from 

Wilson, K. G. (2006). The Heart of Acceptance and Commitment Therapy. 

Wilson, K. G. (May, 2007) The hexaflex diagnostic: A fully dimensional approach to assessment, treatment, and case conceptualization. Presidential address presented at the annual convention of the Association for Contextual Behavioral Science, Houston, TX. 

Empirical clinical psychology has largely been focused on measurement of the frequency and severity of various signs and symptoms and the treatment of psychological syndromes defined by clusters of signs and symptoms (DSM disorders for the most part). These syndromes have increasingly organized clinical psychology in spite of much criticism. It is imperative for us to understand that this is not as trivial as would be yet another theory of psychopathology. In such an instance, the presence of the theory might organize the activities of a relatively small group of individuals who share the area of research interest. Supposedly atheoretical syndromal classification, as seen in the DSM, has had a much more far reaching impact. Our central federal funding agency, the National Institutes of Mental Health, is organized around these categories, as are our abnormal psychology textbooks, journals, assessment instruments, and reimbursement for professional services. Such hegemony is wholly unwarranted based upon available evidence. Concerns about syndromal classification of psychological problems has been around for a good long time. However, only recently has dawn begun to break within the DSM effort. 

The failure of syndromal classification carries with it a call for alternatives. At the University of Mississippi Center for Contextual Psychology and Acceptance and Commitment Therapy Treatment Development Group, we are exploring an alternative approach. Based on the idea that multiple systems of classification ought to compete with the gold standard being the treatment utility of the system of problem classification, we are currently pursuing the development and testing of the hexaflex model as the kernel of a fully dimensional diagnostic system within which there exists close linkage between diagnosis, assessment, and intervention. 

Posted below are 1) slides from the plenary session in which the Hexaflex Diagnostic was presented at the ACT Summer Institute and 2) draft versions of clinician worksheets designed to facilitate use of the hexaflex model in this way. Please feel free to offer any feedback you might have as to the utility of the model and tools presented here. Send feedback to Kelly Wilson at kwilson@olemiss.edu These documents are extracted from a book in progress "The Heart of ACT," please copy and use at will for clinical practice and research. Distribute only with express consent of the author. 

peace all, 

Kelly

Attached is a simple, user-friendly 9-box case conceptualization grid from a functional contextual perspective.  The top row emphasizes the situational/historical context of the presenting problem(s); the middle row allows for a basic functional analysis of unworkable behaviors (taking into account the contextual variables identified in the top row); and the bottom row emphasizes values/process-directed treatment planning.

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

An external website also has an outline of a case formulation framework (based on the chapter in the Practical Guide to ACT) along with a form for therapists to use to complete the process (http://www.drluoma.com/actresources.html).

ACT ADVISOR 

ACT ADVISOR is a hexaflex-based self-report measure of psychological flexibility, its name being an acronym for the hexaflex processes (Acceptance; Commitment & Taking action; Attention to present; Defusion; Values Identification; Self as Observer; and Resulting psychological flexibility). It may be used both in case formulation and in tracking progress during therapy.

On being presented with this “double hexaflex” diagram, users are asked to choose where they would place themselves on the six different scales representing these core ACT processes, each with “opposite” statements at either end. Scoring is simply a matter of recording the user’s numerical responses and totalling them to give their Resulting psychological flexibility score. If ACT ADVISOR is administered repeatedly, scores can be tracked using the charts provided.

The idea for using the hexaflex as a diagnostic/ case formulation tool was, I believe, originally Kelly Wilson's and his materials (see The Hexaflex Dimensional Approach to Diagnostics) influenced the development of this instrument. Steve Hayes made helpful suggestions about the anchor statements for each process in earlier drafts, and I am also grateful for the ACT listserv community’s interest and input.

ACT ADVISOR statement rating form offers an alternative format. In this version users are asked to rate 12 statements independently of each other and without the possible steer of the double hexaflex diagram. Instructions for scoring this version are provided separately, with the Resulting psychological flexibility score here being converted to a percentage. 

ACBS members login their account and then click here to download the ACT ADVISOR and related documents.

Submitted by David Chantry

Psyflex Planning Tool from Hayes, Strosahl, & Wilson