitment Therapy

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Focused Acceptance and Commitment Therapy

Kirk Strosahl HeartmattersConsulting.com

Patti Robinson [email protected]

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Objectives

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1. Describe the difference between psychological pain and psychological suffering

2. Define experiential avoidance and psychological flexibility

3. Understand the on-going tension between avoidance and approach behaviors and the importance of observational distance 4. Use the Contextual Interview Questions 5. Use the FACT Four Square Tool to conceptualize an

intervention

6. Learn to use the Quality of Life Matrix 7. Learn to use the Web of Life intervention

FACT

Focused Acceptance and Commitment Therapy

Designed to support 3 goals:

1. Improve access to behavioral health services

2. Enhance patient engagement 3. Improve psychological

flexibility of people over the

Robinson, Gould & Strosahl, 2010;

Strosahl, Robinson & Gustavsson, 2012 An inter-professional approach to

brief interventions

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All day, everyday

Psychological flexibility (PF)

The human’s ability to make a choice relies on their psychological flexibility at that moment.

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Being aware and accepting of the pain that comes into our lives

while continuing to pursue what we value

• Most people with mental health and addiction problems do not receive service from a MH provider?

• Many barriers to care – stigma, accessibility, cost

• Current system of diagnosis and treat doesn’t match patient utilization patterns

• New approach is necessary – one that emphasizes immediate access, functioning, and brevity

A Therapy for Today

• FACT focuses on functioning.

• FACT focuses on strengths.

• FACT is trans-diagnostic. One approach to assessment, conceptualization, and intervention for many problems – psychological, social, and biological.

• FACT assessment and interventions are designed for the brief context of PC, where patients are most accessible

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Life is Difficult . . .

Psychological Pain Psychological Suffering

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Language as a behavioral control system

• Self instructional control

• Rule following

• Over-identification (fusion)

• Context insensitivity

• Ubiquitous invisibility

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Everyday rules that support society and promote individual suffering

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Experiential avoidance of . . .

Uncomfortable thoughts, feelings, memories, sensations . . .

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Behavioral Avoidance

(our actions . . . what we do that can be observed)

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Find a place of “observational distance” to view approach /

avoidance dynamic . . . Shift from experiential avoidance to “name

and notice”, from behavioral avoidance to ”actions that reflect your

values”

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Focused Acceptance and Commitment Therapy (FACT) Pillars of

Psychological Flexibility

SKILLS LEARNING PACKET,

p. 2

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How do we measure PF?

The Acceptance and Action Questionnaire-II (AAQ-II)*

Measures one-factor of psychological inflexibility: Experiential Avoidance (EA).

EA is the efforts a person is making to avoid difficult thoughts, feelings, and sensations.

The EA score is a sum of the seven items;

higher scores indicate greater levels of PF.

*Bond, Hayes, Baer, Carpenter, Guenole, et al., 2011

Skills Training

Packet, p. 3

What is my PF “temperature” today?

EXERCISE Complete the AAQ-2

Skills Training Packet, p. 3

DISCUSS WITH LEARNING

PARTNER

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What does low PF mean and how do we talk with patients about their AAQ-II score?

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PF and psychological health Low PF is associated with psychological problems and difficulties with functioning, including anxiety, lower quality of life, poorer work performance, difficulties with learning, and long-term disability (Kashdan &

Rotterburg, 2010).

Giving FB to a patient

“This score is an indication of the level of pressure you’ve been feeling at this point in time and your efforts to avoid or resist the pressure”.

What’s the evidence for ACT / FACT?

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ACT RCTs blast past 300 Many from outside US and Europe.

Years to 100 studies = 28 Years to 200 = 4 Years to 300 = 3

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ACT effective with many Psychological Problems

• Psychological Problems

– Anxiety

– Depression – Stress – OCD – Eating Disorders – Psychosis – Substance Use – Trichotillomania – PTSD and other co-morbid

conditions – And more

• Medical Problems

– Diabetes – Hypertension – Healthy weight – Chronic Pain – Tobacco Cessation – Multiple medical conditions

And combined medical &

psychological

Focused ACT or Brief ACT

Use of single-session ACT interventions in CHC populations is an emergent field.

There is preliminary evidence for the acceptability, feasibility, and efficacy of these interventions, which provides support for further testing in fully- powered RCTs.

Additional RCTs will enable larger meta-analyses and stronger conclusions about efficacy.

Dochat, Wooldridge, Herbert, Lee & Afari (2021). Single-session acceptance and commitment therapy (ACT) interventions for patients with chronic health conditions: A systematic review and meta- analysis. Journal of Contextual Behavioral Science, 20, 52-69.

FACT group TX in Integrated PC Glover, et al., 2016

• 4-week group, 51 participants

• Pre- to Post-treatment analyses of variance demonstrated

– Large effects for quality of life

– Moderate effects for depressive symptoms

– Moderate effects for perceptions of mental health functioning – Small effects for perceptions of perceived stress and physical

health functioning

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How do you do FACT?

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Love, Work, Play, Health Time, Triggers,

Trajectory

Agreement & Options

Intervention & Plan

Introduction

Outcome Measure Charting &

Feedback

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FACT FIRST Visit (25 minutes)

Preparing the patient

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Hello. My name is Patti and I am a behavioral health consultant and a psychologist.

My job is to help with stress and problems of living, and health behaviors.

Today, I’ll be asking a lot of questions for 10 minutes-trying to get a picture of your life and an understanding of the problem you’re concerned about today.

Then, we’ll put our heads together and try to come up with a plan to make things better. Our visit will take 20-25 minutes, and I’ll let your doctor know what we come up with.

Sometimes people get what they need from a single visit and other times people return to learn new skills.

I’ll chart in your medical record as we talk to make sure I get things accurately. Any questions?

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Functional assessment

• An alternative to the diagnostic interviewing and treatment matching approach

• Helps clinician develop behavior change plans that target specific factors maintaining problem behaviors

• Helps clinician use evidence-based interventions with greater precision and impact

• Functional assessment of a problem behavior involves – Indirect assessment (e.g., results of a health-related QOL survey) – Direct assessment (e.g., interview questions, rating scales)

– Functional analysis involves the clinician intentionally changing factors in the environment (e.g., changing positions in the room, asking the patient to stand or speak at a faster or slower rate) and then observing the impact of the change of the

problem (e.g., the patient’s attention, experience of emotion, etc.)

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What measure to use in the functional assessment?

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Depends on your setting, relationship with patient, length of appointment Health- related quality of life measures reduce patent sense of stigma

Duke Family Medicine and Community Health Department has developed a variety of measures:

Duke Health Profile (DUKE), Duke Health Profile-8 (Duke-8) Duke Population Health Profile (Duke-PH)

See https://fmch.duke.edu/research/duke-health-measures) Another option for estimating patient functioning is the PROMIS^®(Patient-Reported Outcomes Measurement Information System)

FACT

ASSESSMENT

SKILLS TRAINING PACKET, pages 4-5

Contextual Interview Questions

4 Rating Scale Questions

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Contextual Interview Questions

SKILLS TRAINING PACKET, page 4

Life context LOVE WORK PLAY HEALTH

Problem context TIME TRIGGERS TRAJECTORY WORKABILITY

Rating Scale Questions SKILLS TRAINING PACKET, page 5

How big of a problem is x?

1 = not a problem 10 =, a very big problem

How confident are you that you will do this experiment?

1 = not confident and 10 = very confident

How helpful was this visit?

1 = not helpful and 10 = very helpful

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WORKABILITY

. ..the end of the Contextual

Interview Questions

How has what you’ve tried worked in terms of what matters to you?

Does it bring you closer to the life you want to live?

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FACT Four-Square Tool*

Avoidance / Controls Suffering

Approach / Supports Flourishing

Actions

Thoughts Emotions Sensations (Actions vs thoughts,

emotions, urges, memories, sensations) SKILLS TRAINING PACKET, page 6

*Adapted from Strosahl, Robinson, & Gustavsson, 2012

PILLARS ASSESSMENT TOOL (PAT) Open

• Accepts distressing thoughts and feelings

• Creates a safe observational distance from distressing thoughts and feelings

• Uses experiences to inform behavior, rather than habits and rules

STRENGT HS DEFICITS TARGETS

Aware

• Intentionally focuses on present moment experience

• Uses self-reflective awareness to promote sensitivity to context

• Can change perspectives on stories told about self and others

STRENGT HS DEFICITS TARGETS

Engaged

• Speaks about values with emotion, recalls moments of values-in- action, and accepts vulnerability that comes with caring

• Plans and implements behavior change experiments that promote vitality STRENGT HS DEFICITS TARGETS

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OPEN

• When "stuck", be curious, model acceptance, notice the

"mind"

• Support openness and curiosity about previously avoided thoughts/feelings/

sensations

• Attend to thinking as an ongoing process, rather than the world structured by it

AWARE

• If confused, go to the present, look at different perspectives

• Promote flexible, voluntary and purposeful attention to the present moment

• Support mindfulness and noticing of the continuity of consciousness

ENGAGED

• W h e n e v e r possible, promote c o n n e c t i o n between values and action

• Identify qualities of meaningful action in the here and now

• Collaboratively create SMART behavioral experiments

PILLARS INTERVENTION GUIDE (PIG)

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Transition from Assessment to Intervention

FACT Agreement and Options Worksheet

Use Four Square and PAT to conceptualize and plan

Skills Training Packet – page 9

A behavioral experiment is a plan that identifies a specific action a patient plans to implement in order to observe its impact on the problem of concern or more broadly on their ability to live the

life they choose.

How do you make behavioral variability?

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Day 2

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Outcome Measure

Same, better, worse

Experience with plan Agreement & Options

Intervention & Plan Charting &

Feedback

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FACT Follow-Up Visit (15-25 minutes)

FACT and Complexity

• Definition

• Assumptions

• FACT FIT

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Metaphors for FACT work

• Bull’s – Eye

(See Robinson, Gould, & Strosahl (2011). Real Behavior Change in Primary Care: Improving Outcomes and Increasing Job Satisfaction. Chapters demonstrating use of Bulls Eye with chronic disease, depression, anxiety, chronic pain, child trauma, adult trauma. Also, 30% of book on use of Bulls Eye to enhance resiliency / reduce burnout) (pp. 25---26)

• Life Path (See Strosahl, Robinson, & Gustavsson (2012).

Brief Interventions for Radical Change) (p. 27)

• Today:

– The Quality of Life Matrix – The Web of Life

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A FACT INTERVENTION:

The Quality-of-Life MATRIX

SKILLS TRAINING PACKET, p. 10

C

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E D

Step 1:

Engage the patient

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• Living life with chronic pain is like living life in a matrix

• A matrix is a group of lines where numbers are plotted; often complex in their nature.

• Did you see the movie, The Matrix?

• Well in the movie, humans are living in a stimulated reality and the truth of this is hidden by the matrix. So people think they have no choice but to do the usual and meanwhile machines are taking their energy and using it for something else.

• Living with chronic pain is a lot like this – most people feel a bit trapped and it is very difficult to figure out how to break out of the matrix and pursue a more meaningful and important life.

Step 3:

Provide an overview

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• I am proposing that we use this matrix to help us figure out what’s going on that’s complex and difficult to see. We can experiment and try new things an get smart about the tricky, illusive parts of chronic pain and using opioids.

• The tricky are subtle – subtle and powerful.

• I’ve been studying this in my own life and I share what I know. Other people have used this, too, and found it helpful.

• So it starts with learning to take a slightly different focus on your life . . . That’s the

“me noticing” perspective. It’s here in the middle of the matrix (refer to worksheet).

This is tough perspective because most of us are just living life and not stepping back to see what the heck it is we are doing.

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A FACT INTERVENTION:

The Web of Life SKILLS TRAINING PACKET, p. 11

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CREATING: A Web of Life

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• Help your client to identify specific thoughts, emotions, action tendencies, memories, sensations which they would benefit from untangling from

• Invite them to consider the impact of struggle with a particular thread – e.g., the impact of a painful has had and is likely to continue to have in their life.

• Give your client the opportunity to practice basic defusion exercises

• This exercise can be really useful in helping the client consider how the mind regulates

• Invite them to think of a way to respond when this memory/thought appears that is more value-consistent, while also acknowledging the uncomfortable feelings that accompany the memory

FACT - a brief review

Focused Acceptance and Commitment Therapy

An inter-professional approach to brief interventions

Designed around of goals of

1. Improve access to behavioral health services 2. Enhance patient engagement

3. Improve psychological flexibility of people over the

course of their lives

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FACT ^{- share it}

It’s a Good Playbook for Healthcare Workers

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• All people want and deserve the best health possible at any point in their life. Health is a fundamental human right.

• Healthcare teams working from a common playbook may play better together.

• Healthcare is delivered in groups and cooperative groups produce better outcomes (see Elinor Ostrom).

• Healthcare teams working from a common playbook achieve better outcomes (better patient engagement and persistence, better value).

Questions, ideas

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Robinson, P. J., (2020) Springer

https://www.springer.com/gp/bo ok/9783030320492

Amazon

https://www.amazon.com/Basics- Behavior-Primary-SpringerBriefs- Psychology/dp/3030320499/ref=sr_

1_1?dchild=1&keywords=basics+of

+behavior+change+in+primary+car

e&qid=1590948683&sr=8-1

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Kirk’s new book

Resources

50 Association for Contextual Behavioral Science” http://

www.contextualpsychology.org/ http://www.newharbingeronline.com/

real-behavior-change-in-primary- care.html

Resources

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Resources

Basics of Behavior Change Learning Program

A learner-centered approach Groups of 6-10 people Mix of at home study and live, interactive webinars

Reasonably priced APA approved continuing education credit available

Registration

Basicsofbehaviorchangeinprimarycare.com

Starting July 1, 2020

To express interest, send email with subject: Basics of Behavior Change

Resources

•Association for Contextual Behavioral Science”

•http://www.contextualpsychology.org/ http://

www.newharbingeronline.com/real- behavior- change-in-primary-care.html

•Bonus chapters on anger and lifestyle change with an adolescent

• https://www.mtnviewconsulting.com For PCBH Tool Kit, go to bottom left of home page