ACT and Addictions. Presentation Title DATE HERE. How Acceptance and Commitment Therapy can Offer a Value-Driven Life to the Addicted Mind

Transcription

1 ACT and Addictions Presentation Title DATE HERE How Acceptance and Commitment Therapy can Offer a Value-Driven Life to the Addicted Mind Freud Meets Buddha Conference March 2017 David H. Baron MD, DFAPA Medical Director, Yellowbrick

2 Disclosures Yellowbrick - As a matter of policy, Yellowbrick and its employees are prohibited from accepting gifts from all medical and pharmaceutical companies. - Yellowbrick, Yellowbrick Foundation and Yellowbrick Professional Staff have never accepted gifts, grants, funds or services from Industry. 2

3 Mindfulness: Noticing what is present, no matter how unpleasant 3

4 About Yellowbrick Intensive Outpatient Program in Evanston, IL Includes a supported Residence Apartment, shared with peers In-depth, extended treatment by seasoned professionals, modal experience level years Assistance for re-entry to school & work while in treatment 4

5 About Yellowbrick Emerging Adults, aged 18-30, typically with: Sentinel life threatening or psychotic occurrence Multiple episodes with persistent instability Multiple successful Rx with relapses, and/or unsuccessful Rx Avoidant, quietly disabled Lack of momentum/impasse with low function Complex, high risk Link to NY Times Article on Emerging Adulthood 5

6 Percent Yellowbrick Diagnosis Overview

7 Referrals to Yellowbrick Patients with life threatening suicide attempts: At least one attempt: 53% Multiple attempts: 65% of those who attempted 90+% disabled within past 6 months Multiple hospitalizations: 82% 7

8 Why ACT? Acceptance and Commitment Therapy Group setting at Yellowbrick, ACT is an educational/experiential group Used in conjunction with multi-modal (including contemporary psychodynamic) psychotherapies, supportive services, and neurobiological interventions Distress Tolerance : an essential part of transformative change ACT: acceptance of ALL emotional states, but without the often consequent behaviors Application to addictions 8

9 Acceptance Yellowbrick What is ACT? We cannot control private mental experience Random and reinforced thoughts, emotions, associations occur spontaneously Fusing with these can lead to unworkable behaviors Avoiding or trying to fight them leads to suffering Radical Acceptance: there are no bad thoughts 9

10 Acceptance: In ACT as in Buddhism 10

11 What is ACT? Yellowbrick Commitment Making life more meaningful, fulfilling and workable requires committed action These goals are met most effectively when committed action is taken according to our personal values Our minds will predictably give us thoughts and emotions which, when we fuse with or try to un-do or avoid them, create obstacles to fulfilling our values To live a workable, meaningful, fulfilling life, committed action must be taken regardless of what obstacles our mind creates 11

12 Commitment (addiction?) 12

13 Origins of ACT Yellowbrick Waves of Behavior Therapy First Wave: Skinner: operant conditioning (salivating dogs) Second Wave: Beck: cognitive behavior therapy (transform your thoughts) DBT/Linehan (wave 2 ½? ) Third Wave, Contextual Behavior Therapy, incl. Hayes, Wilson: ACT 13

14 Origins of ACT Yellowbrick Relational Frame Theory (more later ) Role of Language in shaping human behavior Theory goes beyond empirical evidence Evidence supports efficacy of ACT techniques in more than 60 studies Anxiety Depression OCD Schizophrenia Hayes and others theorize far more causal effect of language on human consciousness and behavior than ACT requires for practical use another talk 14

15 Evidence of ACT s efficacy in addiction: Study of ACT vs. Intensive Twelve-Step Facilitation in addition to methadone maintenance with polysubstance abusing opiate addicts who were continuing to use drugs while on methadone maintenance. Results showed that the addition of ACT was associated with lower objectively assessed opiate and total drug use during follow-up than methadone maintenance alone, and lower subjective measures of total drug use at follow-up. Hayes, S. C., Wilson, K. G., Gifford, E. V., Bissett, R., Piasecki, M., Batten, S. V., Byrd, M., & Gregg, J. (2004). A preliminary trial of Twelve-Step Facilitation and Acceptance and Commitment Therapy with polysubstance-abusing methadone-maintained opiate addicts. Behavior Therapy, 35(4),

16 Further Evidence of ACT s efficacy in addiction (see handout/link): Studies showing efficacy in: Smoking cessation (including telephone-delivered ACT) Comorbid substance abuse and PTSD Addressing self-stigma of addiction Methamphetamine use disorders Supporting methadone dose reduction and detoxification Marijuana dependence Heroin use Compulsive pornography use 16

17 Relational Frame Theory: What is a relational frame? Describes the human ability to create connections between any two things (objects, emotions, thoughts, behavioral urges, etc., etc., etc.) These connections are represented by (created by?) language Relational frames can describe various qualities of such a connection: Strength Type Dimension along which the connection exists 17

18 Relational Frame Theory Relational frames can as easily be arbitrary as non-arbitrary Strong implications for the applicaton of RFT to human pain and ACT 18

19 Relational Frame Theory: Arbitrary frames 19

20 Relational Frame Theory: Arbitrary frames How fast did you learn this? 20

21 Relational Frame Theory: What is a relational frame? Audience participation moment: Think of anything that can be described by a noun Now think of a second thing that can be described by a noun 21

22 Relational Frame Theory: What is a relational frame? Audience participation moment: How is [first noun] better than [second noun]? How is [first noun] worse than [second noun]? How is [first noun] the parent of [second noun]? How is [first noun] the child of [second noun]? 22

23 Relational Frame Theory: Examples Language can have affective impact on mind, equal to that of direct sensory stimulus Trauma examples: Father hit me, later Mom says, Wait till your father gets home I was in Afghanistan, came home and heard IED on the news In my residency, a ringing phone often woke me up in the middle of the night to tend to someone in life-threatening danger, now I get anxious/tense/resentful whenever a phone rings at night I was raped, now I panic/become enraged/dissociate when I hear the word rape 23

24 Hexaflex 24

25 ACT: Acceptance During mindfulness meditation--and in life--no thoughts are bad: Radical Acceptance Notice them and return to focus (image, visual point, breath, etc.) 25

26 Committed Action Exercise Try to pick up a pen 26

27 ACT: Try 27

28 ACT: Clipboard Exercise Thoughts in the way (fusion), vs Trying to get rid of them (experiential avoidance) Neither works 28

29 ACT: Values At Yellowbrick, ACT group asked to complete values checklist Asked to prioritize values Which ones are you living most through committed action, and where does it requires more effort? 29

30 ACT: Self as Context Distinct from Thoughts: I am not my thoughts or my pain Recall a pleasant memory from years ago Picture yourself in a desired future For each: Picture it in detail Describe as many senses as possible Who is doing the remembering and picturing? 30

31 Impact of Language: Defusion Exercise Milk Exercise 31

32 ACT as Applied to Addiction What is Addiction? Medical Illness Spiritual sickness Behavioral problem, crime, weak character, etc. Reward Deficiency Syndrome (RDS) Genetically-driven (DRD2 receptor gene polymorphism) Relative lack of dopamine receptors and activity in reward centers of the brain: Nucleus Accumbens Anterior Cingulate Gyrus Prefrontal Cortex Ventral Tegmental Area Hypothalamus Substantia Nigra 32

33 Brain regions that play a role in addiction/reward deficiency syndrome ANTERIOR CINGULATE GYRUS error detection reward-based learning role in consciousness PREFRONTAL CORTEX executive function attention concentration emotions impulses obsessions compulsions ruminations worry pain guilt suicidality 7-7 PFC HYPOTHALAMUS sleep appetite endocrine/hormonal regulation ACG NA Hy VT SN SUBSTANTIA NIGRA part of basal ganglia GABA-nergic activity (benzodiazepines) learned response to stimuli (classical conditioning) temporal processing influence on sleep/wake cycle NUCLEUS ACCUMBENS pleasure interests libido fatigue euphoria reward motivation VENTRAL TEGMENTAL AREA connected strongly to NA reward/pleasure significant area of dopamine activity, therefore major site of action of addictive drugs 33

34 Normal Brain Maturation : The Frontal Lobes mature later into emerging adulthood Gogtay, N., et al (2004). Dynamic mapping of human cortical development during childhood through early adulthood. Proc Natl Acad Sci U S A, 101(21):

35 ACT and Executive Function What is Addiction? a neuroscience frame The brain s top-down regulatory function Higher/outer/evolutionarily later structures ( neocortex ) modify and interpret the information generated by more primitive areas (limbic system/amygdala) ACT can be seen as skill-building, practice, and neuroplastic change in the self-observing centers of the brain 35

36 Brain areas of note in Addiction Limbic system Hyperactive = more emotion to manage Substance Abuse net result is more anxiety, increased likelihood of PTSD, Bipolar Disorder Left pre-frontal cortex Hypoactive Diminished connectivity: wiring between executive function area and limbic/emotional brain is less present (Wilcox 2016) 36

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38 SPECT Scan brain function in an 18 y.o. woman with ADHD, Conduct Disorder and Polysubstance Dependence IMPULSE DYSCONTROL Sx Note the hypofunction = hole in left inferior cortex (OFC)

39 ACT and Executive Function Activating frontal lobe capacities Mentalization ( mindfulness of others ) ACT as a Skills-based therapies (along with CBT, DBT) Executive function/life skills (Paulus) Enhanced use and understanding of language Move behavioral communications into the verbal world Analagous (equivalent?) to engaging executive function to observe and manage results of emotional world 39

40 ACT and 12-Step 12 Steps provide a guide towards: Quieting through attachment Governance/using values as guide to action Self-efficacy & empowerment 40

41 ACT and 12-Step Enhancing self-reflection (mindfulness) Confronts denial and rationalization (acting on emotions) Acknowledges difficulties maintaining sobriety. (acting to avoid or create emotions) Moral Inventory & Amends (mindful, value-driven actions) 41

42 Technique of ACT: Promise vs. Delivery of Reduced Symptoms No promise of: Less anxiety Fewer negative thoughts Fewer cravings/urges Reduction of unpleasant symptoms Holding out promise of above creates mixed behavioral message: Be present to all your experience, including the unpleasant parts Don t put effort into making thoughts go away Adding do this and your unpleasant thoughts will diminish can be confusing and detracts from core message of ACT ACCEPTANCE! BUT Favorable clinical and research outcomes usually include improvement in the workability of life, and reduction of symptoms 42

43 Mindful, ACT-based approach to Addiction ACT Approach Practice mindfulness: be the observer of spontaneous mental experience Learn techniques for de-fusion from painful emotions/thoughts/urges Identify your own values directions that are important to you in the long term Take committed action based on these values Application to Addiction You can t control the urge to use/drink; learn to notice it as something that happens in your mind and body Since you can t make the feelings go away, practice techniques for using your observing self and accepting them Paying attention to values can help highlight the contrast between what s important to you and what you ve been doing ( moral inventory : #4 of the 12 steps ) If you are taking committed action you are not using 43

44 Addiction and ACT RDS is an accentuated version of ACT s view of all experience: Pain is inevitable : RDS means addicts may be more prone to it Suffering is optional : Suffering--as defined by ACT--happens when we don t accept the presence of pain 44

45 Addiction and ACT Addiction-related forms of suffering include: Avoidance: addictive forms of avoidance have potentially lethal consequences Fusion: fusing with cravings, urges perpetuates cycle of addiction Not being in the present moment: being high/drunk/lost in process addictions takes one away from living life Pain of absence: I don t get to go outside and enjoy life because I m too anxious or I don t get to go outside and enjoy life because I need a fix/drink/to see another porn video 45

46 PH Pre/Post Coherence BDI= 28 BDI= 12

47 ACT: When it s (somewhat) Easier Values: I have a job I earn money, it s important to be financially independent I enjoy my work Mind offers: It s really comfortable in bed I stayed up late, I d like to sleep more I m running late, I ll have to face potential criticism when I get to work 47

48 ACT: When it s (somewhat) Easier (committed action below) 48

49 ACT: When (and where) it s More Difficult Values: I want to make a life of my own, separate from my parents Friendships and Intimacy are important I seek fulfillment and meaning in my life Mind offers: I can t stand this anxiety I need a drink I can t stop thinking about heroin I get such a high from gambling, how can I give it up? It s what I ve always done ( I ve always ) 49

50 ACT, When it s Beyond What Most of Us Are Willing to Do Values: Freedom from oppression Equal opportunity Being judged by content of character Mind offers: I m afraid I will be criticized Jail will be very uncomfortable I may die 50

51 ACT, When it s Beyond What Most People Are Willing to Do 51

52 ACT Books Yellowbrick Description of ACT for therapists, by Hayes, Strosahl and Wilson Primer of ACT, by Russ Harris Instruction Manual for therapists, includes DVD with staged examples of technique, by Luoma, Hayes, and Walser Workbook for patients, very accessible for the motivated, by Hayes and Smith 52