Universidade de Aveiro 2019
Departamento de Educação e Psicologia
Dora Filipa
Gonçalves Gomes
Early Maladaptive Schemas and Addictive Behaviors
Esquemas Mal-Adaptativos Precoces e os
Comportamentos Aditivos
Dissertação apresentada à Universidade de Aveiro para cumprimento dos requisitos necessários à obtenção do grau de Mestre em Psicologia da Saúde e Reabilitação Neuropsicológica, realizada sob a orientação científica do Prof. Doutor José Ignacio Guinaldo Martin, Professor Auxiliar do Departamento de Educação e Psicologia da Universidade de Aveiro.
Dedico este trabalho aos meus pais e avós por todo o apoio ao longo dos anos.
o júri / the jury
Presidente / president Prof. Doutora Anabela Maria Sousa Pereira
Professora Associada com Agregação do Departamento de Educação e Psicologia da Universidade de Aveiro
Doutora Laura Maria Cerqueira Marinha Nunes
Professora Auxiliar da Faculdade de Ciências Humanas e Sociais da Universidade Fernando Pessoa
Prof. Doutor José Ignacio Guinaldo Martin
Agradecimentos/ Acknowledgements
Em primeiro lugar agradeço ao Prof. Doutor José Ignacio Martin por toda a orientação prestada. Agradeço também à Prof. Doutora Anabela Pereira e ao Prof. Doutor Carlos Fernandes da Silva, Coordenadores do Mestrado, do Departamento de Educação e Psicologia e à Universidade de Aveiro que permitiram o desenvolvimento deste estudo. Agradeço ainda ao Doutor Daniel Rijo pela amável permissão e autorização para utilização do YSQ-S3, e ao Doutor João Goulão por autorizar, de forma prestável, a realização da recolha dos dados na Comissão para a Dissuasão da Toxicodependência de Aveiro. Um agradecimento especial à Comissão para a Dissuasão da
Toxicodependência de Aveiro, e aos membros desta equipa que permitiram e auxiliaram na realização do meu estudo. Um agradecimento especial à Drª Carla Coelho por toda a ajuda, carinho e compreensão.
À minha família, em especial aos meus pais, irmão e avós, o maior
agradecimento é para eles, que sofreram comigo, que lutaram comigo e que sempre fizeram de tudo para que conseguisse alcançar este meu sonho. Obrigada por serem os meus pilares, por nunca me deixarem cair e por serem o melhor que a vida me deu. Para vocês um obrigado não basta. À minha restante família um enorme obrigado por todo o apoio e por todas as palavras de carinho e conforto.
À minha “partner” Luísa obrigada por todas as horas que perdeste a ouvir-me e a tentar reconfortar-me, por me compreenderes e aturares, ainda que por vezes possa ter sido demasiado insuportável. Obrigada por nunca me teres abandonado e por me teres transmitido todos os teus conhecimentos e todo o incentivo possível.
Aos meus amigos, Margarida, Garcia, Marlene e Ana, um enorme obrigado por todos os momentos em que tiveram de me ouvir, por todos os momentos que me ergueram e por todo o apoio e carinho. Vocês são fundamentais na minha vida. Aos meus restantes amigos, de sempre e aos que a Universidade me trouxe, um enorme obrigado por todo o apoio, por todas as palavras e por todos os momentos de alegria e ânimo proporcionados.
Ao Fernando por acreditar em mim, por me incentivar e por muitas vezes ter de aturar o meu mau feitio, que bem sei que não é fácil. Obrigado por todo o carinho, conforto e amor, que tão bem souberam nestes tempos difíceis. Aos meus camaradas dos Bombeiros, em especial à Alice, ao Murça, ao Renato, à Neuza, à Cris e ao Luís, que tanto me ouviram lamentar e sempre me apoiaram e acreditaram em mim e nas minhas capacidades.
Um obrigado a todos aqueles que embora não presentes fisicamente,
marcaram a minha vida e estiveram sempre comigo, no meu pensamento, ao longo deste meu percurso.
Palavras-chave Comportamentos aditivos, Esquemas mal-adaptativos precoces, Correlação, Efeito preditor, Influência clínica
Resumo Contextualização: Pesquisas anteriores demonstraram que os esquemas
mal-adaptativos precoces (EMPs) desempenham um papel importante, podendo ter um efeito preditor, no consumo de substâncias.
Objetivos: Esta investigação pioneira, teve como objetivo avaliar as relações existentes entre os EMPs e os comportamentos aditivos, frequência e quantidade, e concomitantemente, verificar qual dos 18 EMPs é o melhor preditor no consumo de substâncias.
Métodos: Para a presente investigação foram recrutados, de forma voluntária, sujeitos atendidos na Comissão para a Dissuasão da Toxicodependência (CDT) de Aveiro (n = 39), sendo que estes tinham de ter idades ≥ 18 anos e ser consumidores de drogas.
Resultados: Os resultados demonstraram que setes esquemas, sendo estes pertencentes aos quatro primeiros domínios (“Distanciamento e Rejeição”, “Autonomia e Desempenho Deteriorados”, “Influência dos Outros” e “Limites Deteriorados”), se relacionaram de forma significativa com as variáveis de consumo. Destes sete que se correlacionaram, cinco (“Defeito/Vergonha”, “Vulnerabilidade ao mal e à doença”, “Emaranhamento/Eu subdesenvolvido”, “Subjugação” e “Autossacrifício”) revelaram um efeito preditor nos comportamentos aditivos.
Conclusão: Estes resultados demonstram que os EMPs se relacionam e que podem ter um efeito preditor nos comportamentos aditivos. Pretende-se que estes resultados possam ser úteis em contexto clínico. No entanto, são necessários estudos adicionais para melhor compreender estas questões.
Keywords
Abstract
Addictive behavior, Early maladaptive schemas (EMP), Correlation, Predictive effect, Clinical influence
Background: The previous research has revealed that early maladaptive schemas (EMPs) play an important role and may have a predictive effect on substance consumption.
Objectives: This pioneering research aimed at evaluating the existing relationships between EMPs and addictive behaviors besides verifying which of the 18 EMPs is the best predictor in substance consumption.
Methods: For the present study, subjects were voluntarily recruited from the Commission for the Dissuasion of Drug Addiction (CDT) of Aveiro (n = 39). They were supposd to be aged ≥ 18 years and be users of drugs.
Results: The results showed that seven schemes, belonging to the first four domains ("Disconnection and Rejection", "Impaired autonomy and performance", "Other directedness" and "Impaired limits"), were significantly related to the consumption variables. Of these seven that correlated, five schemes ("Defectiveness", "Vulnerability", "Enmeshment", "Subjugation", and "Self-sacrifice") revealed a predictive effect on addictive behaviors.
Conclusion: The results demonstrate that EMPs are correlated and can have a predictive effect on addictive behaviors. It is envisioned that these results may be useful in a clinical context. However, additional studies are needed to better understand these issues.
Index Introduction ...1 Method ...3 Participants ...3 Instruments ...7 Procedure ...7 Statistical analysis...8 Results ...8
Disconnection and Rejection ...9
Impaired autonomy and performance ... 10
Other directedness ... 11
Impaired Limits ... 12
Excessive Vigilance and Inhibition ... 12
Discussion ... 15
References ... 19
Index of Tables
Table 1. Sociodemographic characteristics of the sample ...4
Table 2. Consumption characteristics of the sample ...5
Table 3. Sociodemographic variables according to the variables of addictive behaviors ...6
Table 4. Results of the mean of each EMP in the sample ...9
Table 5. EMPs of the Disconnection and Rejection domain according to addictive behaviors ... 10
Table 6. EMPs of the Impaired Autonomy and Performance domain according to addictive behaviors ... 10
Table 7. EMPs of the Other Directedness domain according to addictive behaviors ... 11
Table 8. EMPs of the Impaired Limits domain according to addictive behaviors... 12
Table 9. EMPs of the Excessive Vigilance and Inhibition domain according to addictive behaviors ... 12
1 Introduction
Addictive behaviors are the result of the interaction of several psychological, biological, social, and environmental factors (Griffiths, 2005, 2004; Parke & Griffiths, 2006). According to data from the European Monitoring Centre for Drugs and Drug Addiction, the availability of drugs in Europe is high, and seems to be increasing in some regions (European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), 2019). As far as alcohol is concerned, although use has decreased considerably, Europe is the region with the highest use (WHO, 2018). According to the "European Drug Report 2019: Trends and Developments", it is estimated that out of the population of the European Union aged 15-64, almost 96 million people (29%) have experienced illicit psychoactive substances during their lifetime; more frequent in males (57.8 million) than in females (38.4 million). Among existing drugs, cannabis is the most tried and used in all age groups, followed by cocaine, MDMA, amphetamines, and finally opioids (European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), 2019). Estimates from the 'Global Status Report on Alcohol and Health 2018' show that numerous men and women suffer from alcohol use disorders, with greater prevalence in European regions (WHO, 2018).
Substance use can lead to substantial harmful and/or chronic impairment in the life of the subject (WHO, 2004), so it is imperative to increase the means of prevention and treatment to diminish the risk factors besides maintaining these addictive behaviors. Several researchers, over time, have evaluated the possibility that early maladaptive schemas (EMP), negative cognitive and behavioral patterns about oneself and the world, are a risk factor for the development and maintenance of addictive behaviors (e.g., Ball, 2007; Ball & Young, 2000; Brotchie, Meyer, Copello, Kidney & Waller, 2004; Roper, Dickson, Tinwell, Booth & McGuire, 2010). In addition, their conclusions were consistent with the theory that EMPs can be an underlying factor for substance consumption (Ball, 1998; Young, Klosko & Weishaar, 2003).
Early maladaptive schemas (EMPs)
EMPs are extremely stable and lasting structures developed during childhood or adolescence, based on a set of early toxic or traumatic experiences with significant figures (i.e. family of origin or primary caregivers), developed and maintained throughout the
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individual's life (Rafaeli, Bernstein & Young, 2011; Rijo, Bazão, Silva & Vagos, 2017; Shorey, Stuart & Anderson, 2012, 2013b, 2013a; Young et al., 2003).
These dysfunctional schemes, formed by memories, emotions, bodily sensations and cognitions, associated to the individual himself as well as his relationship with others, may generate high levels of disruptive affect, self-destructive behaviors and/or considerable harm to others (Ball, 1998; Ball & Young, 2000; Shorey, Anderson & Stuart, 2012, 2013; Rafaeli, Bernstein & Young, 2011; Pinto - Gouveia & Rijo, 2001; Rijo, 2009; Young et al., 2003; Wainer & Rijo, 2016). They are capable of influencing the way the individual interprets his/her experiences (Young et al., 2003). Also, they are, theoretically, believed to be the basis for the development of persistent clinical disorders (Ball, 1998; Ball & Young, 2000; Shorey, Anderson & Stuart, 2013; Young et al., 2003). EMPs are exceedingly resistant to change, unless there is a therapeutic intervention (Pinto - Gouveia & Rijo, 2001; Young et al., 2003). These dysfunctional schemes are derived from basic developmental needs not met or not achieved by the individual. Thus, it is believed that they significantly interfere with basic needs associated with self-expression, development of autonomy, connection to others, social validation and/or integration into society (Rafaeli et al., 2011; Rijo et al, 2017; Shorey, Anderson & Stuart, 2012; Young et al., 2003).
Young proposed the existence of 18 early maladaptive schemas (cf. Attachments A), organized and divided into 5 broad domains of unmet basic needs (Rafaeli et al., 2011; Wainer & Rijo, 2016; Young et al., 2003).
Early maladaptive schemas and substance use
Several studies have assessed the prevalence of early maladaptive schemas in substance users ( Ball & Cecero, 2001; Bojed & Nikmanesh, 2013; Brotchie et al., 2004; Roper et al, 2010; Shorey, Anderson & Stuart, 2012; Shorey, Anderson & Stuart, 2013), and the predictive effect of the schemas on addictive behaviors ( MansouriJalilian & Yazdanbakhsh, 2015; Razavi, Soltaninezhad & Rafiee, 2012; Zamirinejad, Hojjat, Moslem, MoghaddamHosseini & Akaberi, 2017). Young mentioned that EMPs are underlying characteristics of most mental disorders, explicitly those resistant to change (e.g., substance use disorders) (Shorey, Stuart & Anderson, 2012; Young et al., 2003). Ball (1998) expanded the conceptualization advocated by Young, proposing that EMPs may (1) be underlying characteristics and increase the risk of substance use, and (2) the treatments for consumers, focused on the modification of EMPs, may lead to better results owing to
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their stability, penetration, similarity to personality traits, and the likely underlying influence of these on substance use (Ball, 2007; Shorey, Stuart & Anderson, 2012; Shorey, Anderson & Stuart, 2013). In 1998, Ball created Dual Focus Schema Therapy (DFST) with the objective of reducing EMPs in substance users. Ball (2007), evaluating consumer patients undergoing DFST, found a significant and faster reduction in the frequency of substance use (Shorey, Stuart & Anderson, 2013b; Shorey, Stuart, Anderson & Strong, 2013). In support of the assumptions made, several studies have established that consumer individuals present significantly higher scores than the non-clinical group (e.g. intimate partners; parents; non-consumer population) in most schemes (e.g. Brotchie, Meyer, Copello, Kidney & Waller, 2004; Jalali, Zargar, Salavati & Kakavand, 2011; Roper, Dickson, Tinwell, Booth & McGuire, 2010; Shorey, Anderson & Stuart, 2011, 2012, 2013; Shorey, Stuart & Anderson, 2012, 2013b).
The correlation of EMPs and consumes and the treatment of substance use focused on the schemas have been the subject of extensive research. As no such study was conducted in Portugal, it was considered beneficial to develop a pioneering study, with the aim of identifying the early maladaptive predictor schemas in drug users aged 18 years or older. Specifically, through relation and prediction analysis, this research aims at evaluating the relationship and predictor effect that dysfunctional structures, generated by harmful early experiences, can have on the individual's behaviors, namely addictive behaviors (i.e. substances, frequencies, and quantities). With these results, the therapist, in his context of intervention, may use strategies aimed at these dysfunctional schemas in order to prevent relapse.
Method
Participants
The study questionnaires were voluntarily completed by 39 users of the Commission for the Dyssuasion of Drug Addiction (CDT) Aveiro, a service that ensures compliance with mandatory psycho-educational measures aimed at subjects sent by courts/police forces for drug use, trafficking and/or possession (SICAD, n.d.). The sample of this study had to be 18 years of age or older and drug users.
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The mean age of the sample was 23 years. Most of them were men (92.3%), with the third cycle completed, single (92.3%), and unmarried (92.3%). Most individuals reported having a stable job (64.1%) and a salary of 501€ to 1000€ (59%). All participants mentioned that they have used drugs and 30.8% had a history of use (cf. Table 1).
As far as the consumption of the substances is concerned, a) 89.7% said that they had consumed alcohol, b) 100% had consumed cannabis, c) 2.6% had consumed cocaine, d) 7.7% had consumed opiates, and e) 5.1% had consumed hallucinogens. The main drug most commonly used was hashish (66.7%), with 30.8% of 36 participants reported having used it once or twice in the last 30 days, while 35.9% of 36 participants have used it once or three times a month in the last 12 months. In terms of quantities, 33.3% of the 36 participants reported having used the substance once a day in the last 30 days, while 41.0% of 36 participants reported having used the substance once a day in the last 12 months.
Of the total participants, 61.5% tried to reduce and stop their consumption, and 38.5% reported the presence of withdrawal symptoms in the processes (e.g. sleep difficulties, nervousness or anxiety, irritability or anger, reduced appetite or weight loss, depressed mood, restlessness, and significant discomfort). Of the 37 participants who answered this question, 66.7% felt a strong desire to consume, and 84.6% said that the reason for their consumption is recreational/leisure (cf. Table 2).
Table 1. Sociodemographic characteristics of the sample
Sociodemographic characteristics (n=39) M (DP) Min-Max Age Academic Qualifications 23,38 (4,93) 3,56 (1,07) 18-40 1-7 N % Gender Female Male 3 36 7,7 92,3 Civil Status Single Union of Fact Married 36 2 1 92,3 5,1 2,6 Professional Situation Unemployed Student Regular Work Worker/Student 5 8 25 1 12,8 20,5 64,1 2,6
5 N % Economic Situation No income 500€ or less 501€ a 1000€ 1001€ a 1500€ 13 1 23 2 33,3 2,6 59,0 5,1 Children 4 10,3
Note: M=Mean; DP=Standard Deviation; Min=Minimum; Max=Maximum; n= Sample number
Table 2. Consumption characteristics of the sample
N % Consumption history 12 30,8 Substances consumed Alcohol Cannabis Cocaine Opiates Hallucinogenes 35 39 1 3 2 89,7 100,0 2,6 7,7 5,1 Main SPA Hashish Weed 26 13 66,7 33,3 Frequency of consumption in the
last 30 days No consumption Once or twice
Once or three times a month Once or four times a week Almost daily Daily 6 12 6 6 1 5 15,4 30,8 15,4 15,4 2,6 12,8 Frequency of consumption in the
last 12 months No consumption Once or twice
Once or three times a month Once or four times a week Almost daily Daily 0 10 14 5 3 4 0 25,6 35,9 12,8 7,7 10,3 Consumption per day in the last
30 days None One Two Three Four Seven 6 13 10 4 1 2 15,4 33,3 25,6 10,3 2,6 5,1 Consumption per day in the last
12 months One Two Three 16 11 5 41,0 28,2 12,8 Table 1. Sociodemographic characteristics of the sample (continued)
6 N % Four Five Seven 1 1 7 2,6 2,6 5,1 Cease consumption 24 61,5 Reduce consumption 24 61,5 Abstinence symptoms 15 38,5 Craving 26 66,7
Reasons for consumption Recreational / Pleasure Physical/Psychological needs 33 4 84,6 10,3 Note: n= Sample; % = percentage
Through a statistical analysis (i.e. Student's t-test and Chi-square test), it was found that the sample is homogeneous, and the addictive behaviors are not related to the socio-demographic variables (i.e. gender, qualifications, professional situation, consumption history) (cf. Table 3).
Table 3. Sociodemographic variables according to the variables of addictive behaviors
Gender Qualifications Professional Situation Consumption History t /X2• g.l p t /X2• g.l p t /X2• g.l p t /X2• g.l p Alcohol • 1,880 1 0,170 0,117 1 0,732 0,655 1 0,418 0,070 1 0,792 Cannabis • - - - - - - - - - - - - Cocaine • 0,086 1 0,770 0,027 1 0,869 0,151 1 0,698 0,456 1 0,499 Opioids • 0,271 1 0,603 0,086 1 0,770 0,478 1 0,489 0,010 1 0,920 Hallucinogens • 0,176 1 0,675 0,055 1 0,814 0,310 1 0,578 0,366 1 0,545 Main drug -,163 37 0,871 -,938 37 0,354 0,500 37 0,620 0,377 37 0,708 Consumption 30 days 1,094 34 0,282 1,593 34 0,120 0,937 34 0,356 0,289 34 0,775 Consumption 12 months 1,683 32 0,102 1,625 34 0,113 1,601 34 0,119 0,180 34 0,858 Quantities 30 days 1,212 34 0,234 -,253 34 0,802 -,810 34 0,424 1,089 34 0,284 Quantites 12 months 1,314 34 0,198 -,237 34 0,814 -1,113 34 0,274 0,377 34 0,709 Craving • 0,020 1 0,887 0,435 1 0,510 0,292 1 0,589 0,110 1 0,740 Note: • (Chi-Square test) (T-Student test); g.l = degress of freedom; p = significance value * p<0.05; **p<0.01
7 Instruments
Sociodemographic and consumption questionnaire
This questionnaire was specifically designed for the present study. The socio-demographic part of questionnaire addressed the issues related to the subject's personal and family data, while the consumption part of the questionnaire allowed the assessment of substances consumed in the last 30 days and 12 months, their frequency, quantity, effects of use, reasons for use, and craving.
Young Schema Questionnaire (YSQ-S3) (short version-3) (Young, 2005; Translation and
Adaptation of Rijo, Pinto-Gouveia & Salvador, 2005; Rijo, 2009)
The Young Schema Questionnaire allows evaluating the 18 early maladaptive schemas through the self-answer of 90 items, presented in a non-consecutive way in the questionnaire. Each question presents an answer scale from 1 to 6 degrees (from "Completely false, that is it has absolutely nothing to do with what happens to me" to "It describes me perfectly, that is it has everything to do with what happens to me") (Rijo, 2017; Riso et al., 2006; Shorey, Anderson & Stuart, 2012; Shorey, Elmquist, Anderson & Stuart, 2015).
In the study translated and validated for the YSQ-S3 Portuguese population, the Cronbach's alpha value for all items was 0.967 (Rijo, 2017). In this study, this questionnaire showed good psychometric properties with the Cronbach's alpha value of 0.930, thus demonstrating a high internal consistency of the scale.
Procedure
The author met with team of the CDT, Aveiro, in order to explain the objective and the procedure to be followed for the effectiveness of the study. Data collection started on 30th
January and ended on 29th May.
The questionnaires were administered during the waiting period, after the end of the health technician intervention and before reading the decision of the process, since it is a pause with considerable durability for its completion.
Informed consent was initially presented, and the participants were informed about the research process (cf. Attachments B). After getting the authorization for the study, the
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procedures for filling in the questionnaires (Socio-demographic and Consumption Questionnaire and YSQ-S3) were presented and explained.
Data collection at the CDT, Aveiro, was authorized by the Director General of SICAD (Intervention Addictive Behaviors and Dependencies) and the President of the CDT, Aveiro. Authorization and permission to use the YSQ-S3 were also requested from one of the main authors of the Portuguese version.
Statistical analysis
Data were statistically analyzed using the program IBM SPSS Statistics 25 (Statistical Package for the Social Sciences).
Firstly, a descriptive statistic was performed, where calculations (i.e. means, standard deviations, frequencies, maxima, minima, and respective percentages) were performed for the socio-demographic characterization of the sample. Student t-tests were also performed to compare the means between the socio-demographic variables and the continuous variables related to addictive behaviors. (i.e. frequency of consumption in the last 30 days, frequency of consumption in the last 12 months, quantities per day in the last 30 days, quantities per day in the last 12 months, and main drug).The Chi-square test was also performed to test whether the socio-demographic variables and the dichotomous variables related to addictive behaviors (i.e. alcohol, cannabis, cocaine, opioids, hallucinogens, and craving) differ regarding homogeneity. To verify the internal consistency of the YSQ-S3 instrument, Cronbach's alpha coefficient was calculated.
Subsequently, Pearson's correlations were performed in order to verify the existence of a relationship between EMPs and addictive behaviors. Finally, in order to evaluate the predictor effect of each of the EMPs on addictive behaviors and to verify which EMP shows the highest prediction of the behaviors, multiple linear regressions (Stepwise method) were performed.
Results
In relation to the total YSQ-S3 score, it was found that in at least one of the participants, five EMPs approached the maximum possible theoretical value (i.e. 6), and the mean value varied from a minimum of 1.32 (i.e. EMP "Defectiveness") to a maximum of 3.35 (i.e. EMP "Unrelenting Standards") (cf. Table 4).
9 Table 4. Results of the mean of each EMP in the sample
EMP Min (teoric
minimum possible) Max (teoric maximum possible) M DP Emotional Deprivation 1 (1) 3,20 (6) 1,42 0,56 Abandonment 1 (1) 5 (6) 2,11 0,98 Mistrust/Abuse 1 (1) 5,20 (6) 2,19 0,93 Social Isolation 1 (1) 2,80 (6) 1,69 0,52 Defectiveness 1 (1) 2,80 (6) 1,32 0,41 Failure 1 (1) 3 (6) 1,51 0,59 Dependence 1 (1) 3,40 (6) 1,70 0,60 Vulnerability 1 (1) 4,60 (6) 2,01 0,92 Enmeshment 1 (1) 3,20 (6) 1,69 0,60 Subjugation 1 (1) 2,80 (6) 1,68 0,55 Self-Sacrifice 1 (1) 4,60 (6) 2,37 0,95 Approval Seeking 1 (1) 5,60 (6) 2,24 0,99 Entitlement 1 (1) 5,60 (6) 2,14 0,81 Insufficient Self-Control 1 (1) 3,20 (6) 1,96 0,69 Negativity/Pessimism 1 (1) 4,20 (6) 2,30 0,95 Emotional Inhibition 1 (1) 4,40 (6) 2,26 0,96 Unrelenting Standards 1 (1) 5,80 (6) 3,35 1,16 Punitiveness 1 (1) 4,80 (6) 2,61 0,99
Note: M=Mean; DP=Standard Deviation; Min=Minimum; Max=Maximum;
Initially, Pearson's correlations were performed, encompassing the 18 EMPs and addictive behaviors. It is evident from the following tables of the domains that there is a correlation between the EMPs of four domains and the addictive behaviors, with the exception of: a) cannabis since it was not possible to verify the existence of a relationship as it was a constant variable in this sample; and b) the main drug since there were no significant values.
Disconnection and Rejection
Pearson's correlation for the present domain seems to reveal significantly higher levels in the EMP "Defectiveness" when related to the frequency of consumption in the last 30 days and 12 months. Correlations are positive; when the EMP "Defectiveness" is activated, the frequency of consumption in the last 30 days and the last 12 months tends to increase. However, we seem to be facing correlations of low intensity (cf. Table 5).
10 Table 5. EMPs of the Disconnection and Rejection domain according to addictive behaviors
Emotional Deprivation
Abandonment Mistrust/Abuse Social Isolation Defectiveness R (g.l) R (g.l) R (g.l) R (g.l) R (g.l) Alcohol -.040(38) .153(38) -.070(38) -.028(38) -.015(38) Cocaine .005(38) .120(38) .140(38) -.034(38) -.033(38) Opioids .113(38) -.166(38) -.298(38) -.212(38) -.058(38) Hallucinogens .091(38) .027(38) .099(38) .042(38) -.160(38) Main drug .065(38) -.127(38) -.126(38) -.038(38) .102(38) Consumption 30 days .126(35) .181(35) .105(35) .320(35) .475(35) ** Consumption 12 months .072(35) .243(35) .109(35) .238(35) .416(35) * Quantities 30 days .249(35) .281(35) .007(35) .297(35) .247(35) Quantities 12 months .244(35) .295(35) .138(35) .226(35) .170(35) Craving .104(36) -.160(36) -.043(36) -.144(36) -.187(36)
Note: R = correlation coefficient; g.l = degrees of freedom * p<0.05; **p<0.01
Impaired autonomy and performance
Pearson's correlation for this domain revealed significantly higher levels in: a) EMP "Vulnerability" when related to alcohol, with a positive and low intensity relationship between the variables; b) EMP "Enmeshment" when related to cocaine, opioids, hallucinogens, and craving, all correlated with a low intensity and negative relationship; when the scheme increases, the variables tend to decrease; c) EMP "Dependence" when correlated with the frequency of consumption in the last 30 days, revealing a positive and low intensity correlation (cf. Table 6).
Table 6. EMPs of the Impaired Autonomy and Performance domain according to addictive behaviors
Failure Dependence Vulnerability Enmeshment R (g.l) R (g.l) R (g.l) R (g.l) Alcohol -.264(38) .115(37) .368(38) * -.107(38) Cocaine .086(38) .194(37) -.070(38) -.413(38) ** Opioids .023(38) -.049(37) -.124(38) -.476(38) ** Hallucinogens -.074(38) .040(37) -.074(38) -.436(38) ** Main drug -.207(38) -.087(37) -.098(38) -.184(38) Consumption 30 days -.042(35) .344(34) * .220(35) .315(35) Consumption 12 months -.078(35) .327(34) .261(35) .306(35)
11 Failure Dependence Vulnerability Enmeshment
R (g.l) R (g.l) R (g.l) R (g.l) Quantities 30 days -.111(35) .101(34) .078(35) .092(35) Quantities 12 months -.158(35) .002(34) .040(35) .033(35) Craving -.127(36) -.224(35) -.032(36) -.394(36) ** Other directedness
In the present domain, there were significantly higher levels in the: (a) EMP 'Subjugation' when related to the frequency of consumption in the last 30 days and 12 months as well as the amount of consumption in the last 30 days and 12 months. All correlations were found to be positive but of low intensity; b) EMP "Self-Sacrifice" when related to opioids, craving, frequency of consumption in the last 30 days and last 12 months as well as to the quantities of consumption in the last 30 days and last 12 months, with two of the variables (i.e. opioids and craving) showing a negative relationship, while the others showed a positive correlation. Regarding the intensity of the relationship, the frequency of consumption over the last 30 days and the last 12 months showed a moderate relationship, while the others seem to show a relationship of low intensity (cf. Table 7)
Table 7. EMPs of the Other Directedness domain according to addictive behaviors
Subjugation Self-Sacrifice Approval Seeking R (g.l) R (g.l) R (g.l) Alcohol -.153(37) .031(37) .089(38) Cocaine .086(37) -.251(37) .106(38) Opioids .045(37) -.364(37) * -.222(38) Hallucinogens -.007(37) -.310(37) .128(38) Main drug -.081(37) -,123(37) .064(38) Consumption 30 days .441(34) ** .547(34) ** .051(35) Consumption 12 months .465(34) ** .557(34) ** .215(35) Quantities 30 days .438(34) ** .354(34) * .133(35) Quantities 12 months .366(34) * .366(34) * .194(35) Craving -.079(35) -.352(35) * .071(36) Note: R = coeficiente de correlação; g.l = graus de liberdade * p<0.05; **p<0.01 Note: R =correlation coefficient; g.l = degrees of freedom * p<0.05; **p<0.01
Table 6. EMPs of the Impaired Autonomy and Performance domain according to addictive behaviors (continued)
12
Impaired Limits
Pearson's correlation for the present domain seems to show significantly higher levels in the EMP "Entitlement" when related to opioids, establishing a negative correlation of low intensity (cf. Table 8).
Table 8. EMPs of the Impaired Limits domain according to addictive behaviors
Entitlement Insufficient self-control R (g.l) R (g.l) Alcohol -.003(37) -.103(38) Cocaine .193(37) .226(38) Opioids -.362(37) * -.129(38) Hallucinogens .130(37) -.014(38) Main drug .226(37) -.077(38) Consumption 30 days .237(34) -.001(35) Consumption 12 months .313(34) .067(35) Quantities 30 days .117(34) -.066(35) Quantities 12 months .254(34) -.025(35) Craving -.111(35) -.034(36)
Excessive Vigilance and Inhibition
Pearson's correlation for the present domain does not seem to show significantly high levels in any of the EMPs presented (cf. Table 9).
Table 9. EMPs of the Excessive Vigilance and Inhibition domain according to addictive behaviors Negativity/Pessimism Emotional Inhibition Unrelenting Standards Punitiveness R (g.l) R (g.l) R (g.l) R (g.l) Alcohol .035(38) .126(37) .046(37) .139(37) Cocaine .052(38) .114(37) -.036(37) - Opioids -.133(38) -.003(37) -.200(37) -.216(37) Hallucinogens -.123(38) .089(37) -.092(37) -.100(37) Main drug -.105(38) .168(37) .038(37) -.041(37) Consumption 30 days .276(35) -.129(34) .032(34) .007(34) Consumption 12 months .291(35) -.084(34) .301(34) .182(34) Quantities 30 .136(35) -.095(34) .019(34) -.110(34)
13 Negativity/Pessimism Emotional Inhibition Unrelenting Standards Punitiveness R (g.l) R (g.l) R (g.l) R (g.l) days Quantities 12 months .121(35) -.158(34) .101(34) .036(34) Craving -.175(36) .089(35) .148(35) .301(35)
Afterwards, evaluating the predictor effect of the schemas on addictive behaviors, multiple linear regressions (Stepwise method) were performe.
For alcohol, the regression results revealed a significant model [F (1.37) = 5,913, p < 0.05, R2 = 0.136], and the EMP "Vulnerability" ( = 0.123, t = 2.411, p<0.05) is a
predictor of alcohol consumption, consistent with the results of the previous research, where the predictor effect and the prevalence of this scheme on consumption were evaluated (Brotchie et al., 2004; Razavi, Soltaninezhad & Rafiee, 2012; Roper et al., 2010; Shorey et al., 2011). When the variable cocaine was introduced, a significant model was found [F (1.37) = 7,627, p < 0.01, R2 = 0.171], and the analysis of the standardized regression coefficients indicated that the EMP "Enmeshment" ( = -0.110, t = -2.762, p < 0.01) predicts cocaine use. For opioids, the results revealed a significant model [F (1.36) = 10,575, p <0.01, R2 = 0.227], wherein after analyzing the coefficients, it was found that the EMP "Enmeshment" ( = -0.218, t = -3.252, p < 0.01) is the best predictor of opioid use. In hallucinogens, the model presented is significant [F (1.37) = 8,676, p<0.01, R2= 0.190], and the standardized regression coefficients showed that the EMP "Enmeshment" (= -0.162, t = -2.946, p <0.01) is a predictor of this consumption. When the craving variable was introduced, a significant model was found [F (1.34) = 5,149, p < 0.05, R2 = 0.132],
and the analysis of the standardized regression coefficients showed that the EMP "Enmeshment" ( = - 0.273, t = - 2.269, p <0.05) is the best predictor of strong desire to consume. The predictor effect of the referenced schema was previously observed to be one of the most prevalent and predictive schemes of consumption (Razavi et al., 2012; Shorey, Stuart & Anderson, 2012; Shorey, Stuart & Anderson, 2013b; Wafae, Tarik, Ahmed, Fatima - Zahrae, Khadija & Khaoula, 2018), although the results presented here demonstrate a prediction in the opposite direction.
Regarding the frequency of consumption in the last 30 days, two models seem to be significant: a) Model 1 (F (1.32) = 14,685, p < 0.01, R2 = 0.315), wherein the standardized
Note: R =correlation coefficient; g.l = degrees of freedom * p<0.05; **p<0.01
Table 9. EMPs of the Excessive Vigilance and Inhibition domain according to addictive behaviors (continued)
14
regression coefficients show that the EMP "Self-Sacrifice" ( = 0.957, t = 3.832, p <0.01) is the best predictor in the frequency of consumption in the last 30 days; b) Model 2 (F (2.31) = 10,615, p < 0.01, R2 = 0.406), wherein the EMP "Self-Sacrifice" ( = 0.788, t =
3.172, p <0.01) and the EMP "Defectiveness" ( = 1.298, t = 2.191, p <0.05) seem to be the best predictors of the frequency of consumption over the last 30 days. Regarding the frequency of consumption in the last 12 months, the model presented was significant [F (1.33) = 14,831, p < 0.01, R2 = 0.310], and the EMP "Self- Sacrifice" ( = 0.766, t = 3,851,
p <0.01) proved to be the best predictor of the frequency of consumption in the last 12
months. Regarding the amount of consumption in the last 12 months, the model presented was significant [F (1.33) = 5,114, p < 0.05, R2 = 0.134], and EMP "Self-Sacrifice" ( = 0.599, t = 2,261, p <0.05) is the best predictor of the amount of consumption in the last 12 months. Several studies have revealed that the schemas referenced as predictors of these variables are clinically high EMPs in the substance users (Razavi et al., 2012; Shorey et al., 2011; Shorey, Stuart & Anderson, 2013a; Shorey, Stuart, Anderson & Strong, 2013).
When the consumption quantity variable for the last 30 days was entered, the model obtained was significant (F (1.33) = 7,842, p < 0.01, R2 = 0.192), and the EMP
"Subjugation" ( = 1,334, t = 2,800, p <0.01) is the best predictor of consumption quantity for the last 30 days. MansouriJalilian and Yazdanbakhsh (2015) and Brotchie et al., (2004), in their studies, demonstrated an association and prediction of the EMP "Subjugation" in substance use (cf. Table 10).
Table 10. Prediction of EMPs in addictive behaviors
R SE g.l p Prediction model Alcohol (Model 1) 0,368 0,289 38 0,021 Constant 0,855 0,113 0,000 Vulnerability 0,123 0,051 0,021 Cocaine (Model 1) 0,413 0,148 38 0,009 Constant 2,160 0,071 0,000 Enmeshment -0,110 0,040 0,009 Opioids (Model 1) 0,477 0,243 37 0,002 Constant 2,292 0,121 0,000 Enmeshment -0,218 0,067 0,002 Halluginogens (Model 1) 0,436 0,204 38 0,006 Constant 2,222 0,098 0,000 Enmeshment -0,162 0,055 0,006 Consumption 30 days (Model 1) 0,561 1,380 33 0,001
15 R SE g.l p Prediction model
Constant 0,629 0,655 0,344 Self-Sacrifice 0,957 0,250 0,001 Consumption 30 days (Model 2) 0,638 1,305 33 0,000 Constant -0,660 0,854 0,446 Self-Sacrifice 0,788 0,248 0,003 Defectiveness 1,298 0,592 0,036 Consumption 12 months (Model 1) 0,557 1,102 34 0,001 Constant 1,507 0,519 0,006 Self-Sacrifice 0,766 0,199 0,001 Quantities 30 days (Model 1) 0,438 1,502 34 0,008 Constant -0,508 0,852 0,556 Subjugation 1,334 0,476 0,008 Quantities 12 months (Model 1) 0,366 1,469 34 0,030 Constant 0,684 0,691 0,329 Self-Sacrifice 0,599 0,265 0,030 Craving (Model 1) 0,363 0,429 35 0,030 Constant 1,750 0,220 0,000 Enmeshment -0,273 0,120 0,030 Discussion
Several studies have associated early maladaptive schemas with substance use (e.g. Brotchie et al., 2004; Brotchie et al., 2007; Roper et al., 2010) and the treatment of this issue (e.g., Ball, 1998, 2007; Jalali, Zargar, Salavati & Kakavand, 2011; Shorey, Stuart, Anderson & Strong, 2013).
This study found a correlation between EMPs and addictive behaviors and has concomitantly found which of the 18 EMPs is the most predictor of addictive behaviors of consuming participants, aged 18 years or older, attended at the CDT in Aveiro.
Supporting the findings of previous investigations (e.g., Aaron, 2013; Bojed & Nikmanesh, 2013; Decouvelaere, Graziani, Gackiere-Eraldi, Rusinek & Hautekeete, 2002; Razavi et al, 2012; Shorey, Anderson & Stuart, 2013), the results of this study revealed that the assessed subjects showed greater vulnerability in the EMPs of the first four domains ("Disconnection and Rejection", "Impaired autonomy and performance", " Other directedness", and "Impaired limits"), and only seven EMPs (Vulnerability, Enmeshment, Self-sacrifice, Entitlement, Defectiveness, Dependence, and Subjugation) were significantly correlated (positively and negatively) with addictive behaviors.
Note: R =correlation coefficient; =non-standard coefficients; SE = Standard Erro; g.l = degrees of freedom
16
The schemas of the "Disconnection and Rejection" domain are characterized by an excessive fear that basic needs such as stability, security, empathy, and respect will not be met consistently. In the schemas of the domain "Impaired autonomy and performance", the subjects believe that they do not have the capacity to survive, function independently and/or act in an effective and positive way. Subjects with "Other directedness" schemas overemphasize the desires, feelings, and responses of others, compromising their own needs. The schemas of the "Impaired limits" domain are associated to the difficulties in establishing internal limits, in respecting the rights of third parties, cooperating, making commitments or establishing and achieving realistic personal goals (Gonçalves, Simões & Almeida, 2017; Rafaeli et al., 2011; Young et al., 2003).
Consistent with the results obtained in previous studies (e.g., MansouriJalilian & Yazdanbakhsh, 2015; Razavi et al., 2012), multiple linear regression (Stepwise method) demonstrated that five early maladaptive schemas, namely Vulnerability, Defectiveness, Enmeshment, Subjugation and Self-sacrifice, are the best predictors of addictive behaviors. The EMP "Vulnerability", characterized by an excessive fear that a catastrophe could happen and it is not possible to face it (Young et al., 2003), was considered the best predictor of alcohol consumption. It is possible that the use of this substance will reduce the experiences of negative affect, helping the subject in the feelings of frustration and fear of not being able to avoid damage or a catastrophe.
The EMP "Enmeshment" is characterized by an excessive emotional involvement with significant people (parents), compromising and hindering the social development as well as the individualization of the individual, which can sometimes produce feelings of emptiness (Young et al., 2003). In turn, the results of the study reveal that the activation of the EMP leads to a decrease in consumption, which is possible if the negative feelings and the feelings of emptiness and disorientation experienced are not attenuated by the characteristics of the variables (relaxation, euphoria, state of alertness, and empathy).
EMP "Defectiveness", characterized by the belief that the subject is a loser, a bad and inferior person, and is not worthy to receive love from others (Young et al., 2003), has proven to be the best predictor in the frequency of consumption in the last 30 days. This may be possible since the increase in the frequency of consumption may help subjects deal with and/or avoid the feelings of rejection and shame resulting from this schema.
17
The EMP "Self- sacrifice", characterized by an excessive focus on meeting the needs of others to the detriment of their own needs with the aim of obtaining self-satisfaction (Young et al., 2003), was a predictor of the frequency of consumption in the last 30 days, last 12 months, and the amount of consumption per day in the last 12 months. This may be possible as increasing the frequency and quantity of substance use can be an effective way to deal with the lack of personal achievement resulting from the characteristics of this schema.
EMP "Subjugation", characterized by an abdication of control in favor of others in order to avoid retaliation or abandonment, proved to be the best predictor in the amount of consumption per day in the last 30 days. This scheme can lead to an accumulation of rabies, wherein it can be manifested in maladaptive behaviors (substance abuse) (Young et al., 2003). Thus, increasing the amount of consumption per day over the last 30 days can diminish negative symptoms, namely accumulated rabies.
Previous studies assessing the predictive effect of EMPs on consumption (e.g., MansouriJalilian & Yazdanbakhsh, 2015; Razavi et al., 2012; Zamiribnejad et al, 2017) also proposed that the following schemas: a) Emotional deprivation; b) Mistrust/Abuse; c) Unrelenting Standards; d) Dependence; and e) Insufficient self-control, are also strong predictors of substance consumption.
Although the results obtained are significant and consistent with previous studies, this study has some limitations. A non-probability sample was collected, specifically for patients treated at the CDT in Aveiro, which may not be representative of a consumer population. It is suggested that in order to overcome these limitations, future studies in this area may extend their sampling addressing a larger number of services related to addictive behaviors. The cross-sectional nature of the study prevented the determination of causality among the study variables. Thus, it is imperative that future studies should carry out longitudinal research, so that it is possible to determine how the EMPs and the addictive behaviors interact over time. Regarding the self-report instruments, it has been identified that their use may be responsible for the existence of some bias in responses owing to social desirability. However, the fact that the questionnaires presented were conducted under anonymity may have helped minimize this limitation. The only measure used to obtain data on EMPs was the YSQ-S3, but this may have been insufficient. Efforts have been made to circumvent this limitation by adding the other questionnaire. However, no
18
response was obtained when authorization for its use was requested. Nevertheless, several studies have successfully used the YSQ-S3 in their investigations (e.g., Young et al., 2003). As this is a pioneering study in Portugal, it is suggested that future projects replicate the objectives presented here, as these results may be important in clinical practice.
In conclusion, the results of this study support the idea that there is a significant relationship between EMPs and addictive behaviors. The results of this study also suggest that early dysfunctional schemas may predict substance use besides its frequency and amount. Although this is a pioneering study in Portugal, the results obtained here are intended to help in the therapeutic context, providing a conceptual basis for the therapist to prevent possible relapses in his intervention and treatment context.
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Attachments
24
Attachments A. Early maladaptive schemas
Characteristics Domains Early Maladaptive Schemas (EMP)
Individuals with schemes in this field believe that their basic needs, such as stability, security, empathy and respect, will not be met consistently. It should be noted that the family of origin presents a significant degree of instability, is emotionally distant and cold, rejecting or abusive.
(1)
Disconnection and Rejection
Emotional Deprivation Abandonment Mistrust/Abuse Social Isolation Defectiveness Subjects with schemes in this field
believe they do not have the capacity to survive, function independently and/or act effectively and positively. The family of origin is typically entangled, destructive of the subject's trust, overprotective or tends to fail to reinforce the child's performance in an appropriate way.
(2)
Impaired autonomy and performance
Failure Dependence Vulnerability Enmeshment
Individuals with schemes in this field overemphasize the desires, feelings, and responses of others,
compromising their own needs. The family of typical origin overestimates the feelings, needs and desires of parents to the detriment of those of the child. (3) Other directedness Subjugation Self-Sacrifice Approval Seeking
This area relates to difficulties in setting internal limits, respecting the rights of third parties, cooperating, making commitments or setting and achieving realistic personal
objectives. The typical family of origin is characterized by an exaggerated permissiveness, lack of orientation or sense of superiority.
(4) Impaired limits
Entitlement Insufficient self-control
The individual tends to overemphasize the control of spontaneous feelings, impulses and choices in order to avoid making mistakes, or to comply with strict rules and expectations. The family of typical origin is concerned and perfectionist, and can sometimes be punitive.
(5)
Excessive Vigilance and Inhibition
Negativity/Pessimism Emotional Inhibition Unrelenting Standards
25 Attachment B. Informed Consent
