Literature Review

Discuss about the Systematic Quantitative and Qualitative.

Shame is associated with a series of adaptive behaviours that majorly include substance use. Young population is particularly susceptible to shame sensitivity. A significant association exits between the associated factors of self-concept and substance abuse (McGaffin, Lyons, & Deane, 2013). Many literature explore impulsivity, shame and self-esteem are linked with substance abuse among the young population. But, a thorough understanding of direct relation particularly with shame remains unclear. Shame is negative feelings of self and referred to as a strong pessimistic emotion that could result in powerlessness and inferior feelings. The beliefs about being a flawed person could arise from a difference between real self and ideal self that leads to the feelings of disgust and inadequacy (Tull et al., 2012). Pinto?Gouveia et al., (2014) stated that shame gives rise to negative thoughts, so, need to be eliminated, especially for the substance users. Alternatively, Livingston et al., (2012) mentioned that shame experience at a moderate level could be favourable in helping affected individuals to assess them and their activities in order to moderate them. In this regard, Luoma & Platt, (2015) mentioned that both types of emotions are significant for the human experience. Shame and beliefs about being flawed person support self-assessment and guide interactions of the individuals with each other. Shame is described as ‘failure of being’ that might give rise to the sense of deficiency, being exposed and inadequacy and being a flawed individual means ‘failure of doing’ that might generate a sense of remorseful and wicked. Exposure to shame could arise from conflict between actual self and ideal self, whereas, beliefs of being a flawed person might stem from conflict between ‘should self’ and actual self.     

Experiential avoidance associated with stigma related feelings and thoughts may give rise to difficulties for people misusing substances. An intervention on stereotype threat demonstrates that while an affected individual identifies with stigma, he/she enters into a situation of perceived possibility for devaluation depend upon the identity, which typically allows individuals to adopt avoidance-focused targets  and thought suppression ultimately slows down standard performance Witkiewitz et al. (2013). Stigma and shame hinder substance users to seek for proper treatment, which further delays the initiation of therapy and affects recovery. This in turn could trigger further substance use in order to manage negative feelings that undermine confidence to recover or self-efficacy (Van Boekel et al., 2013). Substance abusers tend to involve in social withdrawal and secrecy in order to avoid rejection from other members within the society that worsen the negative psychosocial effects linked with substance dependence. Individuals, who tend to deal with the fear of shame and stigma, withdraw from significant life domains linked with stereotypes that further lead to disengagement from areas like employment search or seeking treatment. Luoma et al., (2013) in this regard have mentioned about ‘functional contextual model’ that recognizes four factors of self-stigma: individuals identified with sigma internalize negative stereotypes and causes self-devaluation. These individuals feel scared of encountering stigma and tend to react in a problematic way through experiential avoidance. Such way of rending could interfere with individual’s capability to pursue respected life goals. Clement et al., (2015) stated that mental health factors like quality of life, anxiety, depression have greater connection with substance misuse related self-stigma. This indicates a need to design effective treatment programs, which could proactively deal with psychological health concerns and its significant effect on stigma. This would in turn influence retention, more engagement and better outcome in terms of substance use therapy.     

The review would support the proposed study that considers the effectiveness of ACT as a shame intervention compared to people with substance use disorder, who receive alternative, other treatments for a month in a residential treatment center. The review would include a series of already existing literature that majorly focus on ACT intervention, considering time frame, type of sessions and gender.

A study by Luoma et al., (2014) demonstrated that stigma forecasts length of residential treatment for substance abuse disorder. The participants were randomly assigned from cohorts that either received active ACT intervention or usual treatment intervention. The ACT group received 2hours long group session for a week and ‘treatment as usual’ (TAU) group received session for 6hours. The aim was to compare predictor time frame vs. age, SES status and gender. TAU demonstrated fast decrease in internalizing shame, whereas, shame decreased slowly in ACT. The result demonstrated that high level of self-stigma along with shame internalization in inpatients may delay hospital stay that further increase the treatment cost. The assessment regarding existence of relationship between treatment length and stigma variables (shame, stigma and self-stigma) within a residential addiction intervention unit supported the proposed topic to a greater extent. As the proposed study majorly (75%) will involve male, this article would better support the effectiveness of selecting male population majorly as study participant.

A randomized controlled trial by Longo, Wickes & White, (2013) included comparison between the effectiveness of ACT and Cognitive Behavioral Treatment, as both these interventions are beneficial for substance use disorders. 104 treatment seeking adults were assigned in this study, who received 60 minutes individual sessions of CBT or ACT for three months. The results demonstrated improvement in methamphetamine use, reduction in drug dependence and negative consequences in both the groups. However, attendance and treatment outcome significantly increased in CBT compared to ACT. From the result, it could be mentioned that CBT might be a feasible alternative for the substance users, especially methamphetamine. However, this research did not provide a clear idea whether individual sessions in ACT for other substance users would be effective compared to group sessions. 

Livingston et al., (2012) have carried out a systematic review of relevant and published articles, which were empirically assessed intervention structured to diminish stigma associated with substance use disorders. The articles were accessed from electronic databases and considered self-stigma, social stigma and structural stigma as variables. The interventions included direct contact with individuals with substance use disorder and education. It is evident from the review that series of interventions are effective in reducing stigma associated with substance misuse. Very limited interventions demonstrated that stigma could be diminished by therapeutic intervention like commitment therapy and group-based acceptance therapy. Sharing positive stories and motivational interviews are identified as effective strategies for dealing with stigma. At a broader level educational programs and contact-based training for the counselors, medical students and professionals would be highly significant. The review competently demonstrated that shame involves belief of flawed person along with feelings of powerlessness and worthlessness. It also showed that guilt comprises perception of flawed behaviors, while guilty feeling made individual to perceive their prior behaviors, but still keep the beliefs as worthwhile person. This further supports the proposed research study.    

Majority of the selected articles demonstrated the effectiveness of ACT intervention that helps to manage negative beliefs, better emotional management and improved feelings of self-efficacy. However, Longo, Wickes & White, (2013) demonstrated more effectiveness of CBT intervention compared to ACT, which further raised a question on whether CBT with individual session or group session for particular type of substance would be more effective. Articles by Luoma et al., (2014) showed effectiveness of ACT as an effective shame intervention in substance use disorder. Livingston et al., (2012) demonstrated usefulness of various treatment options, where group based commitment therapy considered as one of the positive interventions in diminishing feelings of shame and stigma, experiencing substance use disorders. Affected individuals are highly stigmatized within the society that generates feelings of worthlessness and shame. The users have higher level of anger compare to the population, who do not use substance, which might be a resistance against shame related to substance misuse (Hawkins & Hawkins, (2016). Thus, both resentment and anger are negatively associated with forgiveness. Treatment interventions also aim to develop forgiveness as a potential mechanism that reduces negative impacts of resentment. The review also demonstrated the effectiveness of inclusion of both primary and secondary research on the relevant topic. This would inform the educators, policy makers to develop treatment programs accordingly. It would also help the implementers to use interventions based on the needs and demands of the users, as the requirement varies from one user to another, considering the intensity of the addiction, age, gender and other relevant factors. As this review included study from Australia, it would also enable the respective authorities to focus on the present trend of substance abuse, associated disorder, available treatment options within the country.  The present research would also serve as a blueprint based on what future researchers could select variables and carry out further relevant experiments.   

This further supports the idea that ACT may offer better chance of recovery from substance use disorder. The review also demonstrated that prolonged ACT treatment session would be more effective compared to the sessions provided for short-time frame.

References

Clement, S., Schauman, O., Graham, T., Maggioni, F., Evans-Lacko, S., Bezborodovs, N., … & Thornicroft, G. (2015). What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychological medicine, 45(01), 11-27.

Earnshaw, V., Smith, L., & Copenhaver, M. (2013). Drug addiction stigma in the context of methadone maintenance therapy: an investigation into understudied sources of stigma. International journal of mental health and addiction, 11(1), 110-122.

Hawkins II, R. C., & Hawkins, C. A. (2016). Dynamics of substance abuse: Implications of chaos theory for clinical research. Clinical Chaos: A Therapist’s Guide To Non-Linear Dynamics And Therapeutic Change, 68.

Livingston, J. D., Milne, T., Fang, M. L., & Amari, E. (2012). The effectiveness of interventions for reducing stigma related to substance use disorders: a systematic review. Addiction, 107(1), 39-50.

Longo, M., Wickes, W., & White, J. M. (2013). Psychosocial Treatment for Methamphetamine Use Disorders: A Preliminary Randomized Controlled Trial of Cognitive Behavior Therapy and Acceptance and Commitment Therapy. Mindfulness-Related Treatments and Addiction Recovery, 98.

Luoma, J. B., & Platt, M. G. (2015). Shame, self-criticism, self-stigma, and compassion in Acceptance and Commitment Therapy. Current Opinion in Psychology, 2, 97-101.

Luoma, J. B., Nobles, R. H., Drake, C. E., Hayes, S. C., O’Hair, A., Fletcher, L., & Kohlenberg, B. S. (2013). Self-stigma in substance abuse: development of a New measure. Journal of psychopathology and behavioral assessment, 35(2), 223-234.

McGaffin, B. J., Lyons, G. C., & Deane, F. P. (2013). Self-forgiveness, shame, and guilt in recovery from drug and alcohol problems. Substance abuse, 34(4), 396-404.

Pinto?Gouveia, J., Matos, M., Castilho, P., & Xavier, A. (2014). Differences between depression and paranoia: the role of emotional memories, shame and subordination. Clinical psychology & psychotherapy, 21(1), 49-61.

Tull, M. T., Weiss, N. H., Adams, C. E., & Gratz, K. L. (2012). The contribution of emotion regulation difficulties to risky sexual behavior within a sample of patients in residential substance abuse treatment. Addictive Behaviors, 37(10), 1084-1092.

Van Boekel, L. C., Brouwers, E. P., Van Weeghel, J., & Garretsen, H. F. (2013). Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review. Drug and Alcohol Dependence, 131(1), 23-35.

Witkiewitz, K., Bowen, S., Douglas, H., & Hsu, S. H. (2013). Mindfulness-based relapse prevention for substance craving. Addictive behaviors, 38(2), 1563-1571.