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AToN Center Assessment of Curriculum

AToN Center Assessment of Curriculum

Cassandra Cannon, Ph.D. – PSY24315

Licensed Clinical Psychologist

Clinical Director
AToN Center


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.


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.

Statement of the Problem

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.

Coping Style

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.

Distress Tolerance

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.

Abstinence Self-Efficacy

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

Coping Responses Inventory

This inventory is a measure of eight different types of coping responses to stressors.  Each of these eight types of coping responses are assessed by responses to six items per scale. It has been deemed suitable for administration to healthy adults, psychiatric patients and those with a diagnosis of a substance use disorder.

According to Moos (1993), the Coping Responses Inventory has moderately stable internal and test re-test reliability.  This author also reviews a number of research studies that generally support the construct, concurrent and predictive validity of the CRI scales.  The scale was normed on adults, some of whom had drinking problems.  The population was largely Caucasian, married, and moderately well educated, with average to above average socioeconomic status.  As AToN Center’s population mimics the population the scale was normed upon, there is less concern regarding threats to external validity.

The assessment asks the respondent to think about the most important problem or stressful situation they have experienced in the last 12 months.  They are then asked to respond by utilizing a likert scale comprised of “Not at all,” “Once or Twice,” “Sometimes,” and “Fairly Often.”

Example:  Did you think of different ways to deal with the problem?

The Coping Responses Inventory separates coping styles into four broad domains.  The most favorable domain is the “approach coping” domain.  This domain is problem focused and reflects cognitive and behavioral efforts to resolve the stressor.  It is comprised of four types of responses; two of which are considered “cognitive” responses and two of which are considered to be “behavioral” responses.

Logical Analysis:  Cognitive attempts to understand and prepare mentally for a stressor and its consequences.

Example:  Did you try to find some personal meaning in the situation?

Positive Reappraisal:  Cognitive attempts to construe and restructure a problem in a positive way while still accepting the reality of a situation.

Example:  Did you tell yourself things to make yourself feel better?

Seeking Guidance and Support:  Behavioral attempts to seek information, guidance or support.

Example:  Did you talk with a friend about the problem?

Problem Solving:  Behavioral attempts to take action to deal directly with the problem.

Example:  Did you try at least two different ways to solve the problem?

The “avoidance” coping domain is more emotion focused and reflects cognitive and behavioral attempts to avoid thinking about a stressor and its implications.  The individual also fails to manage the affect associated with it.  It is also comprised of four types of responses; two of which are considered “cognitive” responses and two of which are considered to be “behavioral” responses.

Cognitive Avoidance:  Attempts to avoid thinking realistically about a problem.

Example:  Did you try to forget the whole thing?

Acceptance or Resignation:  Cognitive attempts to react to the problem by accepting it.

Example:  Did you lose hope that things will ever be the same?

Seeking Alternative Rewards:  Behavioral attempts to get involved in substitute activities and create new sources of satisfaction.

Example:  Did you turn to work or other activities to help you manage things?

Emotional Discharge:  Behavioral attempts to reduce tension by expressing negative feelings.

Example:  Did you take it out on other people when you felt angry or depressed?

Distress Tolerance Scale

Simons and Gaher (2005) developed the Distress Tolerance Scale.  This scale assesses emotional distress tolerance.  It has fifteen items which address four areas of distress tolerance.  The scale is organized with a single second order general distress tolerance factor and four first order factors as the final structure of the scale.  An individual who possesses low distress tolerance reports a lack of acceptance of distress, coping abilities to manage distress, avoid negative emotions and are often consumed by stressful experiences.

According to Simons & Gaher (2005), the test-retest reliability is acceptable.  The internal consistency was also good.  The validity of the scale was determined by comparing it with six other measures and its convergent and discriminant validity was supported.  The scale was normed on college students from a state university.

The scale asks the respondent to “think of times that you feel distressed or upset,” and asks them to rate their level of agreement with 15 separate statements that best describes their belief about feeling distressed on a 5 point likert scale.  Participant responses inform the four first order factors, which are tolerance, absorption, appraisal and regulation.

Tolerance:  Perceived ability to tolerate emotional distress.

Example:  There’s nothing worse than feeling distressed or upset.

Absorption:  Tendency to focus attention on stressor and disrupt optimal functioning.

Example:  My feelings of distress are so intense that they completely take over.

Appraisal:  Acceptability of suffering and feelings of shame related to emotional response to distress.

Example:  I am ashamed of myself when I feel distressed or upset.

Regulation:  Efforts to alleviate distress.

Example:  I’ll do anything to stop feeling distressed or upset.

A review of the literature shows that this scale has been largely utilized in examining eating disorders as well as borderline personality disorder.  This scale has also been utilized in a number of research studies focused on substance abuse; mostly focused on marijuana use and tobacco use.  For example, Zvolensky et.al (2009) focused on distress tolerance as a predictor for coping oriented marijuana use.  Using the Distress Tolerance Scale, poor distress tolerance was found to be a significant coping motive for the use of marijuana.  Dennhardt & Murphy (2011) utilized the scale in measuring distress tolerance as a predictor for alcohol related problems in college students.  Distress tolerance was related to alcohol related problems for the African American participants, but not for the other participants.

Abstinence Self Efficacy Scale

This scale assesses an individual’s beliefs about his or her own ability to maintain sobriety.  It is available in multiple versions for different substances of choice.  It is a 20 item scale that asks respondents to rate “how confident you are that you would not (drink alcohol, use drugs, smoke) in each situation.”  Respondents rate their level of confidence on a 5 point likert scale.

DiClemente, et. al report, “The Abstinence Self Efficacy (AASE) scale demonstrated a solid subscale structure and strong indices of reliability and validity. . . the AASE represents a brief, easily usable and psychometrically sound measure of an individual’s self-efficacy to abstain from drinking.”  It is of note that these authors constructed this scale from Marlatt and Gordon’s relapse categories (1985).  The scale was normed on subjects from an outpatient substance use treatment program.

This scale separates responses into four domains – negative affect, social/positive, cravings/urges, and physical/other concerns.

Negative Affect:  Confidence to abstain from use when confronted with uncomfortable emotional states.

Example:  I am confident not to drink alcohol when I am feeling depressed.

Social/Positive:  Confidence to abstain from use when in social situations.

Example:  I am confident not to drink alcohol when I see others drinking at a bar or a party.

Cravings and Urges:  Confidence to abstain from use when experiencing triggers and cravings.

Example:  I am confident not to drink alcohol when I have the urge to try just one drink to see what happens.

Physical and Other Concerns:  Confidence to abstain from use when experiencing physical discomfort.

Example:  I am confident not to drink alcohol when I have a headache.

Literature review demonstrates that this scale has been utilized to assess predictors for relapse; specifically in nicotine dependence.  It has also been utilized in studies focused on depression.   Using the Abstinence Self – Efficacy scale, Ilgen et. al (2007) found that patients who were more engaged in skills training activities had higher self – efficacy and they suggested that higher levels of post-treatment self-efficacy was driven by interventions focused on skills – training techniques.

Data Analysis

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.

Results and Discussion

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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