Hi Tyler,

Thanks so much for expanding on your email and being as transparent as possible. As you say, working in an outpatient setting is a whole different ball game to working with clients in residential care with a deadline hanging over your head. No wonder you want to switch to distress tolerance strategies, so you can feel like you're giving them something. I have always worked in outpatient settings and never in inpatient settings and I take my hat off to you, because you see these clients at their most severe and most distressed.

One of the things that struck me about the residential setting is the amazing opportunity to work with people in-vivo when they are experiencing such intense emotions. I work in a DBT program and the phone is our equivalent for people to call when they're in the crisis situations to work with them at that moment. As therapists, it's so much more challenging that when people come in all regulated and we can just talk about what to do when the crap hits the fan, but also so much more powerful.

I'm very much a fan of Kelly's idea of 'sitting inside the question' without the pull of the need to answer it.... and yet, I don't really know how to do that on a listserve. If others also value the idea of sitting inside the question to give space for something fresh to emerge maybe we can work out how to do that together?

My main suggestion would be to lean in when the emotions are intense and notice with the patient. What is this thing that they believe is impossible to have. Where do they notice the emotion, what does it look like, if it had a colour, what colour would it be, or a shape, can they just breathe into it and have a look at it and be curious about it.... even whilst it's threatening to overwhelm them. At that time the emotions seem like they could destroy them and I've been playing around with your metaphor of the classroom being on fire in my head. Maybe there's so much smoke that it seems like there must be a fire and that everyone will die, but if they could stay and look at the smoke and see through it, they could see that there's no fire (kind of like the passengers on the bus claim that they could really hurt you, and yet, experience shows that they never have). The smoke makes it seem like there is a fire and they probably can't listen to your words and what you're teaching because the smoke is demanding their attention, so go to where they are and look at the smoke with them and they will have an urge to run out of the room, but they've done that before and being in that room is where they need to be for life to be lived. Does this fit for you? I think your metaphor is a really useful one and it'd be good to play around a bit with it. It also reminded me of a client with Bulimia who talked about having urges to binge that felt like she was on fire and the only way to put the fire out was to binge. Not sure how that fits in here, but it was so evocative for me and helped me to see how could she possibly feel like not bingeing was an option when that actually meant feeling like she was burning alive. i can't even remember how we addressed that in therapy, but I do remember that over time she talked about the sense of burning alive reducing.

Also, I wonder if the more the emotional intensity the client presents with, the more driven you feel to talk and help and coach (that's what happens for me).

Are you on the main listserve? Someone posted a question last week about working with a young person with anorexia who is losing weight fast and their were a couple of really lovely responses about the therapist working on acceptance and being where the client is at.

I also discussed this with some of my colleagues who had some different ideas, so I will leave it to them to respond as I think they'll do a better job of explaining what they mean than I will.

I might leave it there for now. I had a few more half-baked thoughts but I have a client downstairs waiting for me and if I wait to have time to write a longer response it won't happen and I wanted to send something off in response to your email.

Thanks again for your honesty and willingness to be vulnerable and to put your questions out there.

Carla.

>>> "jtbeach78" <jtbeach78@yahoo.com> 06-Feb-08 2:30:30 pm >>>
Hi Carla,

Thanks for your response! I find myself using the very same
strategies you describe. In my opinion, I think this works well in
longer term psychotherapy situations when we can circle over and over
until they're ready to approach.

Where I'm having a hard time applying it is with my clients in
residential care, where my they come in for 45-90 days. The situation
is quite different in that all of a sudden these clients are faced
with eating large food portions and tolerating changes to their BMI
in very quick progression.

In the interest of getting some focused feedback, I'm going to be as
transparent as possible. The first few days are sort of a honeymoon
where the food portions are typically small and patient anxiety,
although still high, hasn't reached phobic intensity. At this stage,
orienting someone to an ACT framework is relatively easy. In fact
they really see how avoidance has caused so much trouble. Other
treatments haven't been fully effective so maybe this is worth a try.
But treatment changes quick from this point, and as we know many of
these clients really have a hard time with change. Food portions and
body changes start happening and emotional intensity and suffering
spike to high levels. I try to prime my patients for this change as
much as I can. When the petal hits the metal is when I feel the most
unskilled at guiding my client. I validate, use metaphors, remind
them of their values, remind them we've anticipated this reaction,
etc. All of this helps some but in the middle of such intensity
doesn't seem to sink in the same as it did before. Patients who were
very eager several days before want to run for the hills. Sometimes
my clients look at me like I'm crazy or they just repeat that they
don't want to feel this way no matter what the cost. I validate their
reactions and invite them to look at them. I talk about the nature
of avoidance and how it can limit our ability to get free.

I love the theory but many times with clients, this is the time that
just feels weird to me. Sometimes I feel like I am trying to teach a
class and requesting that my students please pay attention when the
classroom is on fire! I start to worry and my brain starts producing
worry thoughts:

"Am I being presumptuous in thinking I can open them to this
approach and then help them to see some benefit in a reasonable time
period? Is there something else I could be providing them? Is this
work appropriate for where they are? Am I reasonably confident they
have the skills to tolerate this sort of intervention? Will they
leave treatment with some concrete skills they can take with them in
their continued recovery? Should I go back to my old DBT approach
and validate the distressing nature of the current intensity,
encourage distress tolerance (distraction) techniques, thought
stopping and distortion challenges? Or should I focus exclusively on
the validation strategy by empathizing as hard as I can, and put all
of my focus on creating a corrective emotional experience?"

So that is where I find myself sometimes. I sometimes get
discouraged because I feel unskilled at assisting in reducing intense
suffering in the moment without using distracting skills. Also, in
spending more time coaching them towards their values, and analyzing
language. I feel a bit pushy and invalidating of their current
suffering. I remain patient and continue forward but its hard at
times! Part of the journey for me seems to be able to integrate this
in a way that allows me to tolerate my uncertainty.

--Tyler

--- In eatingconcernsandcontextualpsychology@yahoogroups.com, "Carla
Walton" <Carla.Walton@...> wrote:
>
> Hi Tyler,
>
> I'm not sure if I've got any big ideas for that issue, I'm really
wanting to write back to support your wonderings and keep the
conversation alive.
>
> WIth eating disorders, I find myself continually returning to
Creative Hopelessness and particularly the idea of workability, i.e.,
in your experience, has that worked and what's the cost been. I find
with Eating Disorders more than any other client group I work with, I
need to keep revisiting that, cause often just as soon as someone has
opened up to other possibilities, the Eating Disorder comes in and
takes over again. In fact, I guess I find with Eating Disorders, that
I'm often circling back over lots of ACT aspects. My take on it is
that when the lack of food intake affects people's cognitive
abilities, it makes it harder to take stuff in and that the affect
phobicness and fusion with thoughts is really strong with EDs.
>
> In the situation of ambivalence, I'd be likely to move into values,
so that it makes it more meaningful. E.g., "would it be worth having
(describe painful feeling) if it meant that (describe value)?"
>
> Not knowing each other in these situations, I always wonder when I
write things whether these are the things people are doing anyway.
>
> Carla.
>
> Dr Carla Walton
> Clinical Psychologist
> Centre for Psychotherapy
> James Fletcher Hospital
> PO Box 833
> Newcastle NSW 2300
>
> Ph: (02) 4924 6820
> Fax: (02) 4924 6801
> E-Mail: Carla.Walton@...
>
> >>> "Tyler Beach" <jtbeach78@...> 01/11/08 10:02 AM >>>
> Hi group,
>
>
>
> I work as a psychotherapist at a residential eating disorders
facility. I'm
> new to ACT work. I'd done some reading on it and recently went to a
> training offered by an ACT psychologist at Duke. I was originally
trained
> in DBT and mindfulness based psychotherapy, but after going to this
recent
> training, I realized I was doing a bit of ACT work (sans
terminology or
> framework) without even knowing it! For about a year I have been
slowly
> moving away from some of the distraction and blocking strategies
taught by
> DBT (which IMO certainly have their place for certain populations)
and
> leaned more heavily into the defusion strategies and mindfulness
> experiencing skills. I find the work very rewarding and intense.
It is
> always an adventure during the intro stage, especially when I am
engaging a
> client in a conversation where I am actually asking them to stop
fighting
> their thoughts of being "fat" and corresponding feelings. My
experience is
> that most clients are quite intrigued and like the theory, but tend
to
> become more ambivalent in the presence of actual affect or intense
thoughts.
> I wonder if others are coming up against that and what strategies
they use
> to keep a client engaged in the approach vs. avoidance.
>
>
>
> --Tyler Beach, LCSW
>

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