Slow and Steady Wins the Race: A Randomized Clinical Trial of Acceptance and Commitment Therapy Targeting Shame in Substance Use Disorders

Objective: Shame has long been seen as relevant to substance use disorders, but interventions have not been tested in randomized trials. This study examined a group-based intervention for shame based on the principles of acceptance and commitment therapy (ACT) in patients (N = 133; 61% female; M = 34 years old; 86% Caucasian) in a 28-day residential addictions treatment program. Method: Consecutive cohort pairs were assigned in a pairwise random fashion to receive treatment as usual (TAU) or the ACT intervention in place of 6 hr of treatment that would have occurred at that same time. The ACT intervention consisted of three 2-hr group sessions scheduled during a single week. Results: Intent-to-treat analyses demonstrated that the ACT intervention resulted in smaller immediate gains in shame, but larger reductions at 4-month follow-up. Those attending the ACT group also evidenced fewer days of substance use and higher treatment attendance at follow-up. Effects of the ACT intervention on treatment utilization at follow-up were statistically mediated by posttreatment levels of shame, in that those evidencing higher levels of shame at posttreatment were more likely to be attending treatment at follow-up. Intervention effects on substance use at follow-up were mediated by treatment utilization at follow-up, suggesting that the intervention may have had its effects, at least in part, through improving treatment attendance. Conclusions: These results demonstrate that an approach to shame based on mindfulness and acceptance appears to produce better treatment attendance and reduced substance use

Substance abuse and psychological flexibility: The development of a new measure

Psychological flexibility is a relatively new clinical construct targeted by Acceptance and Commitment Therapy, a behavior analytic treatment incorporating mindfulness and values interventions, among other processes. Poor psychological flexibility has been shown to relate to clinical problems as well as normative life challenges, and efforts to increase psychological flexibility have correlated with improvements for a variety of psychological difficulties, including substance abuse. The Acceptance and Action Questionnaire (AAQ) is currently the standard measure of psychological flexibility, but in substance misusing samples, has not shown adequate psychometric properties. Content-specific variants of the AAQ have been effective in other treatment domains, suggesting that a substance abuse focused version of the AAQ may be useful. This article details the construction and initial validation of such a measure, the AAQ-SA, which demonstrated good internal consistency, factor structure, and construct validity. In addition, the AAQ-SA appeared to be empirically distinguishable from the AAQ. Future researchers are advised to address limitations of this study and encouraged to expand the empirical database on substance abuse treatment with this new measure.</

Stigma predicts residential treatment length for substance use disorder

Background: Stigma has been suggested as a possible contributor to the high rates of treatment attrition in substance-dependent individuals, but no published empirical studies have examined this association. Objectives: The present paper assessed the relationship between baseline stigma variables and length of treatment stay in a sample of patients in a residential addictions treatment unit. Methods: The relationship between baseline stigma variables (self-stigma, enacted stigma, and shame) and length of stay for participants (n = 103) in a residential addictions treatment unit was examined. Results: Higher self-stigma predicted longer stay in residential addictions treatment, even after controlling for age, marital status, race, overall mental health, social support, enacted stigma, and internalized shame. However, other stigma variables (i.e. internalized shame, stigma-related rejection) did not reliably predict length of treatment stay. Conclusion: These results are consistent with other findings suggesting that people with higher self-stigma may have a lowered sense of self-efficacy and heightened fear of being stigmatized and therefore retreat into more protected settings such as residential treatment, potentially resulting in higher treatment costs. Specialized clinical interventions may be necessary to help participants cope with reduced self-efficacy and fear of being stigmatized

Reducing self-stigma in substance abuse through acceptance and commitment therapy: Model, manual development, and pilot outcomes

Little is known about the assessment and treatment of self-stigma in substance abusing populations. This article describes the development of an acceptance based treatment (Acceptance and Commitment Therapy-ACT) for self-stigma in individuals in treatment for substance use disorder. We report initial outcomes from a study with 88 participants in a residential treatment program. The treatment involves 6 h of a group workshop focused on mindfulness, acceptance, and values work in relation to self-stigma. Preliminary outcomes showed medium to large effects across a number of variables at post-treatment. Results were as expected with one potential process of change, experiential avoidance, but results with other potential mediators were mixed

The Development and Psychometric Properties of a New Measure of Perceived Stigma Toward Substance Users

A self-report measure of perceived stigma toward substance users was developed and studied. An initial measure was created based on a previously developed scale that was rated by experts for content validity and quality of items. The scale, along with other measures, was administered to 252 people in treatment for substance problems in the United Slates during 2006-2007. Refinement efforts resulted in an eight-item scale with good face validity, construct validity, and adequate levels of internal consistency. Most relationships with other constructs were as expected. Findings suggest that perceived stigma is distinct from other forms of stigma

Suitability of Bupropion SR for nicotine-dependent smokers: Problems in a practice setting

Background: Bupropion SR ( Zyban) has been shown in randomized controlled trials to be an efficacious pharmacological aid for smoking cessation; however, recent reports have raised serious concerns about the breadth of its applicability without complications or contraindications. Methods: We examined this issue in a well-documented medical population, i.e. veterans volunteering to participate in a smoking cessation treatment research program involving the use of bupropion SR. Results: Overall, 22% of the 78 subjects who met the study criteria were appropriate for and completed the course of medication. Conclusions: Thus, bupropion SR in nicotine-dependent veterans may not be broadly applicable when conservative prescribing guidelines are carefully followed. Copyright (C) 2004 S. Karger AG, Basel

Does Acceptance and Relationship Focused Behavior Therapy Contribute to Bupropion Outcomes? A Randomized Controlled Trial of Functional Analytic Psychotherapy and Acceptance and Commitment Therapy for Smoking Cessation

This study evaluated a treatment combining bupropion with a novel acceptance and relationship focused behavioral intervention based on the acceptance and relationship context (ARC) model. Three hundred and three smokers from a community sample were randomly assigned to bupropion, a widely used smoking cessation medication, or bupropion plus functional analytic psychotherapy (FAP) and acceptance and commitment therapy (ACT). Objective measures of smoking outcomes and self-report measures of acceptance and relationship processes were taken at pretreatment, posttreatment, 6-month, and 1-year follow-up. The combined treatment was significantly better than bupropion alone at 1-year follow-up with 7-day point prevalence quit rates of 31.6% in the combined condition versus 17.5% in the medication-alone condition. Acceptance and the therapeutic relationship at posttreatment statistically mediated 12-month outcomes. Bupropion outcomes were enhanced with an acceptance and relationship focused behavioral treatment

Self-Stigma in Substance Abuse: Development of a New Measure

Little attention has been paid to the examination and measurement of self-stigma in substance misuse. This paper aims to fill this gap by reporting on the development of a new scale to measure self-stigma experienced by people who are misusing substances, the Substance Abuse Self-Stigma Scale. Content validity and item refinement occurred through an iterative process involving a literature search, focus groups, and expert judges. Psychometric properties were examined in a cross-sectional study of individuals (n = 352) receiving treatment for substance misuse. Factor analyses resulted in a 40-item measure with self devaluation, fear of enacted stigma, stigma avoidance, and values disengagement subscales. The measure showed a strong factor structure and good reliability and validity overall, though the values disengagement subscale showed a mixed pattern. Results are discussed in terms of their implications for studies of stigma impact and intervention

Acceptance-based treatment for smoking cessation

This pilot study applied a theoretically derived model of acceptance-based treatment process to smoking cessation, and compared it to a pharmacological treatment based on a medical dependence model. Seventy-six nicotine-dependent smokers were randomly assigned to one of two treatments: Nicotine Replacement Treatment (NRT), or a smoking-focused version of Acceptance and Commitment Therapy (ACT). There were no differences between conditions at posttreatment; however, participants in the ACT condition had better long-term smoking outcomes at 1-year follow-up. As predicted by the acceptance process model, ACT outcomes at 1 year were mediated by improvements in acceptance-related skills. Withdrawal symptoms and negative affect neither differed between conditions nor predicted outcomes. Results were consistent with the functional acceptance-based treatment model