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.
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.
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.
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
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.
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:
is a more detailed summary of the study:
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.
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.
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
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.
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.
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
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:
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.