12 Steps 4 Values: Utilizing Acceptance and Commitment

Therapy to Diffuse Resistance to Recovery

Bruce Singer, Psy.D.Chief of Psychology

Crossroads Centre, Antigua

Disclosures:

Bruce F. Singer, Psy.D., has no financial relationships to disclose.

What Causes Resistance to Recovery?

Roadblocks to Recovery

• Denial (of the problem)• Fear (of failure)• Hopelessness (repetition)• Loss (Avoidance)• Belief (in failure)• Doubt (about spirituality)

The Treatment Goal for Recovery:

Greater Self-Efficacy in the Management of:§ Addiction§ Mood§ Overall health

What is Self-Management?

“The individual’s ability to manage the symptoms, treatment, physical and social consequences and lifestyle changes inherent in living with a chronic condition.”

Yet, when it comes to Self-Management, there’s a problem…

You Can Lead a Horse to Water…

…But You Can’t Make It Drink…

So How Do We Facilitate Personal Agency?

Empowering Patients With an Emphasis On:

► reduced focus on cravings, urges, and secondary gains

► differentiating suffering from pain (emotional and physical)

► reduced depression and other psychological reactions

► the individual taking an active role in his or her recovery

Why Is Self-Management So Important?

► Clinical outcomes are dependent on an individual’s actions.

► Self-management is inevitable.

► The provider’s role is to be in partnership with the individual.

► Professionals are experts about diseases, patients are experts about their own lives.

Three Evidence-based Treatments In

The Recovery Tool Bag► Motivational Interviewing

► Cognitive behavioral therapy (CBT)

► Acceptance and Commitment Therapy (ACT)

Motivational Interviewing

►The work of William Miller, Ph.D. (1983)►Initially developed for problem drinkers►Semi-Directive Approach►Focuses on Ambivalence, Goals, Behavioral

Changes

4 Principles of MI

Express empathy by sharing an understanding with the client of their current situation and/or perspective.

► Validation of their position► Reflective listening… with a purpose

Help clients to explore and identify the discrepancies between what they wants in their lives compared to their life current situation.

Roll with resistance• Resistance and reluctance are a natural and not pathological response to

change for the client. • Clients are not reinforced for becoming argumentative

Support self efficacy:• Embrace client autonomy.• Help clients transition toward successful change with confidence.

An MI InterventionTo Build Discrepancy Using the

Language of Change*

Step One: Ask about the benefits of current behaviors.

Example: “I imagine using alcohol has had some real benefits for you. Tell me how it has helped with your life.”

*Trepper, Terry S., Eric E. McCollum, Peter De Jong, Harry Korman, Wallace Gingerich, and Cynthia Franklin. 2010. "Solution focused therapy treatment manual for working with individuals." [Hammond, IN?]: Research Committee of the Solution Focused Brief Therapy Association.

MI Intervention for DiscrepancyStep Two: The Miracle Question from Solution-Focused Therapy*

“I am going to ask you a rather strange question [pause]. The strange question is this: [pause] After we talk, you will go back to your work (home, school) and you will do whatever you need to do the rest of today, such as taking care of the children, cooking dinner, watching TV, giving the children a bath, and so on. It will become time to go to bed. Everybody in your household is quiet, and you are sleeping in peace. In the middle of the night, a miracle happens and the problem that prompted you to talk to me today is solved! But because this happens while you are sleeping, you have no way of knowing that there was an overnight miracle that solved the problem. [pause] So, when you wake up tomorrow morning, what might be the small change that will make you say to yourself, ‘Wow, something must have happened—the problem is gone!’” (Berg & Dolan, 2001, p. 7.)*

*Berg, Insoo Kim and S.deShazer: Making numbers talk: Language in therapy. In S. Friedman (Ed.), "The new language of change: Constructive collaboration in psychotherapy." New York: Guilford, 1993.

Berg, I. K., & Dolan, Y. (2001). Tales of solutions: A collection of hope-inspiring stories. New York: Norton.

Cognitive Behavioral Therapy

►Change thinking to§ Reduce automatic negative thoughts§ Reframe experiences more realistically§ Reduce anxiety related to recovery

►Adapt behaviors to§ Reduce provocation of urges and cravings§ Cope with residual high risk situations

CBT Techniques

► Problem Solving► Skills Acquisition► Modeling► Reinterpreting symptoms

§ Changing cognitive distortions

“I can’t see myself not drinking.”

The Black Duck Intervention*

Once upon a time:

* Singer, J.A., Singer B.F., & Berry, M. (2013). A Meaning-Based Intervention for Addiction: Using Narrative Therapy and Mindfulness to Treat Alcohol Abuse, in Routledge, C. and Hicks, J. (Eds.), The experience of meaning in life: Classical perspectives, emerging themes, and controversies. New York: Springer Press.

“All ducks are white”

And then one day:

Finding Black Ducks

Based on Hempel’s Raven Paradox:

►Cognitive restructuring►Encourages greater insight►Focus on health and empowerment►Promotes self-efficacy through generating

creative and flexible responses to new stressors

Hempel, C.J. (1965). Aspects of Scientific Explanation. Free Press, New York

Roadblocks to Recovery• Denial (of the problem)• Fear (of failure)• Hopelessness (repetition)• Loss (Avoidance)• Belief (in failure)• Doubt (about spirituality)

A LOSS OF VALUES

Acceptance and Commitment Therapy

The work of Steven Hayes and colleagues in the 1980s. *

ACT is a contextual cognitive therapy based on relational frame theory (RFT), a comprehensive theory of language and cognition that is an offshoot of behavioral analysis.

Hayes, S., Strosahl, K.D., & Wilson, K.G. (2012). Acceptance and Commitment Therapy, Second Edition: The Process and Practice of Mindful Change. New York: Guilford Press.

ACT Concepts

►Accept your reactions and be present►Choose a valued direction►Take action

Values

►Are not goals►Help give meaning to life►Are linked to behavioral change►Are purposeful, instrumental, intentional►Must be a free choice►Help establish pragmatic flexible goals

What Do You Want Your Life To Stand For?

Creating Commitments

► Understanding what one has lost► Envisioning a life one wants to inhabit► Engaging in a range of behaviors► Therapy allows for a wide range of techniques

§ Behavioral activation§ Skills training for social issues§ Exposure therapy

► Commitments are made with 100% Willingness

12 Step Programs

►Explores feelings and experiences associated with pain

►Provides a step-wise approach to restoring engagement in life

►Creates a sense of community, reduces isolation

Twelve Steps of AA

Printed by Permission of Alcoholics Anonymous

1. We admitted we were powerless over alcohol—that our lives had become unmanageable.Help2. We came to believe that a Power greater than ourselves could restore us to sanity. Belief3. Made a decision to turn our will and our lives over to the care of God as we understood Him. Trust4. Made a searching and fearless moral inventory of ourselves. Honesty5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs. Sharing6. Were entirely ready to have God remove all these defects of character. 7. Humbly asked Him to remove our shortcomings. 8. Made a list of all persons we had harmed, and became willing to make amends to them all. 9. Made direct amends to such people wherever possible, except when to do so would injure them or others. Self-Respect and Respect for Others10. Continued to take personal inventory and when we were wrong promptly admitted it. 11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him,

praying only for knowledge of His will for us and the power to carry that out. Acceptance12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.Giving Back

12 Steps, 4 Values► 1. We admitted we were powerless over pain and illness – that our

lives had become unmanageable. ► 2. Came to believe that a Power greater than ourselves could restore us

to sanity.► 3. Made a decision to turn our will and our lives over to the care of

God, as we understood Him.► 4. Made a searching and fearless moral inventory of ourselves.► 5. Admitted to God, to ourselves, and to another human being the

exact nature of our wrongs.► 6. Were entirely ready to have God remove our defects of character.► 7. Humbly asked Him to remove our shortcomings.► 8. Made a list of all persons we had harmed and became willing to

make amends to them all.► 9. Made direct amends to such people wherever possible, except when

to do so would injure them or others.

1. Humility

Chronic Pain Anonymous

http://www.chronicpainanonymous.org/

►Organized in 2004 in Maryland►Face to face meetings►Internet meetings►Telephone meetings

Conclusion

► Addiction is a major health problem► Resistance to recovery is multifaceted.► Focusing on one form of treatment alone may be

inadequate► An ACT-based values approach to recovery

increases self-efficacy, promotes healing from the “inside-out”, and takes into account the whole person

Self-Assessment Questions1. True or false: Finding “a black duck” is a form of cognitive restructuring that reinforces the concept that chronic pain is constant, ever-present, and unchangeable.

2. Cognitive defusion in Acceptance and Commitment therapy (ACT) is similar to:a: Cognitive restructuring in CBTb: Cold fusionc: Catch and Release in mindfulnessd: Freud’s theory of suppression

3. The deep values embedded in the 12 Steps are:a: Humility and Surrenderb: Spirituality, Abstinence, Truthc: Co-dependence and Enmeshmentd: Humility, Hope, Faith, Honesty

Bruce F. Singer, Psy.D.Chief of Psychology,

Crossroads Centre, Antigua

Chief Visionary Officer,Treatment Rehab Professionals LLC

(707) 304-4368

brucefsinger@gmail.com