Tuesday, September 28, 2010

Acceptance and Commitment Therapy as a Treatment for Problematic Internet Pornography Viewing

In a post a few weeks ago, I blogged about a blog post by Dr. Steven Hayes on a study using Acceptance and Commitment Therapy (ACT), a mindfulness- and acceptance-based treatment, for problematic Internet pornography viewing. I’ve since had a chance to track down and read the study, and I thought I’d write about it today.

Dr. Michael Twohig, a professor at Utah State University, is a pioneer in the use of ACT for obsessive-compulsive disorder. In a talk I saw him give on OCD at a conference in June, I recall him saying he expanded into problematic pornography viewing after he moved to Utah and found it was a big problem there.

Although this study has a small sample—six men—it’s a big step in that it’s not only the first controlled study of the treatment of Internet pornography viewing using ACT, but it’s the first controlled study of any treatment for Internet pornography viewing! According to Twohig and his co-author Jesse Crosby, there are studies of problematic sexual behaviors with treatments such as cognitive behavior therapy and motivational interviewing, but none of these are experimental.

It’s worth noting that although the media uses terms such as “sex addiction” or “porn addiction,” these aren’t technical diagnostic terms. There’s no official diagnosis for someone engaging in excessive pornography viewing. In fact there’s no consensus on how to classify it: some see it as a compulsion similar to OCD, whereas others see it as akin to substance abuse. Twohig and Crosby define “problematic pornography viewing” as: 1.) “viewing pornography more than 3 times per week on some weeks; and 2.) “the viewing causes difficulty in general life functioning.” Although we could quibble with this criteria—why 3 times a week?—it serves the purpose of the study.

Serving as the therapist for all six men, Dr. Twohig treated each with a flexible protocol of 8 weekly, 1.5 hour sessions. Sessions addressed the major ACT processes. Participants practiced mindful awareness and acceptance of inner experiences such as urges and arousal. Between sessions, they committed to engaging in activities in accordance with their values.

At the end of the last treatment session, five of the six showed significant reductions in viewing pornography. At a follow-up three months after treatment ended, two people weren’t viewing pornography at all and three were viewing at significantly reduced levels. (It’s worth noting that the goal of some was abstinence and that of others was reduced viewing.) Only one of the six participants was viewing pornography as often as he was prior to treatment. Overall, participants exhibited an increase in quality of life and decrease in obsessive features and religious-based obsessive thoughts.

One thing I really like about this article is the modesty around some of the conclusions. The authors humbly note although the study did not use behavior therapy or contingency managements, nor did it draw from some of the other interventions that have been associated with pornography viewing (e.g., CBT, MI), these may also be useful. (A major reason the researchers did not draw upon other tools was that they wanted to rely on ACT-specific processes--a bold move in my opinion.) Results do suggest that focusing on mindful acceptance of urges and movement towards meaningful activity may be helpful in reducing pornography viewing. This is the really cool part--rather than focusing not looking at pornography, treatment focused on mindful acceptance of urges and engagement in meaningful activities outside session.

Although larger randomized controlled trials are a next step towards examining the efficacy of ACT in treating problematic pornography viewing, this study is a really important first step in two ways: 1) It's the first controlled experimental study of a treatment for viewing; 2) It suggests that mindful acceptance of one’s experiences may be more helpful in changing behavior than trying to control one’s urges.

For those who are a member of ACBS, the main umbrella organization for ACT, a pre-publication PDF of the article can be downloaded here.

For the full citation:

Twohig, M. P., & Crosby, J. M. (2010). Acceptance and Commitment Therapy as a Treatment for Problematic Internet Pornography Viewing. Behavior Therapy, 41(3), 285-295.

Friday, September 24, 2010

From Psychology Today: Dr. Kelly Wilson on Acceptance and Depression

Dr. Kelly Wilson, a professor at the University of Mississippi, and one of the early developers of Acceptance and Commitment Therapy (ACT) posted a blog on Psychology Today yesterday. The blog offers vivid illustrations of some basic ACT priniciples rooted in how Dr. Wilson himself came to experience these principles in his own life.

"For me, acceptance was the birthplace of possibility. It was a place where the stories that imprisoned me could ease enough for me to see a way forward or to see a hand outstretched towards me, ready to guide me along the path. An odd fact about word prisons is that the harder we struggle to be free of them, the tighter the confinement they impose. "

Read the full blog post here.

Thursday, September 23, 2010

Mindfulness-Based Relapse Prevention: A Pilot Efficacy Study

In a previous post last week, I wrote a about Mindfulness-Based Relapse Prevention (MBRP), offering an introduction to the treatment and some background information. In this post, I’d like to report in detail about the results of the first randomized controlled trial of MBRP. (For those without a research background, randomized controlled trials or RCT’s are considered the gold standard of research.)

A few years ago, when I was a psychology intern at the Portland Veterans Affairs Medical Center in Portland, OR, I had the opportunity to conduct an MBRP group in the Substance Abuse Treatment Program. It was the first time MBRP had been offered at the VA. The veterans I worked with appeared to really like the program, and some continued to speak fondly of it for weeks after it ended. (I think my involvement may have even raised my own stature as an intern in their eyes!) I wasn’t able to collect any outcome data myself, but I’ve been interested in additional research on the effectiveness of MBRP.

From 2007-2008, a randomized pilot study was conducted with MBRP for the first time. Participants were recruited from a private, nonprofit agency, with 168 total. They were randomly assigned to either MBRP or the agencies standard treatment, which was process-oriented and based on the 12-step model (i.e., Alcoholics Anonymous). Outcome measures were administered at baseline, immediately after the 8-week MBRP program, and at 2- and 4-month follow-ups after the end of the 8 weeks.

Results were published across two articles.

According to Bowen (2009), people who completed MBRP had fewer days of use, fewer cravings, and greater awareness and acceptance compared to those who completed the agency’s standard program. However, when the researchers looked at the follow-up 4 months after MBRP ended, there was little difference in days of substance use between those who had completed MBRP and those who had completed the standard treatment. The authors suggest the reason for this is that those in MBRP returned to the standard program after completing the 8-week MBRP; however, it still doesn’t indicate the treatment gains of MBRP are maintained very well following the end of the 8-week program. In a sense, it suggests the gains associated with MBRP may not stick.

In the second article, Witkiewitz and Bowen (2010), the authors ran additional statistical analyses on the data from the first study to test some other hypothesis. The most interesting finding from these analyses related to differences in the experience of depression. For people who received standard care, there was a relationship between depressive symptoms and cravings; for example, more depressed people reported greater craving for drugs and alcohol. Additionally, as you might expect, those who were more depressed were more likely to use drugs and alcohol. For those who completed MBRP, however, there was no relationship between depression and cravings—those who were more depressed were no more likely to use than those who were less depressed.

What’s really fascinating about this second article is that results suggest depressed people who completed MBRP were less likely to use substances than depressed people who completed the agency’s regular program. It indicates mindfulness may make people more resilient to using drugs or alcohol even when their moods drop. Additional analyses indicated that everyone from the MBRP group who continued meditating (63%) remained abstinent. Although we cannot make causal attributions of this latter finding—those who continue meditating may be more motivated in general than those who stopped—it is promising. This is evidence that MBRP may help to “erase” the relationship between depression and substance use for many who complete the program.

Overall, these results suggest that MBRP is different than standard substance abuse treatment, but it is not clear how much better it is. For me, the most interesting finding is that those who participated in MBRP were less likely to use when depressed. This suggests MBRP may be particularly useful in helping substance abusers learn to tolerate negative moods. I look forward to what additional studies of MBRO may find.

For full citation:

Bowen, S., Chawla, N., Collins, S. E., Witkiewitz, K., Hsu, S., Grow, J., Clifasefi, S., et al. (2009). Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial. Substance Abuse, 30(4), 295-305.

Witkiewitz, K., & Bowen, S. (2010). Depression, craving, and substance use following a randomized trial of mindfulness-based relapse prevention. Journal of Consulting and Clinical Psychology, 78(3), 362-374.

Saturday, September 18, 2010

Steven Hayes in the Huffington Post on Internet Porn Viewing

In the Huffington Post this morning, Dr. Steven Hayes, an eminent researcher and professor at the University of Nevada - Reno, posted a blog on the treatment of Internet pornography addiction. For those unfamiliar with his name, Dr. Hayes is the originator and driving force behind the development of Acceptance and Commitment Therapy (ACT), one of the fastest growing mindfulness- and acceptance-based treatments.

Dr. Hayes writes about some work being done by a former student of his, Dr. Michael Twohig at Utah State University. (Utah has an extremely high rate of online Internet pornography consumption.) Dr. Twohig has pioneered the use of ACT in the treatment of obsessive-compulsive disorder, and he has recently completed the first controlled study of the treatment of problematic viewing of Internet pornography--the first controlled study for the use of any treatment of problematic pornography viewing!

Dr. Hayes writes about how mindful observation and acceptance of urges to watch pornography help people to make choices more in accordance with their values. Trying to suppress these urges often backfires instead.

To read the blog post, click here. (UPDATE: To read a SM post on the study, click here.)

Friday, September 17, 2010

Mindfulness-Based Relapse Prevention: An Introduction

The other day I came across a new article about an important emerging mindfulness-based treatment that we haven’t written about in SM yet: Mindfulness-Based Relapse Prevention (MBRP). MBRP came out of the lab of Dr. Alan Marlatt at the University of Washington. Dr. Marlatt is well-known for his substance abuse research, and he has had a personal and professional interest in mindfulness and meditation since he was a young professor decades ago. I first encountered mention of MBRP 5 years ago in a paper co-authored by Dr. Marlatt with Dr. Katie Witkiewitz, who was a student of Dr. Marlatt’s and is now at Washington State University-Vancouver.

My SC co-founder Jason Luoma and I are currently collaborating with Dr. Witkiewitz on a study of MBRP in a women’s inpatient substance abuse treatment program. During a meeting about the study, Dr. Witkiewitz talked about the genesis of MBRP. Marlatt’s lab had conducted a study of the impact of a 10-day Vipassana meditation course at a Washington jail. (The Vipassana retreat was in the style developed by S.N. Goenka.) Results of the study were extremely promising. Compared to inmates who didn’t participate in the Vipassana course, those who completed it showed significant reductions in substance use following release. Additionally, participants showed lower levels of psychiatric symptoms upon release.

Unfortunately, Marlatt’s lab couldn’t get funding for additional study of the Vipassana course. Apparently, it was considered a little unorthodox. In order to develop something that might be more palatable to potential grant reviewers, they took a cognitive behavioral Relapse Prevention program Dr. Marlatt had developed and combined it with Mindfulness-Based Cognitive Therapy, a well-supported mindfulness treatment for recurring depression. (MBCT in turn was based on Kabat-Zinn’s Mindfulness-Based Stress Reduction program.) In combining the treatments, Marlatt’s lab created MBRP!

MBRP is an 8-week group-based treatment. Participants are initially introduced to mindfulness through a body scan, a practice developed by Kabat-Zinn in his program. Sitting meditation is eventually introduced, and there is also some yoga. Throughout the treatment, participants learn to notice cravings for drugs and alcohol, identify triggers, and prepare for the possibility of relapse.

In my next post, I’ll write about a promising new study supporting the efficacy of MBRP. One article was just published in June in the Journal of Consulting and Clinical Psychology, an extremely prestigious publication. (UPDATE: click here for second post.)

For those interested, I’ve cited research I mention in this post. I’ve included links to PDF’s of the actual articles where possible. Specifically Bowen et al. (2006) and Simpson et al. (2007).


Bowen, S., Chawla, N., Collins, S. E., Witkiewitz, K., Hsu, S., Grow, J., Clifasefi, S., et al. (2009). Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial. Substance Abuse, 30(4), 295-305.

Witkiewitz, K., Marlatt, G. A., & Walker, D. (2005). Mindfulness-based relapse prevention for alcohol and substance use disorders. Journal of Cognitive Psychotherapy, 19(3), 211-228.

Witkiewitz, K., & Bowen, S. (2010). Depression, craving, and substance use following a randomized trial of mindfulness-based relapse prevention. Journal of Consulting and Clinical Psychology, 78(3), 362-374.

Sunday, September 5, 2010

Psych Central Article: Mindfulness for ADHD

I posted twice in April on research incorporating the use of mindfulness skills in the treatment of attention deficit/hyperactivity disorder (ADHD): a study using Metacognitive Therapy and a pilot study using mindfulness meditation. Psych Central posted an article by Lynda McCollough yesterday on this growing body of research. The article focuses on some of the work being done through the Mindful Awareness Research Center (MARC) at UCLA. They've developed a program called Mindful Awareness Practices for ADHD (MAP), and the article has comments by Lidia Zylowska, MD, a psychiatrist who founded MARC. It provides a nice overview of some of their work and has some useful links and citations.

You can read the Psych Central article here.

Thursday, September 2, 2010

A Mindfulness Revolution in Education

Susan Kaiser Greenland, author of The Mindful Child, had an article published last month in The Huffington Post about the application of mindfulness for children and adolescents.

You can check it out here.