Case Conceptualization Outline from Learning ACT

1) Begin with reformulating the presenting problem from an ACT perspective: What is the client’s formulation? How does the client see their problem at the present time? What do they think they need to do to make things better? What are their goals for therapy and their life? Explore the client’s conceptualization of the “problem” that brings them into therapy. Your job here is to draw out the verbal system that may have them stuck in the problem they are presenting. Presenting problem(s) in client’s own words: Reformulate the presenting problem in an ACT consistent way (if necessary). ACT formulations usually focus on helping clients live better and feel better (i.e., get better at feeling), while reducing the emphasis on feeling good. At a deeper level this reformulation needs to be consistent with the client’s most cherished life goals and values and be detailed enough to create a treatment contract around the initial goals and methods of treatment. For example, clients often identify negative feelings, thoughts, memories, or sensations (e.g., depression) as “the problem.” This will often be fundamentally reformulated in therapy. For example, a client may come into therapy complaining that “I just don’t care about anything anymore. I can’t stand feeling so lifeless. It’s hopeless.” Eventually this might be reformulated into something more like “undermines close relationships and work commitments in order to avoid feelings of rejection and failure.” Another client’s presenting complaint might be “I want help feeling better about myself. I need to have higher self-esteem.” An ACT case conceptualization may end up looking more like “fusing with negative evaluations of self and in the process missing out on opportunities that life offers” (i.e., the problem is the struggle itself). 2) What are the most central thoughts, feelings, memories, sensations, and situations that the client is avoiding or fused with? 3) What behaviors does the client engage in to avoid or escape the events described in the previous step. Experiential avoidance can take many forms, such as overt behavior, internal verbal behavior, or combinations of the two. Examples: a. Internal avoidance behaviors (e.g., distraction, excessive worry, dissociation, telling oneself to think differently, daydreaming) b. Overt emotional control behaviors (e.g., drinking, drugs, self-injury, thrill-seeking, gambling, overeating, avoiding physical situations or physical reminders) c. In-session avoidance behaviors (e.g., topic changes, argumentativeness, aggressiveness, dropping out of therapy, coming late to sessions, always having an acute crisis that demands attention, laughing, focusing on the positive) Rate how pervasiven experiential avoidance is as a controlling factor in the client’s life. 4) What valued domains of living is the client engaged in an excessively narrowed or constricted manner or completely absent from? ACT is fundamentally about helping clients create full, meaningful, vital lives. Thus, we want to investigate functioning across a broad range of domains of the client’s life. Consider the 2-3 domains where the client’s behavior is most narrowed and inflexible and where this constriction appears to result in ongoing suffering. These domains are where the therapist is most likely to have leverage for client behavior change. Describe how behavior is limited or constricted in each domain if applicable. 5) Consider other domains of psychological inflexibility and flexibility: Behavior patterns that occur at a particularly high-rate, are invariant, and/or are consistent across situations often involve psychological inflexibility. Consider the following: Cognitive fusion. Cognitive fusion refers to the tendency of human beings to get caught up in the content of what they are thinking. Example patterns include: A strong belief that unworkable control strategies will eventually work or continuing to engage in unworkable strategies even while aware that they are not working. Highly logical or rigid thinking patterns. Attachment to the conceptualized self. The conceptualized self consists of our autobiographical stories and our evaluations of ourselves that we use to justify and explain out behavior. Examples include: Being strongly identified with a particular way of viewing themselves or self concept. A strong belief that one cannot change or that a better life is not possible for them combined with a strong attachment to a life story that supports this idea. Dominance of conceptualized past and future; limited self-knowledge. Fusion, avoidance, and attachment to self as content tend to pull people out of the moment and away from their direct experience. This can result in a lack of ability to notice and to describe what is present or what they are thinking, feeling, remembering, and sensing in the moment. Examples include: The client poorly tracks their ongoing, moment-to-moment experience. Being excessively caught up in the conceptualized past or future. Lack of values clarity; dominance of pliance and avoidant tracking. Experiential avoidance, reason giving, and fusion can increasingly come to dominant a person’s behavior such that short term goals such as feeling good, being right, and defending a conceptualized self dominate over behavior oriented toward long-term desired qualities of life (i.e., values). Examples include: The client is unable to describe wants, goals, or values that are not heavily socially determined or influenced by the presence of the therapist or other major figures. The client’s behavior is so dominated by escape and avoidance that he or she is unable to articulate goals and values that are heart-felt or meaningful. The client may describe tightly held but unexamined goals (e.g., being popular or making money) as if they are values. Inaction, impulsivity, or avoidant persistence. Because of experiential avoidance and its amplification through these other processes, clients develop larger and larger patterns of action that are detached from their longer term goals and life desires. Behavior is oriented toward getting through, getting by, or surviving the moment (i.e., avoidant persistence), rather than building a life that will be more rewarding, satisfying, meaningful or workable in the long run. Examples include: Living a life relatively free of acute experience of pain, but also relatively narrow and unsatisfying. Engaging in impulsive or self-defeating behavior. 6) Consider factors influencing motivation for change. 7) Consider the client’s social and physical environment and its influence on the client’s ability to change. For example, a client may be motivated to not improve in order to keep their disability payments. A spouse may be unsupportive of change because it is challenging to them. They may have friends which encourage their drug use. 8) Consider client Strengths from an ACT perspective (and how you might use them in treatment). 9) Finally, describe a comprehensive treatment plan which considers the particular processes, interventions, and measures you might want to use with this particular client. a) Consider finding and adapting a specific, relevant treatment manual that has evidence for its effectiveness with this type of client presentation b) Consider what ACT process and outcome measures might be relevant c) Consider use of other compatible techniques and theories that may be relevant but not be obviously theorized about in ACT (e.g., contingency management, cue exposure, education). d) Consider whether client has life skills deficits. If so, consider direct, first-order change or education efforts such as social skills, time management skills, study skills, assertiveness skills, etc. e) Review your conceptualization and given the information, consider how much to focus on: 1. Confronting the system/creative hopelessness (client continues to persevere in the unworkable change agenda) 2. Developing knowledge and direct experience with emotional control as the problem and practicing willingness (client does not experientially understand the paradoxical effects of control; life goals are blocked by experiential avoidance) 3. Developing and practicing defusion (client is fused with content of own thought, caught up in evaluation, or trapped by reason-giving; client needs experience with private events as non destructive) 4. Generate experiences of self-as-context (client is unable to separate self from thoughts, feelings, memories, sensations, stories, and self-as-conceptualized; client needs safe place from which to engage in exposure) 5. Make contact with the present moment/mindfulness (client lives in conceptualized future; client is not learning from contingencies present in their environment) 6. Values exploration (client is unable to articulate a set of stated values or has little guide for behavior outside of fusion and avoidance; client has little motivation to engage in exposure) 7. Engage in committed action based on chosen values (client needs help developing consistent patterns of behaving in line with chosen values) 10) Review and update plan in an ongoing fashion during treatment