Top Left Image Top Right Image

CB Login


feed-image Feed Entries

CB Workflows

CB Online

Milk Milk Milk: Breaking down a defusion exercise

Dr. Akihiko Masuda and colleagues recently published a really interesting study where they broke down components of the ACT Milk Milk Milk exercise. In this exercise, the therapist may take a word that has a strong negative self-referential quality to the client (e.g., “fraud,” “ugly,” stupid,” “damaged”); the client then repeats the word over and over again for about 45 seconds. Most people find that the word eventually becomes series of meaningless sounds or vocalizations. In ACT, this is what’s known as a cognitive defusion exercise. The purpose of defusion exercises is to remove the literal function of private events such as thoughts by changing its context. Defusion also helps facilitate acceptance.


Across two studies, this exercise was examined in a sample of undergraduates. Emotional discomfort of the word went down very quickly, within 3 – 10 second range. However, believability took longer to reduce, about 20 – 30 seconds on average. The first conclusion the authors draw is that emotional discomfort and believability may be different constructs. Believability appears to be the more important of the two, in that it shows greater relation to the degree to which individuals become caught up in private events. As a consequence, the authors conclude, focusing on reducing the emotional discomfort of a word, as is common in CBT, may be less important than reducing the believability of the word, which takes a little longer.


Clinical Implications


Although this study was conducted with the Milk Milk Milk exercise, the conclusion may extend to other defusion exercises. In conducting defusion, it may be most important to continue defusion work until believability, not just emotional discomfort, is reduced.

ACTing on diabetes

 Diabetes requires knowledge about proper self-care in order to prevent health complications, so hospitals frequently offer courses in diabetes self-management. However, managing diabetes requires a lot more than simply knowing what to do, it also takes overcoming the emotional barriers to living healthy. A recent randomized clinical trial shows how ACT can help with these emotional barriers.

Self-management of diabetes can be inherently distressing, as the act of monitoring and treating this condition readily leads to unpleasant thoughts and feelings.  As a result, many diabetics neglect their self-management activities even though the health consequences are known. This kind of experiential avoidance was targeted in an ACT intervention developed by Dr. Jennifer Gregg, who provided a 3-hour ACT workshop as part of a standard 7-hour educational seminar for the management of diabetes. This workshop was compared to a standard educational seminar lacking ACT components. She administered a self-report measure of acceptance along with the standard physiological measure of glycated hemoglobin used in diabetes research. Her results showed a significant improvement in the physiological measure for the ACT condition but not the education condition. Furthermore, changes in acceptance predicted these improvements from pre-workshop data to follow up data 3 months later. This study suggests that adherence to the treatment regimen for diabetes is facilitated by incorporating acceptance, mindfulness, and values interventions with the educational package.


Clinical implications

When our clients are struggling with diabetes or any kind of medical problem, it may seem like a problem for their physician and they may see psychological work as irrelevant to this problem. But studies like this show that physical problems and psychological problems are related, and that treatment of avoidance with mindfulness and acceptance can facilitate healthier living and more effective management of medical problems.


For more information:

Here is a more detailed summary of the study:

A range of lifestyle adjustments are recommended for people with Type-2 diabetes. However, education about this condition and the merited changes are often not well adhered to, presumably because the act of doing them occasions unpleasant thoughts and feelings associated with the condition itself. CBT has been examined as an intervention for augmenting the impact of these experiences, but the research has provided mixed results in the effectiveness of this treatment, possibly because eliminating distressing thoughts about diabetes may not be realistic. Acceptance and Commitment Therapy may offer an alternative to this agenda, instead focusing on changing one’s relationship to distressing thoughts and feelings about having diabetes and investing in values-consistent behavior.

This intervention was a 3-hour ACT workshop protocol as part of a 7-hour educational program on diabetes self-management.  Her workshop was compared to the standard 7-hour educational program which lacked ACT components. Measures included a physiological index of glycated hemoglobin, the standard measure of diabetes studies, as well as a self-report of acceptance. Measures were administered at the beginning of the workshops and at a 3-month follow up.

The results showed little-to-no-improvement in the education alone condition, while the ACT condition generated a significant and medium effect in changes for the physiological measure and the self-report of acceptance. Furthermore, changes in the self-report of acceptance significantly predicted outcomes at the 3-month follow up, providing some support for the mediational processes of the ACT model of treatment. Although this pilot study needs replication, the results provide strong preliminary support for the usefulness of ACT treatment in facilitating adherence to the medical regimen recommended for diabetes patients.

For more reading on this topic, see:


The Diabetes Lifestyle Book

Or read the full article:

 Gregg, J. A., Callaghan, G. M., Hayes, S. C., & Glenn-Lawson, J. L. (2007). Improving diabetes self-management through acceptance, mindfulness, and values: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 75, 336-343.

Distress tolerance and nicotine addiction

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:



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.


<< Start < Prev 1 2 3 4 5 6 7 8 Next > End >>

Page 1 of 8
Bottom Left Image Bottom Right Image