Initial RCT of a distress tolerance treatment for individuals with substance use disorders
Introduction
The past two decades have seen the emergence of a new construct: psychological distress tolerance, defined as the ability to persist in goal directed activity when experiencing psychological distress (Brown et al., 2002, Lejuez et al., 2003, Strong et al., 2003). Studies of both community-based and psychiatric samples report that distress tolerance (also referred to in some studies as task persistence; see Brandon et al., 2003) is inversely related to a range of maladaptive behaviors, including antisocial behavior, maladaptive gambling, deliberate self-harm, binge/purge behavior, and, most notably, drug and alcohol use (Anestis et al., 2007, Bornovalova et al., 2008, Buckner et al., 2007, Daughters and Lejuez, 2005, Daughters et al., 2009, Daughters et al., 2008, Ellis et al., 2010, Howell et al., 2010, Keough et al., 2010, Nock and Mendes, 2008, Zvolensky et al., 2009). Indeed, distress intolerance is robustly associated with substance use coping motives, as well as substance use frequency and substance use disorders (SUDs) (Buckner et al., 2007, Howell et al., 2010, Marshall-Berenz et al., 2011, Vujanovic et al., 2011). Additionally, distress intolerance negatively affects drug and alcohol outcomes, with individuals low in distress tolerance more likely to drop out of substance use treatment (Daughters et al., 2005a) and subsequently relapse (Brandon et al., 2003, Brown et al., 2002, Daughters et al., 2005b, Quinn et al., 1996). This is particularly concerning given evidence for a positive association between both treatment dropout and relapse and a variety of other negative outcomes, including arrest and imprisonment, suicide, and lethal drug overdose (Britton et al., 2010, Simpson et al., 1997). Thus, efforts to improve the distress tolerance of SUD patients may have important clinical and public health benefits. Particularly needed are brief, targeted interventions that may augment standard SUD treatments provided in the community (e.g., residential substance abuse treatments; see SAMHSA, 2008).
Despite the clear clinical utility of treatments aimed at increasing distress tolerance among SUD patients, few interventions target this mechanism directly and those that do may not be directly applicable to SUD patients in residential substance use treatment. For example, although Dialectical Behavior Therapy (DBT; Linehan, 1993) specifically targets distress tolerance and has been found to be efficacious in the treatment of co-occurring borderline personality disorder and SUDs (Linehan et al., 2002, Linehan et al., 1999), the duration and intensity of this treatment (as well as its breadth of focus on treatment targets other than distress tolerance, e.g., interpersonal effectiveness and mindfulness) preclude its use as an adjunctive treatment to relatively brief residential SUD treatments. Additionally, although Brown et al. (2008) provide preliminary support for the utility of a 15-session (6 group and 9 individual) smoking cessation treatment that specifically targets distress tolerance (including both an emotional exposure and skills training component), the authors did not actually examine changes in distress tolerance over the course of this open trial. Thus, it remains unclear if this treatment actually improves distress tolerance as theorized. In addition, given that this treatment was developed specifically for nicotine-dependent individuals only, its applicability to and utility for other (arguably more severe) substance dependent populations is unclear.
Thus, the current study sought to extend the extant literature in this area by examining the efficacy of a brief distress tolerance treatment specifically developed as an adjunctive treatment for SUD patients in residential substance abuse treatment. This intervention—Skills for Improving Distress Intolerance (SIDI)—was developed to teach SUD patients skills for tolerating distress, including increasing the ability to experience emotional distress and controlling behaviors in the context of emotional distress. To this end, SIDI draws on skills from DBT (Linehan, 1993, Linehan et al., 2002, Linehan et al., 1999) and Acceptance and Commitment Therapy (Hayes et al., 1999)—both of which have been shown to reduce substance use and other maladaptive behaviors. Further, this intervention draws upon the treatment approach of Brown et al. (2008) by including an emotional exposure component in addition to the skills-training component. Specifically, the emotional exposure component (see also Otto et al., 2004, Zvolensky et al., 2003) requires participants to practice the skills in session in the context of negative affect (induced through emotional exposure to everyday stressors). The rationale for incorporating emotional exposure comes from research documenting the importance of contextual (in particular, emotional) cues in triggering maladaptive behavioral responses such as substance use (Chaney et al., 1982, Childress et al., 1994, Drummond and Glautier, 1994, Franken et al., 1999, Litman et al., 1990, Lowman and Allen, 1996, Monti et al., 1993, O’Brien et al., 1990, O’Connell and Martin, 1987, Powell et al., 1993, Robbins et al., 2000, Sherman et al., 1986, Wikler, 1965). This component of the treatment also has the added benefits of promoting immediate behavioral practice and the replacement of maladaptive coping behaviors with more adaptive responses, as well as providing a sense of mastery as patients are assisted in applying new skills to high levels of negative affect (Otto et al., 2005, Otto et al., 2004). Thus, SIDI involves systematic and repeated exposure to negative mood states, during which patients are assisted in practicing distress tolerance-enhancing strategies.
To provide an initial test of the efficacy of SIDI as an adjunctive treatment to standard SUD treatment, residential SUD patients with distress tolerance deficits were randomly assigned to receive SIDI or one of two comparison conditions, Supportive Counseling (SC) or treatment-as-usual (TAU). These three conditions were then compared on outcome measures of distress tolerance and depressive symptoms. The inclusion of the SC comparison condition allowed us to control for the nonspecific treatment effects of contact time and client-therapist alliance. We hypothesized that the addition of SIDI to TAU in this residential treatment facility would have a positive effect on patients’ distress tolerance, even when controlling for improvements in negative affect (on a measure of depressive symptoms).
Section snippets
Participants and treatment setting
Data were collected between May 2006 and May 2008. Participants were drawn from 110 consecutive admissions to a residential substance use treatment facility in NE Washington, D.C. General treatment at this center involves a mix of strategies adopted from Alcoholics and Narcotics Anonymous and group sessions focused on relapse prevention. All participants complete detoxification (if needed) prior to entering this treatment facility. Complete abstinence from drugs and alcohol (except for caffeine
Construct validity of the distress tolerance tasks
Providing support for the use of latency to task termination on the MTPT and PASAT as measures of distress tolerance, results of a series of paired t-tests performed on pre- and post-task negative affect ratings revealed an increase in negative affect in response to both tasks at both baseline and posttreatment (for MTPT: ts(1) > 5.14, ps < .001, ds > .52; for PASAT: ts(1) > 5.82, ps < .001, ds > .73). In addition, indices of task performance were not significantly associated with distress tolerance on
Discussion
This study compared a novel adjunctive treatment, Skill for Improving Distress Intolerance (SIDI), to Supportive Counseling (SC) and treatment-as-usual (TAU) among SUD patients with low distress tolerance receiving residential substance abuse treatment. Results indicate that patients in the SIDI group evidenced (a) greater mean-level improvement in distress tolerance than those in the SC and TAU groups, as well as (b) higher rates of clinically significant improvement in distress tolerance than
Role of funding source
Funding for this study was provided by the national institute on drug abuse grants National Institute of Drug Abuse Grants R36 DA021820 and P30 DA028807, and the NIDA had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Contributors
Bornovalova and Gratz designed the study and wrote the protocol. Daughters, Lejuez, and Gratz managed the implementation. Bornovalova undertook the statistical analysis and wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.
Conflict of interest
All authors declare that they have no conflicts of interest.
Acknowledgement
Data for this project were collected at the University of Maryland.
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