Rehab 4 Addiction

Acceptance and Commitment Therapy (ACT) is a form of behavioural therapy and psychological intervention. It encourages mindfulness and acceptance to help people become more psychologically flexible.

ACT was invented by Dr Steven Hayes, of the University of Nevada. Hayes also came up with Relational Frame Theory (RFT), a theory of language. He describes RFT as a major inspiration for ACT.

ACT is a third-wave behavioural therapy. Other third-wave behavioural therapies include Dialectical Behaviour Therapy (DBT) and third-wave Cognitive Behavioural Therapy (CBT).

The central thesis of ACT is that psychological flexibility is key to overcoming difficulties. This holds true in the treatment of substance use disorders (SUDs), where psychological flexibility is a means of navigating life without resorting to substances.

ACT for SUDs helps patients come up with effective strategies for dealing with difficult situations, whether they be cravings, negative emotions or conflict.

What goes on in Acceptance and Commitment Therapy?

Acceptance and Commitment Therapy gives patients the tools to accept their thoughts and feelings, rather than resist them. Substance use often comes about as a result of trauma, or negative thoughts. By accepting the existence of negative thoughts and experiences, and defusing them, ACT hopes to prevent these thoughts and experiences from causing the patient to use substances.

A good example of how this works in practice is the ‘Sing It’ exercise.

This is how Steven Hayes, the inventor of ACT, describes the exercise:

‘This is a method that is powerful when you’re having a really sticky thought. Turn it into a sentence and try singing it – out loud if you are alone, in your head if you have company. Any tune will do. My default is “Happy Birthday.”’ [1]

In other words, whenever you have an invasive or negative thought, such as ‘I’m not good enough’ or ‘I’m a failure’, try signing it out loud. The act of singing something allows you to ‘see it as a thought… and do so just a bit more clearly.’

This is the aim of the ‘Sing it’ exercise: to step back from something and see it as a thought. Doing so allows you to distinguish between the thought itself and the meaning you invest in the thought.

For instance, it might be that you have a negative thought which you have invested with a lot of meaning. Singing it out loud might help you to realise that it is not as meaningful or accurate as you imagined it to be.

The ‘Sing it’ exercise is just one example of a technique used in Acceptance and Commitment Therapy. More broadly, ACT helps people to deal with traumatic past experiences, develop coping strategies and move forward with their lives. It does by identifying key values and working out actions that are in line with those values.

Key ideas behind Acceptance and Commitment Therapy

There are three key elements that underpin Acceptance and Commitment Therapy. They are:

  • Mindfulness is a relatively modern philosophy. It is based on the idea that people need to be present in their lives, rather than going around on autopilot. It teaches various techniques for staying present and living in the moment.
  • Psychological flexibility. Becoming more psychologically flexible is arguably the main aim of ACT. Psychological flexibility means having the necessary tools to deal with the obstacles which life puts in our way. From a SUD point of view, it means learning how to cope with things without resorting to substances. Part of being psychologically flexible is having a set of core values which you can apply to situations in order to work out how to behave. Knowing what you value – whether it’s family, kindness, love or any other combination of things – helps you make the right decision.
  • Creative hopelessness. This idea refers to the realisation that things you have done in the past to improve your situation may not have worked. Understanding this fact could lead to despondency. Instead, according to ACT, we need to use it to fuel a search for better solutions. By accepting that it is futile to try and avoid pain and suffering completely, we can explore new ideas and techniques without fear of failure.

Important skills in Acceptance and Commitment Therapy

  • Ascertaining values. Values are key to making good decisions in life. They are the things we hold most dear. Acceptance and Commitment Therapy helps patients to work out what their values are through a variety of exercises. One is called ‘I’ve Got a Secret’. In order to do it, ‘Pick an action that manifests a deeply held value, and see if you can plan a way to do that in total secrecy.’ [2] Then, after you have completed the action, spend ten minutes writing about how the action felt and whether you can do other actions like it in the future. This will help you to work out what is important to you.
  • Developing self-awareness. A set of skills in ACT revolve around the self. Specifically, they involve coming to an awareness of self which is not based in contingent properties like personality. One exercise is to ‘catch self-awareness’. [3] In this exercise, you should ask yourself regularly ‘And who is noticing that?’ This allows you to notice your ‘transcendent self’. The point of this is to detach oneself from one’s experience, which in turn encourages compassion and connection with others.
  • Being present. This is a concept which comes from mindfulness, and has a special bearing on the treatment of SUDs. Many see substance use as a form of escape; mindfulness (and the idea of being present) might be the antidote to this. What if people didn’t need to escape? What if they could simply take joy in their here and now? ACT teaches people to pay attention to the present moment, ignoring the past and the future. It does so through techniques like meditation.
  • Defusion involves understanding that a thought is just that – a thought. Thoughts can be irrational. They may not represent reality. Understanding that your thought is just a thought can help you to take a step back from it. Detachment is the key to all this. To give an example, you might have a thought like ‘I’m not good enough’. Defusion involves reframing this thought as ‘I’m having a thought that I’m not good enough’. The simple act of reframing can help to defuse the thought and prevent it from leading to an undesirable action, such as using substances.
  • Acceptance can be contrasted with avoidance. When you accept a negative thought, you embrace it – whatever it may be. Then you try to move forward by making a decision based on your values. One exercise to promote acceptance is called ‘The Impossible Game’. In this exercise, you need to notice when you have a resistance to doing something – such as, for example, getting out of bed on a cold day. The Impossible Game is to do exactly what your mind says you cannot do – in this case, get out of bed as quickly as possible. If you can do this, then why not other things? Why not challenge yourself to go a day without substances, when your mind is convinced you that is impossible?
  • Committing to Action. The final skill is to commit to action based on value judgements. If you have decided that one of your values is helping people less fortunate than yourself, then try to commit to doing just that. Using your psychological flexibility, you can face up to any obstacles that get in your way when you are pursuing your goal. Commitment is difficult, but it is necessary for real change.

Evidence for Acceptance and Commitment Therapy

A range of studies have shown Acceptance and Commitment Therapy to be an effective form of therapy, for teenagers, veterans, inmates, older people, and people in both inpatient and outpatient settings. [4]

One study carried out by Luoma et al looked at substance use among female inmates. It found a large reduction in substance use over 4 and 6 months. [5]

Due to the relatively recent nature of Acceptance and Commitment Therapy, there are fewer studies on it than, for example, Cognitive Behavioural Therapy. Some of these studies also suffer from small sample sizes. However, the evidence points towards ACT being a useful intervention for certain people.

This meta-analysis also suggested that ACT was effective, even when compared with other treatments like CBT. ‘A significant small to medium effect size was found favouring ACT relative to active treatment comparisons following treatment.’ [6]

Benefits and limitations of Acceptance Commitment Therapy

Acceptance Commitment Therapy carries several benefits. These include:

  • Acceptance is a good way to face up to problems and reduce anxiety. ACT can help people to combat shame, anxiety and depression by giving them the tools to accept their problems and negative thoughts.
  • Cognitive defusion helps patients who struggle with negative thoughts to take a step back from them. This can have a positive knock-on effect for substance use.
  • Mindfulness is a great way of finding joy in life and being less judgemental. It can also help reduce behaviours that are escapist and damaging, such as substance use.
  • Commitment is a very useful inclusion in this form of therapy. It stresses the need for positive action. There is a danger with therapy that the patient takes things on board but never puts any of the techniques they learn into action. ACT makes it very clear that action is crucial to success.
  • Psychological flexibility helps patients get better at dealing with problems. Social, financial and relationship problems can sometimes derail even the most committed of recovering addicts.

It also has a few drawbacks. These include:

  • Acceptance and Commitment Therapy needs several sessions to take effect, as there are several parts to it. It may not be as time-efficient as, for instance, Motivational Enhancement Therapy.
  • There are relatively few practitioners of Acceptance and Commitment Therapy, as it requires some specialization and is less common than some other therapies. [7]

Acceptance and Commitment Therapy as part of addiction treatment

Psychological flexibility is a key concept for those struggling to stay sober. Substance use disorders involve a lack of impulse control which, when combined with an inability to deal with difficult feelings, leads to substance use.

By introducing psychological flexibility, ACT helps patients to deal with difficult feelings. The hope is that this leads to a reduction in substance use.

ACT is an excellent option when combined with a detox, other therapy and aftercare. In combination with a full regime of addiction treatment, it can help most people to get clean and stay clean.

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