CADD Corner: Symptom Management and Values-Focused Practice in Clinical Social Work

By Blake Beecher, PhD, Director, CSU San Marcos

Hector, a 29-year-old divorced father of two, presents at a community behavioral health outpatient agency with significant depression and anxiety. He lost his job two months ago, has been isolating in his apartment and missed his last three visits with his children.

Many therapeutic approaches typically utilized with Hector would likely place a heavy emphasis on attempting to change his cognitive and affective symptoms related to his depression and anxiety. All stages of the generalist intervention model (engagement, assessment, planning, intervention, evaluation, termination and follow-up) with a typical treatment approach would focus on Hector’s symptoms. For example, his treatment goal may be something like “reduce thoughts and feelings of hopelessness to less than two times per week”. Depressive scales measuring symptoms may also be used, such as the PHQ-9, to assess progress toward the goal. The intervention will likely focus on strategies to address symptoms, such as tracking and challenging thoughts and developing coping skills such as self-soothe skills, guided imagery, progressive muscle relaxation and deep breathing. In the evaluation phase, the success of the intervention with Hector is measured based on the symptom-focused goal, of reducing thoughts and feelings of hopelessness. Let’s suppose that the symptoms of hopelessness decreased and Hector terminated with his treatment.

However, the question could be asked: Is Hector’s life any more rich and meaningful?

Several evidence based interventions would take a different approach with Hector by focusing on living a meaningful life as a principal outcome in treatment, rather than solely on symptom reduction. The purpose of Dialectical Behavioral Therapy (DBT) is to assist individuals to build lives worth living (Linehan, 1993) and in the new DBT Skills Training Workbook (Linehan, 2015), values and valued living are main focus of several core skills. The most recent edition of the renowned Motivational Interviewing text includes an entire chapter on values, values assessment and how values motivate individuals and guide their lives (Miller & Rollnick, 2013, pp. 74–90). The purpose of Acceptance and Commitment Therapy (ACT) is to help individuals create meaningful lives while effectively handling the pain and stress that life inevitably brings (Harris, 2009; Hayes, et al., 1999).

Values focused modalities such as ACT have been touted as being a good fit for clinical social work, as ACT is consistent with social work values, has a person-in-environment emphasis, is capable of being applied in multiple contexts, and is supported by extensive research (Boone, et al., 2015; Montgomery, et al., 2011). Values focused interventions are also consistent with behavioral health recovery principles (SAMHSA, 2012). In the Encyclopedia of Social Work, Dewane (2013) states that ACT may be very appropriate for social workers to use and a potentially significant contribution to social work interventions.

Returning to the example with Hector, an intervention such as ACT may focus on Hector’s value related to being a loving and attentive father. The treatment goal may be something like “engage in supportive interactions with daughters at least two times weekly.” The Valued Living Questionnaire (Wilson, et al., 2010) or other quality of life scale may be used to help assess the efforts Hector is making in moving toward his values. The intervention would likely utilize mindfulness, exposure, acceptance, skill building and other processes within the context of assisting Hector to take action toward building a meaningful life. Each session, the homework may be a small action that Hector wants to take (e.g., calling his daughters on the phone) which would help him move toward his value of being a loving and attentive father.

The question could again be asked: Is Hector’s life any more rich and meaningful?

References

Boone, M.S., Mundy, B., Stahl, K.M., & Genrich, B.E. (2015). Acceptance and commitment therapy, functional contextualism, and clinical social work. Journal of Human Behavior in the Social Environment, 25(6), 643–656.

Dewane, C.J. (2013). Acceptance and commitment therapy. Encyclopedia of Social Work. Retrieved from http://socialwork.oxfordre.com/view/10.1093/acrefore/9780199975839.001.0001/acrefore-9780199975839-e-843.

Harris, R. (2009). ACT made simple: a quick-start guide to ACT basics and beyond. Oakland, CA: New Harbinger Press.

Hayes, S.C., Strosahl, K., & Wilson, K.G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press.

Linehan, M. (1993). Cognitive-Behavioral treatment of borderline personality disorder. New York: Guilford Press.

Linehan, M.M. (2015). DBT skills training manual: Handouts and Worksheets (2nd ed.). New York: Guilford Press.

Miller, W.R. & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). New York: Guilford Press.

Montgomery, K.L., Kim, J.S., & Franklin, C. (2011). Acceptance and commitment therapy for psychological and physiological illnesses: A systematic review for social workers. Health & Social Work, 36(3), 169–181.

Substance Abuse and Mental Health Services Administration. (2012). SAMHSA’s working definition of recovery (SAMHSA publication PEP12-RECDEF). Retrieved from https://store.samhsa.gov/shin/content/PEP12-RECDEF/PEP12-RECDEF.pdf.

Wilson, K.G., Sandoz, E.K., Kitchens, J. & Roberts, M. (2010). The valued living questionnaire: Defining and measuring valued action within a behavioral framework. The Psychological Record, 60, 249–272.