Using Acceptance and Commitment Therapy during Methadone Dose Reduction: Rationale, Treatment Description, and a Case Report

Valued living after mild traumatic brain injury: Characteristics and relationship with outcomes

Psychological factors are strong predictors of mild traumatic brain injury (mTBI) recovery, consequently, psychological interventions can form part of an individual's rehabilitation. This may include enhancing valued living (VL), an approach that is effective in severe and mixed acquired brain injury samples. This study aimed to characterize VL in mTBI and explore its relationship with mTBI and mental health outcomes. 56 participants with a mTBI completed self-report measures before engaging in a psychological intervention. Pre-injury mental health and other demographic and injury-related variables, VL, post-concussion symptoms (PCS), functional disability, and stress, anxiety and depression were measured. A pre-injury mental health condition was significantly associated with VL. VL was uniquely associated with depression after mTBI (β = -0.08, p = .05), however, there was no relationship with PCS, functional disability, stress or anxiety (p > .05). Following mTBI individuals with a pre-injury mental health condition or who experience heightened depressive symptoms may benefit from a values-based intervention as part of their rehabilitation. Future research, however, is needed to examine the role of VL in mTBI recovery.

The Promise of Third-Wave Behavioral Therapies in the Treatment of Substance Use Disorders

Substance use disorders are common and frequently complex, with overlapping medical, legal, social and psychiatric problems. Innovative treatment models to address the full range of problems in new ways using common principles are needed. Third wave behavior therapies such as Acceptance and Commitment Therapy (ACT) and Dialectical Behavior Therapy (DBT) comprise novel approaches and methods that have great potential to address complex substance abuse cases. These treatment models derive from contextual and behavioral science and have a common emphasis on developing empirical, principle-driven methods for approaching unwanted or distressing psychological and physical experiences common to substance use and other disorders. Randomized controlled trials targeting substance use with ACT and DBT have been conducted across varying populations, including various target substances (opiates, methamphetamine, polysubstance) and settings (prisons, methadone clinics, residential treatment, and outpatient). Despite methodological heterogeneity, ACT and DBT have compared favorably to passive and active control conditions. Further research is needed, however, with larger samples and active control conditions, along with studies of treatment mechanisms, to inform and shape theoretical models and substance abuse treatment protocols for enhanced efficacy.

A preliminary randomized controlled trial of a distress tolerance treatment for opioid dependent persons initiating buprenorphine

BACKGROUND

Buprenorphine opioid agonist treatment (OAT) has established efficacy for treating opioid dependency but early relapse rates are high and are often associated with withdrawal-related or emotional distress.

METHODS

To determine whether a novel distress tolerance (DT) intervention during buprenorphine initiation decreases opioid relapse, we conducted a preliminary randomized controlled trial with opioid-dependent outpatients. Participants received buprenorphine-naloxone induction and 3-months of maintenance buprenorphine plus seven, 50-min manualized, individual sessions (DT vs. health education (HE) control) over a 28-day period, linked to clinician medication dosing visits, and beginning 2 days prior to buprenorphine induction. Primary outcomes included use of illicit opioids (positive defined as any self-reported use in the prior 28 days or detected by urine toxicology) and treatment drop out.

RESULTS

Among 49 participants, the mean age was 41 years, 65.3% were male. Persons randomized to DT had lower rates of opioid use at all three monthly assessments, and at 3-months, 72% of HE participants were opioid positive compared with 62.5% of DT participants. Rates of dropout were 24% and 25% in the HE and DT arms, respectively.

CONCLUSIONS

This distress tolerance treatment produced a small, but not statistically significant reduction in opioid use during the first three months of treatment although no differences were found in drop-out rates between conditions. If replicated in a larger study, DT could offer clinicians a useful behavioral treatment to complement the effects of buprenorphine.

A pilot study of a distress tolerance treatment for opiate-dependent patients initiating buprenorphine: rationale, methodology, and outcomes

Buprenorphine, an opioid that is a long-acting partial opiate agonist, is an efficacious treatment for opiate dependence that is growing in popularity. Nevertheless, evidence suggests that many patients will lapse within the first week of treatment and that lapses are often associated with withdrawal-related or emotional distress. Recent research suggests that individuals' reactions to this distress may represent an important treatment target. In the current study, we describe the development and outcomes from a preliminary pilot evaluation (N = 5) of a novel distress tolerance (DT) treatment for individuals initiating buprenorphine. This treatment incorporates exposure-based and acceptance-based treatment approaches that we have previously applied to the treatment of tobacco dependence. Results from this pilot study establish the feasibility and acceptability of this approach. We are now conducting a randomized controlled trial of this treatment that we hope will yield clinically significant findings and offer clinicians an efficacious behavioral treatment to complement the effects of buprenorphine.

Are mindfulness-based interventions effective for substance use disorders? A systematic review of the evidence

Mindfulness-based interventions (MBIs) are increasingly suggested as therapeutic approaches for effecting substance use and misuse (SUM). The aim of this article is to review current evidence on the therapeutic efficacy of MBIs for SUM. A literature search was undertaken using four electronic databases and references of retrieved articles. The search included articles written in English published up to December 2011. Quality of included trials was assessed. In total, 24 studies were included, three of which were based on secondary analyses of previously investigated samples. Current evidence suggests that MBIs can reduce the consumption of several substances including alcohol, cocaine, amphetamines, marijuana, cigarettes, and opiates to a significantly greater extent than waitlist controls, non-specific educational support groups, and some specific control groups. Some preliminary evidence also suggests that MBIs are associated with a reduction in craving as well as increased mindfulness. The limited generalizability of the reviewed findings is noted (i.e., small sample size, lack of methodological details, and the lack of consistently replicated findings). More rigorous and larger randomized controlled studies are warranted.

Long-term follow-up of a randomized controlled trial comparing acceptance and commitment therapy and standard cognitive behavior therapy for anxiety and depression

The present study represents one of the first comparisons of the long-term effectiveness of traditional cognitive behavior therapy (i.e., Beckian cognitive therapy; CT) and acceptance and commitment therapy (ACT). One hundred thirty-two anxious or depressed outpatients were randomly assigned to receive either CT or ACT, and were assessed at posttreatment (n=90) and at 1.5-year (n=91) follow-up. As previously reported, the two treatments were equivalently effective at posttreatment according to measures of depression, anxiety, overall (social/occupational/symptom-related) functioning, and quality of life. However, current results suggest that treatment gains were better maintained at follow-up in the CT condition. Clinical significance analyses revealed that, at follow-up, one-third more CT patients were in the clinically normative range in terms of depressive symptoms and more than twice as many CT patients were in the normative range in terms of functioning levels. The possible long-term advantage of CT relative to ACT in this population is discussed.

The third wave of cognitive behavioural therapies: what is new and what is effective?

PURPOSE OF REVIEW

The purpose of this study was to shortly characterize the evolving psychotherapeutic methods summarized as 'third wave psychotherapies' and to review recent research on the therapeutic impact of these methods.

RECENT FINDINGS

'Third wave psychotherapies' comprise a heterogeneous group of treatments, including acceptance and commitment treatment, behavioural activation, cognitive behavioural analysis system of psychotherapy, dialectical behavioural therapy, metacognitive therapy, mindfulness-based cognitive therapy and schema therapy. Several randomized controlled trials, longitudinal case series and pilot studies have been performed during the past 3-5 years, showing the efficacy and effectiveness of 'third wave psychotherapies'.

SUMMARY

The third wave of behavioural psychotherapies is an important arena of modern psychotherapy. It has added considerably to the spectrum of empirically supported treatments for mental disorders and influenced research on psychotherapy. The presented methods open up treatment possibilities for patient groups such as borderline personality disorder, chronic depression or generalized anxiety disorder that had received only little specific attention in the past. The available evidence now allows considering all third wave treatments as empirically supported.

A stage I pilot study of acceptance and commitment therapy for methadone detoxification

BACKGROUND

While agonist replacement therapies are effective for managing opioid dependence, community treatment programs are increasingly choosing detoxification. Unfortunately, success rates for opioid detoxification are very low, in part, due to physical and psychological symptoms associated with opioid withdrawal. Few behavior therapies specifically address the distressing experiences specific to opioid withdrawal. A novel behavioral treatment, acceptance and commitment therapy (ACT), works from the premise that the avoidance of unpleasant private experiences (thoughts, feelings, bodily sensations) is ubiquitous yet may be pathogenic, resulting in treatment drop-out and further drug use.

METHODS

This Stage I pilot study developed and tested an ACT-based opioid detoxification behavioral therapy. Opioid dependent patients (N=56) who were attending a licensed methadone clinic were randomized to receive either 24 individual therapy sessions of ACT or drug counseling (DC) in the context of a 6-month methadone dose reduction program.

RESULTS

While no difference was found on opioid use during treatment, 37% of participants in the ACT condition were successfully detoxified at the end of treatment compared to 19% of those who received DC. Fear of detoxification was also reduced across time in the ACT condition relative to DC.

CONCLUSION

This first study of ACT to assist opioid detoxification indicates promise. Research is needed to refine specific treatment strategies for this population to further strengthen effects.