Experiential Avoidance and Self-Stigma in Addiction: Two New Measures

1. Experiential Avoidance and Self-Stigma in Addiction:Two New Measures Jason B. Luoma, Ph.D.

2. RCTs are not enough • Data on outcomes for ACT targeting substance misuse have started to emerge • Outcome data are not enough • We need to know how an intervention results in change, not simply that it does • To do this, we need to measure mediating variables

3. Measuring psychological flexibility in addiction Definition: the ability to contact the present moment more fully as a conscious human being, and to change or persist in behavior when doing so serves valued ends” (Hayes, Luoma, Bond, Masuda, & Lillis, 2006, p. 6) Most commonly measured by the Acceptance and Action Questionnaire (AAQ)

4. The AAQ in addicted samples Has adequate internal consistency in most samples, but not in substance misusing samples. • α = (Bissett, 2002;) • α = (Luoma, Kohlenberg, Hayes, Bunting, & Rye, 2008) • α = .40 (this study) Mediates outcome in some non addicted samples (e.g., Bond & Bunce, 2000), but not addicted samples • Not in RCT with ACT for polysubstance abusing clients (Bissett, 2002) • Not in ACT-based self-stigma intervention in substance abusing sample (Luoma, Kohlenberg, Hayes, & Fletcher, 2010)

5. Developing a substance abuse specific AAQ (Luoma, Drake, Kohlenberg, Hayes) Step 1: Item Generation – adapted the original 49-item pool used for the development of the AAQ-II to include items specific to substance misuse

6. Step 2: Expert Rating All items rated across two dimensions by 8 ACT experts 1) Face validity 2) Overall quality On a 1-4 scale from 1 (poor) to 4 (excellent) • Dropped eight items because of scores below 2.5 (the mid-point of the rating scales) for one or both scales. • Remaining 41 items had an average fit rating of 3.16 (SD = .32) and an average quality rating of 3.24 (SD = .37)

7. Step 3: Validation Sample 352 patients receiving residential (n= 29) or outpatient (n = 323) substance abuse treatment • Gender: 210 men, 141 women, 1 unidentified • Age: Averaged 31.1 years (SD = 10.2, range 18 – 63) • Race: .6% identified as Alaskan Native, 3.4% American Indian, .9% Asian/Pacific Islander, 4.3% Black/African American, 80.4% White, 6.5 % other, and 4% providing no response. • Hispanic/Latino(a): 7.4% identified as Mexican, 4.6% other Hispanic, 41.8% not of Hispanic origin, and 46.3% no response. • 30% (n=97) of the sample had less than a high school education, 52.9% (n=171) had completed high school or obtained a GED, and 17% (n=55) had at least some college. • Prior treatment averaged 1.2 episodes (n = 342, SD = 1.7).

8. Step 4: Initial Factor Analyses Series of analyses led to an 18-item two-factor solution, using oblimin rotation

10. AAQ-SA internal properties • Values commitment: α =.82 • Defused acceptance: α =.84 • Overall scale: α = .85 • Two subscales correlate with each other at a low level, r (288) = .26, p < .001.

11. Step 5. Check for differentiation from AAQ Compared participants reporting zero days of usage in the last 30 days to those reporting any days of usage. Summary: AAQ-SA scores were significantly lower in group reporting usage, while AAQ scores were not In a combined factor analysis, AAQ items sorted on a different factors from AAQ-SA items

12. Step 6. Examine relationship with other measures • General Psychological Flexibility. The Acceptance and Action Questionnaire (AAQ;Hayes, Strosahl et al., 2004 • Depression.The Beck Depression Inventory • Internalized Shame.The Internalized Shame Scale (ISS;Cook, 1996) • Social Support.The Multidimensional Scale of Perceived Social Support (MSPSS;Zimet, Dahlem, Ziment, & Farley, 1988 • Self-Esteem.The Rosenberg Self-Esteem Scale (RSES;Rosenberg, 1965) • Self Concealment.The Self Concealment Scale (SCS;Larson & Chastain, 1990) • Stigma-Related Rejection. The Stigma-Related Rejection Scale (SRS;Luoma, Twohig et al., 2007) • Active Coping with Stigma. We created a seven-item scale based on two subscales from previous research on stigma toward mental illness (Link, Struening, Neese-Todd, Asmussen, & Phelan, 2002).

13. Step 6. Relationship with other measures

14. Step 6. Relationship with other measures

15. Future studies on AAQ-SA • More convergent and discriminant validity for values commitment subscale • Differentiate from self-efficacy scales • Examine possible method variance through confirmatory factor analysis

16. Developing a self-stigma scale The Substance Abuse Self-Stigma Scale (SASSS)

17. Reasons to develop a new measure of stigma • Only one validated measure of stigma in substance abuse • Perceived stigma (Luoma et al., 2010) • We have developed a self-stigma intervention but no validated, self-stigma measures exist

18. Self-stigma: 3 parts 1) Shame and self devaluation and 2) Fear of enacted stigma, 3) Psychologically inflexible ways of responding to 1 & 2

19. 1) Shame and self devaluation • Many people apply the common stereotypes of addiction to themselves • They devalue themselves, experience shame, and see themselves as deeply flawed, discredited, or broken

20. 2) Fear of enacted stigma People fear being judged or rejected. Fear of enacted stigma is associated with • avoidance of treatment (Cunningham, Sobell, Sobell, Agrawal, & Toneatto, 1993; Hingson, Mangione, Meyers, & Scotch, 1982; Klingeman, 1991; Tuchfeld, 1981). • diminished self-esteem/self-efficacy (Corrigan & Watson, 2002a; Link, Struening, Neese-Todd, Asmussen, & Phelan, 2001; Wright et al., 2000); • lower quality of life (Rosenfield, 1997); • early dropout from treatment (Sirey et al., 2001); • poorer social functioning over time (Perlick et al., 2001a).

21. Psychological inflexibility in self-stigma • Much of the harm of self-stigma does not come merely from the presence of self-devaluing thoughts, shame, and fear, but also from the manner in which people respond to these experiences. A common response is experiential avoidance – the attempt to control, reduce, or eliminate negatively evaluated private experiences (e.g., thoughts, feelings, memories), even when doing so causes harm.

22. Evidence for EA in stigma Stereotype threat • When people who identify with a stigmatized group enter situations where they perceive the potential for devaluation based on this identity (Steele, Spencer, & Aronson, 2002), they often expend energy searching for and defending against this perceived threat. • The effort is taxing and distracts the individual in ways that can hinder social or intellectual performance (e.g., Quinn, Kahng, & Crocker, 2004).

23. Evidence for EA in stigma Disengagement from valued domains • People withdrawing their efforts from domains of living that relate to relevant stereotypes where they fear judgment, rejection, or that they might “confirm” a stereotype (Major & O'Brien, 2005).

24. Evidence for EA in stigma Withdrawal and Secrecy • Typically predicts negative psychosocial outcomes (Ahern et al., 2007; Link, Mirotznik, & Cullen, 1991; Luoma et al., 2007; Rüsch et al., 2006).

25. Measure development process Followed the guidelines of Clark and Watson (1995) • Conducted a thorough literature review on stigma and related measures and developed a definition of stigma • Focus groups: • 3 groups of clients in treatment, 2 groups of addictions professionals • Tried to identify common domains of stigma toward substance users.

26. Common Stigma Content Difference / Alienation - Substance abusers (SAs) are different, separated, set apart, strange, difficult to understand, or alien. Devaluation – SAs are losers, failures in life, disappointments, or generally inadequate as human beings. Moral Weakness – SAs are indecent, lack virtue, and morally weak, sinners, immoral, dishonorable, have poor character, or are disreputable Lack of Willpower or Work Ethic – SAs are weak-willed, lack self control, lazy. Hopelessness/ Helplessness – SAs are unlikely to recover and their future is bleak. Incompetence – SAs are incompetent, inept, and generally ineffective in their lives. Blameworthy – SAs are to blame for their difficulties and worthy of contempt. Violent/Unreliable – SAs are easy to anger, often violent, erratic in their behavior and generally untrustworthy. Shame – SAs should be ashamed of themselves and feel guilty about their behavior. Concealment – SAs are secretive and work hard to conceal their problem behavior.

27. Item generation and refinement • Based on existing measures of stigma, our content domains, and measures of psychological flexibility, we generated a large pool of items (500+). • We refined these through an extensive rating process to arrive at 128 items which were given to a sample of 17 individuals • Further refinement resulted in a 74 item scale that was given to a validation sample.

28. Initial Scale 3 scales • Self devaluation • Fear of enacted stigma • Experiential avoidance of self-devaluation and fear of enacted stigma

29. Validation Sample Essentially the same sample as the last study (n=323)

30. Factor analyses and scale reduction • Used principal components factor analysis with varimax rotation • Resulted in four factor solution based on scree plot: • Self devaluation • Fear of enacted stigma • Experiential avoidance of stigma • Stigma as a barrier to valuing

32. Scale 1: Self-devaluation (alpha=.82) • I have the thought that a major reason for my problems with substances is my own poor character.  • I have the thought that I should be ashamed of myself. • I have the thought that I deserve the bad things that have happened to me. • I have the thought that I can’t be trusted. • I feel inferior to people who have never had a problem with substances. • I feel out of place in the world because of my problems with substances. • I have the thought that I’ve permanently screwed up my life by using drugs. • I feel ashamed of myself.

33. Scale 2: Fear of enacted stigma (alpha=.88) • People think I’m worthless if they know about my substance use history. • People around me will always suspect I have returned to using substances. • People without a substance use history could never really understand me. • A job interviewer wouldn’t hire me if I mentioned my substance history in a job interview. • If someone were to find out about my history of substance use, they would expect me to be weak-willed. • People would be scared of me if they knew about my substance abuse history. • If someone were to find out about my history of substance use, they would doubt my character. • People will think I have little talent or skill if they know about my substance history. • People think the bad things that have happened to me are my fault.

34. Scale 3: Stigma avoidance (alpha=.85) • I would choose to avoid someone who seemed interested in my friendship if I knew they had never used substances. • When I feel incompetent at something I want to do, I stop trying. • I put a lot of effort into hiding my substance use history. • I avoid doing things where I would be blamed if it didn’t work out. • I wouldn’t try to fill roles that required a person of character. • Shame gets in the way of how I want to live my life. • I withdraw from other people because I’m afraid I will scare them. • I would lie to people in my life about my substance use if I were sure they would never find out. • I avoid situations where another person might have to depend on me. • I avoid situations that make me feel different. • I can’t stand feeling like the bad things that happen to me are my fault. • I would willingly sacrifice important things in my life to feel like I fit in. • I need to control my angry thoughts and feelings. • Blaming myself for my substance abuse history gets in the way of my success. • I would willingly sacrifice important life goals if that meant I could feel better about myself.

35. Scale 4: Stigma as a barrier to valuing (alpha=.81) • I do things that are good for me, even if I feel like I don’t deserve it. (r) • If something is important to me, I keep doing it, even if I feel incompetent. (r) • I’m willing to be in situations where I might feel different from others. (r) • I am getting on with the business of living, no matter how guilty I feel. (r) • I am open about my substance use history with most people. (r) • I pursue important goals in life, even when I fear I might not follow through. (r) • I can set a direction for my life even if I feel hopeless. (r) • Even if I knew the employer didn’t like to hire people in recovery, I would still apply for a job if it interested me. (r) • I can set a course in my life and stick to it, even when I feel like I’m a bad person. (r) • If I didn’t have a job, I would still look for one, even if it felt hopeless. (r)

36. Intercorrelations among scales

39. Discussion • Psychometrics look good • Good internal consistency (alpha) • Good correlations with other measures • Strong factor structure • Not as sure what to make of scale 4 (values interference) • Correlates less with other scales • Additional research could indicate whether this is really 3 factors versus 4

40. Discussion • Next steps • Sensitivity to change • Separate validation sample and confirmatory factor analysis