Case Formulation in ACT
With the intake session completed and information gathered, we can think about case formulation. The first thing to examine is the presenting problem as described in the client’s own words. What Deborah said most directly in her intake session was that she hated that bad things kept happening to her, and she didn’t want other people’s choices to restrict how she lived her life.
ACT Categories
In addition to the statement from the client’s perspective, we also work on building the case formulation based on understanding ACT-related categories. For those who are new to ACT, a brief introduction to those is in order.
Fusion
With individuals who’ve been through traumatic events, we look for fusion with the past. In ACT, fusion is when a person is so deeply connected with their thoughts that they operate as if the thoughts were true. When Deborah said other people restricted her life, you can see how that was her experience. It felt like their choices, through a series of interpersonal traumas imposed on her, led to her life being restricted. But that doesn’t tell the whole story. We can look at how potential overidentification with the past might define who a person is now.
Through ACT treatment we can help Deborah to take a step back from those thoughts and help her get some distance from them. We’re not trying to dispute what she said, but can help her to gain some perspective and understand that, while these terrible things did happen to her, she still has a choice about how to respond.
Lack of Contact With the Present Moment
You hear a lot these days about mindfulness, and using it as a way of being more effective in your day-to-day life. This can be difficult for trauma survivors, because they may experience frequent and intrusive thoughts and memories, then engage in avoidance of them. If you’re busy doing all that so you don’t have to think about the past, you’re unlikely to be in much contact with the present.
Deborah spent hours every day scrolling through her phone and watching goofy videos on social media. That’s a prime example of lack of contact with the present moment. If she purposefully decided, “I’m going to take five minutes to watch videos of cats in dog beds as a coping mechanism,” that’s very different than mindlessly scrolling and hours going by without effectively living her life.
Lack of Contact With Personal Values
Deborah talked about having the value of being in gainful employment that used her skills, but wasn’t able to articulate much else. There might be other domains of valued living that we would want to explore.
Barriers to Action
Finally, we want to look at things which get in the way of Deborah taking the steps forward that she knows she wants to. We also want to identify some of her personal strengths.
There was already a lot of evidence in Deborah’s first session of avoidance being a problem. There were hints of fusion with the past, such as the sense that other people’s choices had restricted her life. There were some obvious barriers, like financial difficulties and the stress of not working.
We could also hypothesize about social isolation. While she didn’t really talk about it in those terms, Deborah didn’t have much support from anyone else. As noted, this was not one of her priorities, but an ACT therapist would certainly note it as something to perhaps explore at some point.
In addition to struggles, Deborah clearly also had many strengths. She was bright, hardworking, and dedicated to service. Those qualities could be drawn on and built on while moving through the hard work ahead.