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12 Steps 4 Values: Utilizing Acceptance and Commitment
Therapy to Diffuse Resistance to Recovery
Bruce Singer, Psy.D.Chief of Psychology
Crossroads Centre, Antigua
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.”
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
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.
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.
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
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