Slow and steady wins the race: a randomized clinical trial of acceptance and commitment therapy targeting shame in substance use disorders
Open accessAbstract
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.
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The study from which this intervention was derived among people with substance use disorders in residential treatment showed that internalized shame did not lower directly after the intervention but at a four month follow-up and was associated with attendance of outpatient treatment.
“Notably, the study from which this intervention was derived among people with substance use disorders in residential treatment showed that internalized shame did not lower directly after the intervention but at a four month follow-up15 and was associated with attendance of outpatient treatment.”
From An acceptance-based, intersectional stigma coping intervention for people with HIV who inject drugs—a randomized clinical trial (2023) · cites this paper as [15]
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Experimental — accuracy not yet measuredHigh ACE rates and trauma may cause individuals with SUDs to self-medicate as a means of escaping self-critical feelings.
“High ACE rates and trauma may cause individuals with SUDs to self-medicate as a means of escaping self-critical feelings 14,54.”
From Effects of a trauma-informed mindful recovery program on comorbid pain, anxiety, and substance use during primary care buprenorphine treatment: A proof-of-concept study (2023) · cites this paper as [54]
The paper’s discussion of shame and experiential avoidance (page not available in our copy) says self-critical thoughts can increase substance use and that substances may be used to avoid shame and other negative emotions. It does not connect that behavior to high rates of adverse childhood experiences (ACEs) or trauma. (LLM, conf=0.88)
Experimental — accuracy not yet measuredThe intervention's effects improved qualitatively at each follow-up visit, similar to other ACT trials.
“The effects of the intervention qualitatively improved at each follow-up visit akin to other ACT treatment trials [5, 9].”
From A brief behavioral intervention targeting mental health risk factors for vascular disease: A pilot study (2015) · cites this paper as [9]
The Results (Primary Outcomes and Secondary Outcomes; page unavailable) show that some ACT outcomes were better at follow-up than immediately after treatment. But the Method (Procedure; page unavailable) specifies only one follow-up visit, at four months, so this trial cannot show improvement at each of multiple follow-up visits. The passages do not establish the comparison with other ACT trials. (LLM, conf=0.86)
Experimental — accuracy not yet measuredSelf-stigma negates one's ability to achieve valued life goals.
“and negate one's ability to achieve valued life goals (Luoma et al., 2012).”
From Self-help interventions to reduce self-stigma in people with mental health problems: A systematic literature review (2020) · cites this paper as Luoma et al., 2012
The introductory passage identifies shame as the emotional core of self-stigma and associates it with poorer social functioning. The Discussion describes how shame and avoidance can impede recovery, but the paper does not say that self-stigma negates a person's ability to achieve valued life goals; that wording overstates the connection. (LLM, conf=0.82)
Experimental — accuracy not yet measuredSelf-stigma is a cluster of shame, negative thoughts and fear experiences by individuals who self-identify with a stigmatised group.
“Luoma et al. (2012) describe self-stigma as a cluster of shame, negative thoughts and fear experiences by individuals who self-identify with a stigmatised group.”
From Self-help interventions to reduce self-stigma in people with mental health problems: A systematic literature review (2020) · cites this paper as Luoma et al., 2012
The paper says that shame is the emotional core of self-stigma and discusses self-stigmatizing thoughts and negative self-conceptions (Conclusions; Method, ACT for Shame Intervention; Discussion; page numbers unavailable). It does not describe self-stigma as a cluster that includes fear, or define it in terms of identifying with a stigmatized group. (LLM, conf=0.83)
Experimental — accuracy not yet measured
Some studies have found that interventions targeting stigma may initially cause an increase in stigma relative to control conditions.
“Some studies have found that interventions targeting stigma may initially cause an increase in stigma relative to control conditions.15”
From An acceptance-based, intersectional stigma coping intervention for people with HIV who inject drugs—a randomized clinical trial (2023) · cites this paper as [15]
The Results (Mediation Analysis) report higher posttreatment shame in the ACT group than in the control group, supporting an initial difference relative to control. But the Results (Primary Outcomes) show that shame decreased from pretreatment in both groups; the paper does not report an initial increase in stigma itself. (LLM, conf=0.86)
Experimental — accuracy not yet measuredPositive effects on distress and disability were maintained or strengthened at the final 6-month follow-up.
“Consistent with previous ACT research, positive effects on distress and disability were maintained or strengthened at the final 6-month follow-up period [42].”
From One-Day Acceptance and Commitment Therapy Compared to Support for Depressed Migraine Patients: a Randomized Clinical Trial. (2020) · cites this paper as [42]
The Results > Secondary Outcomes section reports that ACT participants retained an improvement in general mental health and maintained an improvement in quality of life through follow-up; the quality-of-life measure includes aspects of functional status. But Method > Procedure specifies a 4-month follow-up, not 6 months, and the paper does not report a separate disability outcome. (LLM, conf=0.88)
Experimental — accuracy not yet measuredVisual analyses were consistent with previous studies suggesting ACT intervention trends carry over into follow-up assessment phases.
“Visual analyses were consistent with previous studies suggesting ACT intervention trends carry-over into follow-up assessment phases (Luoma, Kohlenberg, Hayes, & Fletcher, 2012).”
From Acceptance and Commitment Therapy modules: Differential impact on treatment processes and outcomes (2016) · cites this paper as Luoma, Kohlenberg, Hayes, & Fletcher, 2012
Intervention fidelity was rated from session audio recordings using a coding manual adapted from Luoma et al.
“Intervention fidelity was rated from session audio recordings using a coding manual adapted from Luoma et al.15”
From An acceptance-based, intersectional stigma coping intervention for people with HIV who inject drugs—a randomized clinical trial (2023) · cites this paper as [15]
A previous randomized controlled trial of Acceptance and Commitment Therapy (ACT) to help people with addictions in residential treatment address internalized stigma demonstrated improvements in treatment engagement and reduction in shame.
“A previous randomized controlled trial of Acceptance and Commitment Therapy (ACT) to help people with addictions in residential treatment address internalized stigma demonstrated improvements in treatment engagement and reduction in shame.15”
From An acceptance-based, intersectional stigma coping intervention for people with HIV who inject drugs—a randomized clinical trial (2023) · cites this paper as [15]
Intervention effects may have been stronger if interventionist training were improved, as overall competence was typically rated as adequate (M = 3.3) compared to the trial from which this intervention was adapted, where competence was typically rated as excellent (M = 4.7).
“In addition, intervention effects may have been stronger if interventionist training were improved, as overall competence was typically rated as adequate (M = 3.3) compared to the trial from which this intervention was adapted, where competence was typically rated as excellent (M = 4.7).15”
From An acceptance-based, intersectional stigma coping intervention for people with HIV who inject drugs—a randomized clinical trial (2023) · cites this paper as [15]
Strong evidence indicates that transdiagnostic factors such as psychological flexibility play a critical role in explaining difficulties across various populations, including chronic pain, psychosis, and substance use disorders.
“For example, there is a strong evidence that the transdiagonstic factors such as psychological flexibility (the ability to engage in constructive, value-oriented actions despite the presence of unpleasant thoughts and feelings) plays a critical role in explaining the range of difficulties experienced by various populations including chronic pain 64 , psychosis 65 , and substance use disorders 66 .”
From Anxiety in Informal Dementia Carers: A Meta-Analysis of Prevalence (2020) · cites this paper as [66]
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References 62 · Cited by 336
Research works printed but not linked: 1
- Etzel JC 2006 A diagnostic exemplar of experiential avoidance: Examining shame and self-harm in battered women with PTSD Dissertation Abstracts International: Section B: The Sciences and Engineering 66 8 4480
- Authors
- Luoma, J. B., Kohlenberg, B. S., Hayes, S. C., & Fletcher, L.
- Affiliations
- University of Nevada, Reno (US)
- Venue
- Journal of Consulting and Clinical Psychology
- Published
- 2012-02
- Volume
- 80
- Issue
- 1
- Pages
- 43-53
- ISSN
- 0022-006X (ISSN-L)
- 1939-2117
- PMC
- PMC5067156
- OpenAlex
- W2004719903
- Semantic Scholar
- 2fe22e0efb9cad507e045d8f8c21277d3b9b6214
- Cited by
- 336
- References
- 62
- Citations by year
- 2026: 9 · 2025: 18 · 2024: 21 · 2023: 21 · 2022: 31 · 2021: 32 · 2020: 26 · 2019: 29 · 2018: 22 · 2017: 27 · 2016: 18 · 2015: 27 · 2014: 23 · 2013: 20 · 2012: 11
- FWCI
- 18.60
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Journal of Consulting and Clinical Psychology (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute on Drug Abuse (5 R21 DA017644)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
- Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- shame, acceptance and commitment therapy, substance use disorders, residential addiction treatment, group therapy, treatment attendance, substance use, mindfulness, treatment utilization, mediation
- MeSH terms
- Adaptation, Psychological, Adult, Attitude to Health, Female, Follow-Up Studies, Humans, Judgment, Male, Psychiatric Status Rating Scales, Psychotherapy, Group, Quality of Life, Residential Treatment, Self Concept, Shame, Stereotyping, Cohort Studies, Substance-Related Disorders
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