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Overcoming Barriers to Working with Difficult and Different Clients through ACT

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Title: Overcoming Barriers to Working with Difficult and Different Clients through ACT


1
Overcoming Barriers to Working with Difficult
and Different Clients through ACT
  • Steven Hayes
  • University of Nevada, Reno

2
Welcome
  • 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

3
Housekeeping
  • 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

4
Purposes 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

5
Informed 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

6
A 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
  • mindfulness exercise

8
Introductions
  • 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?

9
A 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

10
One 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

11
The Source of Burnout
  • Single biggest source dealing with difficult
    clients
  • ... especially in the context of low
    institutional support and chaotic organizational
    environments

12
What is Difficult About Difficult Clients and
Difficult Clinical Situations?
  • The floor is open

13
Notice What Just Happened
14
Why 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

15
Why 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

16
Why 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

17
Exercise
  • We need 3 volunteers who are willing to answer a
    few personal questions

18
The 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

19
Stevie is Already Started
20
Things 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

21
Things 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

22
We are Feeding This Process Sleeping Medications
3
2
Billion
Projected 2010 - 9B
1
2005
2003
2000
23
Obesity Among U.S. Adults 1985
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
24
Obesity Among U.S. Adults 1986
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
25
Obesity Among U.S. Adults 1987
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
26
Obesity Among U.S. Adults 1988
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
27
Obesity Among U.S. Adults 1989
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
28
Obesity Among U.S. Adults 1990
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
29
Obesity Among U.S. Adults 1991
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
30
Obesity Among U.S. Adults 1992
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
31
Obesity Among U.S. Adults 1993
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
32
Obesity Among U.S. Adults 1994
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
33
Obesity Among U.S. Adults 1995
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
34
Obesity Among U.S. Adults 1996
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
35
Obesity Among U.S. Adults 1997
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
36
Obesity Among U.S. Adults 1998
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
37
Obesity Among U.S. Adults 1999
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
38
Obesity Among U.S. Adults 2000
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
39
Obesity Among U.S. Adults 2001
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
40
Obesity Among U.S. Adults 2002
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
41
Obesity Among U.S. Adults 2003
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
42
Obesity Among U.S. Adults 2004
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
43
Obesity Among U.S. Adults 2005
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
44
Judgment 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

45
Judgment 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.

46
Judgment, 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

47
Judgment, 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

48
Acceptance and Commitment Therapy
49
Psychological 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.

50
Testing 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

51
Worksite 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

52
Occupational Stress Study
General Health and Stress
14
Behavioral Innovation
12
Control
ACT
10
Pre
Mid
Post
F-Up
53
Occupational Stress Study
Propensity to Innovate
22
Behavioral Innovation
ACT
21
20
Control
19
Pre
Mid
Post
F-Up
54
Thats media workers. What about Drug and Alcohol
Counselors?
55
Treating 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

56
Change 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
57
Effects on Stigma
Controls
ACT
58
And 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

59
OK. But will your snake oil help me be more
effective with my clients? Glad you asked.
60
Severe 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

61
Objectively Assessed Opiates
Percentage Negative QAs
Post
6 Mo Follow Up
Pre
Phase
62
Total Drug
Percentage Negative QAs
Post
6 Mo Follow Up
Pre
Phase
63
Smoke 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
64
And 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)

65
The 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.

66
OK, OK, OK
  • So what are we supposed to do, Mr. Know it all?
  • Well, that is the workshop

67
Most 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

68
Acceptance 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

69
Acceptance 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 )

70
Who 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

71
Pennebaker 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

72
Control is the Problem
  • 95 solutions
  • If you are not willing to have it, you will
  • Polygraph
  • Pain and suffering

73
Defusion
  • 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

74
Defusion
  • Programmed
  • Easy to add programming
  • You cant subtract
  • Minds are quite arrogant

75
Defusion
  • Milk, Milk
  • Leaves on the Stream
  • Tags
  • Thoughts on Cards
  • Mind for a Walk
  • Bus
  • Stigma tags

76
Self as Context
  • Chessboard
  • Observer exercise
  • Shared shame

77
Values 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

78
Values
  • Tombstone

79
Commitment
  • Fear of commitment
  • forgiveness
  • Not a promise Not a prediction
  • A stand a game selected
  • Building larger patterns of behavior
  • Values / goals / actions / barriers

80
Values
  • 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

81
The 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?

82
Carrying 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

83
Name 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

84
Retirement Party
85
Pennebaker 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
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87
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88
  • Here are Our Targets FEAR
  • Fusion
  • Evaluation
  • Avoidance, and
  • Reasons

89
Taking 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

90
Minds 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

91
The 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.

92
Name 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

93
Name 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

94
Eye 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

95
Values
  • Goals vs. values
  • process vs. outcome
  • Distinguish goals and values
  • Chosen, cannot be evaluated, rather are what
    enables evaluation
  • Choice Exercise

96
Carrying 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
  • And Here are Our Methods
  • Accept
  • Choose
  • Take action
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