Evaluation and Formulation

From psychiatric diagnosis to functional analysis of behavior

The initiation of treatment in this therapeutic modality differs significantly from the traditional medical model.

Whereas conventional psychiatry focuses on grouping symptoms to assign a diagnostic label (e.g., "Major Depression" or "Panic Disorder"), ACT prioritizes functional analysis and case formulation.

We are not so much interested in what the problem is called, but how it functions in the individual's life.

The goal is to understand the mechanics of the distress: what events (internal or external) trigger the behavior, what the person does in response to those triggers, and what consequences he or she gets in the short and long term.

To conduct this analysis, we investigate the antecedents and consequents of problem behaviors.

For example, if a client comes in for anger problems, we do not stick with the label "explosive."

We analyze: What happens just before the outburst (perhaps a thought of "they don't respect me")?

What does the person get out of yelling (perhaps an immediate sense of power or relief of tension - negative reinforcement). What is the long-term cost (deterioration of relationships and loneliness).

This mapping allows us to identify that the function of anger is not malice, but avoidance of feelings of vulnerability.

The case formulation becomes a narrative explanation of why the person is stuck, identifying what inflexibility processes (fusion, avoidance, lack of values) are sustaining the problem, which guides the intervention much more accurately than a simple diagnosis.

The Flexibility Assessment and Informed Consent

Before beginning the intervention itself, it is crucial to assess the client's current repertoire of psychological flexibility.

The therapist observes: Can this person notice his or her thoughts without believing them? Is he or she clear about what matters to him or her? Is he or she able to stay in the present or does he or she constantly wander? This assessment is not only done with tests, but by observing the interaction in session.

If the client insists on being right or blaming others, we see rigidity in the "I". If he rationalizes everything, we see fusion with the intellect.

Also, since ACT is a counterintuitive therapy (it asks people to move toward pain rather than away from it), informed consent is a critical ethical and clinical step.

We cannot take someone into difficult territory without their explicit permission. The therapist should explain that the goal will not necessarily be to "feel good" right away, but to "feel good" (with depth) in order to live better.

An analogy can be used such as, "Let's climb a mountain together. I can't carry your backpack, but I can light the way.

Sometimes the path will be steep and I will ask you to do things that will seem strange or uncomfortable, like stop