Acceptance and Commitment Therapy for Substance Use Disorders

What is Acceptance and Commitment Therapy (ACT)?

ACT Therapy is a form of third-wave behavioral therapy, an emerging approach to psychotherapy that represents the evolution and extension of traditional Cognitive Behavioral Therapy (CBT) approaches. Third-wave therapies also includes Dialectical Behavior Therapy (DBT) and mindfulness-based relapse prevention.³ Third-wave treatments grew out of the first wave of behavioral therapies, which emerged in the 1950s.³ Clinical psychologist Steven Hayes and his colleagues developed and refined ACT over the course of the past several decades.^4,5

Motivated to develop ACT due to a lack of empirical support for many of the common cognitive-behavioral therapies widely used in the 1970s and 80s, Hayes and fellow researchers believed that an effective approach needed to also include mindfulness and acceptance strategies to help individuals make meaningful changes.⁶ They maintained that such an approach could help people foster psychological flexibility, making them adept to persist or change behaviors based on the situation and their goals.⁶

ACT stems from Relational Frame Theory (RFT), a therapy also developed by Hayes, which is based on the concept that ineffective verbal behavior (meaning all forms of communication that involve words) leads to problematic behaviors.⁷ ACT is primarily based on principles of mindfulness, acceptance, and values.⁷ It works by helping people develop 6 core skills designed to promote psychological flexibility.⁵

Psychological flexibility, a key component of ACT treatment, means that a person can choose to persist in or change their behaviors based on the specific context they are in and their desired outcome.⁵ Instead of constantly fighting the way an individual feels, ACT encourages acceptance of feelings while advancing toward making changes.¹ In other words, an individual doesn’t necessarily need to control or change the way they feel in order to take action.¹

ACT is a widely used evidence-based therapy, meaning it has demonstrated its effectiveness in clinical research.⁸ In a review of 20 meta-analyses, 133 studies, and 12,477 participants, ACT showed positive results for a wide range of conditions, including substance abuse, chronic pain, and mood disorders.⁸

Using ACT for Substance Abuse

ACT is recognized by the Substance Abuse and Mental Health Services Administration (SAMHSA) and was added to their National Registry of Evidence-Based Programs and Practices in 2010.⁹ ACT views addiction as a chronic pattern of learned behavior, and as with other harmful learned behaviors, it can be modified.⁹ ACT may be used as a standalone therapy or combined with other types of substance abuse therapies.²

ACT is a transdiagnostic approach, which means that is based on the idea that there are common mechanisms that contribute to many different psychological problems, including addiction.⁹ ACT can help people with SUDs get insight into their behaviors and accept the associated urges and symptoms without needing to act on them; this is the acceptance component of ACT treatment.² The greatest focus of ACT comes with the commitment component—helping individuals reduce their urges and symptoms by confronting the present moment and altering their actions based on their goals and values.²

ACT may also be useful for people with co-occurring mental health disorders and substance use disorders, as it can help to address similar issues that contribute to symptomatic “clusters” associated with both problems.⁹

Some of the benefits of using ACT for substance use disorders can include:^2,5

• Increasing an individual’s capacity to tolerate and manage urges to use substances.
• Improving a person’s ability to accept their thoughts, feelings, and bodily sensations without needing to use substances.
• Building a healthier life that involves activities not related to substance use.
• Addressing symptoms of co-occurring disorders.
• Cultivating psychological flexibility, which can help a person choose more appropriate actions.
• Increasing the person’s likelihood of remaining abstinent.
• Helping an individual focus on their long-term goals by encouraging them to identify and work on the values that can lead to recovery and a healthier life.

Process and Goals of Acceptance and Commitment Therapy

As previously mentioned, the goal of ACT is to help you develop greater psychological flexibility.² This means you learn to develop adaptability in your thoughts, feelings, and behaviors based on situations that arise and can then determine whether your actions align with what is important to you.^2,10 In terms of SUDs specifically, the goal of ACT is to help you accept urges to use substances and take healthier actions that may reduce the desire to misuse drugs or alcohol.² ACT aims to accomplish this through the use of 6 core processes, which include: ^2,3

• The present moment. ACT helps you develop nonjudgmental awareness, or mindfulness, regarding your feelings and environment.
• Acceptance. You learn how to experience things and go with the flow instead of fighting or avoiding the present moment.
• Self-as-a-context. This means that you experience a sense of “self” in the context of your environment, thoughts, feelings, etc., and you learn to avoid confusing your core sense of self—who you really are underneath it all—with fleeting psychological perceptions.
• Defusion. You learn to see your thoughts as just thoughts by distancing yourself from your thoughts. Unlike other behavioral therapies that focus on controlling or changing your thoughts, ACT teaches you to accept and understand that thoughts are not necessarily reality.
• Values. You identify those things in life that are truly important to you, such as family, friendship, or health.
• Committed action. This includes building healthier behaviors that align with your values and that allow you to work toward your goals.

ACT Success Rates

Proponents of ACT find merit in mindfulness-based therapy approaches that are based on acceptability and flexibility rather that attempting to encourage individuals to actively change or control unwanted thoughts and feelings the way traditional methods like CBT work. This attempt to change, ACT advocates argue, contributes to stress and poor behaviors, instead of alleviating them.¹¹ Supporters of ACT and other third-wave therapies believe that focusing on mindfulness and acceptance strategies is a more beneficial way to implement change.¹¹

On the other hand, the critics of ACT call for more detailed research to confirm the therapy’s perceived benefits since there are limited studies that directly compare first-wave to third-wave behavioral treatments.¹¹ Additionally, some don’t agree with the method of measurement used to determine an individual’s psychological flexibility, ACT’s core focus.¹⁰

Different studies that have examined the potential benefits of ACT for SUD have shown different levels of efficacy. These include:^2,5,8,11

• A review of three studies that examined ACT for substance use. Two of the studies showed 63.3% to 67.4% of participants exhibiting benefits of ACT compared to the control groups.
• Additional research on the practice of using ACT for SUD examined 22 clinical studies. Results showed that most of these studies demonstrated a significant reduction in substance use right after treatment as well as at the follow-up, which occurred at different markers for each study.
• An analysis of 10 randomized controlled trials showed that only 2 of the studies indicated that ACT had a significant positive effect. Thus, researchers deemed ACT to be “at least as efficacious” as other active treatments examined in the studies, which included CBT, drug counseling, and 12-step therapy.
• One study examined the benefits of ACT for alcohol use disorder (AUD)—the clinical term for alcohol addiction—in individuals in impatient treatment for AUD and co-occurring mood disorders. The results found that individuals, who received ACT, showed a much higher level of abstinence and reduced levels of depression and anxiety at both the 3- and 6-month follow-ups.

Is ACT Covered by Insurance?

Many forms of psychotherapy, including ACT, can be expensive. The good news is that insurance may cover at least part of the cost. Substance abuse and mental health services are an essential benefit as discussed in The Affordable Care Act (ACA).¹² This means that insurance plans purchased from the Health Insurance Exchanges or offered by Medicaid to people who are newly covered (as of 2014) must provide substance abuse treatment coverage similar to the coverage they offer for other medical or surgical care.¹³

However, the specific coverage can vary widely based on your particular plan. If you have Medicaid, you should know that individual states decide what to cover, but all state Medicaid programs offer some mental health and SUD services.¹⁴ Medicare covers a wide range of mental health and substance abuse treatment services.¹⁴ It’s advisable to consult your insurance carrier to verify your benefits before you commit to a course of treatment. If you don’t have insurance, you might consider researching federally-funded health centers and inquiring if they offer ACT treatment, or asking your doctor if they can refer you to a therapist who might offer ACT treatment on a sliding-scale basis, meaning your fee is based on your income.¹⁵