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Clinical Topics

  • January 27, 2018 11:11 AM | Emily Fell (Administrator)

    Josh Cutler, MSW, LICSW

    I am always eager to learn new skills and modalities to use with clients. Earlier this year I was working with a client on gaining an increased sense of direction in their life, when a colleague recommended that I use some values clarification exercises from Acceptance and Commitment Therapy (ACT). It wasn’t long before I found myself using ACT values exercises with most of my clients - with great success.  I started exploring more of what was available in the ACT model, and was impressed with the approach to cognitive distortions.  Rather than disputing and trying to change thoughts, clients are taught to unhook from them in a process called defusion. I tried these techniques with my clients, who were very responsive.  People started to feel better, faster.  I have since read up extensively on ACT and taken several courses--it has been transformational, both personally and professionally.

    So what is ACT?  It is one of the third-wave Cognitive Behavioral Therapies (along with Dialectical Behavioral Therapy, Mindfulness Based Cognitive Therapy, and Behavioral Activation Therapy).  According to co-founder Steven Hayes, PhD: “ACT uses acceptance and mindfulness processes, and commitment and behavior change processes, to produce greater psychological flexibility.”

    Over one hundred randomized controlled studies have found ACT to be efficacious for a broad range of physical and mental health issues.  Its application ranges from chronic pain to depression, anxiety to addiction, trauma to eating disorders - the list goes on and on.  ACT’s premise is that human suffering is not pathological.  It is normal.  The problems come when our mind tries to fix psychological pain with the same processes that we use to solve other problems in our environment.  When this happens, people lose contact with the present moment and get lost in their minds.  We become preoccupied with avoiding those painful feelings and fall into patterns of behavior (including rumination) that pull us off course or distract from engaging in activities or relationships that give life purpose and meaning. Too often people are disabled by the notion that pain must be avoided or neutralized if they are to move forward.  ACT uses a number of processes to help people to recognize that they have no control over their thoughts or feelings, but they can interact with them in healthier ways, and move forward with what matters in their life.  

    Russ Harris, MD explains that ACT is about “learning skills to handle difficult thoughts and feelings more effectively so they have less impact and influence over your life.”  

    A = Accept your thoughts and feelings, and be present.
    C = Choose a valued direction
    T = Take action

    The six core processes of ACT (Cognitive Defusion, Acceptance, Observer Self, Present Moment, Values, and Committed Action) are used in concert with the goal of developing greater psychological flexibility.  We know that psychologically flexible people are more resilient and better able to handle the inevitable life challenges that come their way.  Therapists are encouraged to call out what they notice happening emotionally in the room, including disclosing feelings that come up for them in session (if it serves the client).  For example, if a client changes the subject when they touch on a painful emotion, the therapist might point that out and gently guide them back to experiencing and noticing that feeling.  As part of this practice, metaphor is used frequently to highlight the way the mind works.  One I often refer to is imagining your mind like a stage show: pain or distressing thoughts might show up on one part of the stage, but instead of focusing attention on battling the distress, you can instead learn to shift the spotlight to more valued activities on other parts of the stage, even while those uncomfortable thoughts and feelings are still present. I have found that ACT’s close attention to context fits well with social work’s person in environment perspective. Unlike more manualized evidence-based approaches, ACT invites therapists to bring other clinical wisdom, skills, and tools into the model.  As long as you are consciously working in one of the processes and your intervention is ACT congruent (i.e. not disputing thoughts or trying to eliminate feelings) then you are doing evidence based ACT, even if the specific example or intervention is not described in a research study or textbook.

    Finally, mindfulness is a key part of the ACT approach.  Its application in ACT is different than other traditional religious and “new age” meditation approaches that I have encountered.  Inner peace, higher consciousness, relaxation, and/or a quiet mind are not the goal - though these are welcome side-effects.  The goal of mindfulness in ACT is to get present so that you can get going with doing the things that matter to you, even in the presence of pain.  Dropping the inner peace agenda has been very freeing for me as I have reengaged with mindfulness practice through ACT.  I sit with my eyes open, noticing what I see, hear and feel; I notice my thoughts and let them go, catch and release.  I don’t worry if they keep coming.  I breathe into my belly and bring my attention into the room.  It isn’t about relaxation.  It is about being present.  I find that clients respond very well to this approach, especially those that have been unsuccessful with meditation in the past.

    I am just at the beginning of an intense immersion in this approach.  I would highly recommend it to anyone looking to develop their clinical skills with a concrete set of tools and strategies that can readily be tailored to your own unique approach - I believe that ACT has made me a better therapist and a better human.

    These are some books and resources that I’d recommend:

    • The Happiness Trap and ACT Made Simple by Russ Harris, MD (his online course is also excellent)
    • The ACT Approach by Timothy Gordon, MSW
    • Learning ACT by Jason Luoma, PhD
    • Get Out of Your Mind and Into Your Life by Steven Hayes, PhD
    • Things Might Go Terribly Horribly Wrong by Kelly Wilson, PhD
    • Association for Contextual Behavioral Science https://contextualscience.org/
    • YouTube has many lectures and clips of ACT in practice; check out the Praxis channel to start.
    • Praxis offers expert live training: https://www.praxiscet.com/events


  • January 27, 2018 11:08 AM | Emily Fell (Administrator)

    Lara Okoloko, LICSW

    Stigma and shame are favorite topics of discussion in addiction circles. They are two sides of one coin: stigma resides within society and  shame is its internalized shadow, lurking deep within the person with the addiction. Addiction providers, myself amongst them, are always wondering how we can “end the stigma” of addiction and how we can dislodge the shame that sabotages treatment for our clients. Why does such a virulent strain of shame so universally afflict people with substance use disorders? How can I, as a therapist and an advocate for systemic change, work to diminish the power of shame and stigma for people suffering with addiction? 

    Renowned trauma therapist Janina Fisher believes shame comes from a fear of rejection. Speaking at a recent conference, she demonstrated the posture of shame for her audience: chin to chest, shoulders slumped, eyes cast down. In the animal kingdom (and we are animals too), it’s a posture of submission, useful in evoking generosity in the other: either pity or empathy, or forgiveness. The tendency towards shame resides in us to serve a purpose, securing our place in relationship, family, or community when those bonds are threatened. I remember the first time I saw this shame posture in my toddler. I scolded him for something unmemorable and his whole body slumped like a rag doll as he fell to his knees, his shoulders curling around his thighs. I remember the weight of him limp in my hands as I tried to lift him to look at me. His eyes would not meet mine. I was instantly distraught – any annoyance I had while reprimanding him evaporated.  In its place was a desire to pull him close, reassure him and mend the tear in the bond between us. His shame was immediately effective at evoking my forgiveness. 

    Addiction is brutal on relationships. Often, as the substance use demands more and more dedication, the addicted person functions less and less elsewhere, not only at work or school but as a friend, partner and parent. Loving family members may pick up the slack, over-functioning for the addicted person, creating an imbalance which breeds resentment in the family. Finding it difficult to say no to overwhelming needs and requests, loved ones feel manipulated and unappreciated. The relationship is strained by the demands of the addiction. 

    Recognizing shame as a fear of rejection makes sense when you consider the risk to an unbalanced relationship. Fear of rejection is made worse by the narrative of detachment that dominates advice to friends and family of people with substance use disorders. When you have a life-threatening disorder that seems to have really gotten the better of you, the risk of being ostracized by your support system is terrifying. Of course everyone benefits from having boundaries in relationships, and has a right to say “no” to help they don’t want to give. But this refrain about detachment is unique to addiction, even though loving someone with depression, dementia, traumatic brain injury or PTSD, can be equally exhausting.

    “Kick them out!”

    “Quit enabling!”

    “Detach!”

    “Let them hit rock bottom!”

    These are the chorus lines of an anxious song, lines sung to every person who loves an addicted person. The sentiment that family involvement and closeness is damaging to people with addiction extends beyond the family into the treatment rooms. Or maybe it’s the other way around. Did the mindset originate in the treatment rooms and then infect the family? What better metaphor for familial detachment could there be than termination from treatment?

    Addiction is the only disorder I can think of in which symptomatic patients who are having trouble finding remission are terminated from care rather than given more – or different - care. Certainly someone who wants to stop attending group because abstinence is not currently their goal, or wants to stop therapy (especially for trauma) because it’s too painful, inconvenient or unhelpful, should have the right to stop. But I am not talking about that; I am thinking of people who want help changing their relationship with substances but have not yet achieved their goals of abstinence or reduced substance use. 

    I am thinking of the person whose emotional or physical discomfort drove them back to the street after 24 hours of medically supervised detox, whose motivation returns but is then refused re-entry into treatment because “We aren’t a revolving door.” I am thinking of the person who is asked to leave out-patient group despite months of success at abstinence from heroin because their  urine screens are positive for marijuana. I am thinking of the person who wants to reduce their problem alcohol use, but won’t be allowed into a treatment group because they can’t or won’t agree to abstain completely. I am thinking of the person in rehab who leaves AMA with urges to use that feel insurmountable, and returns within hours of relapsing, remorseful and ready to recommit to treatment, only to be asked to pack a bag and leave. 

    Journalist Johann Hari proclaimed in his popular TED Talk that “The opposite of addiction is not sobriety; the opposite of addiction is connection.” While his may be an overly simplistic view of the complexity of addiction, it’s a useful idea that resonated with millions of viewers. Hari’s Ted Talk came on the heels of Dr. Gabor Mate’s best seller on addiction, “In the Realm of Hungry Ghosts.” Dr. Mate urges us to ask not “why the addiction?” but “why the pain?” Mate would say that the pain of people with addictions almost always comes from attachment trauma – rejecting or abusive early relationships. While his theory may be just as narrow as Hari’s, both Mate and Hari recognize of the role of connection and relational attachment in addiction, and it has struck a  chord with people. 

    What might it look like if we truly recognized the power of shame in addiction – the fear of rejection and disconnection? What would empathy and connection, as a response to relapse, look like in the context of addiction treatment? 

    I dream of the day when we pull people closer into therapeutic care when they are symptomatic rather than cast them out; when we spend more time in counseling rooms creating a safe space for vulnerable self-disclosure about patients’ use rather than spend energy rooting out hidden substance use; when we use words like person-, patient-, client-, father-, woman-“with a substance use disorder” instead of addict, alcoholic, crack-head or junkie; when we stop urging families to “Kick ‘em out and let them hit bottom” and instead support families with quality, accessible, affordable care for their loved ones (and maybe even a casserole or a card);  when we let each family identify their own limits of closeness or support; when we provide “caregiver support groups” for families of people with substance use disorders to learn self-preservation skills and limits, rather than “co-dependency” workshops that preach detachment and tough love. As long as we keep rejecting people with substance use disorders, we should not expect to make much progress in reducing stigma and healing shame in people with substance use disorders. 


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