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Positive Psychology and Treatment for Substance Use Disorders in a Residential Facility in NicaraguaJavier D. LeyMississippi CollegeAuthor NoteJavier D. Ley, Doctorate of Professional Counseling Program, Mississippi College.Correspondence concerning this article should be addressed to Javier Ley, Department of Psychology and Counseling, Mississippi College, Clinton, MS 39158. Email: jdley@mc.eduAbstractAddiction, as it relates to Substance Use Disorders, impacts our society in a negatively profound way. This has costly effects on the individual in many of the human and life dimensions. After experiencing many negative consequences, it could become increasingly difficult for the individual to become aware of positive aspects of their personalities and their lives. Treatment as usual, involving Twelve Steps of Alcoholics Anonymous / Narcotics Anonymous, can fail to address this issue. The present paper proposes an integrative model of Twelve Step components with those of Positive Psychology in an attempt to help the individual obtain a more complete and balanced perspective of themselves and their lives. This integrative model will be outlined utilizing the Developmental Research and Utilization Model.Keywords: addiction, substance use disorder, positive psychology, twelve steps, Developmental Research and Utilization Model, character strengths, gratitude Positive Psychology and Treatment for Substance Use Disorders in a Residential Facility in NicaraguaAddiction is understood as a primary brain disease that affects reward circuitry, motivation, and memory and that becomes manifested in multiple dimensions, including biological, psychological, social, and spiritual (ASAM, 2011). Within the broad range of addictions, Substance Use Disorders (SUD) represent a heavy burden on our society with over 22 million people in the United States meeting diagnostic criteria in 2012 (SAMHSA, 2013). The common presence of co-occurring psychiatric disorders compounds the problem. For example, those individuals with SUD’s are two times more probable to have a mood or anxiety disorder (NIDA, 2010). Other co-occurring conditions and negative social impacts, such as a higher rate of suicide, death, and legal problems, also come into play, surrounding the individual living with a SUD with negative experiences in many aspects of their lives. In relation to the emotional aspect, Koob and Volkow (2010) describe drug addiction as being characterized by the “emergence of a negative emotional state” (p. 217) Research has also shown that people in recovery from drug addiction score higher on measurements of shame, depression, and maladaptive guilt (Meehan et al., 1996). Having been engulfed in these negative affective consequences for many years, it can prove a challenging task for the individual to identify and acknowledge positive aspects in their personalities and in their lives.In this sense, integrating the theoretical premises and interventions of Positive Psychology (PP) with treatment as usual (TAU) which utilizes components of the Twelve Steps of Alcoholics Anonymous / Narcotics Anonymous can prove beneficial for individuals in treatment for SUD. The overarching aim of this attempt is to balance the individual’s self-concept through a more complete perspective of TAU combined with an inclination towards the positive aspects of human nature. PP can be understood as supplementing what psychology has traditionally done: being just as concerned with treating pathology as it is in making the lives of people fulfilling (Seligman, 2010). Currently, the literature on PP’s theoretical premises and/or interventions for individuals with SUD is scarce. There is extensive research on SUD treatment and positively inclined topics—spirituality, gratitude, positive emotion—but none under the encompassing theory of PP. The PP interventions that will be identified, utilized, and integrated will be evidence based under the theoretical umbrella of PP. Prevalence of SUDIn the United States (US), 8.5% of those 12 years of age and older (over 22 million people) met diagnostic criteria for a SUD in 2012. About 67% of these individuals met criteria for an alcohol use disorder (AUD) only, 20% met criteria for other substance use disorder, and 13% met criteria for both an alcohol and other substance use disorder (SAMHSA, 2013). In regard to lifetime prevalence of alcohol use disorders, it has been found that 17.8% of those 18 years of age and older met criteria for alcohol abuse, while 12.5% of the same population met criteria for alcohol dependence during their lifetime (Hasin, Stinson, Ogburn, & Grant, 2007). There are other important factors that are relevant when discussing SUD and alcohol and other substance use. First, there is the compounding difficulty encountered with those with a co-occurring psychiatric disorder. Out of the US population with any mental illness (AMI), 19.2% also met diagnostic criteria for a SUD, while only 6.4% of those without AMI met diagnostic criteria for a SUD (SAMHSA, 2013). Second, there is an important influence of SUD in the criminal justice population. About half of all prisoners meet diagnostic criteria for a SUD (Chandler, Fletcher, & Volkow, 2009) making it a special population that requires treatment. Lastly, there is also a relationship between SUD, alcohol and drug use, suicides, and mortality. Including alcohol and other substance disorders, the risk of suicide for these individuals is more than six times the average risk for suicide (CSAT, 2008). In relation to deaths, around 3.5 million people around the world lose their lives in alcohol and drug related deaths (UNODC, 2013; WHO, 2014). Development of the DisorderThere are diverse risk factors that can lead to the development of an AUD. These factors include but are not limited to gender, psychiatric disorders, age of onset, family, and stress in early life. Although men are about twice as likely to develop any SUD as females, data has shown that females progress faster than males—progressing from regular use of the substance to treatment of the disorder. In relation to age of onset, it has been shown that those who drink before age 15 have a significantly higher probability of developing an AUD (Gilbertson, Prather, & Nixon, 2008). The rate of alcohol dependence is far greater for those who drink at 14 years of age and before as compared to those who start drinking after age 19 (Chorlian et al., 2013). Family history also plays a role in the development of AUD. It is estimated that 40% to 60% of the risk of developing AUD can be attributed to genetics. Children of alcoholic parents are about four times more likely to develop alcoholism than children from non-alcoholic parents (Gilbertson et al., 2008). The role of stress early in life also deserves attention in the development of a SUD. It has been found in a review that experiencing early life stress in the form of maltreatment or other stressful events can be associated with early problem drinking and substance dependence in the early adult years (Enoch, 2010). Evidence Based PracticesThe field of addiction treatment has progressed toward more widely accepted support for evidence based practices (EBP), as manifested by extensive research on psychosocial practices considered EBP—motivational interviewing (MI), cognitive behavioral therapy (CBT), and contingency management (CM)—as well as readily available manualized treatment models (Carroll, 2012). Another important clinical aspect related to the advancement of EBP is the shift from a highly confrontational style of counseling towards a more respectful and ethical way to treat the client through a new view of addiction itself and the people who suffer from it. Confrontation has played an important role in treatment history. A premise behind the use of confrontation is that people with SUD are in such strong denial that they need to be broken down to then be built back up (White & Miller, 2007). The use of confrontation seems to lack evidential support (Polcin, 2003), and other EBP alternatives such as MI have gained much ground. In relation to outcome studies of EBP utilized in the treatment of SUD, there does not seem to be statistically significant difference on the effectiveness of one specific EBP over another. For example, Project Match (PM), the largest multi-site randomized controlled clinical trial regarding alcohol treatment, compared the following three therapeutic approaches: Twelve Step Facilitation (TSF), Cognitive Behavioral Therapy (CBT), and Motivational Enhancement Therapy (MET). The results at one year follow up (Project Match Research Group, 1997) and at three year follow up (Project Match Research Group, 1998), demonstrated that all three approaches produced significant reductions in drinking frequency and severity and that there was not a significant difference among the three. Other psychotherapeutic comparisons of approaches have produced similar results. There are also medications that have shown positive effects in the treatment of SUD and have evidence support. Specifically, positive effects have been shown for alcohol use outcomes when combining psychosocial interventions with certain medications, including acamprosate and oral naltrexone. In relation to medications utilized off-label, moderate benefits were found with nalmefene and topiramate (Jonas et al., 2014) for AUD. Other medications have also shown positive evidence in the treatment of opioid use disorders, such as Methadone Maintenance Treatment (MMT). Buprenorphine is an alternative to MMT that provides some advantages, such as less physical dependence and less probability of an overdose (Barnett et al., 2001) and it is used as a detoxification method for maintenance or for opioid withdrawal. Another medication used for treating opioid use disorders is naltrexone which acts as a blocking agent. Self-Help or Mutual-HelpThe self-help movement, also known as the mutual-help movement, has historically been a common pathway to recovery from SUD. Among these self-help options, Alcoholics Anonymous (AA) is the most commonly known. AA was founded in 1935 by two alcoholic individuals who wanted to help others in their same situation. According to estimates of AA’s General Service Office, there are currently more than 2.1 million members worldwide who meet in more than 115,000 groups in 170 countries around the world (AA General Service Office, 2014). Also, principles found in AA have been used in professionally led treatment, starting with the Minnesota Model (White, 1998).About 58% of those entering SUD treatment had attended AA meetings (Magura, 2007), showing a relationship between formal treatment and self-help groups. A study by Fiorentine and Hillhouse (2000) showed that attending both AA and treatment improves abstinence, resulting in higher rates of abstinence for those who attended both formal treatment and 12 step programs versus those who attended only one or the other. As far as outcomes in the long run, AA involvement following treatment also resulted in better outcomes 16 years after (Moos & Moos, 2006). Another 12 step alternative is provided by Narcotics Anonymous (NA), a fellowship that also centers on recovery from drugs, alcohol included.The 12 Steps are a spiritual program with specific practices and principles which attempt to affect cognitive and emotional aspects of the individual, as well as attempting to change behavior through reinforcements (DiClemente, 1993). As other spiritual programs, one of the fundamental objectives is to obtain self-knowledge and inner peace (Magura, 2007) as a way to achieve abstinence and sustain it. The 12 Steps and its principles provide the framework through which to achieve this. The application in one’s life of the 12 Steps is known by AA members as “working the steps.” There are many principles that are associated with the work of these steps in many local AA groups and literature material. These include honesty, hope, faith, courage, integrity, willingness, humility, brotherly love, justice, perseverance, spirituality, and service. Also, NA publishes a book called the NA Step Working Guide (NA World Service Office, 1998) with information specific to all 12 steps. Each step is devoted a chapter and in each chapter there is a section called “Spiritual Principles.” For example, in Step One, the principles described are honesty, open-mindedness, willingness, humility, and acceptance. It is suggested that members practice these principles in their daily lives.Positive PsychologyPositive Psychology (PP) is a field that represents a supplementary perspective to traditional psychology’s concentration on psychopathology and human deficit. This supplementary perspective directs its focus to the positive aspects of human experience above and beyond the removal of suffering, psychopathology, or deficit. In this sense, PP does not seek to substitute psychology as usual, but to provide a more complete vision of human beings and their experience (Seligman, Steen, Park, & Peterson, 2005). One of the basic assumptions of PP is the idea that the positive is not just the absence of the negative. This means that there are some positive experiences or traits that are independent of negative experiences or traits (Duckworth, Steen, & Seligman, 2005). This translates into the knowledge that alleviating the deficit is not enough for well-being.From the above described assumption, it follows that the interventions for achieving well-being are different from and work through different processes than those designed to relieve psychopathology. Seligman and colleagues (2005) designed five PP exercises hypothesized to increase happiness and decrease depression: one exercise dealt with gratitude (gratitude visit), two dealt with increasing awareness of what is most positive about oneself (three good things and you at your best), and two dealt with the identification of character strengths (using signature strengths in a new way and identifying character strengths). The gratitude visit exercise resulted in large positive outcomes at one month follow up, the largest increase in happiness, and the largest decrease in depression at post-test compared to all other interventions and placebo (Seligman et al., 2005). The exercise on three good things and the exercise on using signature strength in a new way proved to increase happiness and decrease depression for the six months of the study. The other two exercises resulted in short-lived but positive changes (Seligman et al., 2005).Another relevant topic in regard to PP is that of character strengths. In 2004 Seligman and colleague Christopher Petersen published the book Character Strengths and Virtues: A Handbook and Classification. This volume was intended to be to PP what the DSM has been for psychopathology (Seligman et al., 2005). The character strengths are considered to exist in people in varying degrees and not as present or lacking. Six main virtues were found to be common around the world: wisdom, courage, humanity, justice, temperance, and transcendence. Twenty four character strengths were then identified as belonging under one of the six virtues (Seligman et al., 2005). Positive Psychology and AddictionsPresently, the literature related specifically to theory and practice of PP in relation to treatment and recovery of SUD is scarce. In a search, the resulting article “Review of the Application of Positive Psychology to Substance Use, Addiction, and Recovery Research” (Krentzman, 2013) was noteworthy. Despite the fast rate of growth of PP its integration into SUD research and practice has not followed suit. Krentzman (2013) points to the potential for integration of PP and existing addiction treatments within the recovery movement due to the shared movement away from an emphasis on pathology and toward a more positive and complete outlook of individuals. In relation to specific interventions that could be utilized in an integrative manner, Krentzman (2013) highlights two PP interventions with potential for benefit among those with SUD: the three good things exercise and the best future self (you at your best) exercise. Also of importance is that those with low affect, physical illness, or who are highly self-critical could benefit more than healthier individuals from gratitude interventions (Krentzman, 2013). This supports the rationale behind integrating PP and SUD treatment and recovery, as many who suffer from SUD also exhibit traits similar to those posited to benefit more from gratitude exercises.Akhtar and Boniwell’s (2010) article “Applying positive psychology to alcohol-misusing adolescents: A group intervention” was the only article found on specific interventions applied to people with SUD of any age, in any setting, making it of particular relevance. The authors assumed that PP could be an alternative route to seeking happiness, resilience, and positive emotions for young people, instead of drinking and/or drugging. As far as the sample is concerned, the experimental group of 10 was compared with a control group (no intervention) of 10, making up a very small sample as it was a pilot study. The findings from quantitative and qualitative measurement instruments suggested a significant increase in well-being and decrease in alcohol use. Specifically, the experimental group presented increases in happiness, optimism, and positive affect, while also presenting a reduction in negative affect and in drinking outcome. From the qualitative interviews, it was shown that gratitude interventions resulted in strongest effects, especially with female participants. Through these findings, the authors recommend that gratitude become an essential aspect of future PP interventions for youth.Statement of the ProblemThe problem of this study is developing a model integrating Positive Psychology with Treatment as Usual for Substance Use Disorders in a Residential Facility in Nicaragua.Purpose of the StudyThe purpose of this study is to determine the components of Positive Psychology that could be beneficial for those in treatment for Substance Use Disorders, to determine the components of the Twelve Steps of Alcoholics Anonymous / Narcotics Anonymous used in Treatment as Usual, and to examine the process of integration between the selected components of Positive Psychology and those of Treatment as Usual which includes the Twelve Steps of Alcoholics Anonymous / Narcotics Anonymous. This process of integration will be evidenced through the development of a model that could serve as a framework for the therapeutic action of counselors. Significance of the StudyThis study could be useful in providing an integrated framework that attempts to balance the individual’s self-concept and narrative through a more complete perspective and with an inclination towards the positive aspects of human nature. Treatment as Usual utilizing the Twelve Steps of Alcoholics Anonymous / Narcotics Anonymous could present the individual with the negative aspects and consequences of their alcohol and/or drug use. This could prove a heavy emotional burden for some. The proposed integrated framework is intended to help individuals identify and recognize in themselves positive aspects of their personalities and their lives that could have easily been obscured by addiction, therefore providing a more balanced view of themselves and their histories. Research QuestionsThe research questions addressed in this study are as follows:What are the selected components of Positive Psychology that could be beneficial for those in treatment for Substance Use Disorders?What are the core components of the Twelve Steps of Alcoholics Anonymous / Narcotics Anonymous used in Treatment as Usual?How can selected components of Positive Psychology be integrated with the core components of Treatment as Usual, specifically those that include the Twelve Steps of Alcoholics Anonymous / Narcotics Anonymous?MethodIn a broad sense, developmental research addresses the creation of an end product through the stages of planning, producing, and evaluation. It also includes product utilization and product management (Richey, Klein, & Nelson, 2004). One possible end product is found in the creation of knowledge, specifically knowledge that provides solutions to practical problems. When this relates to social sciences, knowledge can be one of three kinds: systems of laws, descriptions, or structural models. This third type of knowledge is presented in the form of processes that are explained through these models (Diesing, 1991). One way to encompass and present these processes is through the Developmental Research and Utilization Model (DRU) as adapted by Stephen Southern (2007). In this adaptation, the DRU was aimed at program development, evaluation, and consultation. This is the specific model that will be utilized in this study to integrate selected components of Positive Psychology with core components of Treatment as Usual for SUD, specifically those that include the Twelve Steps of Alcoholics Anonymous / Narcotics Anonymous. The DRU is designed to guide the dissemination of knowledge, as well as the development, implementation, and adoption of new programs or novel concepts. The DRU consists of two stages, research and utilization. The research stage consists of three phases: analysis, development, and evaluation while the utilization stage has two phases: diffusion and adoption (Southern, 2007). See Table 1. For the purpose of this study, phase 1 (analysis) and phase 2 (development) of the research stage will guide the process of integration of interest in this study. Table 1Developmental Research and Utilization Model______________________________________________________________________________PhaseConcernsOperationsActivitiesResearchI. AnalysisA. Problematic1. Problem statementProblem analysis and identification;Human ConditionState-of-the-art reviewB. Basic Information2. Information selectionSelection of basic or applied research,Sourcetechnology, or practice experience;Selection of product language, goals,and objectivesII. DevelopmentC. Relevant Data3. Information gatheringLiterature review, site visitation, orassessmentD. Product Design4. Product innovationNovel assembly, application, or invention E. Product Preparation5. Product realizationConstruction of prototype, product, orstatement of proceduresIII. EvaluationF. Field Trial6. Trial applicationPilot implementation or demonstration7. Data collectionCollection of relevant data from trialG. Outcome Analysis8. Product evaluationEmpirical research study, program evaluation, process review, or policyanalysisUtilizationIV. DiffusionH. Diffusion Media9. Diffusion mediaPreparation of guides, manuals, orpreparationtraining materials10. InformationDemonstration, professionaldisseminationpresentation, or publicationV. AdoptionI. Product Acceptance11. ImplementationbySystematic use by practitioners;UsersMonitoring of adherence orcompliance; Administrative supportJ. Product Renewal12. InstitutionalizationMaintenance of community, staff, andadministrative support for product;Follow-up, periodic review, and qualitycontrol;Revision or expansion of product;Ongoing participation in planned change________________________________________________________________Note. This developmental research model was supplied by Stephen Southern (2007).Definitions of TermsAddiction is defined as a primary brain disease that affects reward circuitry, motivation, and memory and that becomes manifested in multiple dimensions, including biological, psychological, social, and spiritual (ASAM, 2011). For the purpose of this study, the term Addiction will be used specifically to designate a Substance Use Disorder. Positive Psychology is defined as the field that represents a supplementary perspective to traditional psychology’s concentration on psychopathology and human deficit. This supplementary perspective directs its focus to the positive aspects of human experience above and beyond the removal of suffering, psychopathology, or deficit. (Seligman, Steen, Park, & Peterson, 2005).Treatment as Usual is defined in this study as all interventions used in the treatment for those with Substance Use Disorders and which utilize some form of the Twelve Steps of Alcoholics Anonymous / Narcotics Anonymous. This could include Twelve Step Facilitation Therapy, readings from Alcoholics Anonymous / Narcotics Anonymous texts, homework utilizing content from Alcoholics Anonymous / Narcotics Anonymous, individual and/or group counseling utilizing content from Alcoholics Anonymous / Narcotics anization of Remainder of StudyThis first chapter provides an introduction to Substance Use Disorders, its treatment, and Positive Psychology, a statement of the problem, purpose of the study, the significance of the study, research questions, a description of the method, and definition of terms. Chapter 2 will offer an extensive review of the literature related to Substance Use Disorders, its treatment, and Positive Psychology. Research methodology will be detailed in Chapter 3. Chapter 4 will provide the results of the research. Chapter 5 will include a discussion of the results, implications of findings, and recommendations for future application of the proposed model. ReferencesAkhtar, M., Boniwell, I. 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