Reducing Shame in Addictions: Slow and Steady Wins the Race
I’m pretty excited about publishing the 51st randomized clinical trial on Acceptance and Commitment Therapy (in The Journal of Consulting and Clinical Psychology). Our study is the first randomized trial ever published to test the effectiveness of an intervention targeting shame in substance use disorders. Authors have been writing about the importance of shame in addiction for decades, but no one has spent the time and money to actually test an intervention. It’s pretty cool to be the first.
This study adds to the rapidly growing database on ACT
The number of randomized clinical trials on ACT is growing rapidly, with most studies published in just the last four years (see graph below of the number of published randomized clinical trials on ACT, by year, courtesy of Steve Hayes – the graph is missing the five most recently published randomized trials).
Those who follow this blog are going to get a sneak peak at what will be in the manuscript. Below, I’ll snip out a few findings and the abstract. I’m pretty excited about this work and where our research on shame and self-stigma is leading. Keep tuned to this blog for more about where this work goes. You can find past publications on the topic on our Portland Psychotherapy publications page.
First, the abstract:
Objective: Shame has long been seen as relevant to substance use disorders, but interventions have not been tested in randomized trials. This study examined a group-based intervention for shame based on the principles of Acceptance and Commitment Therapy (ACT) in patients (N = 133; 61% female; M = 34 years old; 86% Caucasian) in a 28-day residential addictions treatment program. Method: Consecutive cohort pairs were assigned in a pair-wise random fashion to receive treatment as usual (TAU) or the ACT intervention in place of six hours of treatment that would have occurred at that same time. The ACT intervention consisted of three, two-hour group sessions scheduled during asingle week. Results: Intent-to-treat analyses demonstrated that the ACT intervention resulted in smaller immediate gains in shame, but larger reductions at four month follow up. Those attending the ACT group also evidenced fewer days of substance use and higher treatment attendance at follow up. Effects of the ACT intervention on treatment utilization at follow up were statistically mediated by post treatment levels of shame, in that those evidencing higher levels of shame at post treatment were more likely to be attending treatment at follow up. Intervention effects on substance use at follow up were mediated by treatment utilization at follow up, suggesting that the intervention may have had its effects, at least in part, through improving treatment attendance. Conclusions: These results demonstrate that an approach to shame based on mindfulness and acceptance appears to produce better treatment attendance and reduced substance use.
And the overall summary of the findings from the discussion:
A six-hour group using an ACT approach to shame as a small part of a 28-day residential program led to slower immediate gains in shame, but better long term progress….Results indicated that reductions in shame during active treatment predicted higher levels of substance use at follow up. Mediational analyses suggested that the more gradual reductions in shame found in the ACT group protected against the pattern seen in TAU for shame reductions to be associated with subsequent higher levels of substance use. As predicted, the ACT intervention led to higher levels of outpatient treatment attendance during follow up, which in turn was functionally related to lower levels of substance use. Across the board, participants in the ACT condition showed a pattern of continuous treatment gains, especially on psychosocial measures, rather than the boom and bust cycles seen in treatment as usual.
Our explanation for this pattern of results:
… something in the six hours spent in the ACT group changed the overall effect of this residential program. Unhealthy suppression of shame may be involved in the “treatment high” sometimes seen in early recovery in which sobriety can lead to unrealistic treatment gains, only to be followed by urges to use, relapse, or depression … It seems plausible that these six hours [of the intervention] kept participants from interacting with the overall treatment program in a way that produced illusory short term gains, perhaps by helping them experience shame in a more open and mindful fashion, thereby allowing the emotion to perform its regulatory function of warning against or punishing violations of personal values or social norms and of helping to repair strained social roles. The resulting improvement in functioning and reintegration into healthy social networks, such as those found in a recovery community, led to less shame over time.
At the end of our article we summed up our hopes for how this research might help people with addiction:
Many people with substance use disorders experience shame as a result of the stigma of substance abuse, failure to control their substance use, and failures in role functioning. Understandably, people are motivated to avoid or reduce this extremely painful affect. Unfortunately, when the emotion of shame itself becomes the target of avoidance, this may exacerbate shame in the long run, even though it may provide some relief in the short-term. In a similar way, while negative self-conceptions are painful, direct change efforts can paradoxically increase the frequency and regulatory power of negative self-conceptions. Results of this study suggest that acceptance and mindfulness based interventions may help people to step out of a cycle of avoidance and shame and move toward a path of successful recovery that leads to more stable reductions in shame and to more functional ways of living.
Luoma, J. B., & Kohlenberg, B.S., Hayes, S. C., & Fletcher, L. (in press). Slow and Steady Wins the Race: A Randomized Clinical Trial of Acceptance and Commitment Therapy Targeting Shame in Substance Use Disorders. Journal of Consulting and Clinical Psychology.
The full study should be available shortly on the journal’s website.