Changes in clients’ well-being (ORS) and state hope (SHS) during inpatient substance abuse treatment

Rese arc h re port C h a n g es i n cli e nts’ w ellb ei n g ( O R S) a n d st at e h o p e ( S H S) d uri n g i n p ati e nt s u bst a n c e a b us e tr e at m e nt E e v a E k q vist Ta m p er e U niv ersit y, Fi nla n d K atj a K u usist o Ta m p er e U niv ersit y, Fi nla n d A bst r a ct Ai ms: D uri ng i n pati e nt s u bsta nc e a b us e tr eat m e nt, pr of essi o nals s e e k t o h el p cli e nts t o ac hi e v e i m pr ov e m e nt i n vari o us lif e d o mai ns aff ect e d by s u bsta nc e a b us e. Pr ogr ess m o nit ori ng d uri ng s u bsta n c e a b us e tr eat m e nt has b e e n call e d f or, a n d i n t his st u dy w e e xa mi n e h o w cli e nts’ l ev els of w ellb ei ng a n d h o p e c ha ng e d uri ng i n pati e nt s u bsta nc e a b us e tr eat m e nt. M et h o ds: Cli e nts ( N ¼ 1 6 8) e nt er e d t h e tr eat m e nt facility b et w e e n Ja n uary 1, 2 0 1 7 a n d A ug ust 3 1, 2 0 1 8. T h e pr os p ectiv e data w er e gat h er e d fr o m o n e tr eat m e nt u nit l ocat e d i n c e ntral Fi nla n d o n e ntr y i nt o tr eat m e nt, d uri ng a n d at t h e e n d of tr eat m e nt. Usi ng t h e O utc o m e Rati ng Scal e ( O R S) as a t h era p e utic t o ol was sta n dar d pr oc e d ur e i n t h e tr eat m e nt u nit. D e m ogra p hi c i nf or mati o n o n partici pa nts, i nf ormati o n o n t h eir pr evi o us s u bsta nc e us e a n d sc or es o n t h e Stat e H o p e Scal e ( S H S) w er e c oll ect e d t hr o ug h str uct ur e d q u esti o n nair es. N o npara m etrical t ests ( Ma n n – W hit n ey U t est; Kr us kal – Wallis w 2 ; S p ear ma n’s r h o) w er e us e d t o st u d y c ha ng es i n i n dicat ors of w ellb ei ng a n d h o p e. R es ults: As hy p ot h esis e d, i n pati e nt tr eat m e nt ha d a p ositiv e eff ect o n b ot h O R S a n d S H S a n d t h e y w er e i nt err elat e d. Diff er e nc es i n g e n d er, livi ng sit uati o n a n d pr evi o us a d missi o ns w er e f o u n d w h e n st u dyi ng h o w t h e bac kgr o u n d i nf or mati o n of t h e partici pa nts was r elat e d t o t h e c ha ng e ac hi ev e d i n O R S a n d S H S. C o n cl usi o ns: I n pati e nt s u bsta nc e a b us e tr eat m e nt s e e m e d t o e n ha nc e b ot h w ellb ei ng a n d h o p e of t h e cli e nts of i n pati e nt s u bsta nc e a b us e tr eat m e nt. S u b mitt e d: 2 5 N ov e m b er 2 0 1 9; a cc e pt e d: 1 6 Marc h 2 0 2 0 C or r es p o n di n g a ut h or: E eva E k qvist, Fac ulty of S ocial Sci e nc es, S ocial W or k, Ta m p er e U niv ersity, Li n na B uil di ng, R o o m 6 1 0 5, Ta m p er e FI3 3 0 1 4, Fi nla n d. E mail: e eva. e k qvist @t u ni.fi N or dic St u di es o n Alc o h ol a n d Dr ugs 1–16 ªT h e A ut h or(s) 2 0 2 0 Articl e r e us e g ui d eli n es: sag e p u b.c o m/j o ur nalsp er missi o ns D OI: 10.1177/1455072520922025 j o ur nals.sag e p u b.c o m/ h o m e/ na d Cr eati v e C o m m o ns N o n C o m m er cial C C B YN C: T his articl e is distri b ut e d u n d er t h e t er ms of t h e Cr eati v e C o m m o ns Attri b uti o nN o n C o m m ercial 4. 0 Lic e ns e ( htt ps://cr eativ e c o m m o ns. org/lic e ns es/ bync/ 4. 0/) w hic h p er mits n o n-c o m m ercial us e, r e pr o d ucti o n a n d distri b uti o n of t he w or k wit h o ut f urt h er p er missi o n pr ovi de d t he origi nal w or k is attri b ut e d as s p ecifi e d o n t he S A G E a n d O p e n Acc ess pag es ( htt ps:// us.sag e p u b.c o m/ e nus/ na m/ o p e n-acc ess-at-sag e). K e y w or ds c ha ng e, h o p e, O R S, S H S, s u bsta nc e a b us e tr eat m e nt, w ellb ei ng P e o pl e r ef erre d t o i n p ati e nt s u bst a n c e a b us e tr eat m e nt oft e n e x perie n ce s e ver e s o cial, ps yc h ol o gic al a n d p h ysic al c o nse q u e n c es of t heir alc o h ol, dr u g or pres cri pti o n dr u g de p e n d e nc y. I n s u c h c ases o ut pati e nt treat me nt has be e n c o nsi d ere d i ns ufficie nt a n d m or e i nte nsi ve s u p p ort, s u c h as i nter ve nti o ns i n r esi d e nti al setti n gs, is n ee d e d. S u bsta n ce a b us e tr e at m e nt n o l o n g er s e e ks s ol el y t o a c hi e v e a n d m ai nt ai n a bstin e n ce, b ut als o t o e n h a n ce i n di vi d u als’ pr osp e cts f or a f ulfilli n g lif e ( L a u d et & W hit e, 2 0 1 0, p p. 5 1 – 5 2). T his mirr ors a br o a d er c o nce pt of r ec o ver y as a n “i n di vi d ualize d, i nte nti o n al, d y n a mi c, a n d r el ati o n al pr o c ess i n v ol vi n g s ust ai n e d eff orts t o i m pr o v e w ellness ” ( As hf or d et al., 2 0 1 9, p. 1 8 3). I n r ece nt d e c a d es, w ellb ei n g a n d h o p e h a v e r e c ei v e d i n cre asi n g s c h ol arl y atte nti o n i n g e n eral (s e e Gall a g h er & L o p ez, 2 0 1 8). H o we v er, rese arc h has be e n sc arc e i n N or dic s u bsta n c e a b us e tre atme nt s etti n gs. I n t his arti cl e we f o c us o n t h e effects of i n patie nt s u bsta nc e a b use tre at m e nt o n cli e nts’ w ellb ei n g a n d h o p ef ul n ess usi n g data fr o m o n e tre at me nt u nit l oc at e d i n c e ntr al Fi nla n d. I n t hera p e utic tr e at m e nt s etti n gs, s yste mati c e v al u ati o n of tre at m e nt o ut c o m es is i n cre asi n gl y be c o mi n g a c ust o m ar y pr oc e d ur e a n d has be e n c alle d f or i n s u bsta n c e a b use tre at m e nt as w ell as i n r es e ar c h ( G o o d m a n, M c K a y, & De P hili p pis, 2 0 1 3). I n t his st u d y w e us e d a pr os p ecti v e desi g n t o e xa mi ne t h e effe cts of i n p ati e nt s u bsta n c e a b us e tre at m e nt o n c h a n g e i n clie nts’ w ellb ei n g a n d h o p e. Ass essi n g c h a n g e i n w ellb ei n g a n d h o p e is a n et hic al a n d clie ntorie nte d w a y of st u d yi n g t he effe cti ve n ess of tr e at m e nt. Ass e ss m e nts d uri n g tr e at m e nt i nf or m cli nic al d ecisi o nma ki n g d uri n g tr eatme nt a n d e n ha nc e cli e nt p artici pati o n, b ut als o a d dr ess e m er gi n g r e q uir e m e nts f or eff e cti v eness a n d pr o gress m o nit ori n g i m p ose d b y f u nd er s ( L a m b ert, H a ns e n, & Fi n c h, 2 0 0 1; La m b ert et al., 2 0 0 3; Miller, D u nc a n, Br o w n, S p ar ks, & Cla u d, 2 0 0 3). It is ess e ntial t o u n dersta n d w h at ha p p e ns d uri n g treat me nt a n d w h at basis it pr o vi des f or mai ntai ni n g t h e ac hie ve d c h a n g e after tre at m e nt (s e e S h u m w a y, Br a ds h a w, H arris, & B a ker, 2 0 1 3). Wellbei ng, ho pe, a n d s u bst a nce a b use As tre at me nt is pr o vi de d i n or der t o g e nerate p ositi v e c h a n ge, w ellb ei n g a n d h o p e t o g et h er e x press ess e ntial ele m e nts of rec o v er y (s e e Best & L u b m a n, 2 0 1 2; Le a m y, Bir d, Le B o utillier, Willia ms, & Sla d e, 2 0 1 1). Wellbei n g a n d h o p e c a n b ot h be t h e oris e d a n d defi n e d i n v ari o us wa ys. Wellb ei n g ofte n r ef ers t o p ositi v e m e nt al he alt h, s u bje cti v e, ps y c h ol o gic al or s o cial w ellb ei n g, lif e s atisfa cti o n or q u alit y of life ( D o d g e, D al y, H u yt o n, & S a n ders, 2 0 1 2; Li nt o n, Di e p p e, & M e di n aL ara, 2 0 1 6). I n t h eir r e vi e w, D o d g e et al. ( 2 0 1 2) d efi n e st a bl e w ellb ei n g as a st at e of e q uili bri u m b et w ee n a n i n di vi d u al’s r es o ur c e p o ol a n d t h e c h all e n g es f a c e d i n ps y c h ol o gi c al, p h ysi c al, a n d s o ci al d o mai ns of lif e ( D o d ge et al., 2 0 1 2, p. 2 3 0). W h e n e n c o u nteri n g c hall e n g es, a n i m b ala n ce is i n e vita ble a n d i n di vi d u als are c o m pelle d t o a d a pt t h eir p ers o n al r es o ur ces t o me et t h e n e w sit u ati o n ( Kl o e p, H e n dr y, & S a u n d ers, 2 0 0 9, p. 3 3 7). T his hi g hli g hts t h e d y n a mi c n at ur e of w ellb ei n g. S u bst a n c e a b us e a n d iss ues relate d t o it m a y c a us e i m b ala n ce, b ut it ma y als o be t h e i m b ala n ce t h at le a ds t o pr oble matic s u bsta n ce us e. T his wa y, h el p se e ki n g ca n be defi ne d as a n e n d ea v o ur t o e xert i nfl ue n ce o n t his i m b ala n ce. D uri n g i n p atie nt s u bsta n ce a b us e tr eat me nt, pr ofessi o n als s ee k t o hel p clie nts t o gai n i m pr o v e me nt i n vari o us lif e d o mai ns affe cte d b y s u bsta nc e a b us e ( A n d erss o n, Otter h olt, & Gr a ˚we, 2 0 1 7; Orf or d et al., 2 0 0 6), s u c h as i ntr a pers o n al w ellb ei n g, s o cial r el ati o ns hi ps, a n d lif e f u n cti o ni n g, i. e. t o 2 Nor dic St u di es o n Alc o hol a n d Dr ugs e n h a n c e t h eir w ellb ei n g (s e e Mill er et al., 2 0 0 3; s ee als o L a m b ert et al., 1 9 9 6). I m pr o v eme nt i n t h es e d o m ai ns ma y als o i ncr eas e clie nts’ h o p e of a bett er f ut ur e. Sc hr a n k, St a n g h elli ni, a n d Sla de ( 2 0 0 8) i n t h eir r e vie w c o nsi d er h o p e a n i m p orta nt t h er ape utic fa ct or a n d a vital c o m p o n e nt of re c o ver y. W hil e d efi ni n g it i n v ar yi n g w a ys, t h e y c o ncl u d e t hat h o p e is a d y na mic v aria ble i n v ol vi n g t h e att ai n m e nt of i n di vi d u all y v al u e d f ut ur e g o als ( Sc hra n k et al., 2 0 0 8). I n t er ms of f ut ure g o als, S n y d er et al. ( 1 9 9 1) c o nc e pt u alis e h o p e as a d u al c o nstr u ct of a g e nc y (i. e., g o aldir ecte d d et er mi n ati o n or m oti v ati o n) a n d p at h w a ys (i. e., str ate gi es or pl a ns f or a c hie vi n g g o als). T h ere h as b ee n dis c ussi o n o n w h et her h o p e is t h e s a m e as, or h o w it differs fr o m, ot her relate d c o nstr u cts s u c h as s elfeffi c a c y, o ut c o m e e x p e ct a n ci es or o pti mis m. T h ere s e e m t o b e si milarities a n d o v erla ps b et we e n t h e c o n ce pts, s u c h as p ositi ve o utl o o k o n t h e f ut ur e, b ut als o s o me f u n d a m e ntal diff ere n ces, s u c h as w h et her t h o u g hts a b o ut o n e’s a bilit y t o m e et g o als or t he g e n eralis e d e x p e cta n c y t h at g o o d t hi n gs will h a p p e n is e m p h asis e d ( R a n d, 2 0 1 8; s e e als o S n y d er et al., 1 9 9 1). Alt o g et h er, t h e f o c us is o n a b etter f ut ur e. I n s u bsta n ce a b us e tr eat m e nt t h e pr of essi o n als’ tas k is t o i ns pire t h eir cli e nts’ h o p e i n a tr eat m e nt pr oc ess b y a cti vel y cre ati n g differ e nt visi o ns wit h t h e m ( K oe h n & C utcliff e, 2 0 1 2, p. 8 5). P ositi ve f ut ur e g o als f or m e d d uri n g t he tre at m e nt pr o c ess c a n s er v e as a m otivat or a n d pr o d u ce c h a n g e. As t h ere are ma n y w a ys t o ass ess b ot h wellbei n g a n d h o p e (se e D o d g e et al., 2 0 1 2; Li nt o n et al., 2 0 1 6; S c hr a n k et al., 2 0 0 8), d efi niti o ns us e d i n earlier st u dies a n d t h e res ults o btai n e d var y. I n t er ms of pers o n al wellbei n g, s u bsta nc e a b us e h as b ee n ass o ciate d wit h ne g ati ve p h ysical a n d me ntal he alt h, i nj uries a n d s u bsta n cerelate d d e at hs (e. g., C orra o, Ba g nar di, Za m b o n, & La Ve cc hia, 2 0 0 4; O n y e ka et al., 2 0 1 3; Pirk ola et al., 2 0 0 5; Re h m, 2 0 1 1; R o¨ n ka¨, Karj alain e n, M arti k ai n e n, & M a¨ k el a¨, 2 0 1 7). F or e x a m ple, i n c o m paris o n wit h ot h er p o p ulati o ns, pe o ple w h o i nje ct dr u gs re p ort l o w er l e vels of b ot h p h ysic al a n d me ntal h e alt h ( Dietze et al., 2 0 1 0; Fis c h er, C o nr a d, Cl a v ari n o, K e m p, & Naj ma n, 2 0 1 3). W hil e hi g h le v els of h o p e ha v e b ee n ass ociate d wit h e n g a gi n g i n h ealt he n h a n ci n g b e h avi o urs ( Ber g, Rits c hel, S w a n, A n, & A hl u w alia, 2 0 1 1; N ot h w e hr, Cl ar k, & Per ki ns, 2 0 1 3), l o w le vels of h o pe pre dicte d al c o h ol use a n d bi n g e dri n ki n g a m o n g c oll e g e st u d e nts ( B er g et al., 2 0 1 1; s e e als o Br o o ks, M ars h al, M c Ca ul e y, D o u ai h y, & Miller, 2 0 1 6). H o pe h el ps t o c o p e wit h p ai n ( S n y der et al., 2 0 0 5), i nj uries ( Cr e amer et al., 2 0 0 9), a n d ill ness ( M a da n & Pa k e nha m, 2 0 1 4; Sta nt o n, Da n offB ur g, & H u g gi ns, 2 0 0 2). It is als o r elate d t o s atisfa cti o n wit h life des pit e c hr o nic a n d d e ge n er ati ve ill n ess ( G ali n, H er uti, B ar a k, & G ot ki n e, 2 0 1 8). H o p e h as be e n c o nsi d ere d a pr ote cti ve fa ct or a g ai nst ps yc h ol o gic al distress a n d e m oti o n al har ds hi p, pr om oti n g r esili e n c e a n d g o o d m e nt al h e alt h ( C h a n g & D e Si m o n e, 2 0 0 1). I n a r e vi e w of h o p e as a s o ur ce of r esilie n ce f or p h ysic al a n d me ntal he alt h, t he li n k b et w ee n h o p e a n d b etter he alt h has b ee n esta blis h e d. H o w e ver, it is still i n c o ncl usi ve w het her wellb ei n g is a res ult of h o p e or vic e v ers a ( O n g, Sta n dif or d, & D es hp a n d e, 2 0 1 8; s e e als o t h e m et aa n al ysis b y Alarc o n, B o wli n g, & K h a z o n, 2 0 1 3). Rese arc h o n t he s ocial d o mai n of wellb ei n g a n d h o p e is s o me w h at li mit e d, b ut Le e a n d G alla g h er ( 2 0 1 8, p. 2 9 3) ar g ue t h at t h e y ar e i ntert wi n e d, a n d t h at h o p e pr o m otes s o ci al fac ets of w ellb ei n g. S u bst a n c e a b us e aff e cts n ot o nl y pers o n al wellbei n g b ut als o s o ci al i d e ntit y a n d relati o ns hi ps ( Di n gle, Cr u w ys, & Fri n gs, 2 0 1 5; Di n gle, Star k, Cr u w ys, & Best, 2 0 1 5; P ole nic k, C ott o n, Br ys o n, & Bir ditt, 2 0 1 9) as w ell as r es o ur ces li k e e d u c ati o n, w or k, h o usi n g, a n d i n c o m e ( O n y e k a et al., 2 0 1 3), c a usi n g c h all e n g es t o w ellb ei n g a n d h o p ef ul n ess. F or e x a m ple, a c o n n ecti o n b et we e n h o pe a n d c o mp assi o n f or s elf, s o ci al s kills, c o m m u nic ati o n a p pr e h e nsi o n ( U m p hr e y & S h er bl o m, 2 0 1 4, 2 0 1 8) as w ell as s atisf a cti o n wit h a v ail a bl e s o ci al s u p p ort ( H ort o n & W alla n d er, 2 0 0 1) h as be e n f o u n d. A d diti o n all y, h o p e h as b ee n ass ociate d wit h pr o ble m-s ol vi n g a bilit y, a ca d e mic a c hi e v e m e nt, a n d j o b p erf or m a n c e ( A b b as, E k qvist a n d K u usisto 3 R aj a, D arr, & B o u c k e n o o g h e, 2 0 1 4; C urr y, S n y d er, C o o k, R u b y, & R e h m, 1 9 9 7; R ei c har d, A v e y, L o p ez, & D oll wet, 2 0 1 3). T h e res ear c h s o far o n s u bsta n ce a b use tre atm e nt a n d its eff e cts o n b ot h w ellb ei n g a n d h o p e s e e ms pr o misi n g. W hil e w ellb ei n g o n e nteri n g tr eat m e nt has b ee n r e p ort e dl y l o w, t h e p ositi v e c h a n g e i n w ellb ei n g d uri n g tr eat m e nt has be e n si g nific a nt ( Q uir k, Miller, D u n ca n, & O we n, 2 0 1 3; Sc h u ma n, Sl o n e, Reese, & D u nc a n, 2 0 1 5). M or e o v er, w ellb ei n g a n d h o p e a p p ear t o b e i ntert wi n e d i n diff ere nt tre at m e nts a n d t h eir effe cts. I n 1 2-ste p gr o u ps, h o p e h as be e n a c k n o wle d g e d t o ha ve a m e diati n g eff ect o n h ealt hpr o m oti n g b e ha vi o urs ( Ma g ur a et al., 2 0 0 3; W n u k, 2 0 1 7). I n r esi d e nti al tr e at m e nt setti n gs, h o p e h as b ee n ass o ci ate d wit h b etter q u alit y of lif e, gr e at er s o ci al s u p p ort fr o m frie n ds a n d fa mil y, a n d l o n ger d urati o n of a bstine n ce (Ir vi n g, Sei d n er, B urli n g, P a gliari ni, & R o b bi nsSis c o, 1 9 9 8; s ee als o Mat his, F err ari, Gr o h, & J as o n, 2 0 0 9). S h u m w a y et al. ( 2 0 1 3) e x a mi n e d i n p atie nt s u bsta n c e a b us e tre at m e nt a n d its effe ct o n r e a di n ess f or c h a n ge, cr a vi n g, resilie n ce, f a mil y f u n cti o ni n g, a n d h o pe. T h e res ults w er e p ositi v e i n all t h es e d o m ai ns. I n fa mil y tre at m e nt setti n gs, h o pe has b ee n f o u n d t o b e relate d t o r ea di ness t o c h a n g e a n d he alt h y c o pi n g s kills ( Br a ds ha w et al., 2 0 1 5). Pr e vi o us st u dies pres e nte d h ere us e d vari o us d efi niti o ns a n d m e as ur es f or ass essi n g w ellbei n g a n d h o p e. I n t his st u d y we utilis e d t h e O ut c o m e R ati n g S c al e ( O R S; Mill er et al., 2 0 0 3), w hi c h di vi des w ellb ei n g i nt o i n di vi du al, r el ati o n al, s o ci al a n d o v er all s e ns e of wellbei n g. T o m eas ur e h o p e we us e d t he State H o p e Sc ale ( S H S; S n y d er et al., 1 9 9 6), as it vie ws h o p e as sit uati o n al b ut is als o g oal a n d f ut ur e ori e nte d. As far as w e k n o w, i n t he i n p atie nt s u bsta nc e a b use tre at m e nt c o nte xt, t h er e is s o f ar n o r es e ar c h usi n g b ot h O R S a n d S H S me as ur es. Hy p ot heses B as e d o n e arli er r es e arc h o n w ellb ei n g a n d h o p e, w e h y p ot h esis e d t h at d uri n g i n p ati e nt s u bsta n c e a b use tr eat m e nt a p ositi ve effect o n b ot h w ellb ei n g ( O R S; Miller et al., 2 0 0 3) a n d h o p e ( S H S; S n y der et al., 1 9 9 6) w o ul d a p p ear. O ur s e c o n d h y p ot hesis was t hat O R S a n d S H S w o ul d b e p ositi vel y i nterrelate d. M at eri als a n d m et h o ds St u dy desig n T his st u d y w as c o n d u ct e d i n a n i n pati e nt s u bsta n ce a b us e treat m e nt u nit l oc at e d i n c e ntr al Fi nla n d as a part of rese arc h pr oje ct C h a n gi n g e x p e ct ati o ns i n cli e nts a n d s u bst a n c e a b us e tr e at m e nt o ut c o m es. T h e tr e at m e nt u nit pr o vi des n o nm e dic al, t h era p e uti c c o m m u nit yb as e d tr e at m e nt f or b ot h i n di vi d u al s a n d fa milies. T he tre at me nt a p pli es c o g niti v e be havi o ural t h era p y, i. e., t he f o c us is o n pr o vi di n g i nf or mati o n a b o ut r ec o v er y, rela pse a n d b e havi o ural p atter ns i n or d er t o a c hie v e c h a n g e i n pr o ble m atic s u bsta nc e a b use. T h era pe utic c o mm u niti es ar e b ot h a w a y of or g a nisi n g d ail y pr a cti c es d uri n g tr e at m e nt a n d a t h er a p e uti c m et h o d i n cl u di n g gr o u p s essi o ns i n a d diti o n t o i n di vi d u al s essi o ns wit h e m pl o y ees. Participa nts ar e als o e n c o ur a ge d t o t a ke part i n 1 2-ste p gr o u ps. T h es e off er a pl ac e f or p e er s u p p ort al o n gsi d e t h e pr of essi o n al h el p r e c ei v e d i n i n p atie nt tre at m e nt. A tr eat m e nt p eri o d us u all y l asts o n e t o t hr ee m o nt hs a n d m u ni ci p aliti es b e ar t h e m aj orit y of t h e tr e at m e nt c osts. As p arti ci p a nts are us u a ll y ref err e d t o tr e at m e nt fr o m s o cial s er vices, t h e y m ost li k el y d o n ot ha ve a cli nic al dia g n osis of s u bsta n c e use disor der ( S U D). Als o, t he criteria f or ref erral t o tr eat m e nt m a y var y de p e n di n g o n t h e p articipa nt’s m u nici p alit y of resi de n c e. H o w e ver, pr ofessi o n als ha v e vi e we d t heir s u bsta n ce us e a n d its c o ns e q u e nc es as s e vere a n d o ut patie nt tr eatme nt i ns ufficie nt f or t h eir nee ds. C o ns e nt fr o m t h e dir e ct or ate of t h e tr eat m e nt u nit was o btai n e d i n Oct o b er 2 0 1 4 a n d et hical a p pr o v al was re cei ve d fr o m T he Et hics C o mmitt e e of t h e T a m p er e r e gi o n. T h e r es e ar c h c o m pli es wit h t h e g ui d eli n es of t h e Fi n nis h c o d e s of r es e ar c h et hi cs a n d g o v er n a n c e 4 Nor dic St u di es o n Alc o hol a n d Dr ugs ( R es p o nsi bl e c o n d u ct of r es e ar c h ..., 2 0 1 2). T h e i m pl e m e nt ati o n of t h e st u d y a d h er e d t o nat ur alisti c pri nci ples, t h at is, clie nts were n ot selecte d a n d tr eat m e nt w as arra n ge d a cc or di n g t o t h e u nit’s e v er y d a y pr a cti c es. T h e st u d y arr a n g e m e nts w er e pla n n e d i n s u c h a wa y as t o ca us e as little b ur de n o n p artici pa nts as p ossi ble. A p art fr o m filli n g o ut q u esti o n n air es a n d str uct ur e d m eas ur e m e nts, t he tre at me nt pr oc ess was n ot disr u pte d (s e e K y pri, La n gle y, Sa u nders, & C as h ellS mit h, 2 0 0 7). T h e tr e at me nt pr oc e d ure w as a pr os pe cti v e f oll o wu p st u d y wit h meas ure m e nts at b aseli n e, d uri n g, a n d at t he e n d of t h e tr eat me nt a n d als o at t hr e e a n d si xm o nt h f oll o wu p. T h e pr es e nt st u d y c o nsists of meas ures d uri n g tre at m e nt. T he partici pa nts fille d o ut str uct ure d q uesti o n nair es c o nsisti n g of q uesti o ns f o u n d us ef ul i n earlier st u dies o n tr e at m e nt eff e cti v e n ess i n Fi nl a n d (see, e. g., K u usist o & Sa ar ni o, 2 0 1 2) a n d str uct ure d meas ure me nts, s uc h as t he O R S a n d t he S H S. M o nit ori n g of w ellb ei n g ( O R S; Mill er et al., 2 0 0 3) is sta n d ar d pr oc e d ure i n t h e tr eatme nt u nit. I n t he O R S, m ulti ple ass ess me nts are c o n d u cte d d uri n g tre at m e nt o n a we e kl y basis, w hic h ma y b e us ef ul f or e x a mi ni n g d y n a mi c pr oc ess es a n d m a ki n g it p ossi ble t o e x a mi n e t he m e c h a nis ms of c h a n g e u n d erl yi n g tr e at m e nt effi ca c y (se e Wit kie witz & M arlatt, 2 0 0 4). T his part of t h e d ata aris es fr o m t he treat me nt u nit’s dail y pra ctic es. D e m o gr a p hi c i nf or m ati o n o n p arti ci p a nts (s e e T a bl e 1), i nf or m ati o n o n t h eir pr e vi o us s u bsta n c e use (se e Ta ble 2) a n d sc ores o n t h e S H S ( S n y d er et al., 1 9 9 6) w er e c oll e ct e d t hr o u g h str u ct ur e d q u esti o n n air es. T o st u d y i n p ati e nts’ h o p ef ul n ess, w e utilis e d t h e S H S ( S n y d er et al. 1 9 9 6), w hic h is b ase d o n g o alf o c us e d c o n ce pt u alis ati o n of h o p e b y S n y d er et al. ( 1 9 9 1). T h e clie nts pr o vi di n g writte n c o ns e nt t o p artici p at e i n t h e st u d y (N ¼ 1 6 8) e nt er e d s u bst a n c e a b us e tr e at m e nt b et w e e n J a n u ar y 1, 2 0 1 7 a n d A u g ust 3 1, 2 0 1 8. P arti ci p a nt fl o w d uri n g t he st u d y is pres e nte d i n Fi g ure 1. As w e st u d y c h a n g e d uri n g i n p ati e nt tr e at m e nt, n u m b ers of O R S a n d S H S ass ess m e nts wer e d ecisi v e e x cl usi o n criteri a. At t h e b e gi n ni n g a n d at t h e e n d of treat m e nt at le ast t w o O R S a n d S H S ass ess m e nts were c o n d u ct e d a m o n g 1 3 3 a n d 8 9 p arti ci p a nts r es p e cti v el y. Ei g ht y p arti ci p a nts ha d u n d er g o n e at le ast t w o O R S assess me nts a n d t w o S H S ass ess me nts. P artici p a nts Ta bles 1 a n d 2 pr ese nt d e m o gra p hic data o n t he partici pa nts a n d t h eir pri or s u bsta n c e us e. T h e maj orit y w ere me n a n d t he lar g est a g e gr o u p was 3 0 – 3 9 ye ars. A mi n orit y of t h e p artici pa nts were h o meless or la c ke d r e g ular h o usi n g. T h eir T a bl e 1. B ac k gr o u n d i nf or m ati o n o n parti ci pa nts (N ¼ 1 4 2). n % G e n d er ( n ¼ 1 4 2) F e mal e 4 1 2 8. 9 Mal e 1 0 1 7 1. 1 Ag e (y ears; n ¼ 1 4 1) L ess t ha n 3 0 2 7 1 9. 1 30–39 55 39.2 40–49 26 18.4 5 0 or m or e 3 3 2 3. 4 H o usi ng ( n ¼ 1 3 1) O w n erocc u pi er, t e na nt 1 0 3 7 8. 6 Wit h r elativ es or fri e n ds 9 6. 9 H o m el ess, n o r eg ular h o usi ng 1 9 1 4. 5 Livi ng sit uati o n ( n ¼ 1 2 8) Al o n e 6 5 5 0. 8 Wit h s p o us e 1 9 1 4. 8 Wit h s p o us e a n d c hil d(r e n) 2 1 1 6. 4 Wit h c hil d(r e n) 6 4. 7 Ot h er 1 7 1 4. 3 E d ucati o n ( n ¼ 1 3 0) L ess t ha n c o m pr e h e nsiv e sc h o ol 9 6. 9 C o m pr e h e nsi v e sc h o ol c o m pl et e d 9 5 7 3. 1 Hig h sc h o ol 2 6 2 0. 0 E m pl o y m e nt stat us ( n ¼ 1 1 0) N ot e m pl oy e d, i n s ervic es t hat pr o m ot e e m pl oy m e nt 6 5 5 5. 1 E m pl o y e d 2 7 2 2. 9 St u d e nt 8 6. 8 R etir e d 1 2 1 0. 2 O n par e ntal l eav e 6 5. 1 E k qvist a n d K u usisto 5 l e v el of e d u c ati o n w as r at h er l o w a n d t h e e m pl o y m e nt rate a m o n g partici pa nts w as hi g h. T h e d e m o gr a p hic d at a c orres p o n d e d t o t h at of clie nts of i n p ati e nt s u bsta n ce a b us e tr eat me nt d es cri b e d i n e arli er Fi n nis h st u di es ( S a ar ni o et al., 1 9 9 8). T h e m aj orit y of partici p a nts w er e i n i n di vi du al tr e at m e nt. H o w e v er, s o m e p arti ci p a nts atte n d e d f a mil y tr eat m e nt wit h t h eir c hil d(re n) a n d/ or p art n ers. Partici p a nts h a d us e d vari o us s u bsta n c es b ef or e e nteri n g tr eat m e nt. F or t h ose a b usi n g o nl y o n e s u bsta nc e, t his w as alc o h ol. T h e fact t h at u n d er 1 0 % of t he partici p a nts use d s u bst a n c es o nl y at w e e k e n ds hi g hli g hts t h e s e v erit y of t h e clie nts’ pr o bl e ms. T h us, it is n ot e w ort h y t h at t h e m aj orit y of p arti ci p a nts w er e stri vi n g f or a bsti n e n c e. I n v ol u nt ar y a d missi o n i n cl u d e d, f or e x a m pl e, cli e nts r ef err e d fr o m t h e c hil d pr ot e cti o n or ot h er s o ci al or he alt hc are s er vices. Attriti o n w as a n al ys e d usi n g b ot h t he O R S a n d t h e S H S. First, we c o m p ar e d clie nts wit h 0 – 1 O R S ass ess m e nts t o p artici pa nts wit h at l east t w o O R S ass ess me nts. W e als o c o m pare d clie nts wit h 0 – 1 S H S assess me nts t o partici p a nts wit h at l e ast t w o S H S ass ess m e nts. Attriti o n w as a n al ys e d usi n g cr osst a b ul ati o n a n d C hi S q u are a n al ysis. O nl y statisti call y si g nifi ca nt diff er e n c es i n b a c k gr o u n d i nf or m ati o n v aria bles (se e T a bles 1 a n d 2) w ere f o u n d re gar di n g a g e. I n b ot h t h e O R S a n d t h e S H S, a g e of 3 0 ye ars or m or e was ass o ciate d wit h hi g h er pr o ba bilit y of m ulti pl e ass ess m e nts ( O R S: w 2 ¼ 9. 7 4 6, df ¼ 3, p ¼ . 0 2 1; S H S: w 2 ¼ 1 1. 3 7 2, df ¼ 3, p ¼ . 0 2 0) i n di c ati n g l o n g er tr e at m e nt peri o ds. M ateri als T he O utco me R ati ng Sc al e, O R S. S u bje cti ve w ellbei n g w as ass ess e d usi n g t he Fi n nis h v ersi o n of t h e O utc o m e R ati n g Sc al e ( O R S; Miller et al., 2 0 0 3), a s elf-r e p ort i nstr u m e nt d esi g n e d t o me as ure pr o gr ess i n cli e nt f u n cti o ni n g d uri n g tr eat m e nt. T he tr eat m e nt u nit calls t h e O R S a wellbei n g ass ess me nt (i n Fi n nis h: Hy vi n v oi nni n arvi o ). T he O R S c o nsists of a vis u al a nal og u e s cale wit h f o ur ite ms: i n di vi d u al, relati o nal, s o ci al, a n d o verall se ns e of w ellb ei n g. Eac h of t h e f o ur 1 0c m li n es i n dicates o n e of t he f o ur ite ms, wit h i nstr u cti o ns t o pla ce a m ar k o n e ac h T a bl e 2. I nf or mati o n o n p artici p a nts’ (N ¼ 1 4 2) s u bsta nc e us e b ef or e tr eat m e nt. n % Tr eat m e nt m o dality ( n ¼ 1 3 2) I n divi d ual tr eat m e nt 1 1 8 8 9. 4 Fa mil y tr eat m e nt 1 4 1 0. 6 S u bsta nc e us e d* ( n ¼ 1 3 0) Alc o h ol 1 2 0 9 2. 3 Tra n q uilis ers 5 9 4 5. 4 Ca n na bis, has his h, marij ua na 5 8 4 4. 6 A m p h eta mi n e, ecstasy, pr escri pti o n sti m ula nts 5 1 3 9. 2 B u pr e n or p hi n e, o utsi d e o pi oi d tr eat m e nt 4 1 3 1. 5 M et ha m p h eta mi n e 3 3 2 5. 4 O pi oi ds ( e.g., tra ma d ol, f e nta n yl, c o d ei n e, m or p hi n e) 3 1 2 3. 8 Pr ega bali n, ga ba p e nti n 3 1 2 3. 8 C ocai n e 1 7 1 3. 1 N e w d esig n er dr ugs ( e.g., M D P V) 2 0 1 5. 4 Hall uci n og e ns 1 9 1 4. 6 Ga m ma 1 1 8. 5 H er oi n 8 6. 2 Ot h er 1 3 1 0. 0 Ty p e of s u bsta nc e us e* ( n ¼ 1 3 0) Si ngl e s u bsta n c e 5 1 3 9. 2 P oly-s u bsta n c e us e 7 9 6 0. 8 Ha bit of usi ng s u bsta nc e* ( n ¼ 1 2 5) Daily 7 5 6 0. 0 At w e e k e n ds 1 1 8. 8 P eri o dically 3 9 3 1. 2 Cli e nt’s o bj ectiv e ( n ¼ 1 2 5) A bsti n e nc e 9 5 7 6. 0 M o d erat e us e of l egal s u bsta nc es 2 2 1 7. 6 L ess usag e t ha n b ef or e tr eat m e nt, a b ov e of m o d erat e us e or s elfm o nit or e d us e of ill egal s u bsta n c es 8 6. 4 Pr evi o us a d missi o n t o t h e u nit ( n ¼ 1 3 2) Y es 2 6 1 9. 7 N o 1 0 6 8 0. 3 V ol u ntary a d missi o n ( n ¼ 1 3 2) Y es 1 0 0 7 5. 8 N o 3 2 2 4. 2 * F or t h e y ear b ef or e tr eat m e nt. M D P V ¼ M et hyl e n e di o xy p yr oval er o n e. 6 Nor dic St u di es o n Alc o hol a n d Dr ugs li n e wit h l o w esti m at es t o t he left a n d hi g h estimates t o t h e ri g ht, a d di n g u p t o a t otal s c or e of 4 0 ( Miller et al., 2 0 0 3). I n t h e tr eat m e nt u nit, t h e O R S was us e d as a t h era p e uti c t o ol o n a w e e kl y b asis. T h e cli e nt c o n d u ct e d t h e first assess me nt i n a s essi o n wit h t he t her a pist. Later ass ess m e nts w er e c o n d u ct e d i n t h er a p e uti c gr o u ps wit h ot her clie nts a n d a u nit e m pl o ye e. It t o o k a p pr o xi m at el y o n e t o t w o mi n ut es t o c o m pl et e t h e O R S; h o w e v er, cli nic al dis c ussi o ns a b o ut t h e r eas o ns be hi n d t he s c or es laste d a p pr o xi matel y 2 0 mi n utes p er cli e nt. T h e o v er all al p ha r elia bilit y f or t he O R S c o mp osite sc ore i n t he ori gi nal st u d y was . 9 3. It h as be e n s h o w n t o be se nsiti ve t o c ha n g e i n tre at m e nt s etti n gs w hil e r e m ai ni n g st a bl e f or t h os e n ot u n d er g oi n g tr e at m e nt ( Mill er et al., 2 0 0 3). Acr oss st u dies usi n g t h e O R S, Cr o n b ac h’s al p ha c o efficie nts f or s c or es ha ve b ee n . 8 5 o n a v er a g e i n cli nical s a m ples ( Gillas p y & M ur p h y, 2 0 1 1; se e als o Bri n g h urst, Wats o n, Miller, & D u n ca n, 2 0 0 6; Ca m p b ell & H e msl e y, 2 0 0 9). I n t he prese nt sa m ple, t he Cr o n b ac h’s al p ha c oefficie nt f or t h e O R S c o m p osite sc ore at bas eli n e w as . 8 3. O n Fi g u r e 1. Partici pa nt fl o w a n d e xcl usi o n crit eria. O R S ¼ O utc o m e Rati ng S cal e; S H S ¼ Stat e H o p e Scal e. E k qvist a n d K u usisto 7 a v er a g e clie nts’ w ellb ei n g was m e as ur e d si x ti mes (M d n ¼ 5, m o de ¼ 4). T he St ate H o pe Sc ale, S HS. H o p e was m e as ure d usi n g a Fi n nis h versi o n of t he State H o p e S cale ( S H S; S n y d er et al., 1 9 9 6) as a part of a str u ct ure d q u esti o n naire i n t h e first a n d l ast w e e ks of tr eat m e nt. T h e S H S was use d i n t his st u d y d u e t o its g o al a n d f ut ur eori e nt e d vi e w o n h o p e (s e e S n y d er et al., 1 9 9 1). T h e S H S h as t w o d o mai ns, b ot h usi n g a Li k ert s c ale 1 – 8: t hr ee ite ms a b o ut a ge nc y t hi n ki n g (i. e., g o aldir e cte d d eter mi n ati o n or m oti v ati o n) a n d t hre e ite ms a b o ut p at h w a ys t hi n ki n g (i. e., str at e gi es or pl a ns f or a c hi e vi n g g o als) ( S n y d er et al., 1 9 9 6). As treat me nt s h o ul d pr o vi de p arti ci pa nts wit h t o ols f or r e c o v er y a n d pr o gr ess, it is i m p ort a nt t o meas ure sit uati o n al h o p e (se e als o Ir vi n g et al., 1 9 9 8). T h e S H S m eas ur es h o pe as a sit u ati o n al a n d d y na mic p he n o me n o n. H o we v er, st at e h o p e t y pi call y fl u ct u at es wit hi n a li mite d ra n g e ar o u n d a p ers o n’s l e vel of dis p ositi o n al (i. e., tr ait) h o pe. I n t h e ori gi nal st u d y, c oll e ge st u de nts c o m plete d t h e S H S e ver y da y f or 2 9 c o nse c uti v e d a ys. T he Cr o n ba c h’s al p h a c o efficie nts ra n g e d fr o m . 8 2 t o . 9 5. I n a ge nc y t hi n ki n g, i n dic es r a n g e d fr o m . 8 3 t o . 9 5, a n d f or p at h w a ys t hi n ki n g, fr o m . 7 4 t o . 9 3. ( S n y d er et al., 1 9 9 6). I n t h e pr es e nt s a m pl e t h e Cr o n ba c h’s al p h a c o efficie nt f or S H S c o m p osite sc or e at b aseli ne w as . 8 9, f or a g e nc y t hi n ki n g . 8 6, a n d f or p at h w a ys t hi n ki n g . 7 5, a n d at t h e e n d of tr e at m e nt t h es e w er e r es p e cti v el y . 8 9, . 8 6, a n d . 8 1. St atistic al a n alysis Statisti cal a n al ys es w ere c arrie d o ut usi n g I B M S P S S St atistics 2 5 s oft w are. D ata are sel d o m n or m all y distri b ut e d i n tr e at m e nt st u di es, as als o i n t his st u d y. I n o ur a nal ys es w e utilis e d n o npara m etric al tests – M a n n – W hit n e y U t est ( U), Kr us k al – Wallis test (w 2 ), a n d S p e ar ma n’s r h o (r s ) – f or t esti n g c orrelati o ns. R es ults T h e a n al ysis starte d b y e x a mi ni n g h o w w ellb ei n g ( O R S) c h a n g es d uri n g tr e at m e nt. T h e c h a n g e i n i n di vi d u al, r e l ati o n al, s o ci al, a n d o v er all w ellb ei n g c a n b e s e e n i n Fi g ur e 2. T h ese ite ms se e m i ntert wi n e d es pe ciall y at t he se c o n d, t hir d, a n d f o urt h ass ess me nt p oi nts. C h a n g e i n t ot al O R S m ea n s c or es d uri n g t h e first fi v e ass ess m e nts is pr es e nt e d i n Fi gure 3. T h e m e a n t otal O R S s c ore at t h e first ass ess m e nt w as l ess t h a n 2 5, w hi c h h as b e e n c o nsi d er e d a c utoff p oi nt f or w ellb ei n g Fi g u r e 2. It e ms of t h e O utc o m e Rati ng S cal e ( O R S) wit hi n fiv e ass ess m e nts. 8 Nor dic St u di es o n Alc o hol a n d Dr ugs ( Miller et al., 2 0 0 3). It i n di c at es t h at t h e le v el of w ellb ei n g is li k el y t o b e i n a r e d u c e d stat e w h e n e nt eri n g tre at m e nt. T he c ha n ge i n t otal O R S s c ores ( 0 – 4 0, N ¼ 1 3 3) b et wee n t h e first a n d last ass ess me nts w as p ositi ve f or t he m aj orit y of parti ci p a nts ( n ¼ 1 1 7, % ¼ 8 8, M ¼ 1 1. 6 0, S D ¼ 7. 1 4, mi n ¼ 0. 2 0, ma x ¼ 3 5. 9 0). N e g ati ve c ha n g e was m ore i nfre q ue nt a n d s m aller (n ¼ 1 6, % ¼ 1 2, M ¼ 4. 6 9, S D ¼ 4. 8 3, mi n ¼ – 1 6. 2 0, m a x ¼ – 0. 7 0). S e c o n d, w e st u di e d h o w h o p e ( S H S) c h a n g es d uri n g tr e at m e nt. T a bl e 3 pr es e nts c h a n ges i n a g e n c y t hi n ki n g, pat h w a ys t hi n ki n g, a n d t otal S H S. As i n O R S, t h e c ha n g e i n S H S a n d its d o m ai ns w as p ositi ve f or t he m aj orit y of p arti ci p a nts. H o w e v er, al m ost e v er y f o urt h pers o n e x perie n ce d a n e g ati ve c h a n ge i n p at hwa ys t hi n ki n g. Aft er i n v esti g ati n g t h e pr e vi o us r es e ar c h q u esti o ns, w e c o n cl u d e d t h at o ur first h y p ot hesis, d uri n g i n p atie nt s u bst a n c e a b us e tr e atm e nt a p ositi ve eff e ct o n b ot h O R S a n d S H S will a p pe ar , was c o nfir me d. W e c o nti n u e d t he a n al ysis b y e x a mi ni n g h o w t h e b a c k gr o u n d i nf or m ati o n of t h e partici pa nts w as relate d t o t h e c h a n ge of O R S a n d S H S s c or es. Ma n n – W hit ne y U a n d Kr us kal – Wallis t ests w er e us e d t o t est distri b uti o n of w ellb ei n g a n d h o pe re gar di n g t he b ac k gr o u n d i nf or m ati o n varia bles ( pres e nte d i n T a bles 1 a n d 2). I n t h e t ests, n ull h y p ot hes es w ere t h at distri b uti o ns of O R S a n d S H S w o ul d b e t h e s a m e Fi g u r e 3. C ha ng e i n t otal O utc o m e Rati ng Scal e ( O R S) sc or es wit hi n fiv e ass ess m e nts. T a bl e 3. C ha ng e i n Stat e H o p e Scal e ( S H S) d uri ng tr eat m e nt. m S D mi n ma x n % C ha ng e i n ag e nc y t hi n ki ng d uri ng tr eat m e nt ( N ¼ 8 9) P ositiv e 4. 4 1 3. 5 4 1 1 6 6 1 6 8. 5 N e utral 0. 0 0 0. 0 0 0 0 1 4 1 5. 7 N egativ e – 3. 2 9 1. 5 9 – 6 – 1 1 4 1 5. 7 C ha ng e i n pat h ways t hi n ki ng d uri ng tr eat m e nt ( N ¼ 8 9) P ositiv e 4. 2 2 3. 3 8 1 1 9 5 8 6 5. 2 N e utral 0. 0 0 0. 0 0 0 0 9 1 0. 1 N egativ e – 2. 2 7 2. 0 7 – 9 – 1 2 2 2 4. 7 C ha ng e i n Stat e H o p e Scal e ( S H S) d uri ng tr eat m e nt ( N ¼ 8 9) P ositiv e 7. 5 4 6. 7 5 1 3 5 6 5 7 3. 0 N e utral 0. 0 0 0. 0 0 0 0 9 1 0. 1 N egativ e – 4. 8 0 3. 3 0 – 1 2 – 1 1 5 1 6. 9 E k qvist a n d K u usisto 9 of h o p e. J o ur n al of Pers o n ality a n d S o ci al Psychology,60, 570–585. S n y d er, C. R., Ra n d, K. L., Ki n g, E. A., F el d m a n, D. B., & W o o d w ar d, J. T. ( 2 0 0 2). “ F als e ” h o p e. J o ur n al of Cli nic al Psy c h ol o g y , 5 8 , 1 0 0 3 – 1 0 2 2. S n y d er, C. R., S y m ps o n, S. C., Y b as c o, F. C., B or ders, T. F., Ba b y a k, M. A., & Hi g gi ns, R. L. ( 1 9 9 6). De v el o p m e nt a n d vali dati o n of t he state h o p e s c al e. J o ur n al of P ers o n alit y a n d S o ci al Psy c h ol o gy , 7 0 , 3 2 1 – 3 3 5. Sta nt o n, A. L., D a n offB ur g, S., & H u g gi ns, M. E. ( 2 0 0 2). T h e first ye ar after breast c a n c er dia g n osis: H o p e a n d c o pi n g strate gies as pr e dict ors of a dj ust m e nt. Ps y c h oO nc ol o gy , 1 1 , 9 3 – 1 0 2. U m p hr e y, L. R., & S h er bl o m, J. C. ( 2 0 1 4). T he relati o ns hi p of h o p e t o selfc o m p assi o n, r el ati o n al s o ci al s kill, c o m m u ni c ati o n a p pr e h e nsi o n, a n d lif e s atisfa cti o n. I nt er n ati o n al J o ur n al of Wellbei n g , 4 ( 2), 1 – 1 8. U m p hr e y, L. R., & S h er bl o m, J. C. ( 2 0 1 8). T he c o nstit uti v e r el ati o ns hi p of list e ni n g t o h o p e, e m oti o nal i nt elli g e n ce, str ess, a n d lif e s atisf a cti o n. I nt er n ati o n al J o ur n al of List e ni n g, 3 2 , 24–48. Wit kie witz, K., & M arlatt, G. A. ( 2 0 0 4). R el a ps e pr e v e nti o n f or alc o h ol a n d dr u g pr o ble ms: T h at was z e n, t his is t a o. T h e A m eric a n Ps yc h ol o gist , 59, 224–235. W n u k, M. ( 2 0 1 7). H o p e as a n i m p orta nt f a ct or f or m e nt al h e alt h i n al c o h old e p e n d e nt s u bj e cts atte n di n g alc o h olics a n o n y m o us. J o ur n al of S u bst a nc e Use,22, 182–186. 1 6 Nor dic St u di es o n Alc o hol a n d Dr ugs