How long can you hold your breath? If you are a smoker, the results of this test would predict the likelihood of being successful at quitting those cigarettes. This is not because holding your breath is related to your lung capacity. Rather, it has something to do with distress tolerance.

We probably all know someone who has been unable to discontinue their cigarette habit, even in spite of numerous attempts to quit. As Richard Brown and colleagues elaborate in a recent article, smoking is very difficult to discontinue for three basic reasons: 1) It is a well-rehearsed habit. 2) Nicotine is physically addictive. 3) Smoking provides and maintains a sense of comfort. Although there are good treatments for smoking cessation, a sizable percentage of people attempting to quit never abstain from cigarettes for more than a few days, even with multiple cessation attempts across years or decades. Brown hypothesizes that this unfortunate population happens to be particularly intolerant of the inevitable distress of withdrawal from nicotine. Given that ACT is designed to promote acceptance and willingness to have these kinds of experiences, he developed a preliminary treatment program for smoking cessation with participants who reported being unable to abstain from cigarettes for more than three days over the past ten years of use. The results of this trial showed that, although everyone eventually relapsed by the 26-week follow up, the median number of days that participants abstained from cigarettes was 24, a whopping increase over their previous efforts and potentially a precursor to more successful attempts in the future.

Clinical implications

It is not unusual to encounter clients who present for treatment of certain psychological difficulties and mention in passing that they also smoke and cannot seem to quit. And cigarettes are just one drug of choice – most of us have clients with addictions to alcohol and other drugs (whether we know about it or not). Part of the trap of addiction is not just the onset of unpleasant withdrawal symptoms, but also the loss something that is like a dear, comforting friend. Just as acceptance and mindfulness can teach a client to relate in a different way to their unwanted thoughts and feelings, so also can it be used to relate to withdrawal symptoms and urges to return to substance use.

For more information:

Here is a more detailed summary of the study:

Though interventions are available that have demonstrated effectiveness in helping people quit smoking, cigarettes continue to be the leading cause of preventable deaths in the United States. Data on smoking habits suggest that a substantial subpopulation of smokers are unable to successfully quit and remain abstinent, and that these people commonly relapse within just a few days of entering treatment. Given that smoking becomes a habitual, addictive, and comfort-inducting activity over time, it is conceivable that this subpopulation is susceptible to relapse because of an inability to tolerate the distress of withdrawal and related symptoms. In fact, a simple breath-holding task has been shown to predict success rates upon entering smoking cessation treatment.

Given that Acceptance and Commitment Therapy builds willingness to have distressing internal experiences like urges, ACT treatment components were built in to a smoking cessation treatment involving pharmacotherapy and traditional exposure. Treatment consisted of six individual sessions, nine group sessions, and 8 weeks of transdermal nicotine patch usage. Participants were two cohorts of 8 smokers each, all reporting an inability to abstain from cigarettes for more than 3 successive days in the past 10 years.

Participants provided self-reports of smoking status at the conclusion of treatment as well as at 8-, 13-, and 26-week follow ups. Reports of abstinence were verified by expired carbon monoxide. A relapse was determined to be 7 consecutive days of smoking after quit day. Results showed that half the participants relapsed about 45 days after quit day, and that all participants relapsed by the 26-week follow up. Although relapse was shown to be inevitable, the amount of time abstaining from cigarettes was markedly longer on the average than any quit attempt in the past 10 years, and 82% of participants reported that the skills in the program were very or extremely useful in helping them quit. The authors point out that this pilot study represents the only known published attempt to work with early-relapse smokers. They report that data on a small, randomized controlled trial is forthcoming. For more on the use of ACT with substance abuse, check out:

• A Practical Guide to Acceptance and Commitment Therapy

Or read the full article:

Brown, R. A, Palm, K. M., Lejuez, C. W., Kahler, C. W., Zvolensky, M. J., Hayes, S. C., Wilson, K. G., & Gifford, E. V. (2008). Distress tolerance treatment for early-lapse smokers. Behavior Modification, 32, 302-332.

On being a mindful therapist

Have you ever wondered why ACT experts encourage experiential workshops as part of the training regimen? There are a few answers to this question, but a new study out of Germany suggests that mindfulness training can help therapists be generally better at what they do.

Therapy is complex. Consider all the possible sources of information available during any given therapy session that may assist the therapist in their work. During the session, attention may be directed outward to the client’s statements, expressions, and posture or inward to the therapist’s own reactions, analyses, and actions. And all of this, ideally, is done in order to further the work of assisting the client in his or her life. In addition to informational complexity, the way the therapist responds emotionally to the client affects the outcome of therapy. Ludwig Grepmair and colleagues felt that mindfulness training might be helpful for therapists in managing this complexity and their own emotional responding in the room with their clients. In a recently published study, they provided mindfulness training to a group of psychotherapy trainees and compared outcomes on their clients with outcomes on clients receiving therapy from trainees who did not receive mindfulness training. Responses to a variety of symptoms measures showed significantly larger reductions for clients receiving treatment from therapists who had mindfulness training.

Clinical implications

While many of us may engage in a mindfulness practice for personal reasons, this study suggests that doing so may benefit others in our lives as well, namely our clients. Perhaps therapy is more than knowing what interventions to conduct or how to cultivate the therapeutic alliance, but also the capacity and willingness to hold our experience and the experience of our clients lightly in the service of being a more effective instrument for them. Adding a regular mindfulness practice to your routine or utilizing mindfulness and acceptance with your own behavior may add quality to your professional work as well as your life more generally.

A blog called Psychotherapy Brown Bag has done a good job of reviewing a recent paper which continues to add to the pile of evidence on the centrality of experiential avoidance in maintaining a variety of psychological disorders. This paper is about the Trichotillomania and is worth a read. Here's what they had to say about it:

In a study just released in Behaviour Research and Therapy, Anna Shusterman, Lauren Feld, Lee Baer, and Nancy Keuthen (2009) utilized data from a massive online survey to examine the role that emotions play in prompting and sustaining this disorder.  The description of TTM in the DSM-IV-TR as well as a number of prior studies have linked TTM behaviors with a sense of relief on the part of the individual exhibiting the behavior.  In other words, many individuals have reported that pulling out their own hair has resulted in immediate decreases in negative emotions.  Despite this potentially valuable function, the behavior also includes a variety of less comfortable correlates, namely subsequent feelings of shame and guilt and a strong desire to cease the behavior.  So, the behavior becomes rewarding through its ability to quickly reduce certain negative emotions, but also results in several emotional and social consequences.

Research Update

New data on ACT for chronic pain

Fresh data on ACT and RFT seem to be surfacing almost continuously these days. In this edition of our newsletter, we are especially intrigued by a forthcoming article on the use of ACT with children experiencing chronic pain.

One of the distinctions that we often make as ACT therapists with our clients is that between pain and suffering. While pain is regarded as the direct result of difficulties in our lives, whether it is a physical ailment or natural response to life challenges, suffering is the indirect result of being a verbal human being who compares, evaluates, and struggles with our pain. Much of ACT treatment involves teaching clients to cultivate a different relationship with their suffering. A new study by Rikard Wiksell, working with adolescents with physical ailments, suggests that ACT can be a useful treatment for changing one’s relationship to chronic pain as well. Dr. Wiksell compared ACT treatment with a multidisciplinary treatment approach that included an antidepressant, and found that children receiving ACT had better outcomes not only in their psychological functioning, but their physical functioning as well. In fact, these better outcomes were still significantly better than the multidisciplinary treatment at a 7 month follow-up. Although these children had physical problems, their physical and psychological suffering decreased via the exposure-based processes in ACT. Arguably, acceptance, defusion, and commitment to valued activities increased the quality of these kids’ lives.

A growing body of literature suggests that chronic pain is a substantial problem among children, and that these children are at risk for continuing problems into adulthood. Most of the research has addressed means of reducing pain and distress, and CBT is an established treatment for this condition, although the body of supportive data is relatively small. ACT views experiential avoidance as the key measure in human functioning, rather than the presence or absence of pain. This pain can be psychological or physical. More specifically, the ACT model suggests that efforts to control, minimize, and avoid unwanted thoughts, emotions, and sensations leads to excessive time focusing on pain and less time building upon the quality in one’s life. ACT treatment builds competency in accepting one’s experience while engaging in valued activities as the alternative to this control agenda.

Wisksell and his colleagues provided ACT treatment to 16 children coping with chronic pain and compared outcomes to 16 children with chronic pain who received a multidimensional treatment package at a children’s hospital. This multidimensional treatment included amitriptyline, an antidepressant. Children were assessed pre-treatment, and the conclusion of treatment, and approximately 3.5 and 7 months after treatment. The assessment package included various measures of daily physical functioning, pain intensity, and beliefs about impairment due to pain, and psychological well-being. Treatment was provided individually on a weekly basis. ACT treatment lasted roughly 4 months while the multidimensional treatment lasted somewhat longer.

The results showed improvements in all measures for both treatments, and most revealed large effect sizes. Furthermore, the ACT condition consistently produced significantly better outcomes than the multidimensional treatment. On a more qualitative note, the authors point out that the ACT treatment was of shorter duration and may have cost substantially less than the alternative. Given that this treatment reduced reports of pain and increased reports of quality of life, these data strongly suggest that ACT is a viable and promising treatment for chronic pain among children.

Clinical implications

Many of us may have clients struggling with health problems on top of the psychological struggles that they present in therapy. Chronic physical pain and health problems can be exacerbated by experiential avoidance and fusion, just as can psychological pain. If you are interested in applying ACT in the realm of chronic pain, there are a number of ACT books and workbooks that cover these topics. Here are three:

• ACT for Chronic Pain

• Living Beyond Your Pain: Using ACT to Ease Chronic Pain
• Contextual Cognitive-Behavior Therapy for Chronic Pain

Citation: Wicksell, R. K., Melin, L., Lekander, M., & Olsson, G. L. (in press). Evaluating the effectiveness of exposure and acceptance strategies to improve functioning and quality of life in longstanding pediatric pain – A randomized controlled trial. Pain.