8/13/2023

FLEXIBLE, PROCESS-BASED, AND CLIENT-FOCUSED THERAPY

Robyn D Walser, PhD

Trauma and Life Consultation Services
National Center for PTSD
Assistant Clinical Professor, University of California, Berkley
Bay Area Trauma Recovery Clinic
Robyn.walser1@gmail.com

WHERE WE ARE HEADED

 4 levels of process
 Therapeutic stance and relationship
 Existence and purpose
 Living consciously

rdwalser 2022 2

1
 8/13/2023

 Permits a number of dynamic processes unfolding over time in the ongoing flow of
life:
 Recognize and adapt to various situational demands;
 Shift mindsets or behavioral repertoires when current strategies compromise personal or
social functioning;
 Maintain a balance among important life domains;
 Be aware, open, and committed to behaviors that are congruent with deeply held values.
 Considers the flexible application of different types of emotional expression (joy, pain,
anger, anxiety) as the situation warrants;
 Shifting perspective

rdwalser 2023 3

BUT FIRST….

2
 8/13/2023

Contact with the

Present Moment

The Essence of ACT Work Acceptance Values

Psychological
Flexibility

Defusion Committed
Action

Self as
Context

rdwalser 2022 5

Context Matters
Taking the flex in hexaflex more seriously
Contact with the
Present Moment

Acceptance Values

Defusion Committed
Action

Self as
Context

rdwalser 2021 6

3
 8/13/2023

RE-ORIENTING
TO
THERAPEUTIC
PROCESS
When techniques
become the therapy
Versus a therapy that
uses techniques

rdwalser 2022 7

rdwalser 2022 8

4
 8/13/2023

“Just” Accept

rdwalser 2022 9

ACT AS
TECHNIQUE
 Insensitive Defusion

rdwalser 2022 10

10

5
 8/13/2023

ACT AS TECHNIQUE
Turn to present moment in
an artificial way

11

ACT AS
TECHNIQUE
Complete and utter
skipping of SAC/PT

rdwalser 2022 12
12

6
 8/13/2023

Vague and diffuse goals

rdwalser 2022 13

13

ACT as Technique
Values are treated as
Sticks not carrots

rdwalser 2022 14

14

7
 8/13/2023

 Stuck in explanation
and intellectualization

rdwalser 2022 15

15

Metaphors and
exercises without
purpose

rdwalser 2022 16

16

8
 8/13/2023

Form not function

rdwalser 2022 17

17

Content not
process

rdwalser 2022 18

18

9
 8/13/2023

ACT STARTS TO LOOK LIKE A CARTOON OF ITSELF

19

I HAVE BEEN ASKING MYSELF?

Where did the client go?

Where did the therapist go?

Where did the function of behavior go?

Where did the process go? And do we know what is meant when we
say “process”?

Where did the system go?

Where did the compassion go?

Why is this looking like sets of techniques and tools?

20

10
 8/13/2023

21

Process

 A continuous action or series of

changes that are going forward or on.

Function
 The purpose of an action/behavior
 Three term contingency

rdwalser 2022 22

22

11
 8/13/2023

SIX CORE PROCESSES

OF ACT
Accepting
Defusing
Present momenting
Self-as-contexting
Valuing
Acting

rdwalser 2022 23

23

rdwalser 2022 24

24

12
 8/13/2023

 CONTEXT MATTERS:

 3 LEVELS OF PROCESS WHERE 6 CORE ARE

CONTINUOUSLY APPLIED BASED ON ONGOING
FUNCTIONAL ANALYSIS

 Intrapersonal Process

 Interpersonal Process

 Overarching and ongoing Process

rdwalser 2022 25

25

Intervention

Therapist Client
rdwalser 2022 26

26

13
 8/13/2023

A DELICIOUS
DISH

rdwalser 2022 27
27

Knowing yourself is the beginning of all wisdom.

Aristotle

rdwalser 2022 28

28

14
 8/13/2023

AN HONEST CHECK WITH YOURSELF

When and where do you use technique?

Have you become over-reliant?

What elements of ACT do you shy away from?

Are there ones that you avoid or use too often?

If you work in a setting using brief therapy, how can you

introduce and use process?

Where do you think personal growth is needed?

rdwalser 2022 29

29

DISCOMFORT
PROCEEDS
GROWTH

rdwalser 2022 30

30

15
 8/13/2023

31

OPENING TO HEART OF ACT

rdwalser 2022

31

NO
ARRIVAL

rdwalser 2022 32
32

16
 8/13/2023

CHECK ON NO ARRIVAL

 I thought I was over this?

 Why can’t I just let go?
 Why is this still catching me?

rdwalser 2022 33

33

34
Holding the client as whole
rdwalser 2022

34

17
 8/13/2023

GROWTH IS
POSSIBLE
 Genuine faith in the client’s
capacity to change behavior
 Includes respect, deep
listening, and empathy inside
of a safely vulnerable and
developing relationship

rdwalser 2022 35

35

 Something can
be done

rdwalser 2022 36

36

18
 8/13/2023

EXERCISE
GETTING STUCK AND
UNSTUCK
 Groups:
 Describe the places you get stuck
 A kind of behavior in your client
 An issue you get unsure about
 A client that didn’t change

 Pick one issue from the group that most

or all can relate to

rdwalser 2022 37

37

rdwalser 2022 38

38

19
 8/13/2023

Groups of 3
 Therapist, client, observer

 Go to a difficult place in therapy where the

client has “pushed your button”
 Therapist: briefly describe (2 minutes)

 Therapist says whatever it is that they truly

want to say – no holds barred
 Client simply listens without responding

 Client give feedback: what did you notice

emotionally only
 Explore with the observer and discuss how
to re-do the message with ACT processes
and change in mind
 Say again with ACT approach

 Client give feedback: what did you notice

rdwalser 2022 emotionally only 39

39

Process better prepares

you for changing the
course of therapy to fit
the needs of the client at
any moment
rdwalser 2022 40

40

20
 8/13/2023

rdwalser 2022
41
41

42

rdwalser 2022

42

21
 8/13/2023

YOU

rdwalser 2022 43

43

 What is happening and flowing

within yourself
 Being awake, alive and curious about
your internal states - your senses,
your emotions, your mind
 Practice self-knowledge

rdwalser 2022 44

44

22
 8/13/2023

45

rdwalser 2022

45

WRITING EXERCISE
 Consider a time when you have had a strong emotional reaction in session (anger,
sadness, distrust, etc.) that you did not share with the client.
 What elicited the emotion? Did the client remind you of a historical event?
 Write about this reaction for about 5 minutes, include thoughts, feelings,
sensations, and what the likely historical event(s) was that got triggered.

 Discussion in Pairs
 Is it possible to share this emotion in a way that serves the client? Is it possible it
points to the function of the clients’ behavior? Is there an ACT core process or
processes that could help you get there?
 Write down one process and then work with someone to explore it or try it out in
finding a way to share this intrapersonal experience. Get feedback.

rdwalser 2022 46

46

23
 8/13/2023

 Reviews have been quite consistent: the alliance-

outcome correlation is moderate but significant
(ranges from .22 to .29), client’s assessments
tend to be more predictive of outcome than are
SUMMARY OF other sources, early alliance is as good or better
predictor of outcome than assessments taken

THE later, and the alliance as measured appears to be

related but not identical to parallel therapeutic
gains (Horvath, 2005).
RELATIONSHIP  The relation of alliance and outcome does not
appear to be influenced by other moderator
RESEARCH variables, such as the type of outcome measure,
the type of rater, the time of alliance assessment,
the type of alliance rater, the type of treatment
provided, or the publication status of the study.
(Martin, Garske & David, 2000).

rdwalser 2022 47

47

 First, we need more theoretical debate about

the construct of the relationship.
 Dynamic evolution of the therapeutic relationship over
time and perhaps its unique unfolding within particular
diagnostic contexts needs to be investigated.

CHALLENGES  Second, the field needs to struggle with the

question of how therapists can be trained to
develop better alliances with their clients.
 Third, we need to examine changes in the
quality of the alliance over time.

rdwalser 2022 48

48

24
 8/13/2023

 Challenging to explore in detail – what

was missed, what was focused on
 There may be moments in the therapy
where what the therapist thought to do
next is not going to work based on what
just happened interpersonally.
 Requires Awareness

rdwalser 2022 49

49

 The therapeutic stance involves being able

to recognize your personal capacity to be
open, aware, and engaged in the therapy
 It means understanding your behavior,
knowing when you are fused, avoidant, or
out of touch with your values
 But self-awareness also means being
connected to and aware of how others
perceive you and the impact of your
behavior on others, in the moment, and
across time.
 Dyadic Discussion
 How do you think you are perceived?
 How do you hope to be perceived?

rdwalser 2022 50

50

25
 8/13/2023

THE ACT (EXPERIENTIAL) STANCE

 Vulnerable
 Genuine
 Equal

rdwalser 2022
51

51

INTERPERSONAL
PROCESS

rdwalser 2022 52
52

26
 8/13/2023

I have just three things to teach: simplicity,

patience and compassion. These three are your
greatest treasures.
Lao Tzu

rdwalser 2022 53

53

rdwalser 2022 54

54

27
 8/13/2023

In its fullness, the stance of intra and interpersonal

work with the ACT therapist is not separable into
categories. Rather the stance is a set of interwoven
concepts that are tied together in whole cloth by the
threads of what it means to engage in a relationship
designed to compassionately support another being
in creating a meaningful life.

rdwalser 2022 55

55

 The unique persons engaged in the

dynamic quality of a relating
between two people working
together in therapy in efforts
designed to promote change, growth,
evolution, or whatever movement is
desired and agreed upon by the two

rdwalser 2022 56

56

28
 8/13/2023

An allowing that is awake to

experiencing “how large and fluid
and full of color and energy our
world is”

Pema Chodron

rdwalser 2022 57

57

CONSCIOUS BEING
IN THERAPY
 Consciousness to your internal
experience (intra)
 Consciousness to the experience
between you and your client (inter)
 The two are deeply intertwined

 Choosing what experiences to act on in

any moment depends on this awareness
and creates a more flexible, larger
capacity to respond to the function

rdwalser 2022 58

58

29
 8/13/2023

Discovery exercise
When I see others
suffering, what
breaks my heart is
I am sometimes
What I find hard in
reluctant to share
the work I do is….
my pain because…

When I recognize my
When I think of own passing, what
I feel the most joy
what my legacy is, it potentially breaks
when….
looks like… my heart is….

rdwalser ACBS 2023 59

59

rdwalser 2022 60

60

30
 8/13/2023

rdwalser 2022 61

61

 Exercise

rdwalser 2022 62

62

31
 8/13/2023

We had to teach the despairing men,

that it did not really matter what we
expected from life, but rather what life
expected from us.
 Victor Frankl (Man’s Search for Meaning)

rdwalser 2022 63

63

FREEDOM AND
RESPONSIBILITY
Inside of being able to
observe your “hereness”
what will you do?

rdwalser 2022 64
64

32
 8/13/2023

DOOMED TO FREEDOM

 Liberation  Fear

rdwalser 2022 65

65

You are alive and

here

You are
conscious

rdwalser 2022 66

66

33
 8/13/2023

• Values cannot be lived from a

“still” position
• We are carried into and
through our values with our
actions
• Life is found in the feet

rdwalser 2022 67

67

ACT’S HEART:
PROCESS AND FUNCTION

68

34
 8/13/2023

rdwalser 2022 69

69

rdwalser 2022 70

70

35
 8/13/2023

rdwalser 2022 71

71

rdwalser 2022 72

72

36
 8/13/2023

ROBYN'S MOM'S
WORDS FOR ROBYN

“Life should not be a journey to the grave

with the intention of arriving safely in a
pretty and well-preserved body, but rather
to skid in broadside in a cloud of smoke,
thoroughly used up, totally worn out, and
loudly proclaiming “Wow! What a Ride!”
-Hunter S. Thompson

rdwalser 2022 73

73

THANK YOU!
 Robyn.walser1@gmail.com

rdwalser 2022 74

74

37