A great deal of our suffering is caused by the fact that when we are unable to de-tangle ourselves from our thoughts, we become enslaved by them. From a contextual behavioral science perspective, this is called psychological rigidity and it is the primary target in treatment in acceptance and commitment therapy (ACT).
When working with clients who struggle with addiction, this rigidity can often be seen in the ways people use substances to avoid painful thoughts with which they may have fused. An alcoholic may latch on to thoughts that she is an awkward and unlikable person, which may drive her substance use both in social situations (using alcohol as a social lubricant) and in private (as an emotional pain killer).
In ACT, the goal is to help clients develop a wider repertoire of behaviors that can co-exist along with their difficult thoughts and feelings. Rather than the narrowing effect of psychological rigidity, which typically leaves room only for behaviors that focus on avoiding difficult feelings or chasing pleasant ones, psychological flexibility makes space for a broader set of actions that open doors and make way for new possibilities to live a meaningful life.
“Through psychological flexibility, one can gain a sense of choice and purpose in decision making and obtain an ongoing sense of fulfillment regardless of how he thinks and feels at any given time,” says Nick Turner, MSW, in Mindfulness-Based Sobriety: A Clinician’s Treatment Guide for Addiction Recovery Using Relapse Prevention Therapy, Acceptance and Commitment Therapy, and Motivational Interviewing.
To achieve this goal of greater psychological flexibility, ACT focuses on six processes that can help broaden the scope of behaviors in the face of stress: Acceptance, mindfulness, self as context, defusion, values and committed action.
The following, which is very loosely adapted from Mindfulness-Based Sobriety, presents a brief overview of how each of these psychological flexibility promoting processes can be applied to addiction treatment.
In the therapeutic context, acceptance means being open to everything that the human experience has to offer. This includes the pleasant, unpleasant, and everything in between. This concept may be entirely new to a client, so helping them shift their orientation to one that is more accepting of the full range of internal stimuli can be transformative.
A client who struggles with substance abuse may not even realize the function that substance use has in relation to his/her willingness or unwillingness to accept difficult or painful feelings. Simply helping clients their behavior through this lens may be a significant step in moving toward healthier coping behaviors.
- Present moment awareness or mindfulness.
Mindfulness is popular. You probably know what it is, for the most part. In the ACT context, mindfulness is about flexibly paying attention to the present moment. This term basically means that as thoughts of the past and future compete for our attention constantly, we are able to continuously bring ourselves back to the present moment, rather than getting fused with the things that come up such as regret, worry, self-criticism, or anticipation of future events.
In the case of people who struggle with addiction, an inability to be flexible with attention can lead to fixation on thoughts of the past or future, which can in turn motivate, maintain or exacerbate substance use.
Take for example someone who has repeated self-criticizing thoughts about the time she was arrested for driving drunk. When thoughts about the incident come into her consciousness, as they inevitably will, rather than letting them pass, she latches onto them.
The original shame, guilt, and inadequacy that she felt at the time of the original incident come rushing back. She may spiral into an increasingly painful place, which may motivate her to drink . If she was instead able to flexibly bring her attention back to the present moment when she noticed the thoughts come up, she would escape that potential downward spiral before it occurred.
- Self as context.
We are the observer of our experiences, we are not our experiences themselves. This fundamental concept can be extremely healing for people in treatment of any kind because it offers a way out of the painful experience of identifying with every difficult thought or feeling that emerges over the course of our lives.
Our thoughts and feelings come and go, but they do not define who we are. Perhaps more importantly, they do not need to define how we behave.
But without this understanding, our thoughts and feelings can be extremely powerful influential of our behavior and can drive us to do some pretty unhealthy things. In the case of substance abuse, it is thoughts and feelings that are often running the show.
Over-identification with thoughts and feelings often means that the only road map for living is based on the pursuit of pleasure and the avoidance of pain. This idea is problematic, because it is simply not the way life is.
In fact, as any addict will tell you, attempts to avoid pain tend to have the opposite effect. A client who uses oxycontin to numb out his grief over the death of a family member ultimately creates more suffering for himself, which continues to drive more drug use.
The acceptance and commitment therapy model is different from earlier models of cognitive behavioral therapy in that it does not attempt to challenge or restructure thoughts or thinking patterns. Rather, it asks us to accept that those thoughts and thinking patterns exist (independently from who we are as humans) and to change the way we relate to them.
We’ve covered the dangers of over identification with our thoughts and feelings and how this causes problems specifically within the realm of addiction. Defusion is yet another piece of the psychological flexibility puzzle that encourages people to create distance from their thoughts.
In addiction treatment, defusion can be about creating space between the addict and his emotions, whether they be loneliness, anxiety, inadequacy, shame or any other difficult feeling.
When he is able to separate himself from a feeling of worthlessness, for example, defusion can help him shift the way he relates to that feeling. In the throes of his addiction, he might relate to the feeling by drowning it in alcohol.
But with defusion, he gives himself room to interact with it differently, perhaps with a willingness to acknowledge it and let it be there until it passes on its own. This different way of connecting with an emotional experience can make an enormous difference for someone in recovery.
Values are like a compass. They are the answer to the question, “but why do all this?”
The things that matter most to us can be the biggest motivators for change, but it can be all too easy to lose sight of what’s important, especially when we’re on an agenda of constant pleasure-seeking and pain-avoiding.
It’s crucial that recovering addicts identify for themselves some concrete reasons why they’d even want to go through the trouble of doing the work of adjusting the way they relate to their thoughts and feelings. It is work. It takes practice, persistence and commitment.
“Constructing value-based or value-informed goals can provide concrete and temporal structure, which carries the potential to interrupt behaviors such as substance use,” write Turner and his colleagues.
- Committed action.
Using values as guidelines, people can increase their psychological flexibility by committing to particular behaviors, even in the direct presence of thoughts and feelings that challenge them. Committed action is informed by values and executed with the help of the other processes (acceptance, mindfulness, self as context, defusion).
A client in recovery may value social connection and may set a goal of building a social life that allows her to socialize and interact with people without using alcohol to cope with her shyness and social anxiety.
An example of taking committed action would be joining an ultimate frisbee group, and showing up sober each week to play, even though she might feel scared and anxious in the days and hours leading up to the event.
Whereas her previous attempts to avoid her anxious thoughts left her with just two options — show up drunk or don’t show up at all — her commitment to show up sober and her willingness to allow anxious feelings opened up her life to social connection, something she values. In other words, she has achieved greater psychological flexibility.
Flexible image via Shutterstock.