Intervention Programme for Substance Use

INTERNAL CUES AND DRUG DEPENDENCY: COGNITIVE REAPPRAISAL AND COGNITIVE DEFUSION AS POTENTIAL PROCESSES OF CHANGE

Drug Dependency (DD) is a serious worldwide condition associated with longstanding health and social consequences (NSDUH, 2012). To date, efficacious treatments for DD, such as CBT relapse prevention (RP), have achieved only mediocre abstinence rates (40% post treatment and 20% at follow-up; Rawson et al., 2002). CBT RP uses the same techniques (e.g., drug cue avoidance, cognitive reappraisal, behaviour modification) to bring about change in people irrespective of their drug of choice (Larimer, Palmer & Marlatt, 1999). However, given the evidence from various levels of examination e.g., neurobiological, behavioural, psychological and social levels (Badiani et al., 2013 Bornovalova et al., 2005a; Gillespie et al., 2007; Lejuez et al., 2005; Lejuez et al., 2008 etc.) for differences between classes of drugs, this thesis aims to add to the growing literature in support of the “drug of choice” model (Wardle, Marcus & deWit, 2015) by linking it to individual difference and psychological vulnerability factors such as Addiction Severity, Anxiety Sensitivity (AS) and Distress Tolerance (DT). A total of 75 participants were recruited from different drug rehabilitation centres in the Republic of Cyprus (depressant users (N=19), stimulant users (N=15), alcohol users (N=10) and cannabis users (N= 31)). In this regard, separate independent samples t-tests were used to differentiate between the four groups in terms of Addiction Severity, AS and DT. Results showed that there were significant differences in Addiction Severity between people who used different drugs as their primary drug of choice. More specifically, stimulant users were significantly more severe than alcohol users on the legal subscale of the European Addiction Severity Index (EuropASI). Furthermore, depressant users had higher severity alcohol use, compared to stimulant and cannabis users. Depressant users also had poorer psychological wellbeing compared to cannabis users. Additionally, alcohol users were psychologically and physiologically worse off than both cannabis users and depressant users on the psychological and medical subscale of the EuropASI. Further, results showed that with regards to Anxiety Sensitivity, depressant users had significantly higher scores on the physical subscale of the ASI compared to cannabis users. Additionally, alcoholics presented with higher overall, physical and psychological AS compared to other depressant users as well as cannabis users. Moreover, alcoholics scored significantly higher than stimulant users in terms of the physical subscale and overall ASI scores. Finally, concerning DT we found that alcohol users were significantly worse off than cannabis users in terms of both distress absorption and tolerance.

In the second part of our study, the Implicit Relational Assessment Procedure (IRAP; Barnes-Holmes et al., 2006) was used to assess drug related attitudes which are thought to be outside of conscious awareness (De Houwer, 2006; Wiers & Stacy, 2006). More specifically, we compared participants’ private verbal relations or beliefs regarding their drug use across four different types of drug users. For this part of the study, seven depressant users, eight stimulant users, 14 cannabis users and two alcohol users were compared using a one-way between subjects MANOVA. Results showed that compared to stimulant users, cannabis users found abstaining from drugs less negative. Furthermore, with regards to stimulant users, implicit (IRAP) and explicit self-report questionnaires (DCQ and BASAS) were negatively correlated i.e., the more implicitly reported drug positive beliefs the less explicitly reported craving.

Our final study aimed to examine whether a specific component part of the RP treatment, namely that of cognitive reappraisal (CR) contributes to its mediocre abstinence record. Acceptance and Commitment Therapy (ACT; Hayes et al., 1999) is a third-wave CBT intervention that offers an alternative strategy to CR, a strategy coined as cognitive defusion (CD; Hayes et al., 1999), which promises to change one’s relationship with their internal cues, by repeatedly exposing oneself to them in an accepting rather than critical way. New research suggests that CR, where one realistically scrutinizes the content of their thoughts, is an unnecessary, unhelpful and a theoretically flawed component of the CBT package which is unlikely to enhance treatment outcomes for DD sufferers (De Raedt & Koster, 2010). The effectiveness of CD over that of CR however, warrants further investigation (Forman et al., 2007). Mixed design ANOVA comparing four groups (CR vs. CD vs. a psycho-educational control condition (CE) vs. a wait-list control (CC)) on actual relapse rates and self-report questionnaires (e.g., Quality of Life; SF-36 and Drug Craving; DCQ etc.) took place at pre, during, post treatment and three and six month follow-up. For this section of the study, 53 participants were recruited from governmental, private and NGO drug rehabilitation programs in the Republic of Cyprus. Participants were randomly assigned to receive a CR, a CD, a CE or a CD audio-assisted self-help intervention. In this regard, all conditions showed improvements over time towards the right direction; however, only the ASI psychological subscale had a significant main effect of condition. Specifically, participants receiving the CR condition showed greater reductions with regards to Anxiety Sensitivity (psychological subscale) when compared to other conditions (followed by the control group, cognitive defusion and finally the psychoeducation group). Moreover, regarding reported distress levels post challenging or accepting self-referential thoughts, our results showed a significant main effect of condition, with the CR condition causing overall more distress than the CD condition, when employing all three of the techniques being contrasted (e.g., thought records, cost benefit analysis and asking a friend or their “clean self” for advice vs. a drug modified version of the “milk milk milk exercise”, leaves on a stream and the sunglasses metaphor).

In general, our findings suggest that there are differences in severity and psychological vulnerability between drug user groups based on drug of choice. Alcohol, depressant, stimulant and cannabis users might thus require more appropriate tailor-made interventions considering their distinct problems. Further, our findings are suggestive of the overall equivalence of the CD and CR condition; however, flexibility and technique variability should be further investigated. Present findings aid in the deeper understanding of CD and CR techniques and their impact on DD treatment outcomes when used in a 4-week, self-help context.

Stavrinaki, M., Kelly, M & Karekla, M (Submitted) Acceptance and Commitment Therapy (ACT) Approaches for Substance Use Michael P. Twohig, Ph.D., Michael E. Levin, Ph.D. & Julie M. Petersen, B.S. Oxford Handbook of Acceptance and Commitment Therapy

Stavrinaki, M., Karekla, M (2020). Cognitive Reappraisal and Cognitive Defusion as potential processes of change: insights from a 4-week audio-assisted self-help intervention. ACBS symposium presentation.

Karekla, M., Pilipenko, N., Stavrinaki, M., Hanna, E., Siakou, E., Leonidou, C., & Feldman, J.M. (2011, July). Greek Language Validation of the Patient Health Questionnaire. Poster presented at the annual meeting of the European Congress of Psychology (ECP), Istanbul, Turkey.