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.

peace,

Kelly G. Wilson

August 29, 2006

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 [email protected] 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