ACT Case Formulation Framework

I. Context for case formulation

The goal of ACT is to help clients consistently choose to act effectively (concrete behaviors in alignment with their values) in the presence of difficult or interfering private events.

II. Assessment and Treatment Decision Tree

Beginning with the target problem, as specified by the client or significant others, refine these complaints and concerns into functional response classes that are sensitive to an ACT formulation and to the client's contextual circumstances, and link treatment components to that analysis

A. Consider general behavioral themes and patterns, client history, current life context, and in session behavior that might bear on the functional interpretation of specific targets in ACT terms. These may include:

1. General level of experiential avoidance (core unacceptable emotions, thoughts, memories, etc.; what are the consequences of having such experiences that the client is unwilling to risk)
2. Level of overt behavioral avoidance displayed (what parts of life has the client dropped out of)
3. Level of internally based emotional control strategies (i.e., negative distraction, negative self instruction, excessive self monitoring, dissociation, etc)
4. Level of external emotional control strategies (drinking, drug taking, smoking, self-mutilation, etc.)
5. Loss of life direction (general lack of values; areas of life the patient "checked out" of such as marriage, family, self care, spiritual)
6. Fusion with evaluating thoughts and conceptual categories (domination of "right and wrong" even when that is harmful; high levels of reason-giving; unusual importance of "understanding," etc.)

B. Consider the possible functions of these targets and their treatment implications.

1. Is this target linked to specific application of the tendencies listed under "A" above
2. If so, what are the specific content domains and dimensions of avoided private events, feared consequences of experiencing avoided private events, fused thoughts, reasons and explanations, and feared consequences of defusing from literally held thoughts or rules
3. If so, in what other behavioral domains are these same functions seen?
4. Are there other, more direct, functions that are also involved (e.g., social support, financial consequences)
5. Given the functions that are identified, what are the relative potential contributions of:

a. generating creative hopelessness (client still resistant to unworkable nature of change agenda)
b. understanding that excessive attempts at control are the problem (client does not understand experientially the paradoxical effects of control)
c. experiential contact with the non-toxic nature of private events through acceptance and exposure (client is unable to separate self from reactions, memories, unpleasant thoughts)
d. developing willingness (client is afraid to change behavior because of beliefs about the consequences of facing feared events)
e. engaging in committed action based in values (client has no substantial life plan and needs help to rediscover a value based way of living)

C. Consider the factors that may be perpetuating the use of unworkable change strategies and their treatment implications

1. Client's history of rule following and being right
(if this is an issue, consider confronting reason giving through defusion strategies; pit being right versus cost to vitality; consider need for self-as-context and mindfulness work to reduce attachment to a conceptualized self)
2. Level of conviction in the ultimate workability of such strategies
(if this is an issue, consider the need to undermine the improperly targeted change agenda, i.e., creative hopelessness)
3. Belief that change is not possible
(if this is an issue, consider defusion strategies; revisit cost of not trying; arrange behavioral experiments)
4. Fear of the consequence of change
(if this is an issue, consider acceptance, exposure, defusion)
5. Short term effect of ultimately unworkable change strategies is positive
(if this is an issue, consider values work)

D. Consider general client strengths and weaknesses, and current client context

1. Social, financial, and vocational resources available to mobilize in treatment
2. Life skills (if this is an issue, consider those that may need to be addressed through first order change efforts such as relaxation, social skills, time management, personal problem solving)

E. Consider motivation to change and factors that might negatively impact it

1. The "cost" of target behaviors in terms of daily functioning (if this is low or not properly contacted, consider paradox, exposure, evocative exercises before work that assume significant personal motivation)
2. Experience in the unworkability of improperly focused change efforts (if this is low, move directly to diary assessment of the workability of struggle, to experiments designed to test that, or if this does not work, to referral)
3. Clarity and importance of valued ends that are not being achieved due to functional target behavior, and their place in the client's larger set of values (if this is low, as it often is, consider values clarification. If it is necessary to the process of treatment itself, consider putting values clarification earlier in the treatment).
4. Strength and importance of therapeutic relationship (if not positive, attempt to develop, e.g., through use of self disclosure; if positive, consider integrating ACT change steps with direct support and feedback in session)

F. Consider positive behavior change factors

1. Level of insight and recognition (if insight is facilitative, move through or over early stages to more experiential stages; if it is not facilitative, consider confronting reason giving through defusion strategies; pit being right versus cost to vitality; consider need for self-as-context and mindfulness work to reduce attachment to a conceptualized self)
2. Past experience in solving similar problems (if they are positive and safe from an ACT perspective, consider moving directly to change efforts that are overtly modeled after previous successes)
3. Previous exposure to mindfulness/spirituality concepts (if they are positive and safe from an ACT perspective, consider linking these experiences to change efforts; if they are weak or unsafe - such as confusing spirituality with dogma - consider building self-as-context and mindfulness skills)

III. Building interventions into life change and transformation strategy

A. Set specific goals in accord with general values

B. Take actions and contact barriers

C. Dissolve barriers through acceptance and defusion

D. Repeat and generalize in various domains

(Originally posted by Steve Hayes and moved to this location by J. Luoma)