Acceptance & Commitment Therapy: An Evidence-Based Approach to Addictions

Portions of this article are excerpted and adapted from the upcoming book Hope Against Hope, authored by Renascent’s Clinical Director Michael Lochran and consulting Psychotherapist Laura Cavanagh. Hope Against Hope’s anticipated release is in 2022.

Understanding ACT

Acceptance & Commitment (ACT) is a third-wave cognitive behaviour therapy (CBT) that shows promise in the treatment of substance addictions. ACT (pronounced just like the word “act”) is a therapeutic approach based on Applied Behaviour Analysis (ABA). Because ACT is primarily a behavioural approach, it is different from what most people picture when they think about talk therapy. Rather than processing our thoughts and feelings, ACT encourages a shift to focus on values, habits, and behaviour.

Many people think that therapy for substance addictions means discussing their past and talking about their feelings. Unlike cognitive therapies, ACT assumes that we are not in control of our thoughts or emotions and the only thing that is truly under our control is our behaviour. Indeed, ACT maintains that the stories that we tell ourselves about our past or about our feelings are often the ones that keep us stuck in behavioural patterns that are not helpful. But at any point in our lives, we have the power to change our behaviour. So instead of looking to change unhelpful patterns of thinking, ACT takes a different approach by focusing on learning helpful and healthy habits.

When we change our behaviour, our thoughts and feelings may change. But even if they do not, we can live a rich and meaningful life anyway. This is because thoughts and feelings are transient and passing, while committed actions help us to build a life that we want.

The ACT model teaches us that a great deal of pain and suffering is caused by trying to avoid unpleasant thoughts and feelings. Because thoughts and emotions are not under our control, trying to avoid them will not only fail, but will cause us to lose out on the sweetness of life. If we can’t accept suffering as a part of life, we miss out on all that life has to offer. We limit ourselves when we try to control and avoid pain, and lose out on the things that make life meaningful. ACT takes the perspective that a life well-lived will include some periods of pain and suffering. It should not be our aim to avoid these experiences, but rather to fully engage with life in accordance with our most meaningful values and goals.

How Does ACT Work?

ACT starts by identifying our values: the things that are most important to us. Once we have recognized our values, we can find ways to take committed actions that bring us closer to them. For example, suppose you identify health and wellness as a value in their life. You can then commit to actions in line with this value, like eating healthfully or going to the gym. In other words,you don’t have to work on getting motivated to go to the gym. You just need to go, regardless of your thoughts or feelings. It is possible that you won’t want to go. Maybe you feel ashamed about your lack of fitness, embarrassed at your lack of skill, tired after a long day, anxious about not knowing how to use the equipment, or any other “stuck” feeling that could get in the way. ACT encourages you to go to the gym anyway. It is possible that your feelings about going to the gym will change over time. As it becomes a habit, it may become more motivating. You might make friends, or start to feel more confident, or enjoy feeling stronger. But even if that does not happen,you’ll still reap the rewards of regularly going to the gym: becoming healthier and fitter. What you’re thinking matters less than what you’re doing. You don’t need to wait to want to go the gym in order to go. And by going, you’ll become more closely aligned with our health and wellness values – whether you’re having fun at the gym or not!

The ACT Perspective on Addiction

The ACT framework maintains that we begin to make poor choices when we eliminate painful thoughts and memories or avoid difficult feelings and experiences. Because these are inevitable, when we do this we become trapped in a “stuck cycle” of experiential avoidance. The more we avoid these experiences, the more flexibility we lose within our lives. The goal of ACT is to restore psychological flexibility and move out of the stuck cycle into a life of values-based meaningful action. Non-acceptance is actually the underlying cause of our suffering. Our desire to anticipate, control and escape negative feelings and experiences is the problem. The solution is in acceptance rather than control.

Let’s use anxiety as an example of the pain caused by experiential avoidance. Everyone feels anxiety. It’s a normal human emotion. If someone leans into experiential avoidance strategies to eliminate all feelings of anxiety, they will become less and less flexible about experiencing anxiety. Their attempts to avoid anxiety may impact all areas of their life. It may stop them from taking a job they want, or from going on a trip. It might lead them to drop out of school to avoid the stress of deadlines and exams. It might cause them to miss out on social events in order to avoid the discomfort of meeting new people. Life becomes smaller and smaller as a result of trying to avoid the experience of anxiety.

In addiction, substance use is a major experiential avoidance strategy. Breaking the cycle of addiction means breaking the cycle of experiential avoidance. Many people feel that they can only stop drinking or using when they are no longer in emotional (or physical) pain. Because ACT encourages us to accept pain as part of life, we no longer have to wait in order to pursue recovery. ACT offers the freedom to build the life that we want, even if we still experience hurt. We can choose to seek recovery from addiction even if we still have pain in our lives.

Into ACTion

Many people tell us they no longer get any real enjoyment from drinking and using, especially as their alcohol and drug addiction progresses. But even if they no longer experience pleasure, addiction keeps people trapped because it continues to offer relief. This may be relief from physical withdrawal symptoms, or relief from shame, guilt, intrusive thoughts, traumatic memories, or other thoughts and emotions.

While this strategy may work in the short-term it is not effective over the long term. This is because the relief on offer is only short-lived. We will quickly need to use again to seek more relief because as soon as the intoxicative state passes, the unpleasant feelings, sensations, or experiences return. In fact, over time, substance use will amplify these unpleasant thoughts, feelings, and sensations. For example, cannabis use alleviates anxiety temporarily but increases anxiety in the longer term; alcohol temporarily relieves insomnia but disrupts sleep-wake cycles over time. This is what makes “stuck cycle” such a powerful trap: as the unpleasant thoughts, feelings, or sensations intensify, so does the person’s desire to seek relief. When we are trapped in the “stuck cycle”, we are unable to focus on building and creating the things that we want in our life, because we are prioritizing the avoidance of discomfort or pain. ACT gently encourages us to accept discomfort in order to prioritize the things that we identify as being the most important or meaningful in our lives.

Since ACT is a behavioural intervention, it recognizes the need for replacement behaviours, or strategies that can be used when those negative thoughts and feelings come up. Among others, ACT promotes mindfulness skills as a strategy for relief and for distress tolerance.

ACT teaches mindfulness as contact with the present moment, or present-moment awareness: learning to bring awareness, curiosity, and receptiveness to the experiences of the here-and-now without judgement Distress tolerance is promoted through cognitive de-fusion. Cognitive fusion occurs when a person is fused with their thoughts and feelings. Through de-fusion, the person comes to realize that they are the one listening to their thoughts and observing their feelings – but they are separate from these passing experiences. In other words, they are not their thoughts and feelings, they are the observing self, noticing their thoughts and feelings.

Someone who is in a fused state might say: “I want to use. I want to use it so badly. I have to smoke weed after the day that I had. I need to.” In a de-fused state, the observing self would say: “I am having a craving for weed. Cravings are just thoughts. This craving that I am having right now is powerful and intense. But it is still just a thought and it will pass.”

Notice the difference between the two interpretations. In a fused state, the person experiences the craving as meaning they must use. The de-fused state creates psychological flexibility. The craving is interpreted as a thought, one which does not have to govern behaviour. They could choose to use, but they could also choose not to use.

Notice as well that the observing self’s interpretation is non-judgmental, curious, and receptive. This is what allows for psychological flexibility. The observing self does not combat rigidity with more rigidity, but rather with acceptance. The interpretation is not “I can’t use.” The observing self just notices the thought (“I am having a craving.”) and investigates it without judgement (“This craving is powerful.”). Rather than fighting the craving, the person accepts it and rides it out. Psychological flexibility comes from understanding that we have choices (“I could use, but I could also choose not to.”). The thought is an experience, not a command. The person can then choose to use mindfulness techniques to help ride out the passing unpleasantness of the craving.

ACT promotes acceptance of pain or negative experiences. Non-acceptance of the inevitability of pain leads to psychological rigidity and suffering. Acceptance brings psychological flexibility and freedom. Identifying values, and taking committed actions that align with those values, allows us to build a rich and meaningful existence. It is also the key to breaking the “stuck cycle” which keeps us trapped in experiential avoidance behaviours like addiction. Mindfulness, contact with the present moment, de-fusion, and building the self-as-observer allow us to tolerate distress, make committed choices in our behaviour, and notice when we are getting hooked back into the stuck cycle.

Does ACT Work?

There are many studies that demonstrate the effectiveness of ACT with a variety of issues and diagnoses, including obsessive-compulsive disorder, chronic pain, depression, trauma, and even schizophrenia (Harris, 2006; Polk & Burkhart, 2014; Twohig, Hayes, & Masuda, 2006). ACT has been used in prisons, hospitals, and clinic settings. In can be practiced one-one-one or as a group therapy (Bach & Hayes, 2002; Harris, 2006; Polk, 2014).

Current research indicates that ACT is effective in the treatment of substance use disorders, including alcoholism, opioid addiction, and poly-drug addiction. Encouragingly, ACT shows effectiveness with people whose substance use disorders are often treatment-resistant, such as those with concurrent diagnoses (including schizophrenia) (Batten & Hayes, 2005; González-Menéndez et al., 2014; Hayes et al., 2004; Lee et al., 2015; Luoma et al., 2012; Peterson & Zettle, 2009).

One study compared ACT with psychoeducational treatment for individuals with concurrent opioid use disorder and chronic pain. This is a particularly high-risk population because opioid-addicted individuals are at high-risk of relapse – often on prescribed painkillers – due to pain. Neuroimaging showed that participants receiving ACT exhibited a decreased neurological response to pain after treatment. This means that in just eight group therapy sessions, ACT treatment had helped to rewire the brain (Smallwood, Potter, & Robin, 2016).

ACT-Informed Treatment at Renascent

Because ACT is an evidence-based framework for addiction treatment, Renascent has supported its staff in learning how to incorporate its techniques and philosophy into their counselling practices. The counselling staff for our Virtual Intensive Treatment Program received specialized, hands-on ACT training as part of their professional development. Across our programs, our counsellors work to help clients identify their values and take action towards building a life that is personally meaningful and fulfilling.

Renascent Can Help

At Renascent, we are committed to evidence-based best practices in addictions treatment. We understand that many of our clients come in with mixed feelings about seeking recovery and letting go of the substances that have been central in their lives for so long. We help clients to move past those fears and into action by identifying and moving towards what is most important and meaningful to them.

Selected References

Bach, P. & Hayes, Steven C. (2002). The use of Acceptance and Commitment Therapy to prevent the rehospitalisation of psychotic patients: a randomized controlled trial. Journal of Consulting and Clinical Psychology, 70, 1129–1139.