Vol-7, Special Issue-Number2-April, 2016, pp789-796 http://www.bipublication.com
Case Report
The Effect of Cognitive-Behavioral Stress Management with Methadone to
Reduce Stress and Voracity in Drug use among Addicts referring to
Withdrawal Camps
Yaghoub Norouzpour Ahmadi1 and MahinAskari2
1Student of Clinical Psychology,
Department Of Psychology, College Of Humanities, Bandar Abbas Branch, Islamic Azad University, Bandar Abbas,
Iran, Email: Yaghob2960@Gmail.Com 2Assistant Professor Faculty of Medical Sciences , Hormozgan University, Department Of Clinical Psychology,
College Of Humanities, Bandar Abbas Branch, Islamic Azad University, Bandar Abbas, Iran ,
Email: Mahinask2005@Yahoo.Com ABSTRACT
The present study was conducted with the aim of examining the effect of cognitive-behavioral stress management with methadone to reduce stress and voracity in drug use among addicts referring to withdrawal camps. The design of the present study is quasi-empirical (quasi-experimental) and pretest -posttest have been together with control group. Statistical population was all the addicts referring to one of the withdrawal camps in Bandar Abbas that among them 30 persons were selected to participate in group therapy. Scale of 21-question Das- form (DASS-21) from the subscale of the stress and the questionnaire for measuring voracity in drug use in a moment to collect data were used. Training workshop on cognitive - behavioral stress management in 10 sessions was conducted an hour and a half on the experimental group. Covariance analysis was utilized for data analysis. The results showed that cognitive-behavioral stress management with methadone therapy has been effective in reducing stress in addicts referring to withdrawal camps (P≤ 0.05). Also, the results showed that cognitive-behavioral stress management with methadone therapy has been effective in reducing willingness and intention to use drugs, reducing the propensity to consume and negative reinforcement and drug velocity in addicts referring to withdrawal camps (P≤ 0.05). In general, these findings show that this curriculum in addition to reduce the symptoms in three levels of physiological, cognitive and behavioral leads to the change in person's lifestyle that this factor plays an important role in reducing drug use and preventing the recurrence and fault.
Keywords: cognitive-behavioral stress management, stress, voracity to drug, addiction Camp, methadone maintenance treatment
INTRODUCTION
Addiction is a biological, psychological and social disease in which various factors are effective in the etiology of drug abuse and addiction that in interaction with each other leads to start drug abuse and then addiction(Pourghasemi, 2010). United Nations (1950, quoted by Shahidi, 1996)
addiction is that the usefulness of some of them has been confirmed by empirical evidences. Addiction has concerned policy makers and has become a major public health problem that requires appropriate interventions and programs. Methadone treatment is a method of drug therapy that helps addicts to control their dependency on drug (Degenhardtet al., 2004). Different problems claim to improve drug-dependent patients among them medicinal drug treatments (such as maintenance treatment
or detoxification with methadone) individual psychotherapy, behavior therapy, cognitive therapy, family therapy, social skills training, Therapeutic community Narcotic anonymous can be mentioned. Reviewing the literature, we find that the use of MMT not only leads to a reduction or complete cessation of heroin use, but it also increases the person's ability to convert to a generative person with improvements in individuals' mental health and the reduction in social offences related to their abuse (Tacke et al., 2001; Joseph et al., 2000). Numerous studies have indicated a positive impact of this type of treatment on public health and quality of people's life with drug abuse. In a study by Esteban et al. (2003), researchers concluded that the use of MMT in addition to improve and promote health level increases life expectancy in people addicted to heroin Giacomuzziet al. (2002) also showed that after 6 months of using methadone, the general health of addicts increases significantly and this improvement in the areas of leisure, financial condition, treating the spouse and participation, physical health, mental health and their overall satisfaction is well observed. Non-pharmacological treatments with the aim at interventions like changing the improper attitudes of the addict, learning the necessary skills to deal with physical and psychological symptoms of withdrawal and better tolerance of them and intervention in the patient environment with involving family treatment in line with curing the patient and creating a supportive social network have been the interest to researchers (Hides et al,
2010).For example, results of a study showed that oriented integration CBT in treatment of young people suffering from depression, drug abuse have been along with a significant improvement in depression ,anxiety, drug abuse and coping skills and this improvement was maintained in the follow-up of 6 months (44 weeks) (Hideset al., 2010).Fisher (1997) by conducting a study on drug-dependent persons referring to outpatient centers found that patient centered group therapy with cognitive-behavioral group therapy in reducing drug-related problems, the increase in family and social relationships and the improvement in psychological performance in comparison to not receiving any treatment have positive results (quoted by McHugh et al., 2010).Cognitive-behavioral stress management refers to the set of techniques and methods that are used to reduce the stress experienced by individuals or to increase their ability to cope with stressful life events. These techniques are very diverse and may include some behavioral techniques (such as relaxation, meditation and systematic desensitization), or cognitive-behavioral techniques (e.g. coping skills training, assertiveness training, record the thoughts and cognitive restructuring, time management and educational and reasoning discussions) (Sinha, 2008). In recent years, in various studies on the effectiveness, this method of treatment for mental problems (such as anxiety and depression) and physical problems has been approved (Jandaghi et al., 2012).
METHOD Research design
The present study is quasi-experimental.
Population, sample and sampling method
The population is all the addicts referring to one of the withdrawal of addiction camps in Bandar Abbas that among them, 30 persons were selected to participate in therapy group and are placed in the experimental group and other30 persons are in control group. A purpose-based sampling method was used for sampling in this method of sampling those are only selected that are in line with the criteria of entering to study and purpose of the study. Criteria of entering to the study include: written informed consent to participate in the study, necessary readiness to participate in training sessions for experimental groups, people whose entry to the camp is less than a week are selected as a sample for the experimental and control groups, addiction to one of the types of drugs for at least six months, non-suffering from one of the acute psychiatric illnesses.
Research Instruments
The following questionnaires were used to collect data:
a) Stress Subscale of scales DASS (depression, anxiety and stress scale) -21- question Form (DASS-21)
In order to study, the stress scale questionnaire of DASS was used. The questionnaire was created by Lovibondand Lovibondin 1995. Now, 42 and 21- question forms of this questionnaire are available. Stress subscale involves terms such as difficulty in achieving peace, nervous tension, irritability and restlessness (Antony et al., 1998). The rater should rate the frequency of symptoms during the last week using a 4 degree scale (between 0 and 3). Each of the three scales depression, anxiety and stress has 7 questions. Lovibond and Lovibond(1995 ) show that DASS anxiety subscale with Beck Anxiety Inventory (BAI) has a correlation of 0.81 and DASS depression subscale with Beck Depression Inventory (BDI) has a correlation of 0.74 which represents proper
convergent validity of the test. In Iran, the validity and reliability of these instruments on 1070 men and women were examined. The reliability of this scale through internal consistency and its validity using factor analysis and simultaneous implementation of Beck Depression Tests and the perceived Zhang anxiety and stress have been reviewed and approved. (Sahebi, Asghari and Salari, 2005).
b) Questionnaire of measuring the moment voracity of using drug
This questionnaire have been designed focusing on voracity of using drug as a motivational state by Franken ,Hendricks & Van den Brink (2002) and measures the voracity of using drug at the present moment . This questionnaire includes 14 questions with three factors, namely the first factor "desire and intention of using drug", which includes questions 1, 2, 12 and 14. The second factor is "propensity to consume and negative reinforcement" or belief in solving life’s problems and enjoyment simultaneously with drug use that involves questions 5, 9, 11, 4, 7.The third factor measures "pleasure and intensity of loss of control" that includes questions 3, 8, 6, 10 and 13. It is worth noting that the correlation between these components is high. The internal consistency of the components of this questionnaire at the study of Makri et al (2010) in abusers of opiates, crack and heroin is 0.89, 0.79 and 0.40, respectively and in methamphetamine abusers 0.78, 0.65 and 0.81, respectively. In another study, Cranach’s alpha of this questionnaire for drug consumers (injecting heroin) has been reported from 0.98 to 0.90 (methamphetamines) (PourseyedMosayi et al. 2012).
C: Program of training workshop on cognitive-behavioralstress management
First session: After familiarizing participants with each other and with researcher, and making the initial contact, the participants were asked to define the concept of stress and stressors in their own language and talk about them.
Second Session: After reviewing the previous session and discuss home exercises, at first progressive muscle relaxation for 8 groups of muscle was trained.
Third session: After reviewing the previous session and discuss home exercise, with participation of participants themselves, they were thought diagram breathing, illustration, and muscle relaxation for four groups of muscles was discussed.
Session Four: After reviewing the previous session and discuss home exercise, with the participation of the participants, diaphragm breathing with illustration was practiced and reviewed. Then, negative thinking patterns and cognitive distortions that people commonly use were discussed with group members. Fifth Session: After reviewing the previous session and discussing home training, the autogenic training was done. In this way, using self-inductions causing heaviness and heat people can be taught so that to create a state of deep relaxation in their own. This training consists of six standard practices.
Seventh session: After reviewing the previous session and discussing home practice, the autogenic training was done with illustration and self-induction. This training is the same autogenic training with illustration.
Eighth Session: After reviewing the previous session and discussing home practice, the mantra meditation was trained.
Ninth session: After reviewing the previous session and discussing home practice, at first breath counting meditation was trained.
The tenth session: After reviewing the previous session and discussing home practice, the members were told that in this session, two exercises of the past relaxation were re-implemented.
Research method
In order to implement the research one of the withdrawal camps in the city of Bandar Abbas was visited, and addicts who have entered this center from 04/04 2015 to 09/06/2015, 60 people were selected in which 30 people were in the experimental group and 30 in the control group. Method one treatment with cognitive-behavioral stress management was conducted on the experimental group. The control group was on the waiting-list to participate in group cognitive behavioral stress management therapy. Before and after the implementation of group treatment of research questionnaires, the research was implemented on both experimental and control groups. After gathering research questionnaires using covariance analysis with observing presupposition data were analyzed.
RESULTS
Descriptive Findings
The descriptive findings show that the average age in the control group and the experimental group was 39.93, 37.30, respectively. Also, the mean of duration of drug use in the control group and in the experimental group was 12.93 and 9.07, respectively. The following tables show the mean and standard deviation of the scores of variables in both experimental and control groups
Table 1: The mean and standard deviation of the scores of variables in two pre-test and post-test stages in both control and experimental groups
Variable Stage
Group
Control Experimental
Mean (M) Standard Deviation
(SD) Mean (M)
Standard Deviation (SD)
Stress Pre-test 10.08 3.33 9.97 4.31
Desire and Intention to Use Drug
Pre-test 27.60 11.96 25.72 12.76
Pre-test 25.71 0.43 24.45 0.42
Desire to Use and negative Reinforcement
Pre-test 14.13 6.12 14.07 7.88
Pre-test 13.47 5.37 12.47 6.29
Joy and intensity of non-control
Pre-test 9.80 4.07 10.52 3.35
Pre-test 9.30 3.79 9.55 2.90
Velocity to Use Drug Pre-test 51.53 16.49 50.30 18.83
Pre-test 49.30 15.42 45.65 15.56
Inferential findings
The following table shows the results of multivariate analysis of variance test in order to investigate the difference between pre-test of stress and velocity to use drug and its dimensions in both experimental and control groups.
Table 2: The results of multivariate analysis of variance test in order to investigate the difference between pre-test of stress and velocity to use drug and its dimensions in both experimental and control groups
Group
Statistics Value Statistics F Significance level
Pilley effect 0.02 0.36 0.78
Wilks Lambda 0.98 0.36 0.78
Hotelling effect 0.02 0.36 0.78
Roy's largest root 0.02 0.36 0.78 The results in Table 6 show that the value of F
related to the statistic of Wilks Lambda equals 0.79 that is notsignificant in the level of Alpha 0.05 (P> 0.05). Thus,it can be said that the two groups in pre-test corresponds to variable of
stress and velocity to use drugs and its dimensions with each other.Table 3 shows the results of Levin test in order to examine the assumption of homogeneity of variances.
Table 3: Levin test to study the assumption of homogeneity of variances in the two groups at stress variable
Variable Stage The Freedom
Degree 1
The Freedom
Degree 2 Levin Test Significance (P)
Stress Post-test 1 28 2.16 0.15
Desire and Intention to Use
Drug Post-test 1 58 1.25 0.27
Desire to Use and negative
Reinforcement Post-test 1 58 0.70 040
Joy and intensity of
non-control Post-test 1 58 3.15 0.08
Velocity to Use Drug Post-test 1 58 1.31 0.26
Due to the significant amount (a = 0.05). Therefore, the null hypothesis is verified and variances are matched in both control and
experimental groups in variables of stress and velocity to use drug. Table 4 shows the results of analysis of covariance.
Table 4: The results of Covariance analysis of the impact of group membership on stress in the post-test stage
Variables Stage Source
Changes
Some of squares
Degree of Freedom
Mean
Squares F-Coefficient
Significance (P)
Stress Post-test
Pre-test 50919 1 509.19 270.69 0.001
Groups 35.73 1 35.73 18.99 0.001
Error 107.22 57 1.88 - -
Desire and Intention to Use
Drug
Post-test
Pre-test 6750.39 1 6750.39 1233.08 0.001
Groups 23.57 1 23.57 4.31 0.04
Desire to Use and negative Reinforcement
Post-test
Pre-test 1932.87 1 1932.87 2116.27 0.001
Groups 13.41 1 13.41 14.68 0.001
Error 52.06 57 13.41 - -
Joy and intensity
of non-control Post-test
Pre-test 620.17 1 620.17 877.1 0.001
Groups 2.13 1 2.13 3.01 0.09
Error 40.30 57 0.71 - -
Velocity to Use
Drug Post-test
Pre-test 13484.85 1 13484.85 1746.82 0.001
Groups 100.32 1 100.32 12.10 0.100
Error 440.02 57 7.72 - -
The results in the table above shows that cognitive-behavioral stress management with methadone therapy have been effective in the reduction to stress and drug use veracity and its dimensions such as desire and intention to use drug and negative reinforcement in addicts referring to drug withdrawal camps in post-test stage. Comparing the means show that by controlling the pre-test of stress and veracity to use drugs,, addicts who have received methadone treatment with cognitive-behavioral stress management have (control group ) obtained significantly lower scores on the variables of stress and veracity to use drug in post-test compared to the control group (P≤ 0.01).
DISCUSSION AND CONCLUSION
The findings of this study suggest that cognitive-behavioral stress management with methadone therapy in reducing stress in addicts who have referred to the withdrawal camps. These results are consistent with the results of Karimiyan (2011), Jandaghi et al (2011). Jandaghi et al (2011) show that group training of cognitive-behavioral stress management can be used as a helpful intervention for people with drug abuse under treatment with methadone. It has been also shown that cognitive - behavioral stress management is effective on improving the quality of men’s life in men dependent on drug (Karimiyan, 2011).To explain these findings, it can be said that the approaches of stress treatment, range from pharmaceutical to psychoanalytic treatments are widespread. If we consider stress as
having physiological, cognitive and behavioral aspects, we can expect that pharmaceutical treatment affects on the physiological aspect, and cognitive and behavioral therapy on the other two dimensions of stress. Some argue that cognitive-behavioral skills can prevent the cognitive distortions caused by physiological signs and symptoms and thus a vicious cycle with anxiety. In the method of cognitive-behavioral stress management, relaxation techniques play an important role in reducing anxiety and stress that this deficiency leads to reduce the physical symptoms of stress and subsequently, this reduction in behavioral and cognitive symptoms are noticeable .On the other hand, in cognitive-behavioral stress management program it is tried that addicts identifies their weaknesses and shortcomings in interpersonal relationships and they are informed how to eliminate them; that this effect is reinforced by a group of meetings, because the group meetings cause speaking and verbal communication skills with others. In cognitive-behavioral stress management program using relaxation and meditation techniques plays an effective role in reducing stress.
that cognitive behavioral techniques can increase coping strategies in person and reduce the likelihood of relapse to alcohol use (Zlotnick, 2001). To explain this finding, at first we tell the difference between slip and a relapse. In slip person may use drug once after a period of not using drug and feel regret, and again decide to withdrawal but in relapse, a person after another slip has not decided not to use drug and continues using drug. Due to the fact that drug addiction is a chronic disease and recurrent, biological-socio-psychological conditions leads to the tendency to drug consumption after completion of the course of treatment, it is necessary that the centers of treating addiction after the completion of detoxification period, for a while that the likelihood of the recurrence is high keep the relevance of referees to medical centers and teach techniques for coping with stress and change the lifestyle of the addicted person. Generally, these findings suggest that this educational program, while decreasing symptoms in three physiological, cognitive and behavioral levels lead to the change in lifestyle of the individual that this factor plays an important role in the reduction of drug consumption and prevent relapse and slip. The limitations of the study include: the limitation of the sample to the addicts referred to withdrawal addiction camp, some of the individuals samples are addicts who have forcibly been brought to these camps, so the possibility of not giving the correct answer to the questions of the questionnaires can create bias in the results of the research, in the present study the effectiveness of methadone therapy and cognitive behavioral stress management have not been considered separately. Due to the limitations of the research, the research proposals include: to review the effectiveness of cognitive-behavioral stress management method on the addicts referred to the clinics with self-help groups, to compare the effectiveness of cognitive behavioral stress management training in addicts consuming opiates and amphetamines addicts like glass. It is suggested that cognitive behavioral stress management training is used along with
other pharmaceutical ways in clinics of drug withdrawal.
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