Title: Overcoming Barriers to Working with Difficult and Different Clients through ACT
1Overcoming Barriers to Working with Difficult
and Different Clients through ACT
- Steven Hayes
- University of Nevada, Reno
2Welcome
- Let me introduce myself
- This is part of a NIDA grant so this does
influence some things - Please plan to stay the whole time if there are
problems contact staff at the front desk - Your data are important (follow up too!)
without them we cannot learn - Breaks will have to be real
- Dont discuss with others in other groups in the
study, especially until we are done
3Housekeeping
- To get your CEs you must sign in at the morning
and the end of each day - No break this morning (Lunch 12-1)
- Afternoon break around 3 (must be 15 minutes)
Post evaluations at 445 - Start at 830 tomorrow
- Cell phones
4Purposes of the Workshop
- To help you to engage with and work more
effectively with difficult and different clients - To reduce burnout and bring more vitality to your
work - To give you new ways to make a difference in
lives of your clients, especially the most
difficult ones
5Informed Consent
- At times this will be experiential -- may stir a
few things up - Your privacy will never be violated, but you will
be invited to take risks. - For that reason we must agree to confidentiality
- No rescuing
6A Request
- Intend for these two days to make a difference
- My commitment
- To stay present
- To step forward ourselves
- To serve you in this joint effort
7 8Introductions
- In less than a minute
- Your name and where you work
- What you want to get out of this workshop
- What is one way that you might get in your own
way in terms of having that happen here?
9A Focus Dealing with DifficultClients and
Clinical Situations
- Some evidence that the rate of difficult clients
is increasing - A lot of evidence that the delivery system is, if
anything, weakening
10One Reason is to Look At This Burnout
- It is widespread in this field
- Higher stress higher turnover
- Poorer health outcomes for clinicians
- Negative impacts for clients
11The Source of Burnout
- Single biggest source dealing with difficult
clients - ... especially in the context of low
institutional support and chaotic organizational
environments
12What is Difficult About Difficult Clients and
Difficult Clinical Situations?
13Notice What Just Happened
14Why Are Difficult Clients a Source of Stress and
Burnout?
- Part of it is just practical, but they also bring
up painful and difficult thoughts and feelings - We become entangled with our judgments
- We tend to avoid or suppress our feelings
15Why Are Difficult Clients a Source of Stress and
Burnout?
- We begin to become defended, less flexible, less
connected, less engaged - To use a harsh word, these processes can lead to
stigma the objectification and dehumanization of
others. We begin to interact not with people but
with projections of our own thoughts and
feelings. - We have found in our research that this process
is key in burnout
16Why Are Difficult Clients a Source of Stress and
Burnout?
- Stigma does not occur to bad people with bad
thoughts it is something we all carry - It involves entanglement with our judgments and
increasing the impact of the difficult feelings
they bring up by avoidance - And those are often almost invisible processes
17Exercise
- We need 3 volunteers who are willing to answer a
few personal questions
18The Verbal World of Judgment, Evaluation, and
Avoidance
- Human culture has long known that entanglement
with judgments brings us difficult feelings and
self-judgments (e.g., the Tree of Knowledge) - You can easily see the process with your children
(e.g., my own son, Charlie) - And now Jacque and I have a brand new one and
19Stevie is Already Started
20Things Have Also Changed
- We seem to have less training in learning to
disentangle ourselves from our judgments and sit
with difficult feelings - Our exposure to language and through it judgment
and pain has enormously increased due to the
media
21Things Have Also Changed
- Hyperdiversity and hypermobility demands new
skills - But instead our culture is massively promoting a
feel good / dont worry message - And that is creating dramatic change a few
examples
22We are Feeding This Process Sleeping Medications
3
2
Billion
Projected 2010 - 9B
1
2005
2003
2000
23Obesity Among U.S. Adults 1985
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
24Obesity Among U.S. Adults 1986
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
25Obesity Among U.S. Adults 1987
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
26Obesity Among U.S. Adults 1988
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
27Obesity Among U.S. Adults 1989
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
28Obesity Among U.S. Adults 1990
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
29Obesity Among U.S. Adults 1991
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
30Obesity Among U.S. Adults 1992
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
31Obesity Among U.S. Adults 1993
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
32Obesity Among U.S. Adults 1994
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
33Obesity Among U.S. Adults 1995
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
34Obesity Among U.S. Adults 1996
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
35Obesity Among U.S. Adults 1997
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
36Obesity Among U.S. Adults 1998
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
37Obesity Among U.S. Adults 1999
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
38Obesity Among U.S. Adults 2000
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
39Obesity Among U.S. Adults 2001
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
40Obesity Among U.S. Adults 2002
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
41Obesity Among U.S. Adults 2003
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
42Obesity Among U.S. Adults 2004
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
43Obesity Among U.S. Adults 2005
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
44Judgment is Everywhere
- Even what I just showed Didnt it evoke negative
judgment? - But thats not the solution thats the problem!
- Indeed, weve just completed a study showing
exactly this with weight - But we cant lower judgment by eliminating it
- Pick an object in this room
- How do we get out of this room?
- We have to deal with the excesses of judgment in
another way
45Judgment is Everywhere
- We all have stereotypes and judgments
- They have been programmed into us by society. We
cant escape them and we engage in this process
constantly. In fact, this ability to classify and
judge people is built into social adaptation.
46Judgment, Avoidance, and Burnout
- They do not respond well to direct change
attempts - Examples
- The classics (gender race addiction) but also
- My most difficult clients
- My work situation
- And even me
47Judgment, Avoidance, and Burnout
- In this workshop we will focus instead on
- disentangling from needless judgments,
- making more room for feelings,
- focusing on values, and
- committed action linked to values
- Our approach is called Acceptance and Commitment
Therapy. This is the model
48Acceptance and Commitment Therapy
49Psychological Flexibility
- Psychological flexibility is contacting the
present moment fully as a conscious human being,
as it is, not as what it says it is, and based on
what the situation affords changing or persisting
in behavior in the service of chosen values.
50Testing the Model
- We are learning that entanglement with our
attitudes and judgments, and avoidance of our
feelings - makes it harder to work with stigmatized clients
- increases stress
- increases burn out
51Worksite Stress Bond Bunce, 2000
- Study done at BBC in England
- Three treatment conditions (30 per condition)
- Acceptance and Commitment Therapy
- Behavioral Innovation Promotion
- Wait list control
52Occupational Stress Study
General Health and Stress
14
Behavioral Innovation
12
Control
ACT
10
Pre
Mid
Post
F-Up
53Occupational Stress Study
Propensity to Innovate
22
Behavioral Innovation
ACT
21
20
Control
19
Pre
Mid
Post
F-Up
54Thats media workers. What about Drug and Alcohol
Counselors?
55Treating Us
- Approximately 90 Drug and Alcohol Counselors
- Randomly assigned to three groups
- ACT
- Two control conditions said to lower stigma
- Day-long workshop
- 3 Month Follow-up
56Change in Burnout
Control 2
ACT
Control 1
4
0
-4
Pre- Post
Pre- F-up
Pre- Post
Pre- F-up
Pre- Post
Pre- F-up
57Effects on Stigma
Controls
ACT
58And we Now Have Similar Results with
- Stigma toward people with mental health problems
- Racial prejudice
- Prejudice toward people with weight problem
- Mindfulness, acceptance and values seems to help
dissolve the glue that hold these things together
59OK. But will your snake oil help me be more
effective with my clients? Glad you asked.
60Severe Substance Abuse
- 124 abusing multiple drugs within the last 30
days while on methadone maintenance - Three conditions (RCT)
- ACT methadone maintenance
- ITSF methadone maintenance
- Methadone maintenance
61Objectively Assessed Opiates
Percentage Negative QAs
Post
6 Mo Follow Up
Pre
Phase
62Total Drug
Percentage Negative QAs
Post
6 Mo Follow Up
Pre
Phase
63Smoke Free at One Year Follow-Ups (all included)
Nicotine Patch
ACT
Zyban
Overall effect size d .34
ACT FAP Zyban
CBT
ACT
30
25
5
20
15
10
35
Percentage Not Smoking
64And Similar Results with
- Self-stigma for people in recovery
- Marijuana dependence
- Ability of drug and alcohol counselors to learn
new methods (MI group counseling medications) - And an long list of problems outside of substance
abuse (depression, pain, anxiety, OCD, coping
with psychosis, coping with diabetes etc etc)
65The Bottom Line
- You may be a better clinician overall if you
learn ACT - If you apply these methods to your own day to day
work life you likely be less stressed, more
empowered to alter your work environment, less
burned out, more engaged, and more effective.
66OK, OK, OK
- So what are we supposed to do, Mr. Know it all?
- Well, that is the workshop
67Most of What is in this Workshop You Can Take
Home
- Was a best seller last year
- You will get a free copy to use as a follow up on
the workshop - We have evidence that using it helps
68Acceptance of Where We Start
- 4 questions
- Things you might share
- Thing you dont
- What you like least about yourself
- What stands between you and what you most want
- Hands up
69Acceptance of Where We Start
- These are historical (theres no place like )
- Yet we dont have the information (tell me about
- And they are easily programmed (what are the
numbers )
70Who do you Despise?
- Writing exercise (Paper and pen)
- Identify a person
- (1) What are the attributes that made you dislike
him or her? Write them down - (2) Looking at your family, childhood, history,
do any of these attributes remind you of anything
related to that? Write that down - (3) Look at yourself Is any of this somewhere in
you? Could any of this be said about you? If so,
write for a minute about that
71Pennebaker writing exercise
- The task
- Write about a time that you have felt ashamed of
yourself or you felt like a failure for 10
minutes - Completely confidential
- Write like you were talking to another person,
and dont worry about spelling or grammar. - Be sure to include as many thoughts and feelings
and details as you remember. - If you feel stuck, just keep writing, even if you
are repeating yourself, until something new
comes. - Take a moment to think of a situation
72Control is the Problem
- 95 solutions
- If you are not willing to have it, you will
- Polygraph
- Pain and suffering
73Defusion
- Overall purpose to catch language processes in
flight, bringing their functions under contextual
control, so that when needed they can be looked
AT rather than looked from - Targets of Defusion Not values not situations
useless, historical cognitive and emotional
entanglements
74Defusion
- Programmed
- Easy to add programming
- You cant subtract
- Minds are quite arrogant
75Defusion
- Milk, Milk
- Leaves on the Stream
- Tags
- Thoughts on Cards
- Mind for a Walk
- Bus
- Stigma tags
76Self as Context
- Chessboard
- Observer exercise
- Shared shame
77Values and Willingness
- Choice versus decision
- Goals versus directions
- Process versus outcome
- Non-avoidant
- Not for public approval and being right
- Leaping
- Not a matter of wanting
78Values
79Commitment
- Fear of commitment
- forgiveness
- Not a promise Not a prediction
- A stand a game selected
- Building larger patterns of behavior
- Values / goals / actions / barriers
80Values
- What do you want to be about at work
- What have you done to get in the way of that
- What has it cost you and your colleagues and
clients - What will you do from here
81The ACT Question
- Given a distinction between you and the things
you are struggling with and trying to change, are
you willing to experience those things, fully and
without defense, as it is and not as it says it
is, and do what takes you in the direction of
your chosen values in this time and situation?
82Carrying this forward
- Possible steps
- 1. Work with your own chatter with clients (use
mindfulness, defusion, willingness) - 2. Learn more about ACT
- 3. ACT provides a model for a more powerful
therapeutic relationship that is grounded,
present, accepting, and built around the clients
deepest values
83Name Badges Letting go of Attachment
- Write a negative self evaluation you are ready to
let go of on the nametag - Dont go beyond your willingness and dont expect
others to do your work - Feel the pull to explain or avoid
- Do look at others, but no talking about them or
explaining them until later
84Retirement Party
85Pennebaker writing exercise
- The task
- Write about a time that you have felt ashamed of
yourself or you felt like a failure for 10
minutes - Completely confidential
- Write like you were talking to another person,
and dont worry about spelling or grammar. - Be sure to include as many thoughts and feelings
and details as you remember. - If you feel stuck, just keep writing, even if you
are repeating yourself, until something new
comes. - Take a moment to think of a situation
86(No Transcript)
87(No Transcript)
88- Here are Our Targets FEAR
- Fusion
- Evaluation
- Avoidance, and
- Reasons
89Taking Your Mind for a Walk
- Groups of three One is a person, two are minds.
- Person goes where he/she chooses Minds must
follow. - Persons this is your job
- Notice your breath as you walk
- Feel your feet, leg, torso, hands as you walk
go wherever you choose to go - See, hear, smell, feel slow down and note what
is happening around you and in you - See if you can notice things you normally would
not - Smile
- And gently listen to your mind
90Minds this is Your Job
- Get close to your person and communicate nearly
constantly describe, analyze, encourage,
evaluate, compare, predict, summarize, warn,
cajole, evaluate, and so on. - Persons cannot communicate with his or her mind.
The mind must monitor this, and stop the person
("Never mind your mind") if the rule is violated. - Persons should listen to their minds without
minding back and go where you choose to go. - Dont forget work related content
91The Task
- Do this for four minutes. Then switch, person
become a mind and one of the minds become the
person (minds watch the time). - After four more minutes, switch again.
- After four more minutes, split up and walk
quietly by yourself for four minutes. - While you are walking, walk mindfully and
notice that you are still taking your mind for a
walk. Follow the same rules as before during
this time.
92Name badges Letting go of attachment
- Write a negative judgment of yourself on the
nametag - Put something on there that you are willing to
let go of your attachment to it - Rules
- No talking about content of name tags for 30
minutes
93Name badges 2
- Write a judgmental or stigmatizing thought you
have had about a client at some point - Most likely a thought you find difficult to admit
having had or you find uncomfortable that fact
that you thought it - Same rules as last exercise
- No talking about content for 20-30 minutes
94Eye to Eye
- Sit in pairs, knees between knees
- Look at the other person
- Notice the chatter
- Let go and be present to being with another person
95Values
- Goals vs. values
- process vs. outcome
- Distinguish goals and values
- Chosen, cannot be evaluated, rather are what
enables evaluation - Choice Exercise
96Carrying this forward
- Possible steps
- 1. Work with your own chatter with clients (use
mindfulness, defusion, willingness) - 2. Learn more about ACT
- 3. ACT provides a model for a more powerful
therapeutic relationship that is grounded,
present, accepting, and built around the clients
deepest values
97- Accept
- Choose
- Take action