Acceptance and Commitment Therapy for Substance Abuse

“If I had to summarize ACT on a T-shirt, it would say: Embrace your demons and follow your heart.” Russ Harris (2007).

Acceptance and Commitment Therapy (ACT) is a mindfulness-based behaviour therapy that is used to treat a variety of psychological disorders, and is effective for drug and alcohol abuse. It makes some assumptions about human nature that make it different from other commonly used approaches:

Suffering is normal. It is possible to live with pain, sadness and anxiety – and continue to live a rich, meaningful life. This is different to other philosophies which insist on eradicating problems and pain in order to achieve happiness. ACT shows that the idea that you need to get rid of your psychological pain to be normal or content with life, often leads to more pain, as it is often a non-winnable struggle.
Control is the problem, not the solution. Have you ever tried to force yourself to go to sleep because you had something to do the next day? Or tried to not think about an ex-partner? Often people turn to drugs and alcohol when it feels like life is out of control or when they are trying to avoid negative thoughts or situations. Drugs and alcohol do actually work to control how you feel … sometimes … in the short term … but there is usually a painful consequence.

What are you avoiding? Paying bills? Looking for a new job? Traumatic memories? Feeling anxious? Life?

Avoidance of certain activities, thoughts or emotions, can lead to many of life’s problems. When drugs and alcohol are involved, the cost can be very high, often involving a reduction in quality of life and an early death.

Of course many people use substances like alcohol in moderation, in a way that enhances their lives. A couple of standard drinks after work on a Friday is a common way to unwind after a hard week, or it helps people socialize with others doing the same. However, you only have to watch the news to see the devastating effect of alcohol and other drugs in our Australian community. Even sadder for me than the people who make the news, is the army of people who die before their time in body or spirit because of the long term effects of substance abuse.

Six Pieces to the ACT Puzzle

There are six basic themes you will learn about through ACT:

Values – What are your values and how can you live your life by them?
Action – Create concrete and practical goals to help you be the person you want to be.
Cognitive fusion – What thoughts are messing with you and how can you give less power to them?
Acceptance – Rather than avoiding or changing things that can’t be changed, how can you learn to live with the negative things in your life?
Observation – Learn how to take a step back and reflect on what is going on in your head.
The present – Learn how to be more connected to the present moment rather than obsessing about the past or the future.

These themes are expanded on below. I have used a common metaphor from ACT to hopefully explain everything in an easy to remember package.

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The Bus Metaphor

Your mind is a bit like being the driver of a bus full of passengers. Your destination is wherever your life is headed. On the bus are various passengers that represent aspects of yourself. Some are relatively good passengers who sit quietly unless they are needed, while some are disruptive and you wish they would just get off the bus and bother somebody else. Some of the passengers are linked to a particular emotion, such as sadness, anger, fear, shame. Other passengers could be linked to physical sensations like pain or craving for drugs or alcohol.

The Fear passenger might say something like, “If you keep driving down this road then I will begin to panic and then I will make you stop the bus”.

Anger will say something like, “If you don’t stop driving, then I am going to grab the wheel and crash the bus into a tree”.

Despair will say, “What’s the point? You are going to fail anyway!”.

Now imagine how your alcohol, heroin or cannabis passenger controls the bus. Sometimes subtle, sometimes like a brick to the face, if you have been dependent on a drug then they are on the bus along for the ride.

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1. Values

“Your beliefs become your thoughts,
Your thoughts become your words,
Your words become your actions,
Your actions become your habits,
Your habits become your values,
Your values become your destiny.”
Mahatma Gandhi

Values are ideas like courage, love, freedom, tolerance, individuality and responsibility. They are not goals that you can achieve, but ways that you can live your life. Values can change in different situations. For example, your values that you want to uphold while you are with your family (caring, creative) may be different than those you think are most important while at work (responsibility etc).

By exploring and connecting with a few core values, it can give you a guide by which you can live the rest of your life. This is especially important in today’s modern world where we can be easily overloaded with information and different philosophies or worldviews.

If you are engaged in a life where drugs and alcohol are central, it is easy to lose sight of your values. I often hear people say things like, “I cannot believe that I did that”, when referring to things they did while intoxicated or trying to get the money to buy drugs.

It also gets confusing when generally positive values, like respect or loyalty for family or friends, leads to a certain way of life that leads to drug abuse. Some people use drugs because they want to feel free, relaxed, or to stand out from the crowd. The problem is that it is hard to be truly free when you addicted to a substance; or to be an individual when you are doing something that is a problem for a large proportion of Australians.

Using the bus metaphor, your values would be “how” you drive. Are you a driver who gives way to other drivers? Are you a calm driver? How do you treat your passengers? It also affects your destination. Where do you want to go? Why?

2. Action

“Vision is not enough, it must be combined with venture.
It is not enough to stare up the steps, we must step up the stairs.”
Vaclav Havel

The most practical element of ACT focuses on concrete steps that you can take to improve your life. You can break things down into short, medium and long term goals. It is good to have a dream for the future, such as “I want to visit the mountain gorillas in Africa one day”, or “I would like to be a good parent”. It is even more important to take small steps every day in order to create the life that you want.

Drugs and alcohol often complicate things when action is concerned. Take for example someone who drinks 20 plus standard drinks of alcohol every day. They would need to take steps in order to detox themselves because stopping suddenly can be very dangerous. Most alcohol abusers in my experience do not have a complete understanding of the physical effects of long term abuse on their bodies. This type of education can help people decide to quit or reduce their drinking, as well as give them strategies to handle any lasting effects. Medium and long term goals need to include finding ways to social, and have fun without alcohol.

With the bus metaphor, action would be what is your destination; and, how do you handle detours; do you need a road map; or do you listen to the passengers?

3. Cognitive Fusion

“Don’t believe everything you think.”
Various

The science behind ACT talks a lot about the power of language. Humans have an in-built ability to store knowledge in our heads that is often extremely useful for keeping ourselves alive; however this same ability can also be twisted and lead to serious psychological problems.

Take for example a child who is repeatedly told by their mother that they are stupid. The child grows up with a little voice in the back of their head that repeats this phrase so often and for so long that they no longer remember where the voice came from. Every little setback in their lives only goes to prove this belief in their stupidity, until they stop trying at all. Let’s return to the bus analogy from the beginning of this article – there will always be a passenger on that person’s bus that is telling the driver that there is no point driving to the university because they are too stupid.

A common thought for people who feel they need to use drugs or alcohol is: “I won’t enjoy myself at this party unless I get drunk”. Another one is: “I won’t be able to handle these feelings unless I use something to calm myself down.” ACT uses some exercises to help “defuse” these thoughts so they don’t have power over your behavior. The first step is to recognise which beliefs, habits or rules are holding you back in life (who is on your bus). When you become aware of these you learn to stop struggling with them, and get down to the business of living by your values and taking action.

So for the bus metaphor, fusion would be explained as how much attention do you give to your passengers while driving the bus? When you are very fused to the alcoholic passenger, there is not much room between them saying they need a drink and the bus pulling over at a bottle shop. When you learn to defuse, the driver of the bus can calmly explain to the alcoholic that despite their cravings, the bus has a destination and getting drunk is not going to get in the way.

4. Acceptance

“The only way out is through.”
Robert Frost

Acceptance means being willing to experience painful emotions, without trying to avoid them.

For example, imagine a common story, someone who began drinking alcohol to avoid thinking about a particular traumatic event. The pattern gets worse for 10 or 20 years as they drink more and more to get the same result. This leaves them with huge amounts of shame and remorse about the time they lost, and relationships destroyed as a result of the drinking. The alternative would be to seek help soon after the traumatic event, which can be confronting – but better than destroying your body and soul with substances.

In terms of the bus analogy when you reach a state of acceptance, all the passengers on the bus are relatively predictable. The addiction monster is tamed, and while it doesn’t stop craving right away, at least you have the space to put strategies in place. Your anxiety doesn’t feel like an outcast, and can talk to the other passengers as well as the driver. It may even have some good advice to give everyone. Basically they all work together to help the bus get to its destination.

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Here is a simple acceptance exercise:

(Use at your own risk. If in doubt seek professional advice.)

Observe – scan the body for any feelings of tension, pain etc. Try not to listen to your head telling you what the feelings mean, and just observe the actual physical sensation. What, colour, temperature etc is the feeling.

Breathe – imagine breathing into and around any uncomfortable feelings. It is normal for the feeling to shift, becoming bigger or smaller; just hang in there. Remember this is not a relaxation exercise, even if some people do end up feeling more relaxed afterwards.

Allow – come back to the present moment, without pushing the awareness away. Don’t struggle with any thoughts or feelings that come up, but also become aware of the world around you.

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5. Self-as-context (the Observer)

“When you change the way you look at things, the things you look at change.”
Wayne Dyer

With ACT you learn to connect with the part of yourself that is sometimes called the observer. It is the part of you that is not full of labels, judgments, descriptions. It is the observer that is aware that you have a lot going on in your head without getting caught up in it. You learn to say things to yourself like: “I am having the thought that I am a loser”; or, “my heroin demon in being really demanding today”. These are defusion exercises, which also strengthen your concept of the observer, by looking at yourself from a different perspective. It can be a bit confusing at first, but eventually you are able to listen to the negative thoughts or feelings that your brain throws at you without acting on them, or being so affected.

With the bus, the observer would be the driver, once they have learned to defuse from the passengers. They know where they are going, they are aware of what the other passengers are up to, but they can stay calm. It may also be the bus itself, with the driver being part of your mind.

6. Contact the Present Moment

“Right now a moment of time is passing by!… We must become that moment.”
Paul Cezanne

This is the one that most people need to practice, a lot. Sure it is important to think of the past, in order to learn from your mistakes or just remember the good times. It is also important to think of the future and build plans, or enjoy the anticipation of a future holiday.

However, people who are struggling in their lives tend to spend too little time in the present moment. A depressive individual will spend days stuck in shameful or painful memories; an anxious person will spend days worrying about the future.

Drug and alcohol abusers often use their substance of choice to block these thoughts, with potentially dangerous results. ACT encourages people to practice just being in the present moment. This practice is not limited to sitting down and focusing on you breathing, but to do it while gardening, washing dishes, working on the car etc. The more practice the better, but even five minutes a day being mindful while you eat or have a shower is better than nothing.

For the final part of the bus analogy, the driver would be driving extremely mindfully. They would acknowledge that some of the passengers would occasionally say unhelpful things, without getting pulled out of the present moment. They would realize that the past and future have important roles to play in the life of the bus, but would not spend any longer than necessary dwelling or worrying about either.

The Evidence for ACT and Addiction

While ACT is relatively new compared to traditional Cognitive Behavior Therapy or 12 Step programs like Alcoholics Anonymous, ACT has shown great promise as an approach to helping those who have a problem with drugs and alcohol.

For example, studies done with people on methadone-maintenance programs showed that including ACT in therapeutic interventions led to a larger reduction in both opiate and other drug use (4). ACT has also been shown to be more effective than nicotine replacement therapy to quit smoking long term (2).

There is also evidence for ACT and recovery from alcohol addiction. For example, one study was conducted at an involuntary inpatient clinic for patients with alcohol dependence who also had depression (7). Participants were randomly assigned to either the Treatment as Usual (TAU) therapy, or ACT therapy. Both groups received roughly the same amount of both group and individual therapy. The patients in the ACT group were released significantly more quickly from the unit over the TAU group, because they met the criteria for discharge.

A case study was done with a dual diagnosis client who had issues with both Post Traumatic Stress Disorder (PTSD) as well as a Substance Use Disorder (polydrug user) (1). By using ACT the client showed a reduction in both the distress she felt around her traumatic memories, as well as a vast reduction in her drug and alcohol use. She started studying, and basically turned her life around and started to live by her values. Larger studies need to be done with dual diagnosis clients, in order to get more evidence, but early results are very promising.

Acceptance and Commitment Therapy has shown a lot of promise as a method to help people overcome their substance abuse problems; and does it in a way that can also improve every aspect of life by overcoming experiential avoidance. Different people need to focus on different aspects of the model, depending on their individual life circumstances. ACT works relatively quickly, but the strategies learned can last the rest of your life.

If you would like to know more, I highly recommend “The Happiness Trap”, a book by Russ Harris, which is a great introduction to the subject matter.

I have been helping people deal with their substance abuse issues using ACT for over ten years, in government health settings, in private practice and in not-for-profit organizations. If you would like to learn more, make an appointment today.

Author: Jim Adsett, BA Psych (Hons).

Jim Adsett has worked in the drug and alcohol field for more than 11 years. Regardless of the substance, Jim has worked with clients at every point in their journey towards recovery, from admitting that they have a problem to maintaining a new healthy lifestyle. Jim tailors his treatment approach depending on the severity of use and the goals that the client has for themselves, then works collaboratively with his clients to help them practically and sensibly move towards these goals. His treatment approach is non-directive and positive and he uses Acceptance and Commitment Therapy (ACT) as a basic framework, as well as drawing on Cognitive Behaviour Therapy and Transactional Analysis.

To make an appointment try Online Booking. Alternatively, you can call M1 Psychology Brisbane on (07) 3067 9129

References:

Batten, S. V, & Hayes, S. C. (2005). Acceptance and commitment therapy in the treatment of comorbid substance abuse and posttraumatic stress disorder: A case study. Clinical Case Studies, 4, 246-262.
Gifford, E. (2002). Acceptance and commitment therapy versus nicotine replacement therapy as methods of smoking cessation. Unpublished doctoral dissertation, University of Nevada, Reno.
Harris, R. (2007). The Happiness Trap. Exisle Publishing. Australia.
Hayes, S. C, Wilson, K. G., GIfford, E. V, Bissett, R., Piasecki, M., Batten, S. V, et al. (2004). A preliminary trial of twelvestep facilitation and acceptance and commitment therapy with polysubstance-abusing methadone-maintained opiate addicts. Behavior Therapy, 35, 667-688
Heffner, M., Eifert, G. H., Parker, B. T., Hernandez, D. H., & Sperry, J. A. (2003). Valued directions: Acceptance and commitment therapy in the treatment of alcohol dependence. Cognitive and Behavioral Practice, 10, 378-383.
Lappalainen R, Lehtonen T, Skarp E, Taubert E, Ojanen M, Hayes SC: The impact of CBT and ACT models using psychology trainee therapists: a preliminary controlled effectiveness trial. Behav Modif 2007; 31: 488–511.
Petersen, Connie L, & Zettle, Robert D. (2009). Treating inpatients with comorbid depression and alcohol use disorder: A comparison of acceptance and commitment therapy versus treatment as usual. The Psychological Record 59.4 (Fall 2009): 521-536.
Vowles K. E, McNeil D. W, Gross R. T, McDaniel M. L, Mouse A, Bates M, Gallimore P, McCall C:.Effects of pain acceptance and pain control strategies on physical impairment in individuals with chronic low back pain. Behav Ther 2007; 38: 412–425.
Wilson, K. G., & Byrd, M. R. (2004). ACT for substance abuse and dependence. In S. C. Hayes & K. D. Strosahl (Eds.), A practical guide to acceptance and commitment therapy (pp. 153-184). New York: Springer.