By Steven Hayes
Originally published by Psychotherapy Networker, Inc. Sep/Oct 2007

I keep a supply of Chinese finger traps in my office to show to patients. When you push your fingers into each end of these straw tubes and then try to remove them, the tube diameter shrinks and grabs the digits firmly. The more you struggle, the more your fingers are trapped. The only way to create enough room to get your fingers back out is to do something counterintuitive: push them deeper into the tube, which only then relaxes its grip.

These toys demonstrate a basic principle about why so many of the issues people bring into therapy seem insoluble, despite determined and well-intentioned efforts to deal with them: fighting a problem can itself create a problem. I remember giving one of these finger traps to an especially anxious client and watching as he practically pulled his fingers out of their sockets in his frantic attempt to get them free. Suddenly, abandoning his struggle with the toy, he let his hands relax. “Okay,” he said knowingly, “I get it.” He pushed the ends of the tubes inward and then removed his fingers easily. I knew he meant more than understanding how the toy worked, though. He saw in that moment a model of how his battle with anxiety had constricted his life, and that the strange alternative I was putting on the table might not be so strange after all: only by moving into his pain could he ever find the room to live fully.

A moment or two after this small epiphany, he surprised me by voicing an even deeper issue. As if asking himself a question he had no idea how to answer, he added “And then what?” It’s an important question, with a surprising answer.

Dr. Steven Hayes, Ph.D.

During the past 10 years, a number of therapy approaches have come into the mainstream of clinical practice based on the core idea that the more we struggle with the Chinese finger traps of the human mind, the more confused and stuck we become. Mindfulness-Based Cognitive Therapy, Dialectical Behavior Therapy, and the approach my colleagues and I have developed, Acceptance and Commitment Therapy (ACT), all agree that a first step toward fundamental change is to come into the present moment–even if that moment is painful–and let go of the impulse to leapfrog into a desired future from which inner troubles have evaporated. These methods are based on the view that taking the obvious step of trying to escape from difficult thoughts and feelings usually makes them worse–just as with finger traps, in which doing the presumably “sensible” thing is counterproductive–and, in the process, takes us further and further away from a liberated life.

Rather than being preoccupied with changing the painful content of the mind, these methods change our relationship with what troubles us. For example, instead of disputing negative thoughts, patients learn to watch them mindfully and at enough distance to realize, in a visceral and not just analytical way, that they’re just thoughts. Instead of getting rid of sadness, patients learn to detect how sadness feels in their body, how it tugs at their behavior, how it ebbs and flows, and begin to feel at a deep level that they can carry sorrow with them while still living the life they want.

This is an important shift away from many of the traditional methods of psychotherapy, perhaps especially so in my own home territory of the behavioral and cognitive therapies, which have long focused on reducing negative emotions and thoughts as a method of life change. The first wave of behavior therapy aimed at directly changing the intensity of emotions and the form or frequency of overt behavior through desensitization, token economies (using “token” chips or points to reward positive behavior change), and the like. The second wave of behavior therapy put more emphasis on cognition, producing cognitive-behavioral therapy (CBT). But like the first wave, CBT targeted the form and frequency of these cognitions, such as whether they were rational or contained cognitive errors, and tried to change them through testing, disputation, and analysis.

By contrast, ACT and other mindfulness-based methods invite patients to step into the now and fundamentally change their relationship with their own experience. Instead of trying to manipulate and change their inner world into a more “desirable” form, these methods encourage patients to deepen and enrich their contact with a continuously unfolding present.

The Trap of the “Problem”

A basic principle of ACT, buttressed by 20 years of research into the nature of human cognition, is that common-sense problem-solving strategies, when applied to subjective experience, too often become traps. In fact, our research suggests that human problem solving itself contributes to the intractability of human suffering.

Consider how the focus of psychotherapy is defined within the first few moments of clients’ initial sessions. Clients typically begin by saying something like, “I’ve had anxiety for years and lately it’s gotten a lot worse,” or “My husband left me and I’m just lost,” or “I’m constantly worrying,” or “I just feel empty.” Patients frame their complaints as something happening that’s creating difficult thoughts, feelings, memories, or sensations. A thousand explanations will then be devised to explain the existence of these problems (“It’s my childhood,” or “It’s my neurotransmitters,” or “It’s my wife”). In the end, therapist and patient will typically agree, implicitly or explicitly, on the ultimate goal of whatever intervention follows: get rid of these unwanted thoughts, feelings, memories, or sensations.

In doing that, both are complicit in the assumption that these sources of distress need to be changed before real living can begin. You can see that agreement in the names of our most common “disorders,” through which anxieties, moods, thoughts, and other private experiences are appointed to play the role of “the problem.” And you can see it in the names of our treatments, which often suggest we need to restructure, manage, or master our experiences.

Although this appears to be a normal, logical, and reasonable approach, it may not be the most helpful. Consider a person with panic disorder trying to rid him- or herself of anxiety. It’s natural to focus on what seems to make anxiety more likely (stressful situations, not being able to leave a room easily, not having pills available, irrational thinking, and so on), and the apparent solutions that might lessen that anxiety (learning to relax, staying near the exit, being sure to have tranquilizers handy, thinking more rationally). But this commonsense approach is based on what Mark Williams, one of the originators of Mindfulness-Based Cognitive Therapy, calls a “discrepancy-based mode of thinking,” in which clients constantly measure and try to narrow the distance between what’s wrong or bad that’s going on now and what’s right or good that isn’t going on now. Thus their minds continuously cycle between an undesirable present and a desirable future.

This problem-solving approach works wonderfully in addressing many of the challenges of real-world survival, such as getting into a locked car or escaping from a burning building. To illustrate for trainees the vast cognitive capacities of the human animal that have allowed a species of weak, slow, defenseless creatures to take over the planet, I often give them the following challenge: “It turns out that all of the doors and windows are locked” I say, “and we have only one chance to leave here. We can implement any plan you like, but we have to agree on it without leaving our seats, and we can only implement the plan once, without pretesting it. If it fails, we’ll be stuck here forever.”

Usually the group quickly generates alternative escape plans: break the windows, call for help on a cell phone, crawl through the ductwork, kick down the door. Then they begin to consider and discuss the pros and cons of each. The door may not break easily. If we jump from the broken window, someone might get hurt. We may not have the right number to call or the phone battery may be dead. Eventually, a sound plan is agreed to without ever leaving our seats.

But when the target of our problem-solving efforts is our own thoughts and feelings, rather than the manipulation of our external environment, this rational approach typically becomes part of the problem. Once we buy into the idea that we’re in a bad situation that needs to be changed–whether that’s inside a locked room, in a finger trap, or in our own pain–our cognitive problem-solving skills will inevitably lead us to find ways to get out of the difficulty by applying our analytical skills. In the get-out-of-the-room situation, which involves manipulation of external events, rational problem solving works effectively. But applying that same process to an internal emotional state like panic is different, because the target actually tends to grow and spread in reaction to the problem-solving effort itself.

A person trying to “solve” the problem of panic by getting rid of it regularly evaluates the level of anxiety being experienced, and fearfully checks to see whether it’s going up or down. This process actually tends to elicit anxiety, and risks conditioning the person to experience anxiety in more and more circumstances. Anxiety gradually becomes a focus of life, and patients believe they can only live happily by constantly imagining themselves at some point in the future when they’re “cured” and anxiety has left the scene. Typically, life itself has to be put on hold while they continually and repeatedly attempt the impossible task of thinking themselves out of their anxiety.

In contrast, ACT takes the position that “experiential avoidance”–trying to steer away from psychological pain–limits our ability to be present in our own lives. Research has shown avoidance of pain is one of the most consistently troublesome processes in all of psychology, accounting for about 20 to 25 percent of the variance in successful outcome across a broad range of common psychological complaints–everything from depression, to difficulty in learning, to whether a traumatic event will lead to a post-traumatic stress disorder. The research evidence confirms the paradoxical proposition that trying to change your unpleasant thoughts and feelings typically just makes them more entrenched.

Coming into the Present

In contrast with traditional cognitive-behavioral therapies, ACT doesn’t try to change clients’ thoughts or feelings. It concentrates instead on helping them recognize that thoughts are just mental events to be noticed, not true or false pronouncements on the fundamental nature of reality itself. Similarly, feelings are something to be felt, not powerful and dangerous bullies to be avoided at all cost. According to ACT, the therapeutic task isn’t helping clients successfully dispute their thoughts or feelings; rather, it’s enabling people to say yes to their own experience, whatever it happens to be.

In the early development of ACT, my students and I created a protocol and tested it against traditional CBT for depression in a small randomized trial. We found we got better results by teaching patients to see depressive thoughts merely as thoughts than we did by trying to get them to change their thoughts. After nearly 15 years developing the model, we finally published it in book form in 1999. Since then, more than 20 randomized trials that we’ve conducted have shown that the approach can be effectively applied to stress, anxiety, psychosis, chronic pain, depression, burnout, and many other conditions.

How does ACT work? To help clients attain a present focus, it identifies three fundamental skills. The first is Cognitive defusion: separating the process of thinking from the world structured by thought. If you try to describe the present moment, you’ll notice something odd. Anything you have to say about “now” lags slightly behind now. Even if you quickly say the word now, the instant that you’re naming is the now that was there milliseconds ago, not the now that’s there when the word emerges. This is because language is based on the arbitrary relation between symbols and our ongoing experience, and no matter how quickly you relate one to the other, it takes time. Conversely, if you silently look about you for a few moments, everything you see is seen now, not a millisecond ago. There’s no time lag at the level of experience itself.

This difference creates a conundrum. Life can only go on now–it has no place else to go on. But our ability to generate symbolic meaning always lags behind, dampening the vitality of the immediate experience of the moment, and carrying us more and more into a symbolic world where now is merely a concept, not an experience.

There’s a solution to this conundrum, however. Without throwing out human language and all of its wonders and benefits, we can learn to see thinking itself as unfolding in the present. In ACT, we call this process “cognitive defusion.” ACT therapists and researchers have developed scores of defusion techniques. For example, if you have a client distill a painful thought into a single word and say it out loud repeatedly for 45 seconds or so, and by the end of that process, the word will have lost most of its punch based on its meaning. Instead, the client will become aware of the experience of saying the word–how it sounds or the feeling of saying it. Or clients may practice another mindfulness exercise, like viewing thoughts as things floating by like leaves on a stream. If, while doing this, they find themselves taking the thought or feeling literally–becoming emotionally engaged in the feeling of sorrow, anxiety, or anger, for instance–the sense of flow this exercise brings will stop. But once they’re able just to notice thoughts in the present–”I’m having the thought that I’m sad”–without either belief or disbelief, compliance or resistance, the flow continues again.

A thought like “I’m bad” invites us to argue about whether it’s true by providing evidence (usually from the past) on one side or the other. But whether it’s true or false is irrelevant to the fact that the thought is here, now. Simply noticing thoughts as processes, rather than as events that must be true or false, liberates clients from having to put their life on hold while cognitions are evaluated, accepted, rejected, argued with, or put in some sort of order.

The process of defusion dampens down the impact of thoughts and allows more flexibility in responding to them. For example, a panic-disordered person thinking “If I get anxious here, I’ll make a total fool of myself” might short cut the endless problem-solving, discrepancy-reducing mental rigmarole that makes the problem worse by simply thanking his mind for the thought, or by saying the thought again very slowly (“a toooooootaaal foooooool of myseeeeeelllllllfff”), singing the thought to the tune of a popular song, or saying it in a Donald Duck voice. The ACT defusion techniques all carry the same message: thoughts are just thoughts. Notice them and then do what works, not necessarily what they say.

The second fundamental ACT skill is Acceptance. When patients try to avoid, escape, or control painful feelings, the present becomes the enemy. Now is where and when feeling occurs, but they’re concentrating on the imagined future in which the now will be different. Coming into the present requires psychological acceptance–a voluntary and undefended leap into the multifaceted, multisensory moment. As with any leap, this means abandoning some degree of control. In a physical leap, we leave it to gravity to carry us safely back to earth. In a leap of acceptance, we give over control to the now, allowing our experiences to present themselves in their full breadth and depth.

ACT uses a variety of metaphors and experiential exercises, many borrowed from other experiential therapeutic traditions, to help clients get past the judgments and analytical mind-sets that keep them entangled in unproductive problem solving. When a client complains of being in the grip of a particularly painful feeling, which she feels she must get rid of, we’re likely to ask her to spend time getting thoroughly acquainted with it instead. One exercise, called the “Tin Can Monster,” suggests that overwhelming feelings are like huge monsters made up of tin cans, bubble gum, and rubber bands. The total effect can be overwhelming, but if we stop to examine their individual elements, we find nothing really fearsome there. In this eyes-closed exercise, we ask patients to get in touch with the difficult feeling and then notice carefully what their bodies do. The goal is to drop any struggle and just notice each specific bodily reaction. So, for example, as each reaction is named, the therapist takes the client into that sensation in great detail–where is it located, where does it begin and end? Or we might ask the client to imagine that the bodily sensation is an object on the floor and to describe its color, speed, texture, and weight. When the client is fully open to experiencing each sensation without defense, the next bodily reaction is sought. This dismantling process continues through urges to act, emotions, thoughts, and memories.

The task for clients is to drop their struggle with unwanted reactions and amplify contact with what is. Rather than trying to win a tug-of-war with difficult private experiences, clients learn to “drop the rope” and allow themselves to feel the experiences as they happen. That shift of perspective profoundly alters the function of feelings, changing them from something “bad” that must be evaluated and manipulated to something to be fully felt without fear or desperation.

The third basic ACT skill is the acquisition of a transcendent sense of self. Patients commonly confuse their passing thoughts, feelings, and judgments about themselves with their selfhood. They must develop a consciousness that they are their experiences, feelings, thoughts, and judgments, and, in some sense, independent of them. The problem is that we can’t really separate consciousness from the experiences that comprise it: we can’t examine the space where consciousness resides, because to do so would be like jumping to the side of oneself to look back at looking. At best, we can catch fleeting glimpses.

In ACT we produce these fleeting glimpses by exercises that first draw attention to the ongoingnesss of experience and then suddenly call attention to the person who’s aware of these experiences. For example, an ACT therapist might lead a client through the mindfulness exercise of “I’m not that.” It usually begins with eyes open. The client is asked to briefly examine objects in the area, notice the features of each one, and then say, “I’m not that.” The goal is to directly experience the distinction between what’s seen and the conscious person seeing it. After a time, the exercise continues with eyes closed. The therapist asks the client to explore sensations, emotions, thoughts, and memories following the same process–note the features of the inner experiences and then tell himself he isn’t the same as the consciousness noting them. This exercise arrives at a transcendent sense of self by a kind of subtraction. In this way, the constantly changing nature of thoughts and feelings is contrasted with the sense of continuity–the essence of consciousness, in which “you” have been “you” your entire life.

And Then What?

But as mindfulness and acceptance methods help clients more fully inhabit the present moment in their lives, they face an unavoidable question: what will they do with the now-ness of their lives? Once they’ve quit fighting their own experience, what should they do with it? It isn’t enough simply to help clients “live in the present moment.” The real issue, once they’ve “made friends,” so to speak, with their problems and learned to avoid avoidance, is how they should live. What should they live for? Or, as my patient put it so succinctly, “And then what?”

Jack Kornfield’s delightful book about spiritual exploration, After the Ecstasy, the Laundry, captures perfectly the eternal truth that no matter how stimulating and inspiring our adventures into consciousness and expanded awareness are, there’s still everyday life to be lived. For some people, there can be almost a narcotic quality to contacting the present moment, particularly if they’ve spent years trying to escape it. People can often experience dramatic reductions in anxiety or depression just by abandoning their attempts to reduce them in favor of accepting and being mindful of them.

The experience of living in the present, paradoxically, can tempt us into experiential avoidance all over again, just in a new form. It’s quite possible to trade escape from the now for escape into the now. The recent enthusiasm for mindfulness and acceptance in the West needs to be channeled properly or we risk creating just another form of Western self-indulgence. By themselves, mindfulness methods as they’re often used in Western psychotherapy don’t give sufficient attention to the organizing influence of purpose in human life. In the spiritual traditions from which such practices were drawn, “right action” is specified through ethical principles. But Western therapists are encouraged to take a value-neutral professional stance, and not direct our clients to any particular belief or “right action” enjoined by a religious or spiritual tradition. Nevertheless, we still can help our clients gain access to their deepest aspirations and turn a life lived in the present moment into a life worth living.

Avoidance and mindlessness can help us on this journey, if we know how to use them. The things that hurt us do so because we care. A person who fears relationships because of past betrayals is a person who values trust and intimacy: otherwise, the betrayal wouldn’t have hurt in the first place. An ACT saying expresses this idea: in your pain you’ll find your values, and in your values you’ll find your pain. That’s part of why experiential avoidance is so harmful: as we avoid our hurts, we can’t help but undermine our values. So, by helping clients accept their pain and stop avoiding it, we can help them open up to what they most deeply want in their lives. Their pain can serve as a powerful guide to therapy.

In the wake of a painful betrayal, the normal human reaction is avoidance of intimacy. It’s common to hear people who’ve been hurt say, “I’ll never let myself be so vulnerable again.” And yet, such a refusal also cuts one off from the possibility of deep human connection, and thus from one of life’s basic needs. Intimacy implies vulnerability–someone close to you truly can wound you, by definition. People vowing not to be vulnerable think they’re avoiding only the pain, but in fact, they’ve resolved to avoid intimacy itself precisely because they so deeply want it in their lives. This act of self-deception creates a wound far greater than the original hurt: we’re dealing now not just with betrayal, but with the pain of a life unlived.

Acceptance and mindfulness aren’t just about some trendy notion of “being here now,” but comprise a set of skills that enable clients to learn to live with emotions they might otherwise find intolerable–and use them as guideposts to a life of deeper purpose. An ACT therapist might commonly ask the intimacy-avoiding client, “If moving powerfully in the direction of the intimacy you long for implied learning how to carry the pain of your past betrayals, would you do so?”

We take clients into pain because it’ll inevitably come up when they move toward what they really want. Defusion and acceptance help clients realize that plain hurt isn’t devastating. By contrast, the kind of denied, convoluted hurt that comes from avoidance is deeply harmful because it blocks us from achieving full consciousness and full humanity.

By reducing the need to avoid painful feelings, acceptance and mindfulness can actually help people become braver and live with the anxiety, pain, and discomfort required to attain something they deeply value. From an ACT perspective, values are consciously undertaken actions aimed at achieving purposes that are deeply important to one’s sense of selfhood. Research suggests that the only values that can transform lives are those that are purposely chosen, reflect what you really want, and are fully expressed in your actions. Only doing what you truly value for its own sake, because it’s what you want, will ultimately contribute to your development, even your happiness, as a human being.

It’s also important to remember that valuing something isn’t the same as achieving life goals. Values are like directions on a compass. They’re never “achieved,” but in each and every step they influence the quality of the journey. Values dignify and clarify our life course by putting pain in a proper context: it’s now about something that matters to us, which we want with our entire selves. In the realization that values can’t ever be achieved, only lived moment to moment, comes joy, because from the first moment clients acknowledge what their values are, they’re living them. Values aren’t something you can both have and be finished with, like objects you can put in a box and store away–they’re ongoing, active, and perpetually generative.

If a client really owns up to wanting to be a good father, for example, in that very act of acknowledgement, values are coming alive. The path this value implies will never be complete, but a consciousness of that value will enable a coherent journey through a continuously unfolding now. Said another way, the value directs the journey, but it’s the journey that ultimately matters.

There are no shortcuts to living joyfully: we can’t just take refuge in the moment and avoid the messy process of life itself. When we learn to carry our fears, we still have to face all life’s day-to-day decisions and difficulties. But once we’re aware of our values and develop a deeper commitment to our own purposes, life becomes much more vital than it is when we’re merely trying to keep our demons at bay.

If we stay connected with what we most care about, life itself will present us with exactly what needs to be accepted. We can begin to do that by staying right here, right now, in this present moment. But acceptance is then about something. It provides an answer to my client’s question: “And then what?” Acceptance and mindfulness aren’t ends in themselves. Rather, they empower us to live a value-filled, meaningful, committed life by helping us to open up to the full range of thoughts and feelings we experience from moment by moment.

About Steven Hayes, Ph.D.:

Professor of psychology at the University of Nevada at Reno. He’s written 300 peer-reviewed articles and 27 books, including his latest, Get Out of Your Mind & Into Your Life.

At the February 2010 Technology, Entertainment, and Design (TED) Conference, Sam Harris questioned why good and evil, right and wrong are commonly thought unanswerable by science. Sam Harris argues that science can — and should — be an authority on moral issues, shaping human values and setting out what constitutes a good life.

I agree with the premise that is presented here. It is often argued that purview of religion is morality and that science has no place in the discussion. However, a scientific view of morality can, and must, be part of the discussion of the human condition. I believe that Buddhism, unlike western religions, has always viewed the world in a factual, scientific light. Accordingly, this site is dedicated to seeking answers in a discerning, practical manner to understand the human condition related to addiction and substance abuse.

About Sam Harris

Adored by secularists, feared by the pious, Sam Harris’ best-selling books argue that religion is ruinous and, worse, stupid — and that questioning religious faith might just save civilization. ~Full bio and more links

The more difficult the decision we face, the more likely we are not to act, according to new research by UCL scientists that examines the neural pathways involved in ‘status quo bias’ in the human brain.

The study, published today in Proceedings of the National Academy of Sciences (PNAS), looked at the decision-making of participants taking part in a tennis ‘line judgement’ game while their brains were scanned using functional MRI (fMRI).

First author Stephen Fleming, Wellcome Trust Centre for Neuroimaging at UCL, said: “When faced with a complex decision people tend to accept the status quo, hence the old saying ‘When in doubt, do nothing.’

“Whether it’s moving house or changing TV channel, there is a considerable tendency to stick with the current situation and choose not to act, and we wanted to explore this bias towards inaction in our study and examine the regions of the brain involved.”

The 16 study participants were asked to look at a cross between two tramlines on a screen while holding down a ‘default’ key. They then saw a ball land in the court and had to make a decision as to whether it was in or out. On each trial, the computer signalled which was the current default option – ‘in’ or ‘out’. The participants continued to hold down the key to accept the default and had to release it and change to another key to reject the default.

The results showed a consistent bias towards the default, which led to errors. As the task became more difficult, the bias became even more pronounced. The fMRI scans showed that a region of the brain known as the subthalamic nucleus (STN) was more active in the cases when the default was rejected. Also, greater flow of information was seen from a separate region sensitive to difficulty (the prefrontal cortex) to the STN. This indicates that the STN plays a key role in overcoming status quo bias when the decision is difficult.

Stephen added: “Interestingly, current treatments of Parkinson’s disease like deep-brain stimulation (DBS) work by disrupting the subthalamic nucleus to alleviate impaired initiation of action. This is one example of how knowing about disease mechanisms can inform our knowledge of normal decision making, and vice-versa.

“This study looked at a very simple perceptual decision and there are obviously other powerful factors, such as desires and goals that influence decisions about whether or not to act. So, it would be of interest to investigate how these regions respond when values and needs come into play.”

Provided by University College London

By Denis Campbell
Originally published by The Guardian, March 10th,  2010

Joe Gerstein, founder of the SMART Recovery treatment program that is spreading from the US as an alternative to AA, explains why he rejects the myth that alcoholism is a ‘disease’ to be endured rather than cured

Alcoholism is a disease that leaves victims powerless and needing to stay in permanent recovery if they are serious about stopping the demon drink from inflicting further damage, conventional wisdom holds. Given that most people can’t afford to pay for a stay in a Priory clinic, then the best way for chronic drinkers to tackle their addiction, so the theory goes, is to turn to Alcoholics Anonymous, seek the help of a higher power with their struggle, begin using the 12-step program, and be ready to attend meetings for the rest of their lives.

Not so, says Joe Gerstein, a retired clinical professor of medicine in the US. “A myth has grown up that you can’t get over a substance addiction without AA,” he says. “It’s a widely-held belief, but it’s a myth.”

For years, he admits to buying into the myth and referring patients with alcohol problems to AA, with varying degrees of success. “I would see people in my office during the day who had big, swollen bellies from liver cirrhosis and tell them about how serious their problem was, and then I’d see them again at 7pm coming out of the liquor store carrying a bag that didn’t contain doughnuts,” he says.

Joe Gerstein, founding president of the SMART Recovery program, says: "We don't depend on higher powers to help."

Although he describes AA as “an absolutely remarkable program”, given that millions have found it useful over the last 75 years, he also calls it “ethically wrong, medically wrong and psychologically wrong”.

Gerstein is the founding president of SMART Recovery, an alternative to AA that is catching on in America – where it began in 1994 – and worldwide. He was the main speaker at a conference in London yesterday, organized by charity Alcohol Concern, and funded by the Department of Health (DH), that was designed to promote SMART Recovery – Self-Management and Recovery Training, to give it its full title – as another way to help England’s 1.1 million problem drinkers.

The DH, keen to expand the number of options for treating the scourge of alcohol, is funding a £100,000 two-year trial of SMART Recovery, which currently has a low profile and is the David to AA’s Goliath. In London, for example, some 300 different AA groups meet regularly. But there are just 20 or so SMART ones in all of England – even Gerstein is unsure exactly how many – and about the same number in Scotland.

However, it is attracting attention from experts in the field. Nicolay Sorensen, Alcohol Concern’s director of policy and communications, says: “AA is huge, and people wouldn’t go if it didn’t work. SMART Recovery at the moment is the only alternative. It’s got momentum, it’s got a good evidence base, and it’s growing in popularity.”

Similarly, Addiction, the UK’s largest drug and alcohol treatment charity, is setting up an alcohol recovery service for over-50s in Glasgow, funded by the brewers Heineken and using SMART Recovery.

SMART is based on cognitive behavioral therapy (CBT), and especially an element of it called rational emotive behavior therapy (REBT). Gerstein calls SMART “a self-empowerment program”, and rejects utterly AA’s disease theory of alcohol and the labeling of people with serious drink problems as alcoholics.

SMART Recovery and AA are both international not-for-profit organizations. SMART is used in Australia, Uzbekistan and beyond. Its handbook has been translated into Russian, Farsi and Mandarin Chinese, among other languages. Both programs are used in prisons, seek abstinence from participants, and are free – although they rely on donations from those attending their groups. But, crucially, SMART is science-based and secular, while AA has heavy religious associations. Many of the people attending the 370 SMART groups across America have tried AA and been put off by its insistence that members undergo a spiritual awakening, Gerstein says.

For him, though, the key difference is that SMART is a positive philosophy. “We believe that addiction is a very human condition that can be corrected, and that it’s the people themselves who do that through natural recovery,” he says. “We don’t think people are hopelessly taken over by addiction. Other people use books, medicines, help from family or professionals, whatever works for them. But with SMART Recovery, people do it on their own. That belief that human beings have the capacity within themselves to overcome even severe addictions and go on to lead a meaningful life is vital.”

Where AA has its Big Book, SMART has four key points and a “toolbox” – a set of ways in which problem drinkers can change their behavior. For instance, if someone is feeling stressed at the end of their working day, they may choose to use the ABC tool. That is: A for the Activating Event, the walking out of work; B for the Belief, that the person needs a drink now to relax; and C for Consequences, that someone ends up drinking because of their stress.

SMART teaches participants ways to disrupt this irrational belief system by helping them understand why they act as they do – damaging their lives and relationships in the process – and to then challenge that thinking. CBT is also the basis of the “talking therapies” program that the DH has been rolling out in recent years to help people ranging from long-term benefit claimants wanting to resume working to couples whose relationship is in peril.

A key part of the SMART trial is the creation of six SMART Recovery groups – in Birmingham, Norwich, Croydon, Gateshead, Cumbria and Sheffield – so that alcoholics in those areas needing major help can choose between that and AA.

Don Lavoie, a DH alcohol adviser, explains: “The DH has issued some high-impact changes for the alcohol sector – one of which is aimed at supporting and improving specialist alcohol treatment. Involved in that development is the promotion and growth of peer support, and ensuring that there is a range of choices for people with an alcohol problem.” Who comes, why, and how they fare will be evaluated to see which approach works best.

Gerstein points out: “At SMART Recovery meetings, we don’t pray, do the Lord’s Prayer or sing Kumbaya. We don’t depend on higher powers to help and we don’t expect people to come forever. They come, recover, and get on with their life”.

By Kara Gavin
Originally published by UMHS Public Relations October 17, 2005

Smokers often say that smoking a cigarette helps them concentrate and feel more alert, but years of tobacco use may have the opposite effect, dimming the speed and accuracy of a person’s thinking ability and bringing down his IQ, according to a study by University of Michigan Medical Center (U-M) researchers.

The association between long-term smoking and diminished mental proficiency in 172 alcoholic and non-alcoholic men was a surprising discovery from a study that set out to examine alcoholism’s long-term effect on the brain and thinking skills.

While the researchers confirmed previous findings that alcoholism is associated with thinking problems and lower IQ, their analysis also revealed that long-term smoking is, too. The effect on memory, problem-solving and IQ was most pronounced among those who had smoked for years. Among the alcoholic men, smoking was associated with diminished thinking ability even after accounting for alcohol and drug use.

The findings, released online before publication by the journal Drug and Alcohol Dependence, were made by a team from the U-M Addiction Research Center, or UMARC, and colleagues at the VA Ann Arbor Healthcare System and Michigan State University.

Lead author Jennifer Glass, a research assistant professor in the Department of Psychiatry, cautions that the results need to be duplicated by other studies before conclusions are made about smoking’s effect on the brain, or before the findings can be considered relevant to women.

But, she says, the results should prompt alcoholism researchers to re-examine their data for any impact from smoking—a factor that usually is not taken into account in studies of alcoholism’s effects on the brain, despite the fact that 50 percent to 80 percent of alcoholics smoke. The U-M-led team, meanwhile, is launching a study that will examine the issue in adolescents and plans to test the 172 men again soon.

“We can’t say that we’ve found a cause-and-effect relationship between smoking and decreased thinking ability, or neurocognitive proficiency,” Glass says. “But we hope our findings of an association will lead to further examination of this important issue. Perhaps it will help give smokers one more reason to quit, and encourage quitting smoking among those who are also trying to control their drinking.”

Many alcoholism-recovery programs don’t emphasize quitting smoking, even though smoking can be a social and possibly chemical cue associated with alcohol consumption.

Glass notes that her team’s paper is being published at the same time as one from a team at the University of California, San Francisco, in which brain scans showed that alcoholics who smoke have lower brain volume than alcoholics who don’t smoke.

Taken together with previous epidemiological studies, the two papers feed a growing body of evidence for a link between long-term smoking and thinking ability, says Robert Zucker, professor of psychology in the departments of Psychiatry and Psychology, and director of UMARC. Zucker is senior author on the new paper led by Glass.

“The exact mechanism for smoking’s impact on the brain’s higher functions is still unclear, but may involve both neurochemical effects and damage to the blood vessels that supply the brain,” Zucker says. “This is consistent with other findings that people with cardiovascular disease and lung disease tend to have reduced neurocognitive function.”

The data for the paper by Glass come from an ongoing longitudinal project that uses interviews and standardized research questionnaires to look at mental and physical health issues in families, measured every three years.

The study, which has run for more than 15 years and recently was funded for another five, is supported by the National Institute of Alcoholism and Alcohol Abuse, part of the National Institutes of Health (NIH)

The new work that will explore these relationships in youth is being funded by the National Institute on Drug Abuse, also part of the NIH.