Slow and steady wins the race: a randomized clinical trial of acceptance and commitment therapy targeting shame in substance use disorders

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 pairwise random fashion to receive treatment as usual (TAU) or the ACT intervention in place of 6 hr of treatment that would have occurred at that same time. The ACT intervention consisted of three 2-hr group sessions scheduled during a single week.

Results: Intent-to-treat analyses demonstrated that the ACT intervention resulted in smaller immediate gains in shame, but larger reductions at 4-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 posttreatment levels of shame, in that those evidencing higher levels of shame at posttreatment 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.

(PsycINFO Database Record (c) 2012 APA, all rights reserved).

Figures

Figure 1

Participant flow through study. ACT = acceptance and commitment therapy; TAU = treatment as usual.

Figure 2

Average percentage of participants with substance use–free weeks for each week during follow-up for participants in the treatment as usual condition (TAU) and the acceptance and commitment therapy group plus TAU condition (ACT).

Figure 3

Psychosocial outcomes for internalized shame (Internalized Shame Scale), general mental health (General Health Questionnaire-12), quality of life (Quality of Life Scale), and total social support (Multidimensional Scale of Perceived Social Support) at each measurement occasion for the treatment as usual condition (TAU) and the acceptance and commitment therapy group plus TAU condition (ACT). Values shown are adjusted means derived from the MMRM analyses. Note that the total social support measure is scored so that lower values equal more social support. MMRM = mixed model repeated measures.