A randomized feasibility study of a positive psychology journaling intervention to support recovery from substance-use disorders

Spillane N.S., Schick M.R., Hostetler K.L., Trinh C.D., Kahler C.W.

Young adults experience high rates of cannabis use and consequences. Cross-sectional work has linked positive psychological constructs (e.g., savoring) to less cannabis use and consequences, and positive psychological interventions (PPIs) have shown promise in targeting other substance use behaviors. This pilot study sought to provide an initial test of PPIs to reduce young adult cannabis use and consequences.Adults (18-25 years old) who endorsed at least weekly past-month cannabis use (N = 59, 69.6% men, 41.1% White) reported their baseline cannabis use and consequences. Participants were randomized to complete one of three daily exercises (Savoring, Three Good Things, or a control) along with daily text message surveys for two weeks, then completed a follow-up survey at the end of the two weeks.Paired samples t-tests indicated that participants in the Three Good Things group showed medium to large reductions in frequency of weekly cannabis use (p = .08, gav = -0.57) and cannabis-associated consequences (p = .08, gav = -0.57) from baseline to follow-up. In the Savoring and control groups, there were not significant changes in frequency of weekly cannabis use (Savoring: p = .39, gav = 0.20; Control: p = .96, gav = 0.01) nor cannabis-associated consequences (Savoring: p = .84, gav = 0.05; Control: p = .45, gav = -0.18). Participants in both positive psychology conditions reported the exercises were easy to complete, providing evidence for acceptability.Results provide initial support for the feasibility and potential promise of a text-message based PPI as a harm reduction approach for cannabis users. A larger clinical trial is warranted to test the effects of such interventions with adequate statistical power.

Paquette C.E., Reese E.D., Yi J.Y., Maccarone J.M., Stewart Z.J., Daughters S.B.

Reward deficits negatively impact recovery from substance use disorder (SUD). LETS ACT, a behavioral activation treatment targeting substance-free reward, has demonstrated effectiveness in reducing post treatment substance use. There remains room for modifications to extend recovery gains, and LETS ACT remains largely untested in outpatient treatment. We tested the effect of LETS ACT when delivered alongside intensive outpatient SUD treatment, with and without a smartphone app designed to extend access to treatment content outside of clinician-administered sessions.In this three-arm randomized controlled trial (N = 206; 54 % White, 67 % male), all participants received intensive outpatient SUD treatment as usual (TAU) and either LETS ACT (n = 56), smartphone-enhanced LETS ACT (n = 65), or assessments only (n = 61). Substance use days and substance related problems were assessed through 12 months posttreatment.Generalized estimating equations indicated a significant condition*time interaction for substance use days; Days of substance use significantly declined from pretreatment until 1-month for TAU, 3-months for LETS ACT-SE, and 6-months for LETS ACT. Decreases in substance-related problems were maintained across all conditions through 12 months.Adding LETS ACT to intensive outpatient treatment resulted in significant decreases in substance use through 6 months posttreatment, yet these gains were not sustained through 12 months posttreatment. A smartphone app did not facilitate superior treatment outcomes. Future studies should consider factors impacting treatment efficacy in outpatient settings and the utility of providing more than six sessions of behavioral activation.

Zhou J., Lang Y., Wang Z., Gao C., Lv J., Zheng Y., Gu X., Yan L., Chen Y., Zhang X., Zhao X., Luo W., Chen Y., Jiang Y., Li R., et. al.

Negative interpersonal attitudes can affect people’s well-being, interpersonal relationships, and cooperation. Overcoming negative interpersonal attitudes is a key subject in loving-kindness and compassion meditations (LCMs). However, the results and study design of previous research on negative interpersonal attitudes have been inconsistent. Therefore, it is necessary to summarize the effects of LCMs and explore moderators through meta-analysis. A literature search was conducted in the Cochrane Central Register of Controlled Trials, ISI Core Collection, Medline, ProQuest Dissertations & Theses, and PsycINFO databases up to April 2, 2021. Of the 281 identified empirical studies on LCMs, 25 measured negative interpersonal attitudes, and 21 were included in the meta-analysis. The results showed that the effects of LCMs on negative interpersonal attitudes in daily life were significant both for randomized controlled trials (g = -.203) and uncontrolled trials (g = -.539). The instant effects after meditation were also significant in randomized controlled experiments (g = -.187). Leave-one-out sensitivity analysis and nonsignificant subgroup analysis showed that the results were robust except for randomized controlled experiments. Although no significant moderators were identified, moderator analysis suggested that reducing bias and sending wishes to difficult targets were especially effective, and LCM subtypes might impact the results. Individual studies found that the contribution of meditation practice during interventions was weak. In sum, LCMs have the potential to reduce negative interpersonal attitudes, especially in multiweek interventions. Future studies should further explore the underlying mechanisms and consider the implications of study design features, such as the induction of negative interpersonal attitudes and the targets of LCMs.

Hagman B.T., Falk D., Litten R., Koob G.F.

The objective of this article is to provide an operational definition of recovery from alcohol use disorder (AUD) to facilitate the consistency of research on recovery and stimulate further research. The construct of recovery has been difficult to operationalize in the alcohol treatment and recovery literature. Several formal definitions of recovery have been developed but have limitations because 1) they require abstinence from both alcohol and substance use, 2) they do not include the DSM-5 diagnostic criteria for AUD as part of the recovery process (i.e., no focus on remission from AUD), 3) they do not link remission and cessation from heavy drinking to improvements in biopsychosocial functioning and quality-of-life constructs, and 4) they do not distinguish between alcohol and other drug use. The authors present a newly developed National Institute on Alcohol Abuse and Alcoholism (NIAAA) definition of recovery from DSM-5 AUD based on qualitative feedback from key recovery stakeholders (e.g., researchers, clinicians, and recovery specialists). The definition views recovery as both a process of behavioral change and an outcome and incorporates two key components of recovery, namely, remission from DSM-5 AUD and cessation from heavy drinking, a nonabstinent recovery outcome. The NIAAA definition of recovery also emphasizes the importance of biopsychosocial functioning and quality of life in enhancing recovery outcomes. This new NIAAA definition of recovery is an operational definition that can be used by diverse stakeholders to increase consistency in recovery measurement, stimulate research to better understand recovery, and facilitate the process of recovery.

Stellern J., Xiao K.B., Grennell E., Sanches M., Gowin J.L., Sloan M.E.

The ability to regulate emotions effectively has been associated with resilience to psychopathology. Individuals with substance use disorders (SUDs) have been shown to have higher levels of negative emotionality, with some evidence suggesting impairment in emotion regulation compared with individuals without SUDs. However, no previous attempt has been made to systematically review the literature to assess the magnitude of this difference. We aimed to assess the association between SUD diagnosis and emotion regulation as measured by the Difficulties in Emotion Regulation Scale (DERS) and Emotion Regulation Questionnaire (ERQ) through a systematic review and meta-analysis of existing findings.The systematic review was conducted using PubMed, PsycINFO and Embase. We examined cross-sectional studies that compared a SUD group with a control group and measured emotion regulation using the DERS or the ERQ. The primary analysis focused on papers using the DERS, as this was the predominant instrument in the literature.Twenty-two studies met our primary analysis criteria, representing 1936 individuals with a SUD and 1567 controls. Individuals with SUDs relative to controls had significantly greater DERS scores, with a mean difference of 21.44 [95% confidence interval (CI) = 16.49-26.40, P < 0.001] and Hedges' g = 1.05 (95% CI = 0.86-1.24, P < 0.001). The difference was robust, remaining significant after removing outliers and studies with high risk of bias. Individuals with SUDs demonstrated poorer emotion regulation on each subscale of the DERS, with the largest deficits in the Strategies and Impulse subscales. The ERQ analysis revealed greater use of expressive suppression in those with SUDs relative to controls (Hedges' g = 0.76, 95% CI = 0.25-1.28, P = 0.004).People with substance use disorders appear to have greater difficulties in emotion regulation than people without substance use disorders.

Pott S.L., Kellett S., Green S., Daughters S., Delgadillo J.

AbstractBackground One in two patients seeking help for substance use disorders (SUDs) has clinically significant depression symptoms. This co-occurrence impairs treatment outcomes, but limited evaluation of the implementation of evidence-based interventions has taken place. Methods This pilot randomized controlled trial (RCT) assessed the feasibility and potential efficacy of a brief, protocol-driven behavioral activation (BA) intervention delivered by drug and alcohol workers in a community drug and alcohol treatment (CDAT) service. Eligible participants (n = 34) were randomly allocated to either BA (n = 17) or treatment as usual (n = 17) and assessed at baseline and 6-, 12-, and 24-week follow-up. Feasibility outcomes were participant engagement and worker protocol adherence. The primary pilot outcome was severity of depression symptoms (PHQ-9) at 12-week follow-up. Secondary outcomes included percent days abstinent (PDA) in the past month, severity of dependence (SDS), anxiety symptoms (GAD-7), and valued living (VQ) at all follow-up points. Results Fifty-nine percent of BA participants attended at least one session and there was 95% adherence to the treatment protocol. BA was associated with significantly reduced depression at 12-week follow-up (PHQ-9 mean difference − 5.69, 95% CI –10.07 to −1.31). BA participants had significantly greater improvements in PDA (mean difference 17.9, 95% CI 0.99 to 34.82) and VQ-Progress (mean difference 5.34, 95% CI 1.47 to 9.22) at 6-week follow-up and PDA (mean difference 27.69, 95% CI 4.44 o 50.95) at 12-week follow-up. The study found no significant between-group differences at 24-week follow-up. Conclusion BA implemented by drug and alcohol treatment workers in CDAT appears feasible and may add clinical benefit to usual care for SUD patients with elevated depressive symptoms accessing CDAT. Fully powered RCTs are warranted to better investigate the replicability of these preliminary findings. Methodological limitations are discussed and suggestions for future research are provided.

Emery N.N., Walters K.J., Njeim L., Barr M., Gelman D., Eddie D.

Early recovery from alcohol use disorder (AUD) is commonly associated with high levels of negative affect, stress, and emotional vulnerability, which confer significant relapse risk. Emotion differentiation-the ability to distinguish between discrete emotions-has been shown to predict relapse after treatment for a drug use disorder, but this relationship has not been explored in individuals recovering from AUD.The current study used thrice daily random and up to thrice daily self-initiated ecological momentary assessment surveys (N = 42, observations = 915) to examine whether 1) moments of high affective arousal are characterized by momentary differences in emotion differentiation among individuals in the first year of a current AUD recovery attempt, and 2) individuals' average emotion differentiation would predict subsequent alcohol use measured by the timeline follow-back over a 3-month follow-up period.Multilevel models showed that moments (Level 1) of higher-than-average negative affect (p < 0.001) and/or stress (p = 0.033) were characterized by less negative emotion differentiation, while moments of higher-than-average positive affect were characterized by greater positive emotion differentiation (p < 0.001). At the between-person level (Level 2), participants with higher stress overall had lower negative emotion differentiation (p = 0.009). Linear regression showed that average negative, but not positive, emotion differentiation was inversely associated with percent drinking days over the subsequent 3-month follow-up period (p = 0.042). Neither form of average emotion differentiation was associated with drinking quantity.We found that for individuals in early AUD recovery, affective states are associated with acute shifts in the capacity for emotion differentiation. Further, we found that average negative emotion differentiation prospectively predicts subsequent alcohol use.

Gutierrez D., Goshorn J.R., Dorais S.

Emerging models of recovery have redirected the traditional focus on relapse prevention to an emphasis on wellness. According to this new framework of recovery, aspects of thriving can strengthen recovery and prevent relapse in substance use. However, the empirical support for these models is sparse. To fill the gap in the literature, the authors sought to predict the risk of relapse based on factors of thriving.Participants consisted of a stratified sample of 412 adults in early, middle, and late stages of recovery (based on length of time in recovery) who the study recruited via Qualtrics Online Panels. We utilized a sequential regression to examine the ability of factors of thriving, the influence of time in recovery and demographic variables to predict relapse risk.Thriving, length of recovery, and demographics significantly predicted risk of relapse (p < .001, R2 = 65%), with Thriving accounting for 55% of the variance (ΔR2 = 55%).These findings demonstrate that the natural developmental process that comes from the passage of time dedicated to recovery is significant but thriving or the quality of that time serves as a stronger protective factor preventing relapse. Addiction treatment and prevention specialists could benefit from including thriving in conceptual models and interventions for recovery. Further, these findings provide support for holistic models of addiction recovery.

Carr A., Cullen K., Keeney C., Canning C., Mooney O., Chinseallaigh E., O’Dowd A.

Meshesha L.Z., Soltis K.E., Wise E.A., Rohsenow D.J., Witkiewitz K., Murphy J.G.

AbstractObjective Behavioral economic research suggests that increasing the salience of a delayed reward may improve capacity for delaying gratification and increase behavior allocated toward obtaining larger, delayed substance-free reward rather than smaller, more immediate reward such as alcohol use. This study aimed to improve the efficacy of outpatient alcohol use disorder (AUD) treatment by adding elements that target behavioral economic mechanisms of change. Method Forty-one (N = 41) adults in outpatient AUD treatment were recruited and 37 participants were retained at follow-up. Following baseline assessment, participants received either the Substance Free Activity Session (SFAS), a single-session behavioral economic–informed intervention focused on increasing future orientation and engagement in values-based substance-free activities or a health education control intervention. Participants in both conditions received weekly prompts (via text or email) relevant to their respective intervention for four weeks. Participants (68.3% male; 70.7% Caucasian, M age = 38.24, SD = 12.69) reported an average of 3.95 (SD = 4.72) binge drinking episodes (4/5 drinks per occasion for a woman/man) and 5.05 (SD = 5.32) drinks per drinking day 30-days prior to treatment entry. Results The study provided initial support for the feasibility and acceptability of implementing the SFAS within a treatment setting. Participants reported high levels of satisfaction with the SFAS (M = 9.08 (SD = 0.94), on a scale of 1–10). At 3-month follow-up, the SFAS was associated with reductions in the proportion of activity participation and enjoyment (reinforcement) related to substance-use relative to substance-free activities and in alcohol demand compared to control. Conclusion These preliminary results provide initial support for targeting behavioral economic mechanisms of change in an outpatient AUD treatment with a single-session intervention plus remote delivery of booster prompts.

Stein A.T., Carl E., Cuijpers P., Karyotaki E., Smits J.A.

AbstractBackgroundDepression is a prevalent and impairing condition. Behavioral activation (BA) is a parsimonious, cost-effective, and easily disseminated psychological intervention for depression. The current meta-analysis expands on the existing literature supporting the efficacy of BA for depression by examining the effects of BA on additional relevant outcomes for patients with depression, namely the reduction in anxiety symptoms and increase in activation.MethodsRandomized controlled trials of BA for depression compared to active and inactive control were identified via a systematic review. Effect sizes using Hedges's g were calculated for each outcome compared to both active and inactive control using random effects models. Subgroup analyses were used to examine the inclusion of a discussion of values as a moderator of depression symptom outcome in BA.ResultsTwenty-eight studies were included. Meta-analyses of symptom change between groups from baseline-to-post intervention indicated that BA outperformed inactive control conditions for improvements in depression (g = 0.83), anxiety (g = 0.37), and activation (g = 0.64). The difference between BA and active control conditions was not significant for improvements in depression (g = 0.15), anxiety (g = 0.03), and activation (g = 0.04). There was no evidence for a discussion of values augmenting BA efficacy. Study quality was generally low, and there was evidence of publication bias.ConclusionsIn addition to improving depression, BA shows efficacy for reducing symptoms of anxiety and increasing activation. BA may not offer better outcomes relative to other active interventions. There is room for improvement in the quality of research in this area.

Witkiewitz K., Tucker J.A.

Fazzino T.L., Bjorlie K., Lejuez C.W.

Brief reinforcement-based psychosocial interventions such as behavioral activation (BA) and behavioral economics (BE) address imbalances in the reinforcement system that are strongly implicated in substance use. The present study reviewed a growing body of intervention studies that tested the efficacy of BA or BE in addressing substance use outcomes. The study also reviewed a smaller body of evidence exploring mechanisms of action and moderators of treatment efficacy for substance use outcomes.A comprehensive literature search of four databases was conducted to identify studies that tested either BA or BE interventions targeting outcomes and/or mechanisms of action specific to substance use. The search yielded 12 studies that met these criteria. Ten studies reported main outcomes of BA/BE interventions targeting substance use outcomes (N = 7 BA; N = 3 BE). Two additional studies addressed mechanisms of change by conducting secondary analyses of data from one of the other ten studies. Eight of the twelve studies tested mechanisms of change and/or moderators related to substance use.Among all ten outcome studies, 100% provided evidence suggesting efficacy of BA/BE in targeting substance use and/or use-related problems. In 90% (9/10) of studies, the BA/BE intervention condition evidenced significantly higher abstinence rates compared to controls and/or significant decreases in substance use from baseline. Most studies that assessed substance use-related problems (83%; 5/6) reported significant decreases in use-related problems. The majority of studies (80%; 8/10) reported medium to large effect sizes. The pattern of findings was similar for BA and BE interventions. Eight studies assessed change in mechanism of action and 38% (3/8) identified mechanisms of action, however, only two conducted a formal test of whether this variable mediated the relationship between condition and outcome. Two studies tested and identified significant moderators of treatment efficacy.Preliminary evidence supports the efficacy of reinforcement-based interventions in targeting substance use outcomes. The mechanisms driving BA/BE efficacy and factors that may moderate treatment effects are not sufficiently clear from the studies available and require further examination, although existing data does suggest promise and provides clues for next steps.

Sliedrecht W., de Waart R., Witkiewitz K., Roozen H.G.

A relapsing-remitting course is very common in patients with an Alcohol Use Disorder (AUD). Understanding the determinants associated with alcohol resumption remains a formidable task. This paper examines relapse determinants based on a systematic review of recent alcohol literature (2000-2019). Relevant databases were consulted for articles that contained information about specific relapse determinants and reported statistical significance of each relapse determinant in predicting relapse. Relapse was broadly defined based on the characterization in the included articles. From the initial identified 4613 papers, a total of 321 articles were included. Results encompass multiple relapse determinants, which were ordered according to biopsychosocial and spiritual categories, and presented, using a descriptive methodology. Psychiatric co-morbidity, AUD severity, craving, use of other substances, health and social factors were consistently significantly associated with AUD relapse. Conversely, supportive social network factors, self efficacy, and factors related to purpose and meaning in life, were protective against AUD relapse. Despite heterogeneity in different methods, measures, and sample characteristics, these findings may contribute to a better therapeutic understanding in which specific factors are associated with relapse and those that prevent relapse. Such factors may have a role in a personalized medicine framework to improve patient outcomes.

Dickens L.R.

Gratitude is all the rage at present. Both researchers and popular media have latched on to gratitude as an easy way to make significant life improvements, ranging from increasing well-being to strengthening relationships. Can the simple practice of gratitude really produce noteworthy effects? Many authors cite one particular paper in support (c.f. Emmons & McCullough in J Pers Soc Psychol 84(2):377–389, 2003), which has major limitations and open questions, due to at times conflicting findings across three studies and numerous comparison groups. Further, the lack of research in multicultural contexts limits insights and leaves room for wide speculation. In response to this overreliance on one imperfect publication, the purpose of this chapter is to review the current state of the literature on gratitude interventions to determine their effects in diverse contexts. Specifically, a meta-analytic design was employed to determine the collective conclusions about the benefits of such gratitude practices, and the factors that influence the size of the effects. The meta-analysis included 38 articles spanning from 2003 to 2016 and examined 16 positive outcomes of gratitude interventions (e.g., positive affect, physical health, optimism). Data analysis showed small but significant findings for several of the outcome variables. Importantly, effects were generally larger when studies compared a gratitude intervention condition with a negative condition (such as listing daily hassles) and were most often negligible when gratitude was compared with another positive psychology intervention (such as performing random acts of kindness). This latter finding suggests that perhaps gratitude is no more effective at promoting well-being than other positive interventions. Finally, the results showed a significant lack of studies on gratitude practices within multi-cultural contexts. The chapter will conclude with suggestions of ways for the sub-discipline of gratitude to improve.

Stull S.W., Marsch L.A., Lanza S.T.

Ramos S.D., Bernardo A.B.

Experts call for the application of positive psychological interventions (PPIs) to bolster treatment for people with substance use disorders. However, there remains a gap in developing PPIs that promote positive dispositions important to people with substance problems from collectivist societies. In this study, we developed a PPI that can promote well-being and recovery by boosting the locus-of-hope of people with substance use disorders in a therapeutic community. Using a double-blind, randomized controlled trial with pre-treatment, post-treatment, and 1-month follow-up design, we tested the efficacy and mechanisms of the Locus-of-Hope Enhancement Program (LEAP) for Well-being and Recovery, a PPI that fosters cognitive hope. One hundred thirty-eight participants were randomly assigned to LEAP (n = 73) or a stress management control (n = 65). Outcomes were measured using the Locus-of-Hope Scale, Flourishing Scale, Brief Assessment of Recovery Capital, Dimensions of Change Instrument, and the Group Working Alliance Inventory. Results show that participants who received LEAP reported better internal locus-of-hope, external-peer locus-of-hope, community process experience, and group working alliance than the control group across time, but not on external-family locus-of-hope, external-spiritual locus-of-hope, psychological well-being, and recovery capital. LEAP indirectly boosted psychological well-being and recovery capital through community process experience and group working alliance post-treatment. LEAP’s indirect effect was sustained for recovery capital but not for psychological well-being at the 1-month follow-up. The current study provides initial evidence of the efficacy and mechanisms of a PPI for people with substance use disorders that promotes hope, leading to better well-being and recovery.

Krentzman A.R., Bowen E.A., Zemore S.E.

Krentzman A.R., Gass J.C.

New definitions of addiction recovery are aligned with social work’s strengths-based orientation: recovery from addiction is not only a process of reducing pathology but also a process of flourishing and thriving. In response to new recovery definitions, researchers are now designing studies that measure strengths-based, multidimensional aspects of recovery instead of measuring substance use or symptoms exclusively. This study employs grounded theory to investigate this change in measurement strategy; its impact on people in recovery; and its implications for social work research, existing theory, and interventions social workers employ to support client recovery. Thirty-two participants (47% female, M = 40 years in age, 16% BIPOC) in treatment for substance use disorders participated in interviews after completing surveys daily for 28 days that assessed strengths-based, multidimensional aspects of recovery. Participants reported that completion of surveys led them to realize aspects of self that were previously hidden from awareness, use that information to determine where they ‘were at’ in their recovery (doing well, could be doing more, not doing well); and, based on that determination, take steps to strengthen recovery. A minority of participants expressed despair when surveys revealed painful information and these participants did not describe using skills to regulate negative affect. This study found that strengths-based, multidimensional recovery-oriented surveys can provide therapeutic benefit. This grounded theory analysis extends existing theory to include the influence of coping skills on an individual’s ability to derive benefit from the self-monitoring of diverse aspects of their recovery.