A Q&A with Dr. Lilian Dindo
As part of our campaign in support of the Great American Smokeout this week, which encourages people to try (or try again!) quitting smoking and tobacco use, we spoke with Dr. Lilian Dindo, a clinical psychologist and assistant professor at Baylor College of Medicine. She spoke with us about an innovative type of therapy called Acceptance and Commitment Therapy (ACT), how it can help you quit smoking for good (and do a lot of other things better – like cope with negative thoughts or stress) and why compassion for ourselves and others is so important.
Nano: For those who aren’t familiar, what are the main tenets of ACT therapy?
Dr. Dindo: ACT is a scientifically-based approach that aims to help people live richer and more meaningful lives with less struggle. It really starts with the premise that pain – whether it’s in the form of sadness, anxiety, disappointment, illness – are inevitable features of being human. If you’re going to live life, these things are going to happen. The idea is that we can respond to life’s challenges with inflexibility or struggle or we can respond with flexibility and struggle less by cultivating greater resilience.
Nano: What are the hallmarks of a resilient person and how do you cultivate resilience?
Dr. Dindo: Resilient people are people who can do things that are hard, day by day, with purpose. So this can really apply to anyone – whether you’re trying to quit smoking, cope with depression, be a more competitive athlete or a better business person.
In ACT therapy, we try to cultivate six key skills that have been shown to be related to greater resilience.
Nano: Tell us the skills!
Dr. Dindo: They are:
- Willingness – being open to experiencing internal experiences, both pleasant and painful, directly. The opposite of this is avoidance – think of avoiding the discomfort of experiencing a cigarette craving by smoking to feel better in the short-term, for instance.
- Cognitive Defusion – the ability to have distance from our thoughts and recognize that they don’t control our behavior. The opposite of this is cognitive fusion, or that idea that when you think “I need a cigarette,” it really means you need a cigarette – or that when you think “I can’t quit smoking because I have no willpower,” it really means that you have no willpower.
- Awareness – the ability to be present in the moment; paying attention on purpose in the present for the sake of doing something that matters. The opposite of this is being on automatic pilot. Often habits like smoking are done on auto pilot and can become a mindless activity.
- Perspective-Taking – stepping back to notice the stories we’ve built about ourselves in our minds; the ability to also see things from different perspectives. The opposite is an attachment to a “story” we have about ourselves. For example, if you’ve firmly given yourself the identity of “smoker,” that can become a self-fulfilling prophecy where you behave in ways that are consistent with that “story.”
- Values – identifying the people and things that matter to us most. Nietszche had a great saying that went, “He who has a why to live for can bear with almost any how.” I love that because if you keep in mind why it’s worthwhile to stop smoking or sit with the discomfort of a craving, you can figure out how.
- Committed Action – identifying the actions you want to live by that reinforce your values. This is really how you want to behave on a day-to-day basis. It’s important to keep in mind that we don’t spend all of our time being perfect, values-driven humans, but if we identify the path we want to be on, we can notice when we’ve strayed from the path and gently lead ourselves back to it.
Nano: What are some of the challenges of applying this philosophy to quitting smoking?
Dr. Dindo: While a lot of mainstream programs for smoking cessation will teach you to avoid cravings and triggers for smoking (which helps reduce discomfort in the short-term), ACT therapy teaches you how to deal with those uncomfortable thoughts or feelings. We encourage people to “urge surf,” or experience riding the wave of a craving and noticing that it actually only lasts a few minutes before it passes (for context, indulging the craving by smoking a cigarette “turns off” the craving in about six seconds).
So, it requires a willingness to face that discomfort head-on and put in some more work upfront, but the science shows that it’s incredibly effective. Often, learning that a craving will pass if you just sit with it for a few minutes is a revelation for people. You in fact don’t need to “act” on a craving by smoking.
Nano: You mentioned that the science shows that ACT is effective – can you give us some more detail?
Dr. Dindo: Studies have shown that the “avoidance” approaches to quitting smoking actually lead to higher relapse rates over time. If I’m a previous smoker and I go to a bar and see someone smoking, it could be a trigger for me – or if I always used to smoke when I drank coffee, maybe coffee shops could be a trigger for me. You’ll have a lot of lifelong triggers that you’ll have to work to avoid. But learning how to sit with a craving or trigger is a very effective long-term approach.
One trial by Dr. Gifford and colleagues compared ACT to nicotine replacement therapy for smoking cessation and found that participants in both groups fared equally well at the end of the trial period, but at one year post-trial, more than double of the people in the ACT group had continued to cease smoking compared with the nicotine replacement therapy group.
One researcher – Jonathan Bricker at the Fred Hutchinson Cancer Research Center in Washington – found (based on seven years of research and over $13 million of NIH funding) that ACT was two-three times more effective than government anti-smoking campaigns which focused on avoiding cravings. Even better, members of the ACT group were able to better deal with stress and didn’t gain weight in that time period because of the valuable skills they had learned and incorporated into their lives.
Nano: So, how can people access ACT therapy?
Dr. Dindo: You kind find a therapist who practices ACT therapy in-person, but it is a really flexible form of therapy – you can also participate and get results over the phone or through websites or phone apps.
Nano: Smoking can often be trivialized as an addiction – smokers are often asked, “Why don’t you just quit?” Can you put in perspective for non-smokers what people who want to quit smoking are really dealing with?
Dr. Dindo: I find it very interesting that the Latin root for the word “addiction” is “dictator.” That’s really how addiction feels for people – like a dictator who is constantly barking orders and making demands. We also talk about the “craving monster” to put in perspective how cravings can feel like an overwhelming, scary monster that you’re constantly fighting with.
For those who don’t smoke, it’s important to keep in mind that we have an epidemic of unhealthy living right now. Half a billion people are obese and one billion people use tobacco worldwide (40 million Americans). These are two of the most preventable causes of early death – if it were so easy to change, everyone would change. It’s important to have compassion and openness for people who are struggling with addiction. We all have our vices.
Nano: Finally, can you tell us one of your favorite ACT therapy success stories?
Dr. Dindo: I worked with a veteran who had served multiple deployments to Iraq and Afghanistan. He was a really lovely guy in his 20s who had PTSD and had become addicted to heroine, was smoking all the time and was quite depressed. When I met him, he felt that he was broken and beyond help. We talked about how he had been through a really hard experience and was trying to cope in the best way he knew how – he had picked up skills that worked in the short term to turn off the pain, the memories and the flashbacks.
He was able to recognize that these strategies were not helpful in the long-term – and that they came with quite a cost. Just this acknowledgement in itself was valuable for him.
We started suggesting facing the cravings as an alternative to avoiding the pain – which was going to be hard, because he would have to face whatever was going to show up in his mind with gentleness and compassion. We talked about what would make that discomfort worth it – one of the motivators that was very important to him was honoring the veterans he had served alongside and lost. The way he had been living was not honoring their memories. So, within a week, he had signed up for community college and was taking classes and had reconnected with a woman who he had hoped to have a relationship with. He relapsed once – but the beauty of it was that he was able to gently steer himself back on track the following week. It’s all about being gentle and compassionate towards yourself, noticing when you are off track, and getting back on track towards the life worth living. He was amazing to work with.