Values: Clarity of Purpose, Crisis not Required

July was a heck of a month. Having just returned from a 5-month sabbatical, I was ready to get settled back into my life here in Portland when I got a phone call that stopped me in my tracks. We’ve all had those moments, when an unexpected event challenges us to consider what really matters, often with shocking, jarring clarity. Maybe it’s a phone call that a loved one is being rushed to the hospital. Or maybe it’s the day you lose your “dream job” or your physician gives you that unexpected diagnosis that will change the trajectory of your life. Or maybe it’s the moment your loved one looks into your eyes and says they are leaving you. These things can happen to any of us and if you’ve ever been confronted with one of these crises then I’m guessing it gave you pause to reflect.

Crisis and loss often have a way of clarifying what is most important to us. It often takes a crisis or significant loss to make us stop the autopilot of our lives and focus on what really matters. But what if it were possible to live with that kind of clarity of purpose and values without something terrible needing to happen? And what if your work could be about helping people do that?

At its heart, I think that’s what values work in ACT is all about. Living a values-based life is about living with intention, consciously choosing to live out a well-lived life, whatever that would mean for you personally. Values work in ACT is about creating a context where your clients are able to be connected with and live out their deepest values in a sustained and consistent way, not just when the crisis happens.

Our main tool in being able to help clients connect with what is most important to them (without the need for a crisis to shove that in their face!) is language. Although language often gets a bad rap in ACT, language is our ally when it comes to values work. Language and cognition are the very medium of meaning, purpose, and valuing, experiences which are central to what makes us human. Through various perspective taking exercises, for example, we can use language to enter into a remembered past or an imagined future to help us connect with what may be important to us in the grand scheme of things, beyond simply our immediate wants or preferences.

Over the next several months we’re going to be posting a series of pieces on this issue of values, how to have values guide your therapy and specific tools you can use to help your clients live with intention and clarity of purpose without the need for a preceding crisis. So if this is something you are interested in, stay tuned. Also, we’re currently working on a book on this topic called Values in Practice: A Clinician’s Guide to Helping Clients Develop Psychological Flexibility and Live a More Meaningful Life, to come out through New Harbinger Publications sometime next year. If you are interested in getting an announcement about when that will be released, feel free to send us an email and we’ll keep you posted about the publication date.

Jenna LeJeune, Ph.D

Author: Jenna LeJeune, Ph.D

Jenna is a clinical psychologist who specializes in working with people who struggle with relationship and intimacy difficulties and with those who have a trauma history. Her research focuses on developing compassion-based interventions targeting stigma, shame, and chronic self-criticism.

Interview with Jenna LeJeune, PhD on Values Work

I was recently interviewed for the Praxis blog about values work in ACT  in conjunction with the upcoming webinar I’ll be offering through Praxis called “Values: Connecting with Who and What is Most Important.” We covered a lot of ground in the interview, from how I might define values from an ACT perspective to looking at some of the most common difficulties therapists seem to have when working with clients around values.

One of the ways I think people struggle with values work is when we start talking about values as “things” or “words” that occur out there/then. In talking about the need to have values be present in the room when doing values work, I talked about the metaphor of the truffle dog I often use when talking about values work. As an ACT therapist, part of my job is to “sniff out” when values may be present, much like a truffle dog uses his nose to find the precious delicacies underneath the dirt and leaves. When the client and I are able to unearth a value that is present in the room, it comes alive and is something quite precious for both of us to behold and appreciate.

Below are some excerpts from the interview.

On the function of values clarification in psychotherapy:

From my perspective, values work gives you the “why” in treatment planning and in psychotherapy in general. Without getting clarity on a client’s chosen values, I can’t know what the hard work of therapy is in the service of. If I don’t know my client’s values, I can feel more like a technician, simply administering interventions in what can feel like a pretty impersonal manner. But when my client and I can get clear on what her own chosen values are, the work becomes personal, and in my experience, more vital.

On the ways that clients and clinicians get tripped up around values:

People playing the role of therapist often get tripped up around the same things that people playing the role of client do. In terms of values, one of the places where we can all tend to get tripped up, in my experience, comes when we start talking about values as “things.”

We (clients and therapists) can get caught up in trying to identify or choose specific value words. Exercises such as a values card sort, or selecting values from some predetermined list, while very helpful in the right context, in my experience can also lead to conversations that lack vitality, vulnerability, and a sense of being alive in the present moment.

On identifying instances when values work may be called for:

There are several different cues I look for that would lead me to focus more on values work in a session. Values and pain are two sides of the same coin, therefore, when clients are more numb, feel “empty”, apathetic, or otherwise are not in contact with the cost of the avoidance in their lives, it often signals to me that they are also not in contact with their values either. Focusing on values work in these cases can help the client come into contact with the discrepancy between what they are currently valuing by their behavior and what they would choose to value if they were free to do so.

I will also often turn to values work when it seems like the work of therapy is motivated by avoidance or aversive control. If a client is white-knuckling his way through exposure work or is engaged in therapy as a way to “fix” herself, I’ll often turn to values work to orient us to something we would want our work to move us towards.

You can read the entire interview here.

If you’re interested in learning more about incorporating values work into your sessions, you can sign up for the Praxis webinar  “Values: Connecting with Who and What is Most Important.”

Jenna LeJeune, Ph.D

Author: Jenna LeJeune, Ph.D

Jenna is a clinical psychologist who specializes in working with people who struggle with relationship and intimacy difficulties and with those who have a trauma history. Her research focuses on developing compassion-based interventions targeting stigma, shame, and chronic self-criticism.

The 5-Minute Guide to ACT: A Visual ACT Elevator Pitch

The 5-Minute Guide to ACT: A Visual ACT Elevator Pitch

The challenge of explaining ACT

As an ACT trainer, one of the most challenging things for me is when someone who isn’t familiar with ACT says “What’s this whole ACT thing about?” Let’s just say my ACT elevator pitch needs some work! It’s tricky to try to describe something that is supposed to be an experiential therapy. And then there is the whole conundrum of trying to use language to explain a theory that holds that language is at the heart of the problem. But I find that “you just have to experience it” is the trainer equivalent to “because I said so” and is equally unsatisfying (and also not very helpful). So this week I was thrilled when I got another tool in my “what is ACT” arsenal thanks to ACBS member Dov Ben-Yaacov and the 5-minute Guide to ACT Pictogram he created.

The 5-Minute Guide to ACT Pictogram (click on picture to download)

This isn’t something I would necessarily share with clients. However, I do think this simple, yet surprisingly comprehensive pictogram could be very helpful in orienting students and those learning ACT to the general gestalt of how ACT, RFT, and Functional Contextualism fit together.

Another example of the generosity in the ACBS community

One of the things I most love about the Contextual Behavioral Science community is how incredibly generous the community is. I can’t imagine how much time it took Dov to create this. And then he just went ahead and posted it for anyone to use it for free. So it’s with much gratitude to Dov Ben-Yaacov that I pass this along to you. Please use it as it is helpful and also continue to credit Dov Ben-Yaacov as you do so.

Jenna LeJeune, Ph.D

Author: Jenna LeJeune, Ph.D

Jenna is a clinical psychologist who specializes in working with people who struggle with relationship and intimacy difficulties and with those who have a trauma history. Her research focuses on developing compassion-based interventions targeting stigma, shame, and chronic self-criticism.

Portland Psychotherapy’s Clinical-Research Social Business Model Published in APA Journal – Psychology Research and Practice

Portland Psychotherapy’s Clinical-Research Social Business Model Published in APA Journal – Psychology Research and Practice

Many of those reading this blog probably already know that that in addition to providing science-based mental health services, Portland Psychotherapy is also a productive independent research center.

How we fund our research

What many of you may not know is how we go about funding that research. To our knowledge, we are the only organization of its kind to have set up a private mental health clinic and research center based on social business concepts in which the profits from the money-generating activities of the organization go back to serving the greater good (in this case, scientific research) rather than be used as profits for shareholders.

What we discuss in the article

We are very excited that the APA journal Psychology Research and Practice just published our article that outlines our model, which we call the clinical-research social business model. Among some of the things addressed in the article include:

  • An outline of our clinical-research social business model that is based on social enterprise concepts
  • How we overcame the barriers to conducting research outside of academia, including how we created an independent IRB and how to address infrastructure limitations such as assistants and access to journal articles
  • Benefits of conducting research outside of traditional academic settings
  • How we have shifted the contingencies around money in our model and structure our model such that intrinsic rewards such as mastery, autonomy, and purpose can serve as powerful motivators that advance more communal and creative goals.
  • Ideas about how our model might be applicable to other settings.

One thing we are very aware of at our center is that all our work depends upon a supportive community. If you are reading this, it is likely that YOU are a part of that community and we thank you for that. If you are interested in reading more about our model, how it came to be, and what your support of us has helped make happen, you can read the a pre-print of the article here.

Jenna LeJeune, Ph.D

Author: Jenna LeJeune, Ph.D

Jenna is a clinical psychologist who specializes in working with people who struggle with relationship and intimacy difficulties and with those who have a trauma history. Her research focuses on developing compassion-based interventions targeting stigma, shame, and chronic self-criticism.

Tips for Therapists Making the Change to ICD-10

Tips for Therapists Making the Change to ICD-10

In case you didn’t know already, starting October 1st 2015, insurance companies will start using the ICD-10 system for diagnostic codes, rather than the ICD-9/DSM codes. For any Date of Service (not date of claim submission) Sept. 30th or before, clinicians will still need to use the DSM codes. But any claims submitted for dates of service Oct. 1st or later will be rejected if they are not ICD codes. If you are a clinician billing insurance, you need to make this change or else you will be soon running into a lot of problems with rejecte claims.

What’s the difference between the DSM and the ICD system? Do I still need both of them?

DSM is a diagnostic determination guide. It can be a resource in providing information needed to make an accurate diagnosis, but it is a ICD 10 diagnosis (not a DSM diagnosis) that we are to now assign clients. It should be noted that the DSM may not be the ONLY or definitive source in determining diagnosis. According to the APA, “Psychologists might access that content through the DSM or through other resources such as the professional literature, practice guidelines or other accepted sources [to determine appropriate diagnosis]”.

Can’t we just have a simple chart that converts our DSM codes to ICD 10 codes?

No. The DSM V is NOT synonymous with the ICD-10. There are MANY more codes in the ICD-10 than there are in either the ICD-9 (which is roughly equivalent to DSM-IV) or the DSM V. There are approximately 14,000 codes in the ICD-9 but more than 68,000 codes in the ICD-10 (though of course we mental health professionals will only use a small fraction of those codes). While most of the ICD-10 codes are in the DSM V, some of the more specific ones are not. So, psychologists can’t simply convert DSM codes to ICD-10 codes automatically. PTSD is a good example of why a simple conversion from DSM V to ICD-10 isn’t going to be accurate. The DSM-V only has a code for PTSD “unspecified” type, while the ICD-10 has diagnostic codes for both PTSD “Acute” and “Chronic” types that are not in the DSM-V.

How can I find the correct diagnosis?

In general, you can find the correct corresponding ICD 10 code for most of the DSM diagnoses listed in the back of the DSM V. However, there are some ICD10 codes that aren’t listed in the DSM V, as in the case mentioned above about PTSD. So you can’t just rely on the DSM. Instead, we suggest crosschecking your diagnosis using one of several “crosswalk” tools available online. Two such resources would be:

  1. ICD-10 Code Lookup
  2. ICD-10 Tabular List

Need for specificity, particular in relation to substance use disorders

One factor accounting for the increased number of codes in the ICD-10 pertains to the number of specifiers for the different diagnoses in the ICD 10. This is especially true for the substance use disorders. The increased use of specifiers is a main difference many clinicians will need to become familiar with as they move forward using the ICD-10 system starting Oct. 1st. It is important to be as specific as possible in selecting ICD-10-CM codes — that is, when known, use the code structure to indicate severity or other meaningful diagnostic information. Try to avoid “unspecified” diagnoses, as plans may not reimburse for them — plans are looking for increasing specificity in diagnosis.

No More NOS – “Unspecified” versus “Other Specified” diagnoses.

When the DSM switched from IV to V, the NOS specifier was replaced with two options “Unspecified” and “Other Specified”. The ICD 10 also uses this distinction. “Other Specified Disorder” allows the clinician to specify the reason that the criteria for a specific disorder are not met (it is required to give reason(s) why the criteria are not met in the diagnosis field).  An example of this would be other specified depressive disorder, short-duration depressive episode, 9 days.

“Unspecified Disorder” allows the clinician the option to forgo specification.  This would be used instead of deferring a diagnosis when a client does not meet criteria AND the provider cannot specify due to inadequate info.  This will likely not be an acceptable reimbursable diagnosis.

It has been suggested that when you have the choice between an “Unspecified” and “Other Specified” diagnosis and both seem equally valid, choose the latter, and document in the chart what criteria were not met for you to use another diagnoses of this category.

How do I diagnose substance use disorders with the ICD-10?

This is probably the biggest category of changes from the DSM to ICD-10 system. The APA has created a very useful step-by-step guideline for diagnosing substance use problems using the ICD-10 system that can be accessed here.

Jenna LeJeune, Ph.D

Author: Jenna LeJeune, Ph.D

Jenna is a clinical psychologist who specializes in working with people who struggle with relationship and intimacy difficulties and with those who have a trauma history. Her research focuses on developing compassion-based interventions targeting stigma, shame, and chronic self-criticism.

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