Psykoterapi för substansbrukssyndrom – betydelsen av affekter

Book excerpt: Substance use disorder (SUD) is a serious disorder with severe consequences for the individual, the family and for society. Comorbidity is common in the SUD population and the diversity of the disorder calls for a multiplicity of treatment options. The overall aim of this thesis was to explore the role of affects in psychotherapy for SUD. Further aims were to investigate affect-focused therapeutic orientations, demonstrate the importance of common factors and evaluate a measure of affect phobia. In Study I a naturalistic design was employed to examine how the discrepancy between patients' expectations and experience of psychotherapy related to alliance in 41 patients: 24 in individual therapy and 17 in group. An additional analysis concerned whether different dimensions of role expectations predicted retention in psychotherapy. Study II was the first psychometric evaluation of the Affect phobia test – a test developed to screen the ability to experience, express and regulate emotions. Data were collected from two samples: A clinical sample of 82 patients with depression and/or anxiety participating in a randomized controlled trial of Internet-based affect-focused treatment, and a university student sample of 197 students. Data analysed included internal consistency, test-retest reliability, factor analysis and calculation of an empirical cut-off. Study III focused on the feasibility of individual 10 week Affect Phobia Therapy (APT) for patients diagnosed with mild to moderate alcohol use disorder (AUD) and problematic affective avoidance in a nonconcurrent multiple baseline design. Study IV comprised an evaluation of the feasibility and preliminary effectiveness of APT adapted to a structured group format for patients (n=22) with comorbid substance use disorder and ADHD with core features of affective avoidance/emotion dysregulation in an open design. In Study I an overall discrepancy between role expectations and experiences was significantly related to a lower level of therapeutic alliance in group therapy. This relationship was not found in individual therapy. Expectations prior to psychotherapy characterized by defensiveness correlated negatively with therapy retention, even when controlling for waiting time for therapy. In Study II the internal consistency for the total score on the Affect phobia test was satisfactory but it was not for the affective domains, Anger/Assertion, Sadness/Grief, and Attachment/Closeness. Test retest reliability was satisfactory. The exploratory factor analysis resulted in a six-factor solution and only moderately matched the test´s original affective domains. An empirical cut-off between the clinical and the university student sample were calculated and yielded a cut-off of 72 points. In Study III patients reported no adverse events due to the treatment and finished the whole study period. The patients had different trajectories of alcohol consumption and craving and the hypothesis that heavy episodic drinking would subside during the time in therapy did not hold true. In Study IV patients reported significant pre-to post changes in increased self-compassion and decreased affect phobia but no change in psychological distress or emotion dysregulation. Craving fluctuated throughout the study period and patients’ drinking pattern changed in the direction of more social drinking. Main conclusions are the following: The Affect Phobia Test is a useful screening instrument for detecting emotional difficulties related to psychological malfunction. APT in both group and individual format are feasible treatments for the SUD population and has the potential to broaden the treatment options for some patients with SUD. Investigating expectations and fears prior to therapy may be means to prevent attrition. Substansberoende är en allvarlig störning och samsjuklighet ofta förekommande Den stora variationen av svårigheter kräver olika behandlingsalternativ. Syftet med avhandlingen var att undersöka affekters roll i psykoterapi för populationen. Ytterligare syften var att undersöka betydelsen av gemensamma faktorer i psykoterapi samt normera ett självskattningsformulär för affektfobi. I studie I undersöktes skillnaden mellan patienters förväntningar, erfarenheter av terapi och allians. I studie II utvärderades de psykometriska egenskaperna hos affektfobitestet. I studie III och IV undersöktes genomförbarheten av affektfobiterapi individuellt och i grupp. Resultaten av studierna visade att större skillnad mellan rollförväntningar inför- och erfarenheter av terapi var signifikant korrelerade med lägre allians i gruppterapi. Affektfobitestets psykometriska egenskaper var tillfredsställande avseende skalan som helhet. Affektfobiterapi visade sig öka adaptiv affektiv förmåga och självmedkänsla, men behandlingen gav inget säkert stöd för påverkan på substansbruket. Slutsatserna är att fokus på affekter i terapi för substansberoende har betydelse och att affektfobiterapi är en genomförbar behandling för populationen. Genom att undersöka förväntningar och rädslor inför terapi kan avhopp förhindras.