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AToN Center Clinical Director, Licensed Clinical Psychologist
Cassandra Cannon, Ph.D. – PSY24315
Acknowledgements
This curriculum assessment project was developed with consultation with Marie Dumas, Psy.D, who was the Program Director at the AToN Center from 2011-2013. Terra Fuhr, Ph.D. and Megan Lewis, Psy.D. assisted in data collection for several months. Their assistance in this project is greatly appreciated.
Introduction
AToN Center is a small residential treatment program for substance misuse disorders. This program offers daily group therapy and individual therapy with group sizes no larger than seven. Specifically, each resident attends three groups each day: Recovery Study, Psychology Group and Process Group. The clinical team creates an individualized approach for each resident and focuses on building skills that will enhance recovery. The curriculum at the AToN Center is Relapse Prevention and Cognitive Behavioral Therapy. As AToN center offers daily individual therapy, this allows each resident to focus on increasing skill development as well as develop insight into the underlying issues related to their substance misuse.
As the staff and clinical team at the AToN Center prides themselves in providing excellent care, the AToN Center assessed residents to evaluate the curriculum and treatment that AToN Center provides as a whole.
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Substance misuse can be best explained as a pattern of substance use that often progresses in severity over time and often leads to many negative consequences. These negative consequences may include relational problems, legal problems, occupational problems, financial problems and health issues. Substance misuse often continues to occur despite devastating consequences to the substance misuser. At the AToN Center, alcohol, opioid and anxiolytic use disorders are most commonly treated.
Unfortunately, treatment of substance misuse disorders is complicated and requires a great deal of expertise. Often, individuals relapse as a part of their recovery process. According to Prochaska, DiClemente and Norcross (1992), within one month of completing treatment, 30% of individuals relapse. Within months one through three, 30%-60% relapse. Within three months and six months of discharge, about 60% of individuals relapse. In months six through twelve, 62% of individuals relapse. These statistics may or may not be entirely accurate, depending on the specific definition of relapse (switching substance use from original substance of choice) as well as the honesty of the individual surveyed post discharge. Due to these complicated factors, AToN Center set forth with the aim of assessing specific and measureable characteristics of individuals upon admission and upon discharge from the AToN Center to ascertain the level of skill development achieved during their treatment episode. Three important traits were identified for assessment: coping style, distress tolerance and abstinence self – efficacy.
Moose (1993) described a literature review related to substance use disorders and coping styles and indicated that individuals who were diagnosed with a substance use disorder were more likely to rely on an avoidant style of coping (Moos, Brennan, et al., 1990). Avoidant coping can be described as any response that does not directly address a trigger or stressful event – such as avoiding thinking about the problem, is utilized to manage distress. Approach coping focuses on directly addressing the distressing event by using a number of coping techniques, such as problem solving or seeking guidance and support from others. A study by Moos, Finney and Chan (1981) indicated that individuals who relapsed within 2 years relied more heavily on avoidance coping mechanisms. Billings and Moos (1981) found that a greater reliance on avoidance coping skills were associated with increased depression, anxiety and physical symptoms. These authors found in a 1984 study that those who relied specifically on cognitive avoidance (avoiding thinking about a problem) and emotional discharge (utilizing negative self talk, yelling) were more likely to report depressive and physical symptoms.
Moos, Brennan et. all (1990) reported that individuals who utilize approach coping responses are more likely to report better stressor resolution and functioning outcomes. These authors found in the same 1984 study cited above that positive reappraisal (a skill developed during cognitive behavioral therapy) was associated with more self-confidence; a reliance on cognitive and approach coping skills were associated with better treatment outcomes.
Moser & Annis (2002) found that the utilization of active coping strategies were significantly correlated with abstinence maintenance in comparison to the exclusive use of avoidance techniques. These researchers also reported that the combination of both active and avoidant strategies appeared to be the most effective for terminating a drinking episode. Moos & Moos (2006) found that less reliance upon avoidance coping strategies was associated with remission three years post assessment. Additionally, Levin et al. (2007) found that those who minimized avoidance coping techniques in their recovery were less likely exhibit symptoms of alcohol dependence five years later.
Clinicians have long understood that distress tolerance is an important factor that influences a host of diagnoses and behaviors. A review of the literature demonstrates that this factor has been researched in relationship to borderline personality disorder, depression, post traumatic disorder and substance use disorders, just to name a few.
Simons and Gaher (2005) reviewed research that suggested that low levels of distress tolerance may contribute to vulnerability in developing substance use problems, or relapse post treatment episode (Brown et al., 2002). They cited Linehan (1993) who hypothesized that low distress tolerance may contribute to emotional dysregulation and individuals with low distress tolerance may utilize impulsive behaviors to alleviate distress. She also hypothesized that the inability to accept distress as a component of life, likely increases suffering. The authors also discussed Lazarus’s contribution (Lazarus, 1991) who reported that the utilization of emotion focused coping strategies that rapidly alleviate negative affect (such as substance use) is a particularly attractive option to those with low distress tolerance – thus highlighting the importance of developing the skill of tolerance.
Only two studies have focused on distress tolerance and abstinence from substance use. Brown et al. (2002) hypothesized that low distress tolerance was associated with early relapse from smoking cessation. Utilizing a psychological stressor (Paced Auditory Serial Addition Task) and the onset of dysphoria post stressor, these researchers found that those who exhibited low stress tolerance were more likely to relapse than their counterparts. Daughters et. al. (2005) investigated the relationship between the length of sobriety and distress tolerance in a sample of eighty nine substance users from a residential treatment facility. They found a relationship between abstinence duration and distress tolerance; specifically those who demonstrated greater persistence on the psychological stressor had longer periods of sobriety.
At this time, the Distress Tolerance Scale has not been utilized in a study focusing on distress tolerance as a factor in treatment success.
Multiple authors have validated that abstinence self – efficacy is a consistent predictor of treatment outcome (Adamson, Sellman, & Frampton, 2009 – Greenfield, Bryan, Kelly, Slaymaker & Venner, 2012 – Moos & Moos, 2006). Levin et al. studied the interaction between coping style and self – efficacy and found that self – efficacy was the important factor that predicted long – term treatment outcome. Specifically, as self – efficacy decreased, the level of avoidance coping styles and alcohol use increased when assessed five years post baseline assessment. Carbonari and DiClemente (2000) used data gathered at the end of a course of treatment and found that those who were abstinent 12 months later scored higher in abstinence self – efficacy than those who were in the relapse group.
Ilgen et al. (2005) assessed 2,967 participants from 15 separate residential substance use disorder treatment programs and identified levels of abstinence self – efficacy prior to discharge. These researchers followed up with their participants one year later and found that the highest predictor of recovery was 100% full confidence to maintain sobriety.
Witkiewitz (2011) assessed distal and proximal risk factors for relapse and identified increased abstinence self – efficacy as an important variable in decreasing proximal risk over time. Greenfield et. al (2012) reported that abstinence self – efficacy is one of the most consistent predictors of outcomes. Connors et. al (2013) asserted that helping residents increase their sense of self – efficacy is a particularly important task of treatment. Thus, increasing this construct is a worthy goal of any substance use treatment facility.
Cooney et.al (2007) assessed abstinence self – efficacy utilizing emotional diaries in “real-time” reports. These researchers found a correlation of real time decreased abstinence self – efficacy ratings preceding drinking relapse episodes. Holt et. al (2012) identified that decreased tobacco abstinence self – efficacy actually predicted relapse for alcohol; specifically for every 1 point decrease on this 5 point scale, there was almost 30% increase in relapse in both drinking and smoking. Witkiewitz et.al (2012) examined self – efficacy as a potential mechanism of change following drink refusal training. These authors found that change in self – efficacy was a predictor of decreased percentage of drinking days up to one year following treatment.
AToN Center treats residents who have a primary substance use diagnosis, such as Alcohol Dependence, Opioid Dependence or Sedative/Hypnotic/Anxiolytic Dependence. The resident population includes males and females who are 18 or older. The vast majority of residents are dually diagnosed – most often with depression, anxiety, or both.
A recent survey of residents at AToN Center indicated that 45% of the residents endorsed experiencing suicidal ideation the month before entering treatment and 35% endorsed having a plan for suicide prior to entering treatment. Anecdotally, staff and clinicians notice a general inability among residents to tolerate minor incidents of distress as well as difficulty identifying and utilizing coping skills.
The Institutional Review Board approved these procedures prior to collecting data. Each resident participated in the Informed Consent process upon admission, with the assurance that there will be no penalties for declining to participate. Residents were asked to complete three self – report measures within 72 hours: Coping Response Inventory, Distress Tolerance Scale and Abstinence Self Efficacy. Residents who completed at least 20 days of treatment were asked to complete the same measurements as a part of the discharge procedure. This was not a required portion of the treatment at the AToN Center. Data analysis consisted of assessing the difference between group means from the baseline assessment to the discharge assessment.
A Review of Measures
Two hundred and nine residents were recruited for this project. Fourteen residents declined to participate. Thirty six residents discharged prior to twenty days of treatment. Eighty residents did not complete the post-assessments.
Seventy-nine residents participated in the pre and post assessment process. Forty-eight percent were males, fifty-one percent were females. The average age of participants was 39 years old, the youngest 18 years old, the eldest being 71 years old. Sixty-three percent of residents who participated presented with the primary diagnosis of Alcohol Use Disorder. Twenty-five percent of residents who participated presented with a primary diagnosis of Opioid Use Disorder. Three percent of participants presented with the primary diagnosis of Stimulant Use Disorder and one percent presented with Anxiolytic Use Disorder.
Due to the previously reviewed literature, the Primary Investigator identified four planned comparisons. Two of these comparisons are from the Coping Responses Inventory: The Primary Investigator hypothesized an increase in approach coping responses and a decrease in avoidance coping responses. The Primary Investigator also hypothesized that the Distress Tolerance Scale scores would increase and the Abstinence Self – efficacy Scale scores would increase. As the assessment design does not violate parametric assumptions, and an analysis of normality revealed no significant difference from a Gaussian Distribution, a paired t-test was utilized for data analyses. A Bonferroni Correction was applied to counteract the increased likelihood of Type I error due to multiple comparisons. Thus the required p value for significance was p=.0125.
A paired-samples t-test was conducted to evaluate the impact of AToN Center’s programming on the resident’s scores on the Coping Responses Inventory – Approach Subscale. There was a statistically significant increase in scores from admission (M=49.9 SD=7.22) to discharge (M=55.95, SD=8.29), t(78)=5.16, p=0. The eta squared statistic (.255) is considered a large effect size.
A paired-samples t-test was conducted to evaluate the impact of AToN Center’s programming on the resident’s scores on the Coping Responses Inventory – Avoidance Subscale. There was a statistically significant decrease in scores from admission (M=59.23, SD=5.47) to discharge (M=55.81, SD=5.93), t(78)=5.36, p=0. The eta squared statistic (.27) indicated a large effect size.
A paired-samples t-test was conducted to evaluate the impact of AToN Center’s programming on the resident’s scores on the Distress Tolerance Scale. There was a statistically significant increase in scores from admission (M=2.56, SD=.98) to discharge (M=4.16, SD=1.18), t(78)=10.639, p=1.11022E-16. The eta squared statistic (.58) indicated a very large effect size.
A paired-samples t-test was conducted to evaluate the impact of AToN Center’s programming on the resident’s scores on the Abstinence Self Efficacy Scale. There was a statistically significant increase in scores from admission (M=2.57, SD=.94) to discharge (M=4.31, SD=.54), t(78)=15.92, p=0.E+0. The eta squared statistic (.76) indicated a very large effect size.
As hypothesized, resident’s scores on the subscale of the Coping Responses Inventory increased significantly. Resident’s t-scores increased from an “average” range, to “somewhat above average” range. During treatment, residents were encouraged to develop coping skills that were direct in nature, thereby increasing their relapse prevention skills; conversely, there were encouraged to minimize indirect coping, which is reflected in the decrease in t-scores on the avoidance subscale of the Coping Responses Inventory. Resident’s t-scores dropped from the “well above average” range to the “somewhat above average” range. It is of note, however, that while approach scores increased, and avoidant scores decreased, the avoidant scores are still in the somewhat above average range. This is an important piece of clinical information, as ideally the avoidant t-score would be in the “average” to “somewhat below average” range. In assessing the effect size, both analyses demonstrate very large effect of the treatment on the final scores; it is of note that anything over .14 is considered a large effect size.
As hypothesized, resident’s scores on the Distress Tolerance Scale increased from a 2.56 out of 5 to a 4.16 out of 5. In order words, resident’s scores increased from 51% to 83% on the Distress Tolerance Scale. That is a 32% increase in Distress Tolerance, as measured by the Distress Tolerance Scale. As the effect size is .58, it can be considered that treatment had a very large effect on the final outcomes.
Residents also demonstrated improvement on the Abstinence Self-Efficacy Scale. Their average score increased from a 2.57 out of 5 to 4.31 out of 5. That is an increase from 51% to 86% – and 36% increase from pre-assessment to post-assessment. As the effect size .76, again it can be reasonably considered that the AToN curriculum strongly influenced the increase in Abstinence Self-Efficacy as measured by the Abstinence Self-Efficacy Scale.
These results demonstrate that a treatment episode at the AToN Center can significantly contribute to an increase coping skill development, distress tolerance and abstinence self efficacy. The continued consolidation of these skills can assist in maintaining recovery for many who have sought treatment. A treatment episode that can increase these skills can be considered a treatment success.
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