Acceptance and Commitment Therapy for Addiction: The Practice and the Science

Acceptance and Commitment Therapy for Addiction: The Practice and the Science


[Dr. Carlini] Hello everybody. We are gonna get started. I first want to introduce myself — I’m Bia Carlini;
I’m the Northwest ATTC webinar coordinator, several other hats I wear here. As the slide says, questions will be taken at the end. That means please feel
free to type it at any time in the box that you have near your slides, but we are going to just wait until the end. Many people ask us — and we’ll make a copy available of this presentation and
the PowerPoint. It takes like one or two days to post on our website; the link is
on the bottom of the slide here. We also when we post it we make it ADA
compliant and so also having in mind people with different abilities. We
realize that we have a diverse audience, we serve a diverse audience that also
works with a diverse population, and we recognize words matter and we try to
respect diversity. So please if you have any comments or suggestions about this
webinar in this regard, or actually any other regard for this matter, please
contact us on the email in this slide we’ll be very happy to hear and to learn
from you. And without further ado, let’s get started. So we are very lucky today
to have a presentation on ACT, or acceptance and commitment therapy, to the
best possible person to present about this topic. So Jonathan Bricker is not only a colleague but also a friend, and he is
the founder and leader of the HABIT Group — it stands for health and behavior
innovations in technology — and he is a full member equivalent of full professor at
Fred Hutchinson Cancer Research Center and also affiliate professor here at
University of Washington. He has a long track
of working with ACT in developing technological devices and exploring
technology to be able to apply the principles that ACT offer in terms
of dealing with addiction. He’s also a licensed psychologist and he also
has a private practice. So without further ado, Jonathan I’m passing to you
and as soon as you click the slide you have control of the talk. Thanks so much
for talking to us. [Dr. Bricker] Thank you so much, Bia, I really appreciate it. Bia, are you able to
hear me? [Dr. Carlini] Yes. [Dr. Bricker] Okay welcome everybody and thank you for joining. I want to just first show my
disclosures which are listed here and this is our group as Bia mentioned, we’re the HABIT lab. We’re composed of mental health professionals, and people
who are conducting substance use intervention directly, as well as
statisticians and managers, administrators in our lab. The focus of our lab is to develop and then test behavioral interventions to
help people with addictions, and our main behavioral approach is ACT: acceptance
and commitment therapy. And the main addiction we focus on is tobacco use. And as you’ll see as I talk about ACT and its application to smoking, many many
of the concepts will apply to addictions of all types. Outside of my research, my private practice focuses on treating addiction
using ACT. So what we do is to develop and test these technologies. Our goal is
to help a million people to quit smoking. This is a list here of all the different
interventions that were conducting. We have a telephone-delivered intervention
that’s delivered by masters-level coaches
for tobacco cessation, we have a web-based program called WebQuit, we
have the I Can Quit app, we have the Quit 2 Heal app for cancer patients
who smoke, and then we’re also testing now a chat bot, which uses
artificial intelligence and presents a conversation with the user as
if someone was an actual coach to help them quit. We are funded primarily by the
federal government through funds from the National Cancer Institute and the
National Institute on Drug Abuse. We’re also funded by foundations and
other sources, and our total funding we’re grateful for is 15 million dollars
to date. So I mentioned my practice — so I won’t say more about that — it’s ACT mainly for
addictions. So what I want to talk about instead is where we’re headed in this
journey together. I’m going to briefly talk about why treating addiction is
important and then get into how to apply ACT for addiction in terms of what’s the
science saying, and I’ll spend a lot of time on the practice since I know a lot
of people who are listening today practice ACT or administer or
oversee the practice of ACT — oversee addiction treatment and are curious
about how that works using the ACT model. So why is treating addiction important? As you imagine, or may already know, tobacco use in particular leads to 6
million deaths every single year — that’s a third of all cancer deaths. So it’s the
most preventable cause of death worldwide and the problem is, and this
applies not just to smoking cessation but to alcohol and drug addictions, is when
you look at the different ways of treating interventions and you start
with individual then you move to group then there are some delivering telephone
interventions for people who live in remote areas or for whom access to
face-to-face treatment is not practical for them, and then to web, you’ll see that
the reach is much greater, of course, for technologies. Web sites can reach many,
many more people, and telephone
interventions. The problem is the efficacy of these interventions is much
weaker. We use the example of smoking: the efficacy is much weaker when you go from
an individual to a technology intervention. On the flip side though, the flip side though, your population level
impact can be much greater with a digital intervention, even though they
don’t work as effectively. So those are trade-offs that we have to make. For
working with someone individually, we’re more likely to help them, but we’re not
going to be able to help as many people because it’s simply too expensive to do
that and there are many barriers to care, stigma, insurance, location, etc., and so we
we have to consider these trade-offs and these are the kinds of things we grapple
with as researchers and that’s why we actually do both — we do we do telephone
intervention and we also do technology. Okay, so here’s the science and this is
what I want you to know about how well ACT is working right now. And before I
get into how does it work and what does it do — so we have a telephone
intervention that was delivered for smoking cessation, and what we found is
at six-month follow-up 100% of people were satisfied with the
ACT intervention and 31% were not smoking at the six-month follow-up. That’s in comparison to about 20% getting a standard cognitive behavioral
intervention. So that was very promising. We we are delivering this in the quitline
context — these quitlines are available in all 50 states, they reach about a half
million people, and they’re modestly effective and that’s why quitlines
are available — it’s that they’re available to so many people, even though
they don’t they don’t have high quit rates, they reach a lot of people and
they can be delivered very cost-effectively and very briefly. Every
state has a quitline. So we are — I just quickly show you — this is
how we set up our original study. Basically we took 121 people and
we randomized them to get 5 telephone calls, and we follow them at three and
six months. That’s what basically this chart is showing. You’ll see that
people were very engaged in the ACT program as compared to the CBT program. They completed an average of 3.25 calls versus 1.69 in the CBT treatment and about half completed the whole program
versus only 5% for the comparison group. They were very
satisfied, as I mentioned before, in the ACT program, and more satisfied than in
the standard program, and then this is the quit rate I showed you before: 31% vs. 21, 22% that I referred to before. These
are some subgroups — so this is another way you can look at ACT is that we’re
reaching people who are having challenges that are mental health
challenges or challenges with how they’re coping with cravings. So, for
example, people who are depressed they do three times better in the ACT program: 33% success rate versus 13% success rate in the
control group program. If they started out in the program being
depressed they actually benefited more from an ACT program for quitting smoking than for the standard program. So that is leading us to do a very large
study right now that I’ll just say we we were fortunate to get funding to do a
five-year study and we are enrolling 1200 adult smokers. We’re
following them for a year and we’ll know the results of that study in about one
year. Okay so the next thing I just want to briefly touch on, to give you some
context of the science, is our web-based program webquit.ord. Webquit.org is
a program that is an ACT-based website and here’s this the front page of the
website where it shows you leaves on a stream — that’s one of the exercises I’m
going to be showing you in a little bit– it teaches you how to be with your
cravings and let them pass on their own, helps you track progress. WebQuit.org
will be launched publicly for free to anyone in the world who would
like to use it — the Fred Hutchinson Cancer Center will be, is sponsoring a
public launch that should happen in about a year — we’re in the phases
now of planning this public launch but we we conducted a very large study of
2600 people and we followed them for a year and we found that 24% we’re
not smoking at the 12 month follow-up. For a free website, that’s excellent. A typical website only helps about 9% of people. And as you probably are aware
from your own practice, it’s very common that people who might be coming in
to see you for, for example, for alcohol use or other drug use, it’s very common
that they’ll also be using tobacco. This is a very simple way of being able to
give them a resource for free that can go along with your treatment and help them be able to quit smoking. So like I say, webquit.org —
we’re looking to launch it in about a year, it will be free. I’ll just quickly
show you the people here from the website were satisfied with the program. They tended to be more satisfied than the comparison program, which was the US
government smokefree.gov. People like the program, the idea of letting your
urges pass rather than trying to ignore them, and then some mindfulness exercises
that I’m going to show you in a minute. I won’t go into detail about the
quit rate, just that basically even people with bipolar disorder or
who were depressed at baseline did almost as well as the people who were
not depressed or bipolar, who were the just the general sample of the study,
because this study was for anybody who was wanting to quit smoking. That was
amazing. My colleagues Noreen Watson and Jamie Hefner are publishing papers on
very issue right now, but it was really astounding to us, because typically
people with depression and bipolar disorder do worse, they don’t do as well
in treatment, and we’re finding they did just as well from the website as
compared to those who did not have these disorders. I won’t go into too much on
this, just that the ACT program is helping people cope with their urges,
they’re helping them let their urges pass, that’s basically what this slide is
saying. So the public health significance is that if you gave this program, the webquit
program out to a million people, you’d help 240,000 of them to quit smoking. That’s astounding and that’s the kind of impact that we’re excited
we’re able to make with programs like the webquit program. The last thing I
just want to touch on is our, where we have some apps — if you’re
interested in them you can go to — there’s a company
called 2Morrow, that’s the number 2-morrow, and they have a
program called 2Morrow Quit — it is based on our ACT program for smoking
cessation. They licensed this app from the Fred Hutchinson Cancer Research Center. I
have no affiliation with them, I don’t receive any funds from them, just do the
research on it and then that gets licensed from the Cancer Center. What I
wanted to tell you though is that we have the I Can Quit program, the Quit2Heal program, that we’re now testing and this is some screenshots of what they
look like and so far people have been very satisfied with it and we’re getting
some very promising short-term success rates from that. But it’s basically a
level program, that’s called a gamified program. You learn about your urges,
you learn how to cope with them, let them pass, and then you focus on what’s
important to you that guides your quitting, your values, which I’m gonna
show you. Okay so now now you’ve gotten the background, you’ve seen there’s a lot
of scientific support here for ACT for addiction, particularly for smoking
cessation. Well, how does this work? What
is this thing? Maybe you’re curious about it, you’ve tried it, or you’ve heard about
it, or you have a colleague who’s tried it. So I’m going to just introduce first
the concepts. So if you imagine that every day,
we live our lives we have choices. And imagine you’re at a restaurant or you’re
trying to decide what to eat and we have a choice. For lunch we can eat the fried
chicken or we can have the salad. And those choices can be guided by
what’s going on in our heads, our thoughts. So you might decide, you might
be thinking I’m tired, I’m stressed, right, craving, or hey, I’d like to have a drink
right now, and so you can respond to those thoughts. You can also respond to
how you’re feeling. You may be feeling happy, may be feeling excited or sad or
angry, and those choices are also guided by our cravings in our body. So what I
mean by that is you may be feeling hunger in your mouth or craving
in your mouth or you may feel something in your chest or you may feel something
in your stomach and so those are factors inside us that can influence our choices
about whether I’m going to have the chicken or I’m going to have the salad.
And the the problem, though, is that our thoughts and our feelings or cravings,
they can deceive us, they can tell us “I really need a doughnut right
now” or “I really need a drink right now” even though we may not really need a
drink right now or we may not need a doughnut right now. And so when we focus
just on what our thoughts and feelings and cravings are and we take them
literally, we take them for what they say, we can make choices that are not helpful
to us, that are not effective choices, or choices that are harmful to us. And so
there’s two answers to how to deal with this problem of the deception of our
thoughts, emotions, and our sensations, and the two answers first come from
how to be willing to have thoughts, feelings, and cravings come and go
without acting on them. And I call that “willingness” — that’s also referred to as
“acceptance” — and the other way to talk about it is to just let thoughts,
feelings, and cravings come and go, to let them be there, to open up to them, to just
let them pass on their own and come and go without trying to push them away,
control them. Now I’m not talking about willpower. So I do use the word
willingness, and a lot of people say, oh you’re talking about willpower. It’s not
about willpower, it’s about the will to make a choice about what to do with
these internal experiences, our thoughts feelings, and cravings. And some of you
may connect this to mindfulness, and say oh, this is mindfulness. Well it is and it isn’t. Mindfulness is one way that a person can be willing. So you can
practice formal mindfulness, you can do seated meditation, but you don’t have to
do those things to be willing. You can allow a thought to come and go without
practicing any kind of formal mindfulness. So for some people, this is a
relief because mindfulness can seem intimidating or spiritual or it’s just
plain weird, and for other people this is actually very encouraging, because they
may be already be doing mindfulness and they’d say, oh, I can plug ACT into my
mindfulness practice and it makes sense to me. So either way, you can go either
way. Sso you don’t you don’t have to be mindful in order to do ACT, but certainly
mindfulness is is a tool that’s part of the pathway to being to be
willing. And why is willingness so important? Now I talked about this in my
TED talk — I’ve given a TED talk and you can look it up. It’s called “The secret to
self-control,” and you can find it on YouTube really easy, just enter “The secret to
self-control” or you enter my name and you’ll find it. And willingness is so
important because it helps us see the choices really clearly, and so if
you’re really, really focused on the thoughts in your head, and you’re
thinking, oh, I’m tired, I’m stressed, I’m craving, a drink sounds really good, and
that’s all you’re looking at — so we would say you’re looking at the world very
literally, you’re paying attention to these words as if they are truth — it’s
really the world in front of you gets blurry, the things that matter to
you get blurry, you don’t see them as clearly because you’re really, you’re in
your head. On the other hand, if you look on the right hand side, if you just let
these thoughts go to the background and just kind of let them be there, they
become kind of blurry, and the things in front of you become very clear. The
things that really matter to you become very clear. And so it helps you see the
things that matter to you really, really clearly. That’s why willingness is so
critically important, to help you live a life of meaning and purpose. Now the
second reason why the choices matter and that there are two ways to really deal
with these internal experiences we all have, thoughts, emotions, and sensations, is
that we can focus on our values. And as I just referred to, now you have things in
front of you that really really matter to you and they are our personal mission
statement, they are the things that guide us, they are the things that that lead us
to make really, really important life choices, like the choice to become a
chemical dependency counselor, or the choice to be helping others, or to be in
a service profession. That comes from a place of deep values that is inside us. And so some common values that people will often say are to take care of their
body, or to love their family, or to help out the next generation, like
grandchildren, or to do some kind of meaningful work. And so it, over time, you
can begin to help a person put to words or even a picture what they really
really care about, because that guides the choices that we can make in everyday
life. We all have values, it’s just about being able to articulate them, see them
clearly, so that then our actions align with our values. So the simple equation I
put together is being willing plus acting on your values leads to life
affirming choices. It leads to life affirming choices. That’s a really
important equation because it just puts it all together. And those
life-affirming choices, they could be focused on what you eat, whether or not
you decide to use, whether or not you decide to affiliate and spend time with
people who are using. Those are choices that you can make every day, and those
choices are either moving toward what’s important to you or moving you away from
what’s important to you. And in ACT, we’re really trying to help people move toward
what’s important to you and really make what we would call life affirming choice . Now
ACT often uses visuals to communicate and this is a visual I love to use to
quickly communicate what ACT is about. So we see this gentleman moving in a value
direction. He’s steering his motorcycle in a direction. So it’s his compass
heading, it’s the direction he is heading in in his life, and, like all of us, he’s
got baggage, he’s got stuff in his sidecar that he’s got a make room for. And so he’s found a creative way to make room for his baggage. Now you might be
wondering to yourself, well, why doesn’t he just cut off that sidecar so he can
go faster, so he doesn’t have to have a have a load to carry, and, well, in the
physical world, you can do that, you can choose to unhook the sidecar and drive
the motorcycle around and lighten your load. In the world inside our bodies, the
world of thoughts, emotions and sensations, that doesn’t work. So trying
to suppress our thoughts, trying to think something else, trying to not notice pain
that we’re feeling in our bodies, trying to ignore craving, what that will do is
create a paradox, or an ironic process, or a backfiring — kind of like, the more you
don’t want it, the more you get it, so if we try not to think of cravings, if we
try not to think about how much we want to use, we can actually get more thoughts
like that coming back. And a simple way to illustrate this we can do during the
Q&A, if you like, together in an experiential way, is trying not to think of a white bear. If you spend 30 seconds trying not to think of a white bear, find
out what happens. I won’t give you the answer but just experience that. And
that’s a very common way to try to illustrate ACT ideas is not just words
coming out of my mouth as a presenter or your mouth as a is a counselor or
facilitator, it’s more about letting the participant, letting the client or the
patient experience that on their own. And so having them do an experiential
exercise like the the white bear exercise is a great way to be able to
illustrate the idea that what works outside in the physical world doesn’t
work inside our bodies, and that the more we try to push it away, if we try to
metaphorically cut off that side car, we actually don’t make the progress we’re
hoping to make, we actually end up backfiring and often
getting more of it. Okay so getting into the practice. There’s a
really important theory that guides ACT and I know some you wondering, you see
the word “theory,” you say, oh, jeez, theory, theory, boy that’s that seems really
heavy, and what’s this thing called relational frame theory? Now to learn ACT,
you do not need to learn relational frame theory, I will say that. However to learn ACT in a more deep way, and to really make it a part of how you
see yourself as a therapist and how you work as a therapist,
it is important to learn about it. So I do want to just give you a really brief
take on what is relational frame theory and how it relates to ACT, because even
if you’re learning ACT in a more casual way, you’ll hear people who talk
about ACT throw around RFT, or relational frame theory, and you might save yourself
well what’s that, I don’t know what you’re talking about, that’s all that gobbledygook. And I want you to be able to understand a little bit of the gobbledygook, so that you’re in on it and that you’re you’re able to understand what’s
going on. So I just briefly explain this, so imagine that someone is having a
physical urge. Now that urge gets connected with things we do and
things we feel inside. Sso we might take a break when we have urge, we might go have a
drink when we have an urge. Those are things you can see people doing, so those
are things we do with our hands and our feet: we go take a break and we’re drinking. But we also have a thought in our head, urge, and we
might think, oh, I must be stressed right now. So urges, physical urges
can trigger thoughts in our head, like stress or
urge. It can trigger other words too; these are just examples. Now in the case of
someone who, let’s say, is smoking — they could be smoking marijuana, they can be
smoking cigarettes — that thought, “I have an urge,” or that or the thought, “I’m
under stress,” can get connected to a whole set of behaviors like tasting,
holding, inhaling, smelling, and reaching, lighting, and exhaling and
ending — all the sequence of things we do when we’re smoking, we’re
smoking cigarettes or marijuana or something else. So there’s a whole set of
behaviors that then gets connected to a thought like, oh, I’m going to go and
start lighting up right now because I have a thought, but I have an urge. The
problem is, well, when that’s all we’re doing, we’re really caught up in our addiction,
it pushes us away, so you see those dotted lines from living the life that
we value, so living, say, your, if your value is living a healthy and loving
life, which may get connected to doing things like exercising or taking time of
your family, since there are values lead to certain activities that are
consistent with our values, we get a little disconnected from them. So I say
this web, this web of addiction occludes or it gets in the way of living a valued
life, and so that’s the consequence of how we get caught up in this web. So the
answer that ACT has to this phenomenon, to this problem, is to help break free
from the web. So to turn a dotted line to a solid line, meaning to get
connected to your values, you get connected to living a healthy life, to
exercise, to time of your family, to to really doing values-consistent
activities so that you’re not connected to this web. Now what I’m also saying is
that these web of connections are always there, they’re always going to be
connected, so an urge may then be in your life become connected to taking a
break or feeling stressed or drinking and that may get connected to reaching
for a cigarette, lighting up. That history is always there. So we say that that
behavior is historical, so you can’t erase history. Instead what it does, what
you’re doing when you’re doing ACT, is you’re building a new history,
you’re building a history of doing the things that really matter
to you that don’t involve using the drug, your drug of choice. Okay so as I was
saying you know that life gets really — if you’re caught up in the addiction, the
web takes over your life. All right so that’s just a really brief overview of
relational frame theory. No more theory talk, let’s get into the skills. Okay so in our group when we do ACTwe follow five steps and so it’s:
helping a person make a plan, it’s helping them be aware of triggers, it’s
helping them be willing, it’s helping them be kind to themselves, and it’s
helping them stay inspired to really live their values. So I’m gonna walk
through each of these steps. Okay step one is making a plan. So what you would
see here is what is it that’s really, really important to you as a person. So
you ask your client this you know what really matters to you, how do you want
people to remember you when you turn 80? What would you like written on your
tombstone? What would you like people to say about you when you retire or you stop working? And so those are just some practical ways to start to get
out, you know, what matters to you, what matters to you, what kind of family you
want to have, what kind of relationships do you want to have, how do you want to
spend your money, if you had more money, how would you spend it. Those kinds of
questions really quickly get at what matters to a person. You use values than
to set a goal and for addiction that might be harm reduction or it might be
abstinence, and then set a target date –when do you want to reach that end point? Now
if if, depending on what setting you’re in, you may use medications, you may not,
and it just depends philosophically where you are and where the client is,
but it’s an option and so if that’s a conversation, you can talk about how it
can help the cravings and withdrawal. We also emphasize, as many therapies do,
about talking to your inner circle, who’s in your inner circle, what do you want
them to say, what do you want them not to say, do you want them to come to sessions
with you, how do you want them to support you? So that they’re actually not derailing you from your treatment goals. And so what you then do is you start
this planning session and for homework you’ll have the clients complete
something for the next session. So this looks a lot like a standard
cognitive behavioral treatment for addiction, with the key difference being
we front-loaded with values. So you might say oh this looks really similar — it is. The difference is we’re talking about values first to guide those
goals. Then things start to move a little bit more away from the standard program. We do we call trigger tracking. We start with the outside stuff — everybody can
talk about what’s going on around them, oh, I drink when I have an argument, I
drink when I’m driving I drink when I’m eating, I drink when I’m at a bar. Anything you’re doing that’s outside, those are usually easier things to notice. And
then you start to move inside — that’s a little harder for someone. Maybe when
you’re stressed, you’re bored, or you’re guilty or you’re ashamed or when
you’re happy or excited, you can begin to feel and differentiate these different
types of emotions that we feel and if they need it, helping them understand
what these different emotions are, since some people may use these words but they
don’t really know what they mean or know what those things feel like, and then the
physical sensations where in your body do you feel craving before you’re about
to drink or use your drug of choice? Maybe it’s your chest, your stomach, your mouth, your throat, those are common. Then it
gets a little bit harder, and that’s why we build up to it, is we begin to ask
them what’s going through your mind? Sometimes people say, oh, I don’t know, I
just use, you know, I just get together with my friends and use, I’m not really thinking,”
and so just really want to slow that down, look at what’s going through your
mind, like maybe you, like, just before you’re trying it, what might have been
going through your mind? And usually as people start tracking situations,
feelings, and sensations they naturally get to the place where they say, yeah, I
guess I was thinking something. So they might think oh I’m just going to have
one, or they may be very self judging, and say, oh, I’ll never change so I can’t do
this. So this is a really important part of the treatment, because you can’t be
willing without being aware. You have to be aware of these internal experiences
of feeling, sensations, and thoughts before you know what to do with that. And so it’s important in your sessions and for the homework, you try to help
them notice what was just before they had that urge, just before they used, what
were they doing? And we use a triggers checklist to help them with that and we
ask them to track at least daily, at least three times a day, if they can, for
a week. Now of course it just depends on your client, your setting, but
this self monitoring or trigger tracking is super super important. We always get
people saying after a week, saying, you know what, there were things I noticed
that I didn’t realize I had. I didn’t realize I had thoughts before I used. I didn’t realize
I had feelings before I used, I thought I just used. And so they discover really
important things by doing that. Now we’re getting even deeper into the ACT
part, that’s really different from all other therapies, is the willingness part. And there are lots of stories and metaphors to illustrate it. There’s a
book I would recommend if you’re curious about ACT for addictions, it’s called “The Wisdom to Know the Difference” by Kelly Wilson, “The Wisdom to Know the Difference.” So here’s an example of a very common ACT exercise, and it’s
called the urge monster and you imagine that you’re in a tug of war with this
monster, it’s the urge monster, and the more you pull, the harder the monster
pulls back, and if you’re trying to push away a craving, the monster just comes
back with a bigger craving, and so that’s an important reaction for people to see. It’s like you’re pulling, you’re trying to get rid of it, and it comes back. I illustrate
this in the TED talk on stage and it’s just to help illustrate
what’s going on when you try to push your urges away. Now the flip side of
that is to drop the rope. You don’t get in this tug-of-war anymore. And what drop
the rope means is that you’re not giving in to your urges, you’re giving up the
struggle with them and just letting them go on their own without trying to push
them away or do anything with it. I know that’s easier said and done, but it’s
really important, it’s– the crux of the therapy is learning
how to let urges pass. We have learned in our research that people who let urges
past are 11 times more likely to quit tobacco use. This applies to other
substances as well. So this is the meat of it, it’s the heart of it, it all
happens right here is letting your urges pass. Urge monster is a nice example;
there are lots of ways to illustrate the idea of letting the letting yourself
just drop the rope, but it’s it’s absolutely critical, it’s really what
defines ACT unlike other therapies. There’s another example of trying to be
willing and it’s a really straightforward question, it’s 0 to 10, how willing are you
to have craving? Or how to willing are you to have your craving and let it pass?
I’m not willing is 0, 10 I’m completely willing. It’s a really important way to monitor
how you’re doing as a client in terms of letting these
cravings come and go. Can you make room for them if willingness is low? The
question I love to ask people is: have you ever done something important that
was really hard to do? And people might talk about maybe raising a child, or
finishing a program, or school, or something like that. Willingness is like
that — it’s being willing to do something really really hard but it was important. So for homework, I often ask clients to rate their willingness to have an urge
and then rate it again so that they become, it becomes a way of living, really
living and breathing. Willingness is the heart of ACT. Another nice example is the
five senses — it’s a really simple exercise, for sixty seconds
you notice five senses, so notice one thing you see, you spend about ten
seconds on that. Notice one thing you can touch, notice one thing you can taste,
notice one thing you can smell, then wait about five to ten seconds, notice one
thing you can hear. Now what that helps people do is
to get out of their heads, and get out of whatever craving they’re feeling, and see
the larger picture. To see that our sensory experience, our everyday life, is
much much greater than simply the craving, or simply the thought, or simply
the anger we’re feeling toward someone. There’s a much larger experience going on,
there’s almost a rainbow of experiences going on, and this simple exercises helps
you see all the colors of that rainbow, the sight, the touch, that taste, the smell,
and hearing. That’s why we would do such a simple exercise, and yet so
powerful. Okay another example of being willing is leaves on a stream. This is a
classic exercise from ACT, you can see in almost every ACT book, and by now
there are about 75 different ACT self-help books that are only on the
market. Leaves on a stream. So in this exercise you close your eyes
and you imagine that you are seated beside a gently flowing stream
and on that stream are leaves and on each of those leaves are your thoughts. Let those leaves gently float down the stream as you sit on the side of the
stream just looking out and just watching those leaves with your thoughts
on it gently pass by and drift off. And if thoughts keep coming back, putting
those on a leaf and let each leaf gently float down the stream and go off into
the distance. And so you do this and then you go silent, and if we were
working together in a therapy session, we would go silent for about one to two
minutes, just as a client with our eyes closed or looking at a spot, just lets
these thoughts go on their own. So I’ve given you a snapshot of
some common willingness exercises. I want to just briefly talk about kindness. Kindness and self-compassion is a piece of ACT that has come more recently and
it’s actually taking from another therapy called compassion focused
therapy. And there’s related therapies and self compassion therapies. And it’s a,
I call it a close cousin of ACT, it fits the ACT model really nicely. So we
have integrated it into our programs for smoking cessation because when people
are trying to get over an addiction, there’s an incredible amount of shame
and self-loathing that comes with it. They feel very judged by family, by
society, by the laws that are placed that are designed to protect the public but
have a flip side of alienating and shaming people with an addiction. And so
there’s the shame you bring on yourself, self-criticism, and then
there’s the, really I’m referring to as stigma, that, the outside, the
societal judgment of your behaviors. So that’s why we brought this in and why
it’s so important. So here’s an example, it’s called, “you deserve kindness.” It says, and I say, we attack ourselves all the time, and you give some examples, you know, “I’m not able to stop drinking, what’s the matter with me, I’ll never be able to do
this.” And so you ask yourself, is this really helpful? Is this kind of attacking
helpful. Honestly, to say this to yourself, is it really really useful, is it really
really getting you to change your behavior, or is it actually getting in
the way of changing your behavior? And so really take a moment to kind of reflect
on that question. And then I would ask, well how would you like to spend your
time? Would you like to spend your time attacking yourself or doing things that
matter? And most people say doing things that matter. And so it’s just helping you break loose of the cycle of attacking yourself and
seeing that this is actually not helping the problem of your addiction and
helping you live the life that matters. So instead how can you be kind to
yourself, what could you be doing to be kind to yourself? It doesn’t have to be
something complicated. It could be taking a walk, it could be taking a break,
it could be closing your eyes and noticing your breath for one minute. These are really simple things that anyone can do at any time of the day
that are really short. There are little small or micro acts of kindness and the
reason why is because you matter, you are worth it. And so that’s
an example, and we have lots of examples, but this is one that is a popular one. Here’s another one called “time to forgive.” We are always attacking
ourselves for things we’ve done. We attack ourselves for the choices we’re
making, from relapsing, and we can forgive. So imagine you get your wisest
and kindness self, can you look at what triggered your choices? Can you see the
context? Can you see that maybe your friend came over and brought alcohol or
brought drugs over? Can you see that maybe you were having a really difficult
day, that someone left you, that you had a serious argument with someone,
and can you understand that in the context of that, that made sense
that you might have slipped and relapsed in this situation? And once you see your
context and you can see that other point of view, you say to yourself, “I forgive you.” You can put your hands on your chest and you say, “I forgive you.” You
repeat it three times: I forgive you, I forgive you, I forgive you. It’s really
really powerful and you can see people feel emotional when they say this to
themselves, especially if you’re guiding them, you’re saying it with them, it’s a
very powerful moment clinically and it is a way to burn lift the burden of this
incredible judgment that people feel for their choices about their
drug use. Okay just in the interest of time, I’ll just briefly say this is
another self-compassionate exercise for slipping. Imagine you have a cute puppy. It’s scared, it’s stressed out, maybe it almost got hurt? How would you deal with
this puppy? You would be reassuring, of course, you’d be comforting. And maybe you like cats, so you can do it with cats. Would you give this puppy a beer? You know of
course not, you wouldn’t give your puppy a beer. So but would you do that to
yourself, and your stress? Notice how you treat yourself when you’re stressed. So
you flip perspective — you wouldn’t give a puppy a beer, so why would we do that to
ourselves when we’re stressed? And that really is thought provoking, gets people
seeing like, oh, can we treat ourselves as well as we treat the puppy. And that’s
all I’m gonna say about that exercise. It’s very provocative and gets people
really thinking about perspective-taking and self compassion. Okay finally,
throughout our program, and I would I would encourage you is if you’re
learning about ACT and practicing ACT, then you you pepper your sessions, if you
well, with with values. So you bring values in as much as you can. And there a
couple ways to do that in addition to the ones I’ve Illustrated. You may ask
someone, what really matters to you, what you stand for, what kind of photos you
have for inspiration — often people will have photos up there of their partners
or of their children or some kind of symbol that represents the life that they idealize,
the life they want to live — and what would that life and look like?What would
you be doing every day? What kind of actions would you be taking every day?
Because values are abstract and sometimes people have trouble seeing
them or they’re just not comfortable thinking about their life in this
abstract way. So you can say, well, what would you do that would be living the
way you want to live? And then you can go back to, like, oh, that must show to me
that you you value caring for others or giving to others or connecting with
other people, because you want to spend time with your friends, or things like that. So so to kind of move back and forth between these really
reactions to more abstract ideas about values and then back to the to the
concrete and back to the abstract. It’s an important thing because, I won’t get
into the relational frame theory, but there’s there’s something really
powerful going on in there in the background. You don’t even have to name it,
but if you can go back and forth between the, you know, these kind of high-level
things, you know, what I care about, how do I really want to connect with people,
to actions like I want to spend time with my friends,
it does something really powerful for the mind. Okay
the last thing I’m just going to cover is about the letter from the
future and this is a relapse prevention exercise. Imagine it’s 10
years from now, you’re sober, what wisdom would you like to share with you, the
current you? So what would your letter from your wiser self look like to
your current self? And so some ways to help you get thinking about that. And I
would encourage it you do this first as a talking exercise. You can talk it
through and then you work on writing it down. That’s often much easier for people
to do. What tools from therapy would you suggest to your younger self? What would
your wiser yourself give as encouragement? What kind of kind words would your wiser
yourself give? What has your wiser self learned 10 years from now that
your younger self could listen to and hear. And so you can write that together
or think that through together. It is important in the end that it be in writing —
it doesn’t have to be fancy writing or long paragraphs. It can be telegraphic. It’s
that it’s in writing and there’s something permanent about writing that
really makes an exercise powerful. That someone can come back to and look at and
say, wow, those are my words. These are the words I am speaking to myself
as I’m now in the midst of feeling like slipping or trying to recover from a
slip. And so that’s the letter from the future. Okay so I’ll just
briefly say from an ACT perspective, motivation is purely optional. You don’t need motivation to change. It’s a really provocative idea but it’s
really about what actions, that’s what matters. Knowing your values is what matters and taking actions is what matters. And of
course in the 80s, maybe without realizing it, but Nike gave the
slogan for this which is, “Just do it.” Okay, so in summary the five steps can be summarized with this BREAKS metaphor. Put on the brakes,
read what’s there, notice your triggers, expand and exhale, allow everything to be
as it is, and be kind, to know what matters to you, and ask to step in
that direction. Just do it. Now okay, so that is the end of the presentation
and at this point I would be delighted to take your questions. [Dr. Carlini] Okay thank you so
much. This has been really really good. Before we take the questions, and thanks
so much, you’re gonna get a survey in your inbox. We’re gonna send it now, just
after this, and then we’re gonna send it again in a month. We need that. This is
what keeps our program running, collecting here your take on it. Appreciate it so much. It’s quick. And we are going to now go for, let me see, okay. So now we are gonna take the questions and go to see what people think. I see one question about
the PowerPoint, and yes we are going to get the PowerPoint to you, as we said in the first slide. I’m trying to
understand some of the questions here. there is one question about what
“gobbledygook” is? What’s gobbledygook? [Ms. Brunner] I think it’s just a word that Dr.
Ricker used — What does gobbledygook mean? And someone later said I think it just
means “jargon.” [Dr. Bricker] It just means jargon. So one of the challenges of, so one of the
challenges of trying to explain something to someone and say, oh it
sounds using lots of big words. I highly encourage you need to try not
to use a big word. Try to use a $1 word instead of a $5 word, because you don’t
need to use big words to get an idea across. And so jargon gobbledygook, psychobabble, these are just ways of saying we don’t
need to use fancy language to get across these ideas. These ideas are powerful, and
actually the best way to learn ACT is by having people just experience what
you’re talking about. So having them do leaves on a stream for example, or the
five senses, that is a much more powerful way than you explaining it. And so that’s
that’s what I’m getting at, is really take that framework — and in
the TED talk I I kind of jokingly refer to that as well, because I think it’s a
really important thing so that it’s not alienating and it creates more
inclusivity. So if people really feel like you’re
talking with them and you’re really connecting with them when you explain
these ideas, because they’re big ideas, so they don’t need big words. [Dr. Carlini] Thank you, that’s very good and there is one question here about how somebody
can obtain more formalized training in ACT. I don’t know sure where places
you can get this? [Dr. Bricker] Absolutely, yeah, so the first place I would go is the the main website
for the group that that supports ACT and it’s contextualpsych.org — not clearly
named I’m afraid but if you look up contextualpsych.org — or you will find . . . contextualSCIENCE.org. And I know it’s a mouthful unfortunately and I can I can send a
link also to Bia. In there are a wealth of
resources about handouts for ACT, slide presentations for ACT, video presentations
for ACT that our focused on ACT in general, ACT for addictions. ACT for
mental health problems, and so there are so many resources that you can learn
just from there through that website. The other way is on that website is a
list of all the trainings, and the trainings are delivered by people all
over the world. They are delivered at different times just depending on those
people’s schedules. We have in addition an annual conference,
it’s the the main conference — the next one is coming up in in Dublin. It’s international, I mean the ACT community is 8,000 people, professionals,
who are part of this professional society, they’re all over the world, so
usually we meet in different countries depending on the year. And then that’s at the end of June. There will be workshops, many many workshops for
training in ACT. In addition, the year after, it’ll be in New Orleans, and that
will be I believe also the end of June. So go — I would go up to that
website and you can see local trainings, and then the big conference trainings
for if you want to learn more about ACT formalized. And then, as I mentioned,
the book “The Wisdom to Know the Difference.” I think it’s the best book that
practitioners and clients can use for doing ACT for addictions, the
Kelly Wilson book. There’s tons of resources but I’d start with the website —
that’s the best place to start. [Dr. Carlini] Thank you. So we have about three minutes —
so there was one question that I see, it’s pretty much yes or no but, maybe a
little more than that, and then I’m gonna try to get to the last question that I
think needs more. So the question that I think is shortest: until the more
focused apps are available, would you recommend or not the ACT Coach app
available free from the VA? [Dr. Bricker] Yes, you know, I think the broader answer to your question
is I would try it out and have your clients try it out, and if you have
a client who’s using it, I would work sit with them, show them how to download it,
and how to get in it and how to walk through it, because usability is is a big
challenge depending on people’s comfort with technology and skill sets. But
that’s a broader answer to your question. But that app is fine, but it really
depends on the user and so I think it really comes down to your comfort and
the clients comfort in using that particular app. [Dr. Carlini] Perfect. So then there, the last question because we are wrapping up here we have like 1 minute, but feel free to take 2 or 3: will you please explain explain again how willingness
helps you see choices more clearly? Is willingness the same as motivation? Please
say that website again — we won’t say it, we’re gonna send it to you guys later,
okay, so yeah so that’ll be the last question
before we wrap up. [Dr. Bricker] Yeah, so willingness is not the same as motivation. Willingness is about being open to your
cravings, to your thoughts, and to the feelings that you feel. That is willingness and the goal is that if you can be open to
your thoughts, feelings, and cravings, then you can focus. You’re freed up to focus
on doing the things that matter to you. So a metaphor, another way to, often ACT is explained through metaphors, so a metaphor might be: imagine the sky is cloudy and you look up in the sky, you really want to see the
sky, and all the expanse of the sky, the clouds are in the way. Well your thoughts, feelings, and cravings are like the clouds, and so when you’re
willing, you’re opening the clouds, the clouds are opening up so that you can
see beyond the clouds and see like way out there is the sky, the whole expanse
of life, the whole possibilities in front of you. And so it clears things up
for you so that you can do the things that matter in your life. [Dr. Carlini] That’s great, perfect. Well thank you so much again for your participation and your contributions
today, Dr. Bricker, and we’ll finish up now. This is our next webinar, a month from
today, take or give, so our June webinar is going to have CME credit available so
it’s a different thing — we haven’t done that. I encourage you guys to attend. And yeah thank you. [Dr. Bricker] You’re
so welcome, Bia, and thank you everyone for tuning in I appreciate the opportunity. [Dr. Carlini] Okay bye now everybody.

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