Acceptance and Commitment Therapy, known as ACT, is the first evidence-based treatment for addiction that shares the same philosophy as the recovery model. It is also perfectly compatible with the 12 steps. ACT is founded on the idea that treatment is about building a life of meaning and purpose.
ACT is a modern form of CBT (cognitive behavioural therapy) that has been around for just over a decade (Hayes et al, 1999). It is part of the new wave of treatments based on acceptance and mindfulness that have been growing in popularity over the last 25 years, and is a principle-based therapy rather than being driven by treatment protocols. This means that it is suitable for more complex conditions such as addiction, where the client needs to learn only six basic principles: acceptance, defusion, mindfulness, taking perspective, values, and commitment.
When repeating a behaviour leads to increased problems over the long term then the best solution is to let go of it. Addiction is one example, but also more normal behaviours like avoidance can become problematic, for instance social anxiety. Acceptance means letting go of behaviours that do not work.
All people get caught up in thoughts that are not necessarily true, for instance thoughts about the world – ‘if I go to the meeting nobody will talk to me’ – or thoughts about ourselves, such as ‘I am stupid.’ When people buy into their thoughts, ACT calls that being fused and it often produces behaviour that leads away from values. Defusion is about learning to stand back from these thoughts, and choose behaviour that is towards your values.
In ACT the mindfulness component is about learning to be present in the here and now. By noticing the reality of the situation people are better able to choose the behaviours that will work in the current context.
All people get caught up in their lives and lose perspective. Taking perspective is about learning to stand back and see the bigger picture. From this ‘observer’ perspective it is usually easier to see the right moves and make the right decisions.
This describes what is important and meaningful to you as an individual. It is the direction you want your life to go in so that it has purpose and feels satisfying. This is not the same as trying to be happy, rather describing the types of activities that feel right at a deeper level – for example family, work, recreation.
Committed action is at the heart of ACT. Instead of trying to feel better, ACT emphasises carrying on with your values even when it feels uncomfortable. For example if you feel anxious about going to a meeting then go, and take the anxiety with you so long as this is important to your values.
The six components are fluid and summed up in a metaphor called the passengers on the bus:
Imagine that your life is like a bus and you are the driver. On the front of the bus is the route you want to take (valued direction). As you start the bus up a bunch of unruly passengers get on board and start making a noise (your thoughts and feelings). As you set off some of them come down and start harassing you, so you start telling them to sit down. But they don’t, so you stop the bus and try to make them.
ACT uses lots of metaphors like this to help people understand that it can be futile to struggle with unwanted thoughts and feelings, and that when you do it can bring your life to a halt. The alternative is to live with them and learn to drive the bus.
There is an extensive evidence base for ACT across many conditions, as well as a specific evidence base in addiction. More than 50 randomised control trials (RCT) have been published and six of these are in addiction. The overall evidence base has been independently reviewed and compares favourably to CBT (Öst, 2008). In the United States the model has been evaluated by the Substance Abuse and Mental Health Services Administration (SAMHSA) and approved as a recognised treatment for addiction. There is evidence for use in residential rehabilitation, with methadone maintenance and for recovery across alcohol, opiate, stimulant and cannabis use.
For groups, a very simplified version called the ACT Matrix has been developed by myself and Dr Kevin Polk and used throughout the addiction services in Portsmouth. Over the last five years groups have been run across multiple agencies – the hospital, family centre, probation, community drug team and beyond. In that period attendance and outcomes have improved more than 100 per cent year on year. The matrix is also being used as a model for rehab at the Addiction Recovery Centre (ARC), and has been developed into a model of peer recovery.
ACT is compatible with the 12 steps and a perfect fit for the recovery model. It is easy to use through the matrix format, yet highly evidence based. While relatively new, it is now established in the UK within the mainstream treatment agencies, in rehab and in peer recovery. It is a simple model, which can join up the treatment journey for the client and deliver reliable results.
Mark Webster is a registered psychotherapist. Fully referenced version available here.