Experiential Avoidance and Self-Stigma in Addiction:

Two New Measures

Jason B. Luoma, Ph.D.

RCTs are not enough

Data on outcomes for ACT targeting substance misuse have started to emerge

Outcome data are not enough We need to know how an intervention results in

change, not simply that it does To do this, we need to measure mediating variables

Measuring psychological flexibility in addiction

Definition: the ability to contact the present moment more fully as a conscious human being, and to change or persist in behavior when doing so serves valued ends” (Hayes, Luoma, Bond, Masuda, & Lillis, 2006, p. 6)

Most commonly measured by the Acceptance and Action Questionnaire (AAQ)

The AAQ in addicted samples

Has adequate internal consistency in most samples, but not in substance misusing samples. α = (Bissett, 2002;) α = (Luoma, Kohlenberg, Hayes, Bunting, & Rye, 2008) α = .40 (this study)

Mediates outcome in some non addicted samples (e.g., Bond & Bunce, 2000), but not addicted samples Not in RCT with ACT for polysubstance abusing clients (Bissett,

2002) Not in ACT-based self-stigma intervention in substance

abusing sample (Luoma, Kohlenberg, Hayes, & Fletcher, 2010)

Developing a substance abuse specific AAQ (Luoma, Drake, Kohlenberg, Hayes)

Step 1: Item Generation – adapted the original 49-item pool used for the development of the AAQ-II to include items specific to substance misuse

AAQ Item AAQ-SA ItemMy thoughts and feelings get in the way of my success.

My urges and cravings to use get in the way of my success

I can do things that are important to me even when I’m feeling unhappy.

I can do things that are important to me even when I'm feeling urges to use substances.

I work towards things I value, even though at times I feel uncomfortable or uncertain.

I work toward things I value, even though at times I feel cravings to use substances.

I’m afraid of my feelings. I'm afraid of my positive feelings about a substance I've abused.

Step 2: Expert Rating

All items rated across two dimensions by 8 ACT experts1) Face validity2) Overall quality

On a 1-4 scale from 1 (poor) to 4 (excellent) Dropped eight items because of scores below 2.5

(the mid-point of the rating scales) for one or both scales.

Remaining 41 items had an average fit rating of 3.16 (SD = .32) and an average quality rating of 3.24 (SD = .37)

Step 3: Validation Sample

352 patients receiving residential (n = 29) or outpatient (n = 323) substance abuse treatment Gender: 210 men, 141 women, 1 unidentified Age: Averaged 31.1 years (SD = 10.2, range 18 – 63) Race: .6% identified as Alaskan Native, 3.4% American Indian, .9%

Asian/Pacific Islander, 4.3% Black/African American, 80.4% White, 6.5 % other, and 4% providing no response.

Hispanic/Latino(a): 7.4% identified as Mexican, 4.6% other Hispanic, 41.8% not of Hispanic origin, and 46.3% no response.

30% (n=97) of the sample had less than a high school education, 52.9% (n=171) had completed high school or obtained a GED, and 17% (n=55) had at least some college.

Prior treatment averaged 1.2 episodes (n = 342, SD = 1.7).

Step 4: Initial Factor Analyses

Series of analyses led to an 18-item two-factor solution, using oblimin rotation

Item

Factor Loading

values commit

ment

defused accepta

nce

1 I can do things that are important to me even when I'm feeling urges to use substances. (r) .670 .233

2 My urges and cravings to use get in the way of my success. .286 .666

3 If I have urges to use substances, then I am a substance abuser. .043 .522

4 I try to achieve my sobriety goals, even if I am uncertain that I can. (r) .637 .042

5 I work toward things I value, even though at times I feel cravings to use substances. (r) .744 .064

6 I am not very aware of what occurs around me when I am thinking of using substances. .234 .623

7 I can set a course in my life and stick to it, even if I have doubts about my sobriety. (r) .697 .168

8 Memories of my substance abuse history make it difficult for me to live a life that I would value. .205 .570

9 If I get bored working toward my recovery, I can still take the steps necessary to succeed. (r) .668 .257

Item

Factor Loading

values commitment

defused acceptance

10. If I feel uncertain about my recovery, I can still make a choice and take action. (r)

.636 .214

11. If I promised to do something, I'll do it, even if I later don't feel like it. (r)

.702 .154

12 Having some worries about substance use will not prevent me from living a fulfilling life. (r)

.608 .087

13 I would rather achieve my goals than avoid thoughts and feelings about substances. (r)

.508 .251

14 Urges and cravings cause problems in my life. .220 .687

15 I'm afraid of my positive feelings about a substance I've abused. .108 .676

16 When I think of substance use my mind is often on "automatic pilot", not fully involved in what I am doing in the moment.

.079 .713

17 I worry about not being able to control my urges and cravings. .187 .726

18 Feeling sad or anxious makes me want to use substances. .110 .623

AAQ-SA internal properties

Values commitment: α =.82 Defused acceptance: α =.84 Overall scale: α = .85 Two subscales correlate with each other at a low

level, r (288) = .26, p < .001.

Step 5. Check for differentiation from AAQ

Compared participants reporting zero days of usage in the last 30 days to those reporting any days of usage.

Summary: AAQ-SA scores were significantly lower in group reporting usage, while AAQ scores were not

In a combined factor analysis, AAQ items sorted on a different factors from AAQ-SA items

Step 6. Examine relationship with other measures

General Psychological Flexibility. The Acceptance and Action Questionnaire (AAQ;Hayes, Strosahl et al., 2004

Depression. The Beck Depression Inventory Internalized Shame. The Internalized Shame Scale (ISS;Cook, 1996) Social Support. The Multidimensional Scale of Perceived Social Support

(MSPSS;Zimet, Dahlem, Ziment, & Farley, 1988 Self-Esteem. The Rosenberg Self-Esteem Scale (RSES;Rosenberg, 1965) Self Concealment. The Self Concealment Scale (SCS;Larson & Chastain,

1990) Stigma-Related Rejection. The Stigma-Related Rejection Scale

(SRS;Luoma, Twohig et al., 2007) Active Coping with Stigma. We created a seven-item scale based on two

subscales from previous research on stigma toward mental illness (Link, Struening, Neese-Todd, Asmussen, & Phelan, 2002).

Step 6. Relationship with other measures

values commitment defused acceptance full scale

values commitment 1.000 (300) 0.259** (290) 0.779** (290)defused acceptance 1.000 (293) 0.807** (290)full scale 1.000 (290)AAQ 0.192** (289) 0.508** (283) 0.464** (280)depression (BDI) -0.149 (119) -0.333** (115) -0.312** (114)internalized shame (ISS) -0.100 (125) -0.536** (124) -0.424** (122)social support (MSPSS) -0.085 (158) -0.223* (153) -0.185 (153)self-esteem (RSES) 0.481** (153) 0.538** (150) 0.613** (149)self concealment (SCS) 0.015 (135) -0.416** (134) -0.270* (132)active coping with stigma 0.364** (282) 0.135 (276) 0.298** (273)Note: Numbers represent the correlation with sample size in parentheses.*p < .01, **p < .001

Step 6. Relationship with other measures

values commitment defused acceptance full scale

values commitment 1.000 (300) 0.259** (290) 0.779** (290)defused acceptance 1.000 (293) 0.807** (290)full scale 1.000 (290)AAQ 0.192** (289) 0.508** (283) 0.464** (280)depression (BDI) -0.149 (119) -0.333** (115) -0.312** (114)internalized shame (ISS) -0.100 (125) -0.536** (124) -0.424** (122)social support (MSPSS) -0.085 (158) -0.223* (153) -0.185 (153)self-esteem (RSES) 0.481** (153) 0.538** (150) 0.613** (149)self concealment (SCS) 0.015 (135) -0.416** (134) -0.270* (132)active coping with stigma 0.364** (282) 0.135 (276) 0.298** (273)Note: Numbers represent the correlation with sample size in parentheses.*p < .01, **p < .001

Future studies on AAQ-SA

More convergent and discriminant validity for values commitment subscale Differentiate from self-efficacy scales

Examine possible method variance through confirmatory factor analysis

Developing a self-stigma scale

The Substance Abuse Self-Stigma Scale (SASSS)

Reasons to develop a new measure of stigma

Only one validated measure of stigma in substance abuse Perceived stigma (Luoma et al., 2010)

We have developed a self-stigma intervention but no validated, self-stigma measures exist

Self-stigma: 3 parts

1) Shame and self devaluation and 2) Fear of enacted stigma,3) Psychologically inflexible ways of responding to 1 &

2

1) Shame and self devaluation

Many people apply the common stereotypes of addiction to themselves

They devalue themselves, experience shame, and see themselves as deeply flawed, discredited, or broken

2) Fear of enacted stigma

People fear being judged or rejected. Fear of enacted stigma is associated with avoidance of treatment (Cunningham, Sobell, Sobell, Agrawal,

& Toneatto, 1993; Hingson, Mangione, Meyers, & Scotch, 1982; Klingeman, 1991; Tuchfeld, 1981).

diminished self-esteem/self-efficacy (Corrigan & Watson, 2002a; Link, Struening, Neese-Todd, Asmussen, & Phelan, 2001; Wright et al., 2000);

lower quality of life (Rosenfield, 1997); early dropout from treatment (Sirey et al., 2001); poorer social functioning over time (Perlick et al., 2001a).

Psychological inflexibility in self-stigma

Much of the harm of self-stigma does not come merely from the presence of self-devaluing thoughts, shame, and fear, but also from the manner in which people respond to these experiences.

A common response is experiential avoidance – the attempt to control, reduce, or eliminate negatively evaluated private experiences (e.g., thoughts, feelings, memories), even when doing so causes harm.

Evidence for EA in stigma

Stereotype threat When people who identify with a stigmatized group

enter situations where they perceive the potential for devaluation based on this identity (Steele, Spencer, &

Aronson, 2002), they often expend energy searching for and defending against this perceived threat.

The effort is taxing and distracts the individual in ways that can hinder social or intellectual performance (e.g., Quinn, Kahng, & Crocker, 2004).

Evidence for EA in stigma

Disengagement from valued domains People withdrawing their efforts from domains of

living that relate to relevant stereotypes where they fear judgment, rejection, or that they might “confirm” a stereotype (Major & O'Brien, 2005).

Evidence for EA in stigma

Withdrawal and Secrecy Typically predicts negative psychosocial outcomes

(Ahern et al., 2007; Link, Mirotznik, & Cullen, 1991; Luoma et al., 2007; Rüsch et al., 2006).

Measure development process

Followed the guidelines of Clark and Watson (1995)1. Conducted a thorough literature review on stigma

and related measures and developed a definition of stigma

2. Focus groups: 3 groups of clients in treatment, 2 groups of addictions

professionals Tried to identify common domains of stigma toward

substance users.

Common Stigma ContentDifference / Alienation - Substance abusers (SAs) are different, separated, set apart,

strange, difficult to understand, or alien.Devaluation – SAs are losers, failures in life, disappointments, or generally inadequate as

human beings.Moral Weakness – SAs are indecent, lack virtue, and morally weak, sinners, immoral,

dishonorable, have poor character, or are disreputable Lack of Willpower or Work Ethic – SAs are weak-willed, lack self control, lazy.Hopelessness/ Helplessness – SAs are unlikely to recover and their future is bleak. Incompetence – SAs are incompetent, inept, and generally ineffective in their lives. Blameworthy – SAs are to blame for their difficulties and worthy of contempt.Violent/Unreliable – SAs are easy to anger, often violent, erratic in their behavior and

generally untrustworthy.Shame – SAs should be ashamed of themselves and feel guilty about their behavior.Concealment – SAs are secretive and work hard to conceal their problem behavior.

Item generation and refinement

Based on existing measures of stigma, our content domains, and measures of psychological flexibility, we generated a large pool of items (500+).

We refined these through an extensive rating process to arrive at 128 items which were given to a sample of 17 individuals

Further refinement resulted in a 74 item scale that was given to a validation sample.

Initial Scale

3 scales Self devaluation Fear of enacted stigma Experiential avoidance of self-devaluation and fear

of enacted stigma

Validation Sample

Essentially the same sample as the last study (n=323)

Factor analyses and scale reduction

Used principal components factor analysis with varimax rotation

Resulted in four factor solution based on scree plot:1. Self devaluation2. Fear of enacted stigma3. Experiential avoidance of stigma4. Stigma as a barrier to valuing

Scale 1: Self-devaluation (alpha=.82)1. I have the thought that a major reason for my problems with substances

is my own poor character.

2. I have the thought that I should be ashamed of myself.

3. I have the thought that I deserve the bad things that have happened to me.

4. I have the thought that I can’t be trusted.

5. I feel inferior to people who have never had a problem with substances.

6. I feel out of place in the world because of my problems with substances.

7. I have the thought that I’ve permanently screwed up my life by using drugs.

8. I feel ashamed of myself.

Scale 2: Fear of enacted stigma (alpha=.88)1. People think I’m worthless if they know about my substance use history.

2. People around me will always suspect I have returned to using substances.

3. People without a substance use history could never really understand me.

4. A job interviewer wouldn’t hire me if I mentioned my substance history in a job interview.

5. If someone were to find out about my history of substance use, they would expect me to be weak-willed.

6. People would be scared of me if they knew about my substance abuse history.

7. If someone were to find out about my history of substance use, they would doubt my character.

8. People will think I have little talent or skill if they know about my substance history.

9. People think the bad things that have happened to me are my fault.

Scale 3: Stigma avoidance (alpha=.85)

1. I would choose to avoid someone who seemed interested in my friendship if I knew they had never used substances.

2. When I feel incompetent at something I want to do, I stop trying.3. I put a lot of effort into hiding my substance use history.4. I avoid doing things where I would be blamed if it didn’t work out.5. I wouldn’t try to fill roles that required a person of character.6. Shame gets in the way of how I want to live my life.7. I withdraw from other people because I’m afraid I will scare them.8. I would lie to people in my life about my substance use if I were sure they would never find out.9. I avoid situations where another person might have to depend on me.10. I avoid situations that make me feel different.11. I can’t stand feeling like the bad things that happen to me are my fault.12. I would willingly sacrifice important things in my life to feel like I fit in. 13. I need to control my angry thoughts and feelings.14. Blaming myself for my substance abuse history gets in the way of my success.15. I would willingly sacrifice important life goals if that meant I could feel better about myself.

Scale 4: Stigma as a barrier to valuing (alpha=.81)

1. I do things that are good for me, even if I feel like I don’t deserve it. (r)

2. If something is important to me, I keep doing it, even if I feel incompetent. (r)

3. I’m willing to be in situations where I might feel different from others. (r)

4. I am getting on with the business of living, no matter how guilty I feel. (r)

5. I am open about my substance use history with most people. (r)

6. I pursue important goals in life, even when I fear I might not follow through. (r)

7. I can set a direction for my life even if I feel hopeless. (r)

8. Even if I knew the employer didn’t like to hire people in recovery, I would still apply for a job if it interested me. (r)

9. I can set a course in my life and stick to it, even when I feel like I’m a bad person. (r)

10. If I didn’t have a job, I would still look for one, even if it felt hopeless. (r)

Intercorrelations among scalesScale 1: self-devaluation

Scale 2: Fear of sitgma

Scale 3: Avoidance

Scale 4: Values

Scale 1 .49 .62 .23Scale 2 .49 .55 .17Scale 3 .62 .55 .42Scale 4 .23 .17 .42Total score .77 .75 .89 .60

Scale 1: self-devaluation

Scale 2: Fear of stigma

Scale 3: Avoidance

Scale 4: Values

Total score

Total number of years of drug use

.16** .26** .15* .05 .22**

AAQ-9 item version .431** .286** .519** .295** .525**BDI-II .343** .312** .430** .253** .454**Internalized shame scale .588** .431** .687** .363** .688**Internalized Stigma .591** .481** .725** .420** .747**

Scale 1: self-devaluation

Scale 2: Fear of stigma

Scale 3: Avoidance

Scale 4: Values

Total score

Perceived social support 0.137 .234** .196* 0.022 .186*Perceived stigma .255** .426** .375** .217** .444**Self esteem -.522** -.329** -.634** -.546** -.682**Stigma-related rejection .394** .460** .549** .246** .571**

Discussion

Psychometrics look good Good internal consistency (alpha) Good correlations with other measures Strong factor structure

Not as sure what to make of scale 4 (values interference) Correlates less with other scales Additional research could indicate whether this is really 3

factors versus 4

Discussion

Next steps Sensitivity to change Separate validation sample and confirmatory factor

analysis