Informed Consent for ACT

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In a recent discussion on the ACT listserve, a member asked about how we handle issues of informed consent in the use of ACT. Below is my own understanding of informed consent:

In my own training and the way I train folks, therapy should always start with informed consent. Below is a thumbnail of my approach:

1) Address alternative therapies
I think it is beholden on us to mention alternative treatment approaches that have demonstrated efficacy (including pharmacotherapy) and also to mention that alternative treatments where the direct evidence base is not substantial, but appears to be sensible given the more general evidence available in the literature. If there is a gold standard, like Barlow's PCT for panic--I tell them about it.

I do not get into any kind of big theoretical discussion about, my reservations about the overselling of pharmacotherapy or my own understanding of the likely mechanisms of action in cognitive therapy. I don't do those therapies and if people want them, I can point them to folks who are well versed in them. I also do discuss allegiance effects, though I take them quite seriously. I think that whenever possible, one ought to get therapy from someone who is fully invested in that sort of work. So, if someone wanted CT for depression, I would be the wrong guy. I know smart capable people who do that sort of treatment and am happy to refer folks to them. Likewise, if someone presents with panic, I am not going to do a straight up PCT treatment with them, even though it is the gold standard. I will tell them about PCT (including that is the gold standard) and say that I would do work that has many similarities and is based on many of the same principles, but if they want that specific treatment, I refer to another provider in our clinic. (See below the section on describing the treatment I do as to some ways it might differ from a straight up PCT protocol.

2) Address risks and benefits
My addressing of risks and benefits does not look much different than risks and benefits for any treatment--i.e. not everyone benefits from any treatment, even the most successful varieties. I do not bury a client in a lit review or a checklist of diagnoses for which there is ACT evidence. I do not really buy the diagnostics much anyway. I typically tell people that the treatment we do is directly connected to a tradition that has been useful for a lot of difficulties and that the evidence for this particular looks very promising in the breadth of difficulties for which it seems useful. I also tell clients that treatment is difficult work. I tell people that they may experience significant distress during treatment. I promise to talk about how the person is doing along the way and if it looks like this treatment is not beneficial, I promise to work with them to find the best alternative treatment referral (since my group only focuses on ACT and behaviorally-oriented work).

3) Propose specific time frame
I generally tell clients that it can be a problem estimating whether treatment is useful on a moment by moment basis. Sometimes I use metaphors to illustrate this point. For example, if you plant a garden, going outside every fifteen minutes to see how it is coming along doesn't work very well. Or, going to the gym to get in shape--sometimes you feel worse physically before you start to see the benefits. Also, like physical training sometimes you see periods of progress punctuated by periods that are somewhat flat. I like to start with a time frame where we will stop and look back and ask ourselves "are we headed in the right direction." Partly the time frame depends on the client and the difficulty, but I like a window of 4-6 weeks. This does not mean I expect life to be peaches and cream in 4-6 weeks, just that I think in that time period we should have some sense that we are headed in a direction that seems to have some vitality.

4) Orient person to therapist, client roles
I tell clients that we will be working from a perspective that sees the people we call clients and the people we call therapists as being in the same boat. The rock climber metaphor from the book is a reasonable approximation of the relationship. I honestly can't recall exactly what is in the book, but like two rock climbers on opposite rock faces, there are things I might be able to see from where I stand that would be hard for them to see--not because I am all wise or something, just because I am standing in a different place. Likewise, there are things they can see and feel that I cannot--like the feel, temperature and texture of the rock. I tell clients that if I am to be most useful to them, it will help if I can see the world through their eyes, feel it with their hands. I can't, but I tell them that I will ask them to do their best to give me a sense of what it is like to live in their skin. And then I follow through. My aim is that a client leaves the room with no doubt that their experience was the most important thing in that room during that session. The combination of my somewhat different perspective and their own felt sense of their situation seems to me like the best shot at finding a way forward that works. I tell them this.

We used to say I will be very active at the beginning and that will lessen later. I tend to say something more like sometimes I will be more active and sometimes you will be.

5) Give general descriptions of operating principles
Since generally, behavioral methods are justifiable given the evidence base (exposure-based work, behavioral activation) I tell people that ACT is based on many of the same principles as the best supported treatments available, and will use many of the same methods, but that it tends to look at difficulties in the broader context of whole lives and an individual's valued directions. Therefore the treatment will end up looking at valued domains of living and the ways that these difficulties fit into that whole life. I generally tell them that the work is acceptance focused and whole life focused, rather than being focused on very specific problems. Problems are not ignored, at all; however, they are looked at in this broader way. I tell them that it will be very, very hard work and that we will not do a bit of work except in the service of the direction they would like to take their lives.

I hope this is useful.

Kelly G. Wilson