Acceptance and Commitment Training for Substance

Abuse Counselors

Treatment Manual Used for:

Varra, A. A., Hayes, S. C., Roget, N., & Fisher, G. (in press). Using Acceptance and
Commitment Training to Increase the Effectiveness of Continuing Education in
Pharmacotherapy for Substance Use. Journal of Consulting and Clinical Psychology.

Questions or comments may be addressed to: Alethea A. Varra, VA Puget Sound Health Care
System, Mental Health Service (S-116), 1660 S. Columbian Way, Seattle WA 98108, or
alethea.varra@va.gov.

The ACT condition is based on Acceptance and Commitment Therapy and Relational
Frame Theory. As with previous research of this kind (Hayes et al., 2004) it is termed
Acceptance and Commitment Training here in order to distinguish the protocol from similar
protocols used for psychotherapy purposes. It has been deliberately named so that the same
acronym applies, since training consisted of material drawn from the psychotherapy manual. The
following summarizes the approach.
The first part of the presentation included a basic description of the training. Participants
were asked to volunteer their previous experience with evidence based treatments. An
introduction was given to the effects and sources of entanglement with negative thoughts about
evidence based treatments for substance abuse and a rationale for entanglement with these
thoughts as a barrier to effective treatment. Data supporting the ACT approach was briefly
presented from previous studies showing positive effects of this method for training therapists in
motivational interviewing and decreasing therapist burnout.
Participants were then asked to discuss what treatment approaches they have been trained
in, what treatments they use, and their opinions of specific evidence based treatments. This
discussion included any type of treatment with no particular emphasis on either
psychotherapeutic or pharmacological interventions.
The workshop then focused on the psychological barriers to using evidence based
treatments. Participants were asked to discuss what barriers they encounter in their current place
of employment. They were also asked to consider the link between these barriers in their work
setting and the same basic barriers in their personal lives. They were asked to consider the cost of
accepting these barriers as true obstacles.
During the fourth section of the training the group was exposed to principles of cognitive
defusion. The core idea is that thoughts are often automatic, and meanings are arbitrary
depending on an unseen social/verbal context that inputs literal meaning to symbolic events.
Demonstrations included the "Milk, milk, milk" exercise. A direct link was then made to
evaluative terms that come up automatically about barriers to learning or implementing new
treatments and about oneself when working with difficult clients. The arbitrary nature of such
evaluative reactions was explored, using additional defusion techniques drawn from Hayes et al.
(1999).
The training then addressed the issue of avoidance and control of emotions and thoughts.
Participants were asked to explore negative emotions and thoughts about particular types of
treatments or about learning new treatments. The negative impact of trying to control or avoid
these emotions and thoughts were explored and research findings in this area were briefly
described. The possibility was explored that avoiding thoughts about barriers to implementing
new treatments may hinder the therapists ability to treat their clients to the best of their ability.
The idea of accepting these thoughts and emotions rather than avoiding them was discussed and
several metaphors were used to make this point.
Finally, the ACT trainers asked participants to identify their values as a therapist. They
participated in a small group commitment exercise in which they identified what is important to
them as counselors. They were asked to identify what they have been doing instead, what that
has cost their clients, and what their commitment was for future treatment and clients. This was
followed by a brief group discussion of their experience and reactions to the training.

ACT Group Outline

I: Introduction:
A: Introduce Ourselves (the primary researcher and co-leader):
B: Description of the workshop:
Opening Statement:
Today we will explore the effects and source of stigma concerning evidenced based treatments
for substance abuse. There a lot of reasons why people dont use evidence based treatments and
today we are going to talk about what some of those reasons are and how to work towards using
whatever treatments are best for our clients.
We want to make this workshop personal, because learning is most interesting when it is done
that way. We will do this offering exercise that will focus you inward, so that you can experience
what we mean, not just intellectually, but experientially. We will not lecture you on how to avoid
stigmatizing certain treatment approaches. We won't try to change your opinions of any
particular treatments. To be clear, we don't have any investment in you using a particular
treatment, we are just talking about being open to evidence based treatments in general.
Confidentiality:
Our hopes for how you will learn to treat yourselves and each other. Lets keep personal
information that comes up in the room. Of course, we cant eliminate risk. We encourage you to
accept the risk of discomfort and choose to head forward anywaywe think that you will
experience the most meaning that way.
C. General Introductions
- Model perfunctory introductions.
- After participants are all introduced, introduce the notion that they chose to allow some
information to come out, they chose to ignore other aspects of themselves.
"Thank you everyone. Now, see if you can notice that when we were introducing ourselves, we
chose to allow some information to come out, we chose to ignore other aspects of ourselves.
Notice also that when you were listening to others, you began to talk to yourself about who is in
the room with you; what their characteristics are. We had very little information to go on, and yet
that is what our minds do. We categorize."
B. Cross-cutting Categories:
Now lets take a few examples of how cross cutting categories change how we view other.
Can we ask for volunteers to answer this question, in a sentence or two [work though as many as
seem needed and add any that come to mind as this is done when appropriate ask is anyone
else like that to broaden the examples we are getting from a single individual to a portion of the
group]:
1). When are you glad you are who you are?
2). What is your favorite hobby?
3). What do you love most about your children?

4). Why did you become a counselor?

5). If you have spiritual or religious values, how do they inform the activities you
engage in?
6). Do any of you have an experience with a loved one or close family member
that has a problem with substance abuse?
7). What is the hardest day you can remember as who you are?
As we added information, notice what happened to the human beings in this room. See if this is
true: they gradually became more human; more unique;
This quick little exercise points to a basic process that we will work on a lot today:
When a small number of verbal categories are applied to a human being, much is lost; yet this is
a natural and almost automatic process
II. Evidenced Based Treatments
A. What are evidenced based treatments?
Group leaders will provide a current list of evidenced based treatments for substance abuse as
provided by APA.
B. How much do you use evidenced based treatments?
Group discussion.
C. What gets in the way of using evidenced based treatments?
Examples will be given and then group discussion.
Examples may include:
- I havent been trained with them
- I think pharmacological interventions are just substituting one drug for another.
D. Why are we talking about ACT?
Data from previous studies showing positive effects of this method for training therapists in
motivational interviewing and decreasing therapist burnout.
BREAK (10 minute break)
III: Treatments You Currently Use?
A. What therapies have you been trained in?
B. What do you use most commonly?
C. Are there types of treatment you feel strongly about using or not using?
This discussion included any type of treatment with no particular emphasis on either
psychotherapeutic or pharmacological interventions.
D. Psychological Barriers:
Go back to the list of barriers discussed earlier. Highlight the psychological nature of many
of the barriers.
E. Are these Barriers Unique to learning new treatments?
Consider the link between these barriers in their work setting and the same basic barriers in

their personal lives.

F. What is the cost?
Consider the cost of accepting these barriers as true obstacles. (Both for the therapists and for
their clients).
IV. The automatic nature of Barriers
A. The thoughts are often automatic, and we feel the need to respond.
B. Evaluative terms that come up automatically about barriers to learning or implementing new
treatments. Ask participants to brainstorm a list of thoughts, emotions etc.
C. Evaluative terms that come up automatically when working with difficult clients/ substance
abusers. Ask participants to brainstorm a list of thoughts, emotions etc.
D. Cast these feelings as normal reactions to hard situations.
E. The arbitrary nature of such evaluative reactions.
- What are the numbers exercise
- Mary had a little____
F. Taking a half step back from these thoughts.
"Milk, milk, milk"
As a species, language, including thoughts and words, gives us the blessings and the curse of
knowledge. The power of language has pros and cons: there is a "light side" and a "dark side". On the
positive side, we can influence the environment and create a comfortable life. Just look around in this
room. Lights, chairs, central heating, and clothes we are wearing Without language and our
thoughts (e.g., logical thinking), these would not be here. On the dark side, we are the only species
that worries. In the extreme case, we are the only species that commits suicide.
The dark side becomes dominant when we believe that our thoughts are literally what they say they
are, especially thoughts about ourselves could be evaluative and judgmental. For example, "I am no
good." And we tend to think of our thoughts, of what they say, as the reality or as the criteria of the
reality. For example, you are what your thoughts say who you are, what you are, and how you are.
However, are you really what your thoughts say you are?
What if I say that thoughts are simply what they are (thoughts are just thoughts), rather than what
they say they are OR you are not what they say you are. It might be difficult to understand this point,
so let's do a little exercise.
As I say, this exercise sounds silly. First, I'm going to say a word and I want you to tell me what
comes to mind. "Milk".
P: (I have milk at home in the refrigerator).
L: O.K. what else? What shows up when we say "Milk".
P: (I picture it---white, a glass).
L: Good what else? (Can you taste it?). Can you feel what it feels like to drink a glass of milk?
Cold, creamy, coats your mouthright?
L: O.K. let's see if this fits. What came across your mind were things about actual milk and your
experience with it. All that happened is that we made a strange sound Milk --- and lots of
those things show up. Notice that there isn't any milk in this room. Not at all. But milk was in
the room psychologically. You and I were seeing it, tasting it, and feeling it. And yet, only the
word was actually here.
L: Now, here is another exercise. The exercise is a little silly, and you might feel embarrassed
doing it, but I am going to do it with you so we can all be silly together. What I am going to ask

you to do is to say the word, "milk," out loud, over-and-over again, and as rapidly as possible,
and then notice what happens. Are you ready?
L: O.K., Let's do it. Say, "milk" over and over again! (15seconds).
L: O.K. now stop. Tell me what came to mind while you kept repeating it?
P: (e.g., Gone)
L: Did you notice what happened to the psychological aspects of milk that were here a few
minutes ago?
P: Yea, it's just a sound.
L: Right, creamy, cold, gluggy stuff just goes away. When you said it the first time, it was as if
milk was actually here, in the room. But all that really happened was that you just said that
word. The first time you said it, it was "psychologically" meaning-full, and it was almost solid.
But when you said it again and again and again, you began to loose that meaning and the words
became just a sound.
What I am suggesting is that What happens in this exercise may be applied to our personal
thoughts about us or negatively attitudes toward particular treatments or even negative evaluations
about our ability to try something new in our workplace. When you say things to yourself in addition
to any meaning behind those words, isn't it also true that these thoughts are just thoughts. The
thoughts are just smoke, there isn't anything solid in them.

Lunch (60 min break)

V. Avoidance & Control.
A. Discuss how these emotional reactions to learning new treatment impact our own behavior.
What does it look like when we are avoiding stuff at work? We begin to defend ourselves
verbally
B. Can we just stop it?
This is the researchers answer to the difficulty, right? If you have enough facts or information
that should be enough to persuade you. Don't think about it, just do it. . .
C. Try not to think about it.
Dont think of a jelly donut exercise
Suppose I tell you right now that I don't want to think about See? I can't even tell you because you
know what would happen. Well, OK. Let's see. Don't think ofwarm sweet chocolate pie. Don't
think of it. Don't think of how it smells when it first comes out of the oven. Don't think of that.

D. And definitely don't worry about it:

Polygraph example:
Suppose I had you hooked up to the best polygraph machine that is ever been built. This is a perfect
machine, the most sensitive ever made. When you are all wired up to it, there is no way you can be
aroused or anxious without the machine knowing it. So I tell you that you have very simple task here:
All you have to do is stay relaxed. If you get the least bit anxious, however, I will know it. I know you
want to try hard, but I want to give you an extra incentive, so I also have a .44 Magnum that I will
hold to your head. If you just stay relaxed, I won't blow your brains out, but if you get nervous (and I
will know it because you're wired up to this perfect machine), I'm going to have to shoot you. Your
brains will be all over the walls. So just relax What do you think would happen? Guess what you'd
get? Bam! How could it work otherwise? The tiniest bit of anxiety would be terrifying. You'd be
going "Oh my God! I'm getting anxious! Here it comes!" Bam! How could it work otherwise?

VI. Alternative approach to barriers: Acceptance & Willingness:

A. Taking the time to notice.

Leaves on the stream:

I'd like us to do an exercise to show how quickly thoughts pull us away from experience when we buy
them. All I'm going to ask you to do is to think whatever thoughts you think and to allow them to
flow, one thought after another. The purpose of the exercise is to notice when there's a shift from
looking at your thoughts, to looking from your thoughts. You will know that has happened when the
leaves stop, or you are down in the river, or the exercise has disappeared. I'm going to ask you to
imagine that you are sitting on a river bank, watching a stream babble by. Upstream a bit there is a
tree that is dropping leaves into the stream and they are floating by as you sit and watch. As you
watch, imagine each thought you have as written on a leaf as it passes by. Some people have a hard
time putting thoughts into words, and they see thoughts as images. If that applies to you, put each
image on a leaf as it floats down the stream.
So, I am going to ask you to get centered and begin to let your thoughts go by written on leaves as
they float down the stream. Now here is the task. The task is simply to watch the leaves go by without
having them stop and without your jumping down into the stream. You are just supposed to let it flow.
It is very unlikely, however, that you will be able to do this without interruption. And this is the key
part of this exercise. At some point you will have the sense that the stream has stopped, or that you
have lost the point of the exercise, or that you are down in the stream instead of being on the river
bank. When that happens, I would like you to back up a few seconds and see whether you can catch
what you were doing right before the leaves stopped. Then go ahead and put your thoughts on the
leaves again, until the leaves stop a second time, and so on. The main thing is to notice when it stops
for any reason and see whether you can catch what happened right before it stopped. OK?
One more thing. If the leaves on the stream never get going at all and you start thinking, "It's not
working" or "I'm not doing it right," then I let that thought be written on a leaf and send it down into
the stream. OK. Now let's get comfortable, close your eyes, and get centered. Take a few deep deep
breaths. Now image yourself there on the riverbank and allow the leaves to begin floating by. You
stay up on the river bank and let the leaves float by. If it stops or you find yourself in it, note that; see
whether you can notice what you were doing right before that happened, get back up on the river
bank, and let the leaves begin to float by again. OK, let's begin. ...Whatever you think, just put it on
the leaves. [For about 2 minutes, allow the participants to work. Don't underdo it time-wise, and use
very few words. Add a very few comments, as needed such as, "Just let it flow and notice when it
stops." If a participant opens his or her eyes, calmly ask that they be closed and the exercise be
continued.]. OK, now we will let the last few leaves go by, and we will begin to think about coming
back to this room. When you are ready, open your eyes. Welcome back.

Process the exercise

-What did you observe?
-Did you notice what had been happening right before every- thing stopped?
-See if this isnt so. Often when the flow of leaves stopped, it was because you bought a thought.
-The point is just to get a feel for what it is like to be hooked by your thoughts and what it is like to step
back once you're hooked.

Eyes On Exercise:
OK. Now, I want you to find a partner for the next exercise. During this exercise, we will look each
other's eyes for about 3 minutes. I may seem longer when you actually do it, but that's all it takes.
What the exercise will consist ofif you are willing to do itis getting a couple chair and pulling
them close together. The job is to get present with each other and maintain eye contact. It is not a

stare down. You don't have to say anything, or do anything, or communicate anything for the threeminute period. Just be present with your partner. Now your mind will tell you all sorts of reasons that
you can't do that: it will give you body sensations, or perhaps a desire to laugh, or maybe you will be
worrying about how your breath smells, or you'll be bored or distracted. But the purpose of the
exercise is simply to notice these things, to experience all the pieces coming up, and to notice you sort
of come and go from being really present, from really experiencing being here with your partner.
During the exercise, the facilitators say: "See if you can stay with the simple reality that there is
another person over here, looking at you; See whether you can let go of the sense of wanting to do
this "right"; If you find yourself talking about this, or evaluating it, just notice that you are doing
that, and then come back into the room and get n touch with the exercise; I want you to notice the
incredible fact that there is another person here, another human being, looking back at you; See if
you can connect with the experience of discomfort in simply being present to another person".

BREAK (a 10 minute break)

Tin can monster Exercise:
Facing our own difficult feelings and thoughts is like facing a giant monster who is made up of tin
cans and string. The 30-foot monster is almost impossible to fact willingly; if we disassemble him,
however, into all the cans and string and wire and bubble gum that hes made of, each of these pieces
is easier to deal with one at a time. I would like us to do a little exercise to see whether that isnt the
way it works. Start by closing your eyes and relax.

OK. Lets start by recalling something that happened last summer. Anything that happened is
fine. When you have something, raise your finger. Now I want you see everything that was
happening then. Notice where you are and what is happening. See whether you can see, hear, and
smell, just as you did back then. Take your time. (Pause). Now, I want you to notice that you were
there. Notice that there was a person behind those eyes, although many things have happened since
last summer, notice also that the person is here now. Im going to call that person the observer you.
This is the person we want to do this exercise with. See if you can keep that point of view, the view
of someone observing your experience, and lets come back to the experience of learning a new
treatment.

From the observer point of view, I want you to get in touch with one of the barriers that you
experience in your workplace when you think about learning a new, maybe evidence based,
maybe not, treatment. Now I want you see if you can simply notice the thought or feeling and
acknowledge them. The goal here is not that you like the feelings and thoughts, but that you are
having them just as a specific mental event. See whether you can notice exactly where that it begins
and ends. See if you can simply describe the feeling or thought. And as you do that, drop any sense of
defense or struggle with the simple mental event. If other feelings or thoughts crowd in, let them
know that we will get to them later.
Bring the feeling/thought back into the center of your consciousness and again watch it quietly for
what your body does. As you watch, stay with that observer you, the part of you behind you eyes, and
watch from there. OK. Continue to look for things your body does, but this time just look very
dispassionately at all the little things that may happen in your body, and we will just touch each and
move one. So with each reaction, just acknowledge it, as you would tip your hat to a person on the
street. Sort of pat each on the head, and then look for the next one. Each time, see whether you can
welcome that bodily sensation, without struggling with it or trying to make it go away. In a sense, see
whether you can welcome it, as you would welcome a visitor to your home.

After this sequence is done with bodily sensation, do the same things with emotion, thoughts,
evaluation, and memory. Stay with one specific set of reactions at a time. Constantly come
back to the issue of letting go.
B. Nametags Exercise
As an example of having the thought and carrying it around with you, let try something over the
break. Lets everyone take a negative thought that they have about themselves as a therapist, the
kind of thought that might get in the way of trying something new, and see if you can come up
with one word that really captures that thought. Maybe its something like incompetent, or
maybe ineffective, or not a team player, or maybe mean, or stupid. Whatever it is, see if you are
willing to write it down on one of these sticky name tags and wear it around during the break.
BREAK (10 minute break)
V. Bringing in Values
A. Tombstone Metaphor
"What do you want on your tombstone?" Would you want it to say "She never had a patient
on Methadone." What are your values when it comes to your practice and your clients? Are
there ways that you have been ignoring those values and doing what is easy, what is popular
amongst your colleagues, or what is already supported by your system? Some of those barriers
are real, and is there a way to work within your system even with those barriers? What would
you like to commit to in the future?
B. Organize into small groups of 5 or 6 people. Have every person take a turn and finish the
following three sentences:
1) My value as a therapist is __________________________.
2) What I have been doing instead is ___________________.
3) My commitment when I return to work is to ___________.
IX. Wrap up.
A. Group discussion.