During the study period (October 2014 to September 2017), a total of 50 patients sought outpatient addiction treatment in a cognitive behavioral treatment clinic in Western Sweden. The clinic offers adults with substance-related syndrome a one-year program. During the first four months of the program, the patients receive treatment five days a week. During the remaining eight months of the program, the patients participate in follow-up group sessions once a week. The treatment program is not gender specific; the groups and all treatment moments (excluding individual psychotherapy) include male and female patients at the same time. During the program, the patients work with licensed psychotherapists, behavior scientists, alcohol and drug therapists, and a certified acupuncturist. The clinic’s personnel hold team meetings once a week to secure the progression and quality of the program.
At admission and at discharge, each patient completed a survey comprising several validated instruments (see details under “Instruments”). The completion of the survey took on average of 30 min, during which time the patient was left alone in an undisturbed room.
The clinic’s outpatient program lasts for one year. The program starts with four months of integrated intensive treatment followed by eight months of follow-up. The treatment is based on cognitive behavioral therapy (CBT). In CBT, the aim is to directly address the patient’s dysfunctional behavior and thinking in order to induce positive emotional changes. The four-month-long integrated intensive treatment includes the following interventions: psychoeducation, cognitive processing, modulation, problem-solving exercises, affect regulation, exposure and response prevention, behavior experiments and activation, mindfulness, skills training, auricular acupuncture (NADA), and home assignments. During this initial four-month period the patient undergoes treatment five days a week. The aim of this study is to evaluate the effects of the first four months of integrated intensive treatment.
At admission, each patient is given information about the clinic’s daily routines and structure, and about the rules and regulations (including ethical considerations) applicable during the treatment period. All patients are given opportunity to ask questions freely before starting the treatment.
The survey began with demographic questions about gender, age, and marital status. These questions were followed by previously validated psychological measures.
The Beck Depression Inventory (BDI)14 is a self-assessment scale consisting of 21 questions with a four-point scale to measure depression symptoms and severity in the person during the past seven-day period. The BDI has good internal consistency. The average value for Cronbach’s α is 0.86 in psychiatric tests15 and in the current study population it was 0.95. It also has adequate validity in comparison with both clinical assessments and other self-assessment instruments.15 The Swedish version also has high test-retest reliability (r = 0.93).15 The previously identified cutoffs were used to define categories as follows: less than or equal to 13 points identified individuals with no or minimum depression; points from 14 to 19 identified individuals with mild depression; from 20 to 28 points identified individuals with moderate depression and 29 points or over (maximum 63) identified individuals with severe depression.16
The Beck Anxiety Inventory (BAI)16 is a self-assessment scale consisting of 21 questions and measuring the individual’s degree of anxiety by ranks of a Likert scale with the following items: “not at all” (0), “little, has not bothered me a lot” (1), “partly, has been very unpleasant but I could endure it” (2), and “very much, barely could stand it” (3). The BAI’s total score is calculated by adding the scores of the 21 questions. The maximum score is 63. A total score of 0 to 7 points indicates a minimum level of anxiety, from 8 to 15 points indicates a mild experience of anxiety, from 16 to 25 points indicates a moderate experience of anxiety, and 26 points or more indicates a severe experience of anxiety.16 The Swedish version of the BAI has an acceptable test-retest reliability (r = 0.75).17 In this study, the internal reliability of the BAI scale was an acceptable Cronbach’s α of 0.93.
The Hopelessness Scale (HS)18 intends to measure the degree of experienced hopelessness and pessimism over future expectations, which is an indirect indication for suicide, and also a common sign of depression.18 The scale consists of 20 statements to which the test person may answer “true” (1) or “false” (0). The total score is categorized as follows: 0 to 3 indicates no or minimal hopelessness, 4 to 8 indicates a mild experience of hopelessness, 9 to 14 indicates a moderate experience of hopelessness, and 15 to 20 indicates a high experience of hopelessness with definitive risk for suicide.19 The reliability of the HS was high (Cronbach’s α of 0.86) in this study.
The Rosenberg Self-Esteem Scale (RSES) was developed by Rosenberg20 and translated into Swedish by Jonson21. The scale contains ten different statements that together measure the participant’s global self-esteem. Of the ten items, five are positive claims and five are negative claims. The answer options are specified on a four-point Likert scale ranging from “fully agree” (3) to “fully reject” (0). Scores from 15 to 25 points indicate normal self-esteem. Scores under 15 points indicate low self-esteem. Scores over 25 indicate high self-esteem.
Tafarodi and Swann22 have shown that the RSES measures two distinct but related dimensions, namely “self-competence” and “self-liking”. Self-competence is defined as a person’s experience of being capable. This experience is based on the capability of being successful in achieving goals. Self-liking is defined as a person’s subjective assessment of his or her personal value, not necessarily performance, but according to an internalized set of criteria for social value as moral agents. The reliability of both the total RSES and its self-competence subscale were acceptable (Cronbach’s α of 0.81) in this study population, and was close to acceptable for the self-liking subscale (Cronbach’s α of 0.63).
The Trait Hope Scale (THS)23 is used to measure a person’s experience of hope. The scale measures a global experience of hope and is divided into two subscales, namely “Pathway” (four items) and “Agency” (four items). The hope scale consists of 12 descriptive statements such as “I can think of many ways to get out of a jam” or “I meet the goals that I set for myself”. Of the 12 items, four are distraction questions which are excluded from the actual data analysis. Participants can answer the statements on an eight-point Likert scale ranging from “definitely false” (1) to “definitely true” (8).24 The overall THS score can be 64, with the two subscales pathway and agency representing a maximum of 32 points each. In the current study, the overall THS and the agency subscale both had acceptable internal consistency (Cronbach’s α of 0.80 and 0.73, respectively), while it was close to acceptable for the pathway subscale (Cronbach’s α of 0.65).
All the data was processed using the Statistical Package for the Social Sciences (SPSS, version 22, IBM) software package. A Pillai’s mixed MANOVA (2 × 2 factorial design) was carried out with gender (men, women) and treatment (before, after) as independent variables and with RSES, THS, BDI, BAI, and HS as dependent variables. The effect sizes (Cohen’s d) were calculated and interpreted according to Cohen (1988): 0.20 as a small effect, 0.50 as a medium-sized effect, and 0.80 or over as a large effect. The significance level was set at 5%.
The study complied with the Declaration of Helsinki.25 Strict compliance with the ethical requirements laid down in the treatment contract was ensured. These requirements, namely 1) the individual protection requirement, 2) the information requirement, 3) the consent requirement, and 4) the confidentiality requirement, were designed to protect the participants from any physical and/or psychological harm, violation or humiliation, and to protect their integrity against improper disclosure.26 The patients were informed that their participation in the study was voluntary and that they could withdraw from it at any time without consequence. All patients received written and verbal information on the purpose of the data collection and were informed that the results obtained would be published in the form of a scientific article. The participants were ensured that their individual answers would be anonymized in the results and that all data would be managed confidentially. Written consent was obtained from all participants.