Changing Addictive Behaviors using ACT Processes
Description of Clinical Issue
Psychological inflexibility can contribute to the development and maintenance of addictive behaviors because it often involves an unwillingness to experience painful emotions, thoughts, sensations, and memories. Experiential avoidance can become a habitual coping mechanism, reinforcing the association between negative emotions and substance use. Unhelpful, rigid beliefs that substance use is the only way to cope with challenges or that one cannot function without alcohol or substances can limit the ability to live a fulfilling, values-congruent life.
In applying ACT (pronounced like the word “act”) to addiction, a clinician identifies the function or reasons a client engages in substance use, as well as the reasons they want to change. A core goal of ACT is to promote psychological flexibility, which means adapting one's behavior in different situations based on what is most effective in moving towards valued goals, even in the presence of difficult internal experiences (Hayes et al., 2011). An ACT approach might examine how substance use has become an automatic, habitual, and rigid way of coping with distress that limits the client’s ability to respond flexibly to life’s challenges, with full emotional and cognitive presence. In this article, I will discuss six underlying processes of inflexibility that ACT targets in relation to addiction.
Cognitive fusion refers to the tendency to get entangled in the content of our thoughts and believe them as if they are facts or literal truths. Fusion includes rumination about the past and future, reasons, rules, narratives, and judgments, (e.g., “I can't handle stress without using substances" or "I need drugs/alcohol to have fun”). ACT helps individuals identify how specific thoughts or beliefs hook them and drive addictive behaviors. Clients are taught to recognize these thoughts as mental events and not necessarily accurate reflections of reality. In contrast to traditional CBT, there is no attempt to change thoughts; rather clinicians help clients modify how they respond to thoughts with questions such as “Does this thought take you towards or away from your goals? The “defusion” process reduces the influence of thoughts, urges, and cravings that contribute to addictive behaviors.
Therapist: Fighting your cravings and emotions often makes them stronger because you are giving them attention and getting “hooked” by them. Remember, thoughts are just thoughts; they don't have to control your actions. We can work on acknowledging those urges without judgment recognizing them as normal human experiences. Let’s look at what your mind is doing right now. Is it helping you or criticizing you?
As a result of cognitive fusion, people using substances to cope often engage in experiential avoidance, which involves avoiding or suppressing uncomfortable emotions, thoughts, memories, or physical sensations. Experiential avoidance is associated with alcohol and drug cravings, suggesting that targeting experiential avoidance using ACT could help to reduce cravings (Shorey et al., 2017). ACT encourages individuals to make room for uncomfortable feelings and act with willingness, recognizing that avoidance strategies ultimately contribute to greater suffering. ACT places a strong emphasis on acceptance: Acknowledging and allowing one's thoughts, feelings, and experiences without judgment or attempts to control them. For a client who is not ready to change their substance use, acceptance can be crucial in reducing self-criticism, shame and guilt; common feelings when people feel stuck in destructive addictive patterns.
Therapist: It's common to experience anxiety, anger, and sadness during cravings. In ACT, we call this the struggle switch - the urge to avoid discomfort by turning to substances. Instead of fighting those thoughts and feelings, can you imagine willingly acknowledging them with a sense of curiosity, observing them, and making room for them with self-compassion?
Loss of Contact with the Present Moment
When clients are caught up in addictive behaviors, they are often distracted, disengaged, and disconnected from their experiences, thoughts, emotions, and sensations. They may become preoccupied with the past or future, dwelling on regrets or worries, and engage in habitual behaviors without awareness of their actions. ACT emphasizes being present, aware, and fully engaged in the current moment. Mindfulness involves intentionally paying attention to the present moment without judgment. By cultivating mindfulness skills clients can develop greater awareness of their thoughts, feelings, and bodily sensations as they arise. Mindfulness can especially support clients struggling with addiction to become more aware of triggers and cravings, and the costs of living in autopilot mode (Karekla & Kelly, 2022).
Therapist: It sounds like you're experiencing a lot of distress. Let's take a moment to focus on your breath, observing the sensations without trying to change anything. Mindful awareness takes practice, but it can help us stay present with our emotions without getting overwhelmed by them. What did you notice in this exercise?
Attachment to a Conceptualized Self (Self-as-Content)
The conceptualized self or “self-as-content” refers to the social scripts, narratives, and identities (e.g., addict, loser) people have about who they are in the world. In contrast, the observing self or “self-as-context” is the pure awareness of experiences that remains unchanged, stable, and constant. Self-as-context provides a hopeful perspective to clients that they are more than their addiction and allows them to observe cravings as a temporary experience that does not define them. Self-as-context is closely linked to mindfulness and can create psychological distance from negative self-judgments and foster resilience and self-compassion.
Therapist: You are not your addiction. Your addiction is something you are experiencing, but it does not define your core self. Take a moment to close your eyes, take a deep breath, and become aware of your thoughts. Picture yourself as an observer of those thoughts, as if you are the sky and your thoughts are passing clouds. Your thoughts may come and go, but you remain steady and present. It's a new perspective, and as you continue to observe your thoughts and emotions without judgment, you'll notice they lose their power over you.
Lack of Values Clarification
Addiction can lead clients to lose sight of their core values and engage in behaviors that conflict with their long-term goals (e.g., “I cannot believe I did that when I was high”). ACT can help clients clarify their values and guiding principles for what they want to do, who they want to be, and how they will commit to actions aligned with those values. Even if a person is not ready to stop or reduce substance use, ACT helps them explore values in important domains and maps them to long-term goals. By understanding what truly matters (e.g., work, family, community, health, spirituality), they can begin to connect with their deeper motivations and find a sense of purpose. ACT assumes that quality of life is primarily determined by mindful, values-guided action. As such, it does not directly target symptom reduction but rather focuses on values-congruent living as an outcome, which typically results in a reduction of symptoms (Harris, 2022).
Therapist: It's essential to identify your important values and keep them in mind as an internal compass for when you get lost or stuck. Sometimes, addiction can lead us away from what truly matters. Let's look at the ways your substance use may be impacting your choices and values. Can you share a recent situation where you felt your addiction interfered with something important to you?
In ACT, an “unworkable action” is a behavior or response that is not aligned with an individual's values and life goals. In the context of substance use disorders, unworkable actions refer to maladaptive alcohol or substance use behaviors that interfere with the person's overall well-being and lead to negative consequences. For example, clients may be engaging in self-defeating or impulsive actions such as alienating others, reckless spending, or risky sexual behaviors. ACT encourages individuals to take meaningful actions that align with their values, even in the face of difficulty or challenging emotions. By developing an action plan with practical goals, therapists can assist clients in gradually shifting away from addictive behaviors, acquiring new skills, and building healthier patterns.
Therapist: I’m hearing that smoking weed and drinking too much is hindering your ability to be the partner and parent that you want to be. What would you like to say and do differently in those relationships? How can we move you closer to building the life you want, and achieving your goals?
By utilizing ACT processes and experiential exercises such as those described above, clinicians can assist clients in building psychological flexibility and developing more adaptive ways of relating to thoughts, emotions, urges, cravings, and triggers. Taking committed action involves responding effectively to the challenges of recovery by choosing activities aligned with values and putting energy into behaviors that are important and meaningful.
ACT: Accept reactions and be present, Choose a valued direction, Take action.
Nancy A. Haug, PhD is a licensed clinical psychologist, Professor of Psychology at Palo Alto University, and adjunct clinical faculty in the Addiction Medicine fellowship program at Stanford University Department of Psychiatry and Behavioral Sciences. She is the APA Division 50 Member-at-Large for Practice and a member of the Outreach and Dissemination Committee. She is also on the leadership team for the Applying ACT to Addictions Special Interest Group in the Association for Contextual Behavioral Sciences. In private practice, Dr. Haug utilizes ACT and mindfulness to treat addictive disorders.
Harris, R. (2018). ACT questions and answers: A practitioner’s guide to 150 common sticking points in Acceptance and Commitment Therapy. Oakland, CA: New Harbinger.
Harris, R. (2022). The happiness trap: How to stop struggling and start living (2nd edition). Boulder, CO: Shambhala.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2011). Acceptance and Commitment Therapy: The process and practice of mindful change. New York: Guilford Press.
Karekla, M., & Kelly, M. M. (2022). Cravings and addictions: Free yourself from the struggle of addictive behavior with acceptance and commitment therapy. Oakland, CA: New Harbinger.
Shorey R.C., Gawrysiak, M.J., Elmquist J., Brem M., Anderson S., & Stuart, G.L. (2017). Experiential avoidance, distress tolerance, and substance use cravings among adults in residential treatment for substance use disorders. Journal of Addictive Diseases, 36(3), 151-157.