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Adjustment Disorder

An adjustment disorder is a distressing reaction to a difficult situation that lasts longer than what’s usually expected or is more excessive than what’s usually expected.

People normally feel upset or anxious for some amount of time when they develop an illness, get divorced, leave home to go to school, are fired from a job, relocate to a new home, or experience other life-changing situations like these. However, when a person is struggling with an adjustment disorder, the severity or length of the reaction has gone beyond what’s considered typical given the person’s age, culture, and history.

For example, a man who recently lost his job might be diagnosed with an adjustment disorder if he has spent the last three months lying on the sofa, watching television, and feeling upset. So, too, might a woman whose anxiety has interfered with her ability to do her job since her child left home to attend college.

Keep in mind that most people are distressed or saddened by these types of events; however, what makes an adjustment disorder a clinical problem is the amount of time a person is affected by it or the severity of the distress caused by the event.

An adjustment disorder will begin within three months of experiencing a stressful situation and will usually disappear after six months. However, if the stressful situation is ongoing, such as a chronic illness, a difficult divorce, or continuing financial problems, the disorder might last for as long as the situation remains unchanged.

There is no concise psychological definition of what an adjustment disorder will look like. In many ways, an adjustment disorder might look similar to depression or anxiety. However, if a person meets the criteria for depression or one of the anxiety disorders, it would be more appropriate for the person to receive treatment for that problem rather than adjustment disorder.

Also, by definition, if the symptoms of an adjustment disorder are caused by the death of a family member or friend, the diagnosis would be defined more appropriately as bereavement.

ARE THERE OTHER PROBLEMS RELATED TO ADJUSTMENT DISORDER?

In severe cases, an adjustment disorder might also lead to excessive alcohol or drug use, suicide attempts, or physical illness.

WHO IS AFFECTED BY ADJUSTMENT DISORDER?

Some researchers have estimated that adjustment disorder is a widespread problem, affecting 12 percent of the people seeking mental health treatment in hospitals, and as many as 10 to 30 percent of the people seeking treatment at other mental health centers. Women are typically diagnosed with adjustment disorder twice as often as men.

An adjustment disorder is caused by the experience of a stressful situation. Unfortunately, despite the widespread prevalence of adjustment disorders, very little research has been done to determine what specifically happens to a person who experiences this problem or to investigate the problem any further.

Fortunately, the prognosis for a person struggling with an adjustment disorder is good. Research has shown that people in treatment for adjustment disorders generally need less treatment, return to work sooner, and are less likely to suffer from a relapse of the problem when compared to people with other mental health problems. Due to the lack of research, treatment recommendations are scarce. But remember, most adjustment disorders don’t last longer than six months. Therefore, it’s possible that the problems might disappear on their own. However, if the person’s problems are exceptionally difficult or long lasting, it’s best to seek immediate treatment.

It’s reasonable to assume that many forms of psychotherapy will be effective as long as the treatment helps the person examine his or her thoughts, emotions, and behaviors surrounding the stressful event.

For example, if a person needs help finding solutions to specific difficulties, simple problem-solving skills might be all that’s needed. If a person needs help reducing stress, relaxation skills can be helpful. If a person needs help coping with overwhelming emotions, dialectical behavior therapy is often effective. If a person needs help coping with symptoms of excessive anxiety, acceptance and commitment therapy is very helpful. And if a person needs help coping with distressing thoughts about himself or herself, or others, cognitive behavioral therapy is very useful.

PROBLEM-SOLVING SKILLS FOR ADJUSTMENT DISORDER

Problem solving is a simple technique that can be used to figure out new solutions to distressing situations. This can be very helpful for people struggling with adjustment disorders, since they often feel like they don’t know what to do in many situations. Problem-solving skills will help the person identify and select healthy solutions to difficult and anxiety-provoking situations.

The basic steps of problem solving include assessing the problem, brainstorming a list of all possible strategies (no matter how irrational they might seem), narrowing the list to a few possible strategies, considering the consequences of those strategies, selecting a strategy and determining how to implement it, and, finally, evaluating the consequences of using that strategy.

For some people with adjustment disorder, this will be very effective. Others, however, may need to examine how they think about themselves and other people. For example, a man with an adjustment disorder might have the repetitious thought that he’s “not good enough,” while a woman with the same problem might think she’s “broken.” Beliefs like these, called schemas or core beliefs, can often get in the way of effective problem solving and also prolong adjustment disorders. If this is the case, the person will need to examine and restructure his or her core beliefs using tools such as a self-concept inventory, a thought record, and a schema map.

RELAXATION SKILLS FOR ADJUSTMENT DISORDER

Some people with adjustment disorder often experience physical tension in addition to their mental stress. Learning relaxation skills can help relieve both problems and there are a variety of different techniques that a person can learn. Included here are four of the most important. All of these techniques include focusing on slow, rhythmic abdominal breathing, which often produces a feeling of calmness.

The first relaxation skill that’s taught is progressive muscle relaxation. It involves a seven-second tightening and releasing of specific muscle groups from head to toe, with emphasis on noticing the difference between the tense feeling and the relaxed feeling.

The second relaxation skill is learning how to release muscle tension without first tensing the muscles. This is done by focusing attention on the muscles and visualizing the tension being released.

The third skill is cue-controlled relaxation, in which a person is taught to relax his or her body by saying a relaxing word, such as “peace” or “relax,” with each slow exhalation.

And, finally, the fourth relaxation skill is special-place visualization. This skill teaches the person to envision a place of safety and comfort in his or her imagination. The person can go to this “mental safe place” whenever he or she is overwhelmed by distressing feelings.

DIALECTICAL BEHAVIOR THERAPY FOR ADJUSTMENT DISORDER

Dialectical behavior therapy (DBT) is a form of cognitive behavioral therapy. Both types of treatment examine the way in which thoughts, feelings, and behaviors interact and affect each other. However, a psychotherapist who uses DBT is especially interested in learning how a person’s thoughts can create disruptive behaviors and emotions that interfere with the person’s life and relationships. After examining these interactions, a DBT therapist will help the person modify thoughts, feelings, and behaviors using different types of skills training.

The term “dialectic” refers to the examination of opposing thoughts and behaviors that takes place in DBT. For example, one of the fundamental techniques of the treatment is to teach people how to accept themselves, with all of their problems, while simultaneously acknowledging that some basic changes are needed in order for their lives to improve.

The basic DBT treatment is usually composed of six steps:

  1. Conduct an assessment and provide education
  2. Develop distress tolerance skills
  3. Develop mindfulness skills
  4. Develop emotion regulation skills
  5. Develop interpersonal regulation skills
  6. Prevent relapse

1. Conduct an Assessment and Provide Education

The first step in dialectical behavioral treatment for adjustment disorder is to conduct an assessment of the person’s symptoms in order to verify that he or she is struggling with adjustment disorder and not some other similar problem. Once people are diagnosed with adjustment disorder, it’s also important that they understand the basic nature and causes of the problem (as highlighted above), as well as the demands of DBT treatment for adjustment disorder. DBT is an active form of treatment that requires the person with adjustment disorder to do work outside of session.

2. Develop Distress Tolerance Skills

Distress tolerance skills can help a person cope with sudden, overwhelming emotions in a healthier way so that the pain doesn’t lead to long-term suffering. Distraction techniques, like engaging in pleasurable activities or paying attention to someone else, can temporarily help a person stop thinking about something painful and therefore allow the person to choose a healthy way of coping. Self-soothing techniques, like taking a warm bath or listening to pleasant music, use the five senses to bring peace and relief from pain. With practice, visualization and relaxation techniques, like cue-controlled relaxation, can also quickly create a sensation of peace. Making committed actions and connecting with a sense of higher power can make life more fulfilling and meaningful. Radical acceptance is a very important distress tolerance skill that will help people with adjustment disorders reexamine painful situations so that they can stop fighting and judging painful situations that can’t be changed.

3. Develop Mindfulness Skills

Mindfulness skills can help people become more aware of their thoughts, emotions, physical sensations, and actions—in the present moment—without judging or criticizing themselves or their experiences. Mindfulness skills focus a person’s attention on what’s happening now, rather than painful memories of the past or anxious thoughts about the future. The core mindfulness skill is mindful breathing, which focuses attention on the rising and falling of the breath, rather than thoughts. Thought defusion is a technique that can help people learn to let go of those thoughts without becoming angered by them. Mindful emotion techniques allow people to shift focus between what they are feeling and what’s happening in the present moment. The wise mind technique can help people make healthier decisions about life based on rational thoughts and emotions. Doing what’s effective is a mindfulness skill that helps people solve problems in new ways. And, finally, meditation can be used to develop kindness and compassion for oneself and others.

4. Develop Emotion Regulation Skills

Emotion regulation skills serve a number of different purposes. They help people identify their emotions more clearly and easily, and help them cope with painful emotions instead of getting overwhelmed by them. They can also help people reduce their vulnerability to overwhelming emotions, increase their experiences of positive emotions, and learn to be mindful of emotions without judging them. Emotion exposure techniques can help people learn not to fear their feelings. Learning to do the opposite of emotional urges blocks ineffective, emotion-driven responses to situations. And, finally, problem-solving skills can help people develop coping strategies for events that trigger difficult emotions.

5. Develop Interpersonal Regulation Skills

Interpersonal regulation skills help people with adjustment disorder learn how to express their thoughts and feelings in effective ways that help them get their needs met. Mindful attention skills are useful for recognizing how others are feeling and creating more satisfying relationships. Assertive communication and listening skills are also powerful interpersonal tools. These skills can help people get their needs met, set limits with others, learn how to say no, and negotiate for what they want.

6. Prevent Relapse

Finally, the last step of the DBT treatment for adjustment disorder is preventing relapse after treatment is complete. The key to relapse prevention is for the person to continue using the DBT skills learned in treatment and to recognize the early signs of recurring distress, such as avoiding pleasurable activities, in order to take steps to prevent relapse.

ACCEPTANCE AND COMMITMENT THERAPY FOR ADJUSTMENT DISORDER

Acceptance and commitment therapy (ACT) incorporates elements of behavior therapy, meditation and mindfulness practices, and scientific research on how humans think and learn.

ACT (pronounced “act”) is based on the principle that many psychological problems are caused by efforts to control, avoid, or get rid of emotions and thoughts that are undesirable. Often, people try to get rid of feelings and thoughts that make them sad or anxious, just as they get rid of other things they don’t want, such as old clothes. However, as ACT points out, feelings and thoughts can’t be controlled. A person can’t throw them out like an unwanted pair of shoes. In fact, the harder a person tries to control his or her thoughts and feelings, the more powerful they often become and the longer they stick around.

The ACT treatment for adjustment disorder generally includes eight steps:

  1. Educate about adjustment disorder and ACT
  2. Develop creative hopelessness
  3. Clarify values
  4. Commit to taking action
  5. Develop acceptance
  6. Focus on contact with the present moment
  7. Utilize cognitive defusion
  8. Stay committed to values and actions

1. Educate About Adjustment Disorder and ACT

The initial step of the ACT treatment for adjustment disorder is to educate the person about the problem, as well as about the nature of anxiety, sadness, and grief, if necessary. It’s especially important for the person to understand the nature of these things from an ACT point of view. According to this treatment, anxiety and sadness themselves are not the causes of adjustment disorder. Rather, it’s the person’s avoidance of anxious and sad emotions and thoughts that make adjustment disorder an overwhelming problem. Starting with the early stages of treatment, it’s also important for people to understand that ACT is an active, participatory treatment designed to help them live a more fulfilling life, not necessarily a “happier” one.

2. Develop Creative Hopelessness

In order to develop what ACT calls “creative hopelessness,” a person must conduct a thorough evaluation of the strategies that he or she has already used to cope with anxiety and sadness. After doing this, the person often recognizes that all of these strategies have been unsuccessful or actually made the problem worse. This is because these strategies are actually attempts to avoid and control feelings of anxiety and sadness, which can never be successful. For example, a man who attempts to control his anxiety by drinking alcohol actually develops a worse problem, as does a woman who tries to avoid her sad feelings by choosing not to talk to her loved ones about them. But rather than just being hopeless, this stage of treatment is also creative because it allows the person to begin exploring new, more successful ways of coping with anxiety and sadness.

3. Clarify Values

ACT acknowledges that life is often lived on autopilot, without much sense of what a person really cares about. Clarifying and establishing what a person values can often help that person live a more fulfilling life, despite having occasional feelings of anxiety or sadness. Values are the elements of life that give it meaning and importance, like “maintaining a loving relationship with my spouse or partner” or “being an active member of my community.” These values are like compass headings that guide a person through life. They are not destinations at which a person can ever arrive. A person can never stop maintaining a loving relationship and still have a loving relationship. Values are concepts that point a person in the direction of a fulfilling life, and ACT uses many types of values clarification tools to help people identify their values.

4. Commit to Taking Action

After a person has determined his or her values, it’s important to establish goals that support those values and then commit to taking actions that fulfill those goals. For example, if a person’s value is to be an active member of her community, she might list a number of different goals to fulfill that value, such as “attend community meetings twice a month.” This is something that can be completed and thereby create a sense of valued living. The ACT treatment for adjustment disorder includes development of skills and goals that lead to taking committed action.

5. Develop Acceptance

In ACT, learning to accept sad situations and anxious emotions is the alternative to trying to control or avoid them. Acceptance can be hard, but it’s often the only way people can reclaim control of their lives. Many situations cannot be altered, no matter how much a person wishes them to be changed. Accepting this fact is often the first step in reengaging with life. Accepting what cannot be changed frees a person from struggling against it and allows that person to start taking actions based on what he or she values in life.

In order to cultivate acceptance, people are encouraged to experience the distressing emotions that they have been avoiding, to cease fighting things that cannot be altered, and to engage in situations that have been evaded.

6. Focus on Contact with the Present Moment

Focusing on what’s happening in the present moment can help people develop more flexible coping strategies for handling fear and anxiety. When people dwell on the past, they often become sad, and when they anticipate the future, they often become anxious. In both cases, they miss what’s happening at the present time. Paying attention to what’s happening in the moment gives people more control over the decisions they’re making and allows them to see more possibilities in life. This skill is often developed with present-focused mindfulness skills, such as focusing on the rising and falling of the breath or on physical sensations in the body.

7. Utilize Cognitive Defusion

Cognitive defusion is a mindfulness technique that helps people observe their anxious and fearful thoughts without becoming attached to them. “Defuse” is an invented word that means to unstick or to unfuse one’s self from the words that arise in thoughts. The goal of this stage of treatment is to allow people with adjustment disorder to function more freely without judging themselves, their feelings, or their thoughts. Thoughts and emotions often arise haphazardly, so it’s easy to see that adjustment disorder could worsen over time if a person were to follow or believe every thought and emotion that arose.

Cognitive defusion is often accomplished using meditation or mindfulness techniques, such as imagining thoughts floating by on a cloud, repeating the words of a thought over and over until they lose meaning, or imagining a thought as something outside of oneself. By observing the process of thinking and feeling, the goal is to create space between the person and his or her experience. This gives the person more control over decisions made based on those thoughts and feelings.

8. Stay Committed to Values and Actions

In order to create a fulfilling life, it’s crucial for people to continue making decisions based on what they value in life, rather than based on the thoughts and feelings they have tried to avoid in the past.

COGNITIVE BEHAVIORAL THERAPY FOR ADJUSTMENT DISORDER

Cognitive behavioral therapy (CBT) is a form of treatment that combines elements of both cognitive therapy and behavior therapy. Cognitive therapy examines the way people’s thoughts about themselves, others, and the world affect their mental health. Behavior therapy investigates the way people’s actions influence their own lives and their interactions with others. By combining the two, CBT examines the way people can change their thoughts and behaviors in order to improve their lives.

The basic CBT treatment for adjustment disorder is often composed of four steps:

  1. Conduct an assessment and provide education
  2. Get reactivated in life
  3. Challenge and correct self-defeating thoughts
  4. Prevent relapse

1. Conduct an Assessment and Provide Education

The first step of the CBT treatment for adjustment disorder is to conduct an assessment of the person’s symptoms in order to verify that he or she is struggling with adjustment disorder and not some other, similar problem. Once people have been diagnosed with adjustment disorder, it’s important that they understand the basic nature and causes of the disorder (as highlighted above), and that CBT is an interactive treatment that requires them to do work outside of the therapy session.

2. Get Reactivated in Life

The second step of the CBT treatment for adjustment disorder is to help people begin scheduling pleasurable activities back into their lives. When people become anxious or sad as a result of adjustment disorder, they often isolate themselves from the rest of the world and avoid fun and interesting activities, which, ironically, only serves to make them feel worse. One of the most important initial steps of treatment, therefore, is to get people reactivated in life and help them stop avoiding activities. This can be done in many ways, but using a schedule to plan and record activities is often helpful and motivating.

3. Challenge and Correct Self-Defeating Thoughts

The third step of the CBT treatment for adjustment disorder is to challenge and correct self-defeating thoughts. These thoughts are often the cause of sad and anxious feelings. At the most observable level are automatic thoughts. These are critical thoughts that people think and say to themselves that sabotage success and happiness. Two examples of automatic thoughts might be “I don’t deserve anything good happening to me” and “Why bother trying? I’m just going to fail.” A person can be either aware or completely unaware of having a thought like this. However, in both cases the result is that the person feels sad or anxious.

Much of the CBT treatment for adjustment disorder will be spent identifying and reevaluating these errors in thinking. This can be done with the use of a thought record. The thought record helps the person with adjustment disorder look for evidence that both supports and contradicts these thoughts. Then, most importantly, it helps the person create a more balanced thought. For example, if the person struggling with adjustment disorder had the thought “Why bother trying? I’m just going to fail,” the thought record would offer evidence of this thought being true and examples of it not being true in the person’s life.

The thought record also helps the person identify different types of cognitive distortions, unhelpful thinking styles that perpetuate those automatic thoughts. For example, overgeneralizing involves making broad negative conclusions about life based on limited situations, and minimizing and magnifying involve discounting the positive and enlarging the negative aspects of life.

By evaluating the evidence and cognitive distortions, the goal of the thought record is to help the person find a new, more balanced thought and ease feelings of sadness and anxiety. In this example, perhaps a more balanced thought would be “Even though I don’t do everything perfectly, I’m still capable of doing most things pretty well.” And instead of feeling excessively sad, such as 8 on a scale of 1 to 10, perhaps this newer thought will help the person feel less sad, say only a 5 out of 10.

As the work on challenging automatic thoughts continues, a person using a thought record will usually begin to notice common themes among his or her thoughts. These themes often point to deeper, more firmly entrenched core beliefs about one’s self that make a person more vulnerable to adjustment disorder. These core beliefs, often called schemas, include thoughts like “I’m a failure,” “I’m worthless,” and “I’m unlovable.” When these core beliefs are encountered, they too need to be challenged and modified using the thought record and other techniques.

4. Prevent Relapse

Finally, the last step of the CBT treatment for adjustment disorder is preventing relapse after treatment is complete. The key to relapse prevention is for the person to continue using the cognitive and behavioral skills learned in treatment and to recognize the early signs of returning problems in order to take steps to prevent relapse.

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