Focusing on the whole person in

continued care for SUD-patients

The acceptability and possible impact on wellbeing of an ACT-based
after-care intervention in people previously treated for substance use
disorder

Jongejan, I.K. (s1884999)

Master Thesis Positive Psychology and Technology

Twente University

Supervisors: M. Postel & M.E. Pieterse

Enschede, September 2017

 
 Summary

Purpose. Although current addiction treatment has been shown to be effective, many
patients relapse into substance use in the months after treatment has ended. To prevent
relapse, an ACT-based after-care intervention was developed, in which patients were
taught to cope with aversive thoughts and feelings and to explore their values. The
purpose of this study was to explore the experiences of people previously treated for
Substance Use Disorder (SUD) with the intervention ‘Living to the Full’ and to assess its
possible impact on their wellbeing, depression symptoms and relapse into substance use.

Method. The respondents were 8 Dutch adults who had received previous psychological
SUD-treatment at Tactus, an addiction care institute in The Netherlands. The intervention
‘Living to the Full’ consisted of 9 weekly sessions in which ACT-based concepts and
exercises were practised. Respondents were interviewed post-intervention (n=6) and filled
out a pre- and post-treatment test-battery (n=7), consisting of measures for wellbeing
(MHC-SF), depression symptoms (DASS-21) and substance use. This study used a mixed-
method design, in which the interview-data was analysed using Thematic Analysis and the
quantitative data was analysed using paired-sample T-tests and Wilcoxon signed-rank
tests.

Results. Results showed that the intervention was well accepted by the respondents and
considered as proper after-care for SUD. The main reason for this was that the
intervention focused on the person as a whole rather than solely focusing on substance
use. Relapse was prevented in six out of seven respondents during the intervention.
Respondents noticed changes in their coping with craving-related thoughts. Overall-
social- and psychological wellbeing significantly improved, which was confirmed by
respondents’ experience. Finally, the change in depression symptoms showed a clear trend
towards significance and respondents did report relieve of depression symptoms.

Discussion. The acceptability of ‘Living to the Full’ might be explained by the

experienced need for after-care in SUD-patients. Consistent to the theory, ACT helped
respondents to observe and accept thoughts, which is especially useful in coping with
craving. The improvements in overall- and social wellbeing and depression symptoms are
especially important to SUD-patients, as this has been linked to lower substance use and
risk of relapse. The finding that relapse was prevented in most respondents is consistent to
previous research that linked after-care to lower risk of relapse.

Conclusion. The ACT-based after-care intervention ‘Living to the Full’ seems to be

promising after-care for SUD-patients as it was accepted well by the respondents,
constituted significant change in their wellbeing and relieved depression symptoms.
Nearly all respondents did not relapse during the after-care. Future research should be
done to confirm the findings of this pilot-study.

I.K. Jongejan –University of Twente – September 2017 2

 Samenvatting

Doel. Hoewel huidige verslavingsbehandelingen effectief zijn gebleken, vallen veel

patiënten terug in middelengebruik in de maanden na de behandeling. Om terugval te
voorkomen, is er een op ACT gebaseerde nazorg-interventie ontwikkeld waarin patiënten
leren om te gaan met negatieve gedachten en gevoelens en om hun waarden te verkennen.
Het doel van dit onderzoek was om de ervaringen van patiënten die voorheen behandeld
zijn voor middelenafhankelijkheid met de interventie ‘Voluit Leven’ in kaart te brengen,
net als de mogelijke impact van deze interventie op hun welbevinden,
depressiesymptomen en terugval in middelengebruik.

Methode. De respondenten waren 8 Nederlandse volwassenen die voorheen reeds een

psychologische behandeling hadden ontvangen tegen middelenafhankelijkheid. De
interventie ‘Voluit Leven’ bestond uit 9 wekelijkse sessies waarin met op ACT gebaseerde
concepten en oefeningen werd geoefend. Respondenten werden na de interventie
geïnterviewd (n=6) en vulden voor en na de interventie een testbatterij in (n=7), met
daarin vragenlijsten voor welbevinden (MHC-SF), depressiesymptomen (DASS-21) en
middelengebruik. Dit onderzoek gebruikte een mixed-method design, waarin de interview-
data werd geanalyseerd met Thematic Analysis en de kwalitatieve data werd geanalyseerd
met gepaarde T-testen en Wilcoxon signed-rank testen.

Resultaten. Resultaten toonden dat de interventie geaccepteerd werd door de

respondenten en dat het gezien werd als geschikte nazorg tegen middelenafhankelijkheid.
De reden hiervoor was dat de interventie zich richtte op het individu als geheel in plaats
van alleen op de middelenafhankelijkheid. Een terugval in middelengebruik werd tijdens
de interventie voorkomen bij zes van de zeven respondenten. Respondenten merkten dat
ze beter met trek-gerelateerde gedachten konden omgaan. Algemeen-, sociaal- en
psychologisch welbevinden verbeterden significant wat bevestigd werd door de ervaring
van respondenten. Tot slot veranderden depressiesymptomen bijna significant en merkten
respondenten op dat ze minder depressiesymptomen ervoeren.

Discussie. De acceptatie van ‘Voluit Leven’ kan verklaard worden doordat patiënten met
middelenafhankelijkheid zelf ervaren nazorg nodig te hebben. Dat ACT de respondenten
leerde om hun gedachten te observeren en te accepteren is functioneel in het omgaan met
trek in middelen en past bij de theorie. De verbeteringen in het algemeen- en sociaal
welbevinden en in depressiesymptomen zijn specifiek van belang voor patiënten met
middelenafhankelijkheid, omdat dit in verband is gebracht met minder middelengebruik
en lager risico op terugval. Dat terugval werd voorkomen bij de meeste respondenten past
bij voorgaand onderzoek dat nazorg in verband heeft gebracht met een kleinere kans op
een terugval.

Conclusie. De op ACT gebaseerde nazorg-interventie ‘Voluit Leven’ lijkt een

veelbelovende nazorg voor patiënten met middelenafhankelijkheid omdat het goed
geaccepteerd werd door de respondenten, een significante verandering teweeg heeft
gebracht in hun welbevinden en hun depressiesymptomen heeft verlicht. Zes van de zeven
respondenten viel niet terug in middelengebruik tijdens de interventie. Toekomstig
onderzoek zal de bevindingen van deze pilotstudie moeten bevestigen.

I.K. Jongejan –University of Twente – September 2017 3

 Table of Contents
INTRODUCTION  ...............................................................................................................................................  5  
METHOD  ............................................................................................................................................................  9  
RESULTS  ..........................................................................................................................................................  15  
DISCUSSION  ...................................................................................................................................................  26  
CONCLUSION  ..................................................................................................................................................  31  
APPENDICES  ..................................................................................................................................................  38  
REFERENCES  ..................................................................................................................................................  32  

I.K. Jongejan –University of Twente – September 2017 4

 Introduction

Substance Use Disorders (SUDs) are known to cause much suffering. Considering the high
burden of disease of SUD and the high risk of relapse after treatment, SUD-treatment is in
constant need of improvement. Positive psychological interventions such as Acceptance and
Commitment Therapy (ACT) as after-care might improve treatment outcomes. Acceptance
and Commitment Therapy (ACT) focuses on the acceptance of negative thoughts and
emotions and on living a mindful and value-based life (Bohlmeijer, Fledderus, Rokx &
Pieterse, 2011). In this sense, it aims not only to reduce psychopathology, but also to promote
flourishing (Bohlmeijer, Lamers and Fledderus, 2015). ACT applied to substance use
disorders teaches clients to accept their thoughts and feelings, rather than turn to substance
use, and motivates them to create meaningful activities that are not compatible with substance
use (Lee , An, Levin & Twohig, 2015). ACT-based after-care might pose a useful addition to
current SUD-treatment by having attention for and improving overall functioning of SUD-
patients, who are often in need of developing knowledge and skills to live meaningful
abstinent lives (Lee et al., 2015). ACT has already shown to be effective in reducing
substance use in people suffering from SUDs, but has not been researched as after-care.
Additionally, it has shown to be effective in enhancing wellbeing in other populations.
Therefore, this study assesses the acceptability and possible impact on wellbeing of an ACT-
based after-care intervention in people previously treated for SUD.
SUD is diagnosed when an individual meets at least two of the various criteria
described in The Diagnostic and Statistical Manual for Mental Disorders (DSM-V), which
includes continued substance use despite dysfunction in work- and social life, craving the
substance, putting effort and time in getting it and tolerance (Malone & Hoffmann, 2016). The
recurring abuse of drugs and/or alcohol that is typical for this disorder often leads to deep
troubles in many areas of an individual’s life, as well major societal costs (Calabria et al.,
2010). According to the United Nations’ World Drug Report (2016), 28 million people
worldwide suffer form drug use disorder, resulting in an estimated 207,400 drug-related
deaths in 2014. Further, SUDs are associated with a various range of health- and social
problems, including cardiovascular diseases, mental disorders, criminal activities and suicide
(Lee et al., 2015; Fleury et al., 2016). The risk of relapse after regular treatment is around
75% within 3- to 6- months after treatment (Appiah, Danquah, Nyarko, Ofori-Atta & Aziato,
2017), indicating the severity of SUD.

I.K. Jongejan –University of Twente – September 2017 5

Regular treatment of SUD – effects and acceptability
The current treatment of SUDs often consists of a combination of psychological and
psychopharmacological treatment. Several psychological interventions have shown to be
effective in treating SUDs of different substances. Cognitive-Behavioral Therapy (CBT) has
shown to be effective in reducing cocaine use (Farronato, Dursteler-MacFarland, Wiesbeck &
Petitjean, 2013), in reducing alcohol use (Bottlender, Kohler & Soyka, 2006) and in reducing
cannabis use (Gates, Sabioni, Copeland, Le Foll & Growing, 2016). Contingency
Management (CM) was found to be effective in reducing cocaine use (Farronato et al., 2013).
Motivational Interviewing (MI) has been found to be effective in reducing the use of alcohol
(Bottlender et al., 2006) and the use of cannabis (Gates et al., 2016).
To the author’s knowledge, no scientific reviews were published on the effects of
ACT in people suffering from SUD, though some research was done. For instance, Lee and
colleagues (2015) conducted a meta-analysis of 10 RCTs, reporting a small to medium effect
size on substance use abstinence favouring ACT compared to CBT, calling it a promising
intervention for substance use disorders. Further, Hermann, Meijer, Schnurr, Batten and
Walser (2016) created a manual for ACT in patients suffering from both PTSD and substance
use disorder and pilot-tested the treatment in 21 patients who were currently not involved in
any other psychological treatment. They found that indeed, the intervention resulted in
reduced substance-use. Other studies reported similar results (Smout et al., 2010; Menéndez,
García, Lamelas & Lanza, 2014; Hayes et al., 2004; Stotts et al., 2012). Strongly related to
ACT, mindfulness-based interventions have been shown to be effective in reducing substance
use in SUD-patients (Chiesa & Serretti, 2014; Skanavi, Laqueille & Aubin, 2011).
The acceptability of CBT as regular treatment for SUD seems to be sufficient. For
instance, an integrated CBT-treatment for SUD and depression was highly accepted and rated
applicable to multiple areas of life by clients from an in-depth case study of seven respondents
by Osilla, Hepner, Munoz, Woo and Watkins (2009). Additionally, a clinical study of Brewer
and colleagues (2009) showed that CBT treatment for SUD was rated as highly agreeable and
satisfactory. Less is known about patients’ acceptability of MI- and CM-treatment. However,
Aletraris, Shelton and Roman (2015) found that counsellors rated CM as the least acceptable
treatment for SUD, compared to MI and CBT. Previous research has rarely assessed the
experience of SUD-patients undergoing ACT-treatment, with the exception of Brewer and
colleagues (2009) who showed that mindfulness was highly accepted by SUD-patients in their
sample. Additionally, ACT was found to be acceptable in people with psychosis (Johns et al.,
2016). Further, people with symptoms of depression and anxiety rated the ACT-based

I.K. Jongejan –University of Twente – September 2017 6

intervention used in this study as good and useful (Fledderus, Bohlmeijer, Pieterse &
Schreurs, 2012).

After-care treatment of SUD – effects and acceptability

Considering the high risk of relapse into substance use after regular treatment, SUD-patients
are often advised to attend some form of continuous care (McKay, 2001). Mostly, after-care
for SUD consists of less frequent continuation of regular treatment, provided by the original
or a different health care organization. After-care interventions are often flexible and differ in
length and frequency (Vanderplasschen, Bloor & McKeganey, 2010). The beneficial effects
of after-care in SUD-patients include increased abstinence rates (Schaefer, Harris, Cronkite &
Turrubiartes, 2008; Smyth et al., 2005), longer days to relapse (Sannibale et al., 2003),
reduced probability of relapse (Jason, Davis & Ferrari, 2007; Frydrych, Greene, Blondell &
Purdy, 2009; Burleson, Kaminer & Burke, 2012) and decreased substance use (Chong &
Herman-Stahl, 2003). For instance, Vanderplasschen, and colleagues (2010) conducted a
study in which they assessed the long-term effects of attending after-care for SUD-patients.
They found that patients who participated in after-care were twice as likely to stay abstinent
from drugs 8 months later. To the author’s knowledge, no ACT-based after-care intervention
in SUD-patients has yet been researched. However, a mindfulness-based relapse-prevention
programme was assessed by Witkiewitz and colleagues (2014), who reported less drug use for
substance involved offenders at 15 weeks follow-up for a mindfulness-based relapse-
prevention programme compared to regular relapse-prevention.
Little research has been conducted on the acceptability of after-care interventions in
SUD-patients. However, a text-message based after-care programme in alcohol outpatients
has shown to be well accepted (Haug, Lucht, John, Mayer & Schaub, 2015). In this interactive
after-care program, alcohol outpatients monitored their drinking goals, received motivational
text messages and received phone calls by counsellors when they needed support.
Additionally, a phone-intervention in which adolescents with alcohol use disorder received
regular brief therapeutic phone calls was also found to be acceptable (Burleson & Kaminer,
2007). Finally, a mindfulness-based relapse-prevention program was found to be highly
satisfactory to a group of female SUD-patients (Amaro, Spear, Vallejo, Conron & Black,
2014). The program consisted of nine sessions that focused on meditation techniques as well
as self-regulation strategies to manage stress and difficult emotions.
The after-care interventions for SUD that have been researched to date were mostly
based on continuation of regular, CBT-based psychological care or solely on mindfulness.

I.K. Jongejan –University of Twente – September 2017 7

Therefore, the current study will fill up this literature-gap by examining ACT-based after-
care. Further, most studies that assessed the effects of psychological treatment of SUD
focused on substance use and did not include any measures of wellbeing, even though
enhancing wellbeing might be especially important in treating SUD as patients are often in
need of improvement of overall functioning. Earlier research has shown that ACT-
interventions improve wellbeing in people with depression symptoms (Bohlmeijer et al.,
2011; Fledderus et al., 2012; Pots et al., 2015; Lappalainen et al., 2014; Lappalainen,
Langrial, Oinas-Kukkonen, Tolvanen, & Lappalainen 2015). Therefore, this study aims to
assess the possible impact of ACT-based after-care on the wellbeing of SUD-patients.
Additionally, the impact on depression symptoms and relapse into substance use will be
assessed. In addition to the literature gaps, another reason to conduct this study is that Tactus,
the addiction care institute in the Netherlands where the intervention was carried out, has
requested this study because ACT-based after-care fits their work ethic of recovery-focused
therapy that increases clients’ individual control over their mental health.

Research question and hypotheses

As the goal of this pilot-study is to describe the respondents’ experience with the ACT-based
after-care intervention and its possible impact on wellbeing, depression symptoms and relapse
into substance use, this study aims to answer the following questions:
1. What is the acceptability of an ACT-based after-care intervention in SUD-patients?
2. What is the possible impact of an ACT-based after-care intervention on the wellbeing,
depression symptoms and relapse into substance use in SUD-patients?

It is expected that the ACT-based after-care intervention will be well accepted by

SUD-patients and rated as useful. Further, it is expected that the ACT-based after-care
intervention increases wellbeing and reduces depression symptoms of SUD-patients. Finally,
it is expected that the intervention prevents patients from relapsing into substance use.

I.K. Jongejan –University of Twente – September 2017 8

 Method

Design
The current study uses a mixed-method study design, in which data is collected pre-
treatment (t=0) and post-treatment (t=1) as part of the regular Routine Outcome
Monitoring (ROM). Quantitative data was collected using a test-battery of measures of
substance use, wellbeing (MHC-SF) and depression symptoms (DASS-21) pre- and post-
treatment. Qualitative data was collected post-treatment using the method of semi-
structured interviews, both as an evaluation of the intervention as well as a deepening of
understanding on the impact of the intervention. This mixed-method design was chosen
because the goal of this study is both to investigate the respondents’ experience with as
well as the possible impact of the intervention. Semi-structured interviews are suitable to
extensively assess respondents’ experiences. Quantitative analyses are needed to indicate
the possible impact of the intervention.

Respondents
The respondents of the study were 11 Dutch adult SUD-patients, who had recently
received regular, Cognitive Behavioral Therapy (CBT)-based SUD-treatment at the Dutch
addiction treatment institute Tactus. Eight of them formed one group at one Tactus-
location and three of them participated in a group at another Tactus location. Psychologists
that were in charge of previous treatment recruited the respondents by inviting them to
participate in the ACT-based after-care group-intervention after their usual treatment.
Also, they asked them to participate in an evaluation of the intervention for research
purposes. All respondents mastered the Dutch language, as this was the language in which
the intervention was offered. The respondents for the interviews were recruited by asking
the respondents whether they would be interested to participate in an interview after the
treatment had ended.

Intervention
The intervention ‘Living to the Full’ (‘Voluit Leven’) consisted of nine group sessions of
two hours that were led by a psychologist and an ACT- trainer. The intervention aims at
teaching patients to live satisfactory lives, despite their sensitivity to SUD and other
psychological sensitivities; hence the name ‘Living to the Full’. The respondents received
the book ‘Living to the Full’ at the start of the intervention.

I.K. Jongejan –University of Twente – September 2017 9

 Four parts can be distinguished within the intervention. In the first session,
respondents are introduced to ACT and asked to reflect on their goals and desires in life.
Then, in sessions 2 and 3, respondents look back on their attempts to control their
complaints and the effect of this strategy. The third part, session 4, 5 and 6, emphasizes
current experiences and teaches respondents how to accept thoughts and sensations. The
three final sessions evolve around exploring personal values and how to live according to
those values. Throughout the intervention, mindfulness-exercises are practiced
(Bohlmeijer et al., 2011). During every session, the content of one chapter from the book
was briefly discussed, after which exercises were clarified and practiced. After every
session the respondents were asked to do homework during the week, which consisted of
reading the book and various mindfulness- and reflection exercises.
‘Living to the Full’ is based on six core-processes of ACT, described by Hayes,
Luoma, Bond, Masuda and Lillis (2006): acceptance, cognitive defusion, contact with the
present moment, self as context, choosing values in different life domains, and
commitment to make choices based on these values. These processes all evolve around
accepting thoughts and sensations, even though they might be aversive, and living life
according to personal values.

Measures
To assess respondents’ experience with the intervention, an evaluation form was created
(see Appendix A). The first eight questions were derived from the Client Satisfaction
Questionnaire (CSQ-8), a questionnaire that was designed in order to assess clients’
satisfaction with treatment. The CSQ-8 was found to have high internal consistency and
concurrent validity in a sample of Dutch SUD-patients (De Wilde & Hendriks, 2005). The
remaining questions were added to evaluate specific parts of the current intervention.
Respondents’ answers to the questions on the evaluation form were used to personalize the
post-intervention semi-structured interviews.
After the intervention, semi-structured interviews were conducted with the
respondents. The main goal of these interviews was to gain a deeper understanding of the
patients’ experiences with the intervention and the possible impact of the intervention on
wellbeing, depression symptoms and substance use. A semi-structured interview allows
for a rich understanding of a phenomenon. An advantage of this method is that the
interviewer is able to improvise according to respondents’ answers, allowing for more
individual variation than a structured interview would (Robert Wood Johnson Foundation,

I.K. Jongejan –University of Twente – September 2017 10

2008). However, as the researcher designs the interview guide, selects respondents and
interprets the results, a semi-structured interview might be subsequent to biases
(Diefenbach, 2009). The author used a recently published framework for the development
of a semi-structured interview guide, consisting of five phases based on ten
methodological papers on this topic (Kallio, Pietilä, Johnson and Kangasniemi, 2016). The
first phase in this framework is to evaluate whether using the method of semi-structured
interview is suitable for the current research question. As the main goal of the current
research is to assess the respondents’ experiences with the intervention, the method of
semi-structured interview was found suitable. The second phase is to retrieve and use
previous knowledge, which the author did by conducting a literature review on the topic of
SUD and by using their experience working with SUD-patients. In the next phase, the
preliminary semi-structured interview guide is formulated, which is pilot tested in the
fourth phase, resulting in the complete semi-structured interview guide in the final phase.
Experts from the field added comments to the interview guide in the fourth phase. Further,
the author pilot tested the preliminary semi-structured interview during the interview with
the first respondent. After this test, the interview guide was adjusted accordingly. The
semi-structured interview-guide in English and Dutch can be found in Appendix B and C.
The semi-structured interview guide consisted of two parts. Part A consisted of
questions on the experiences with the intervention. Part B consisted of questions on how
the intervention might have affected respondents’ wellbeing, depression symptoms and
substance use. On every topic, an open question was initially asked, after which sub-topics
were discussed depending on the answer of the respondent. Also, the focus in the semi-
structured interview might be adjusted depending on the values respondents filled out in
the questionnaires. For example, if a respondent filled out a relatively high score on
having a hard time to relax in the depression questionnaire, then the interviewer might
zoom into that topic. This was done because it was assumed that higher or lower scores on
a particular topic mean that this topic was more or less relevant to an individual.
Several constructs were measured pre- and post-treatment, including wellbeing
(MHC-SF-21), depression symptoms (DASS-21) and substance use. Wellbeing was
measured using the Mental Health Continuum Short Form (MHC-SF). This 14-item
measure consists of three subscales: emotional- (3 items), social- (5 items) and
psychological wellbeing (6 items; Lamers, Westerhof, Bohlmeijer, ten Klooster & Keyes,
2011). Each of the items consists of the following question: “In the past month, how often
have you experienced…” followed by, for example: “feeling happy?” (0 = never; 1 = once

I.K. Jongejan –University of Twente – September 2017 11

or twice; 2 = once a week; 3 = 2 or 3 times a week; 4 = almost every day; 5 = every day).
The scores for overall wellbeing were calculated by taking the mean of the sum of all 14
items. Additionally, scores for emotional- social- and psychological wellbeing were
calculated by taking the mean of the total scores on those particular items. The MHC-SF
was reported to have high internal reliability (Cronbach’s α = .89) and good convergent
validity in a Dutch sample (Lamers et al., 2011; Lamers, Glas, Westerhof, & Bohlmeijer,
2012) and high reliability (Cronbach’s α = .91) in another one (Fledderus, Bohlmeijer,
Smit & Westerhof, 2010). In four South-African communities, high internal consistency
(Cronbach’s α = .74) and good criterion validity were found (Keyes, 2008). Similarly, the
MHC-SF was found to be a reliable and valid measure in Argentinian samples (Perugini,
de la Iglesia, Solano & Keyes, 2017), Italian samples (Petrillo, Capone, Caso & Keyes,
2015), Polish samples (Karas, Cieciuch & Keyes, 2014) and Chinese samples (Guo et al.,
2015).
Depression symptoms were measured using the Depression Anxiety Stress Scales
short form (DASS-21), a self-report questionnaire that measures depression-related
symptoms. It is a shorter form of the DASS-42, which was developed to indicate the
severity of psychiatric comorbidity, but is also used to evaluate changes in
symptomatology over time (Lovibond & Lovibond, 1995). The DASS-21 consists of three
clusters of 7 items measuring depression, anxiety and overall stress, respectively (Weiss et
al., 2015). The 21 items consist of statements that can be rated on a 4-level scale of
applicability (0 = not applicable; 1 = a bit applicable; 2 = reasonably applicable; 3 = very
applicable). An example of a statement is: “I found it difficult to calm myself down.”
Depression scores were calculated by adding up the scores on each of the 21 items, in
which higher scores indicated more depression symptoms. In a sample of SUD-patients,
the DASS-21 was found to be a reliable measure to screen for PTSD (Kok, de Haan, van
der Meer, Najavits & de Jong, 2015). In a sample of medical patients seeking treatment for
worrying, the DASS-21 was reported to have strong discriminative validity and internal
consistency (Cronbach’s α = .87; Gloster et al., 2008). In a sample of psychiatric patients,
Weiss and colleagues (2015) found good internal consistency (Cronbach’s α = .94), strong
convergent validity and high sensitivity to changes in depression symptoms over
treatment. Similarly, the DASS-21 was reported to be a reliable and valid measure in a
sample of pain patients (Wood, Nicholas, Blyth, Asghari & Gibson, 2010) and psychiatric
in-patients (Ng et al., 2007). The DASS-21 was translated in Dutch and reported to have
similar reliability scores as the original version (De Beurs, 2010).

I.K. Jongejan –University of Twente – September 2017 12

 To measure possible relapse into substance use, Module 1 from the Measurements
in the Addictions for Triage and Evaluation (MATE) was used. The MATE is a test-
battery composed of ten instruments meant to measure relevant concepts in SUD-patients
(Schippers, Broekman, Buchholz, Koeter & van den Brink, 2010). Substance use was
measured using Module 1 of the MATE. This module includes questions on all substances
from the Composite International Diagnostic Interview (CIDI) from the World Health
Organization. This structural interview consists of questions on what substances the
respondent has used during their lifetime and the amount of these substances they have
used in the past 30 days (Schippers et al., 2010). The scores for substance use were
calculated by looking at the frequency of main problem substance use in the past 30 days
(0 = none; 1 = once; 2 = a few times; 3 = once or twice a week; 4 = three or four times a
week; 5 = five or six times a week; 6 = every day). For example, a respondent who would
have used alcohol once or twice a week would receive a score of 3.
All measures were taken pre- and post-treatment, using pen and paper, in the
presence of a trainer. As the current study was part of a larger one, it must be noted that
other constructs were also measured at these particular moments.

Procedures
Before the start of the intervention, the research proposal was approved by the Scientific
Committee of Tactus. The respondents then attended 9 sessions during 9 weeks. The
respondents were not involved in any other psychological SUD-treatment during the
intervention. Wellbeing, depression symptoms and substance use were measured pre- and
post-treatment. Also, respondents were asked whether they were interested in participating
in an additional interview. Respondents who were interested were contacted through
telephone at the end of the intervention to make an appointment for the interview. They
were asked to fill out the evaluation form digitally and return it by e-mail. Respondents
were given the choice to conduct the interview through telephone or in real life. Five
interviews were conducted in real-life at the same location as the intervention; one
interview was conducted through telephone. The interviews each lasted 30 to 45 minutes.

Analysis
The qualitative data from the interviews was analysed according to Thematic Analysis,
which is a method for identifying themes or patterned responses within data (Braun &
Clarke, 2006). This method was chosen as the current specific research question and semi-

I.K. Jongejan –University of Twente – September 2017 13

structured interview questions ask for a theory-driven or deductive approach, whilst the
individual variation that results from semi-structured interviews ask for a data-driven or
inductive approach with no pre-existing coding scheme. Thematic Analysis combines
these two means of analysis (Braun & Clarke, 2006). Thematic analysis requires a cycle of
reading the data, identifying themes and returning to the data. Therefore, the current
research uses the six phases described by Braun and Clarke (2006) in the data analysis.
The verbatim transcription of the recorded interviews formed the first phase of analysis by
familiarization with the data. Then, all transcripts were read once. In the second phase, the
initial codes were generated with the research questions in mind, by going through the
data and identifying any potentially interesting topic. Phase three consisted of sorting the
codes among several potential themes. This process resulted in potential main themes,
which were sometimes similar to interview questions. In the next phase, the themes were
reviewed and refined by reading through the data once more to see if the data fit the
themes and to identify any missed codes. At this point, the themes and their codes were
compared to ones found by another researcher and adjusted according to compromises. In
the final two phases, the themes were named and a coherent analysis was written of the
whole data. Quotes were added and an answer to the research question was formulated.
The coding scheme that emerged from this process can be found in appendix D.
SPSS-software was used to assess whether the mean scores on wellbeing and
depression symptoms changed significantly. First, Shapiro-Wilk tests were conducted in
order to check the normality of the data. The Shapiro-Wilk statistic tests the null-
hypothesis that the sample comes from a normally distributed population. If the p-value is
smaller than the chosen alpha, the null-hypothesis is rejected which suggests that the data
is not normally distributed. In the case of normally distributed data, paired-sample T-tests
were conducted to compare the mean scores. The paired-sample T-test assesses whether
the difference between a pair of two related means is zero. This null-hypothesis is rejected
when the p-value is smaller than the chosen alpha, indicating that the difference between
the two means is not zero. In the case of non-normality, the Wilcoxon signed-rank test was
used as an alternative test because as a non-parametric test, it does not require normality of
the data. As the goal of this study is get a rough understanding of the possible impact of
the intervention based on a small sample size, an alpha of 0.10 was chosen for both
statistical tests. To determine whether patients had relapsed into substance use, individual
pre- and post-treatment main-problem substance use scores were compared.

I.K. Jongejan –University of Twente – September 2017 14

 Results

Respondents
The total number of respondents who participated in the intervention was eleven (n=11).
Seven out of eleven respondents finished the intervention as well as the pre- and post-
intervention test-battery (n=7). Six respondents were interviewed (n=6) (see table 1).
Reasons for dropout included non-matching expectations (respondent 11), occupation with
private issues (respondent 9) and a serious traffic accident (respondent 10). Respondent 9
later continued the intervention individually. Respondent 11 was not willing to participate
in the interview, although he did tell the author through telephone that after one session,
he did not feel the need to continue because he felt like he had recovered sufficiently after
regular treatment. He added that the intervention also felt too ‘woolly’ for him to continue.

Table 1. Overview of sample

Resp. Group Completed Interviewed? Sex Age Substance

intervention?

1 Kampen Yes Yes F 43 Cannabis

2 Kampen Yes Yes M 56 Alcohol

3 Kampen Yes No M 41 Alcohol

4 Zwolle Yes Yes F 41 Alcohol

5 Zwolle Yes Yes M 54 Alcohol

6 Zwolle Yes Yes M 61 Alcohol

7 Zwolle Yes No M 58 Gambling

8 Zwolle No Yes M 26 Gaming

9 Zwolle No No F 43 Alcohol

10 Zwolle No No M 58 Alcohol

11 Zwolle No No M 43 Alcohol

I.K. Jongejan –University of Twente – September 2017 15

Experiences with the intervention
General impression

All respondents that were interviewed (n=6) were generally satisfied with the intervention
and said that they would recommend it to a friend. The mean score that was assigned to
the intervention by five respondents was 9 out of 10 (n=5). For example, respondent 4
said: “The general impression is good, positive. It helps people to get through harder parts
of life, which is really important. It helps in becoming aware of what you are doing and
what makes you happy.” Further, respondent 6 shared: “It was an exiting experience. I
received some tools, which I can use from now on.” Respondent 4 said: “I think it’s a
wonderful construction, to combine psychology and mindfulness. It makes the intervention
accessible; there is a connection between the head and the heart.”
Four respondents thought that the intervention came across a bit ‘woolly’
sometimes, meaning that they associated it with spirituality with negative connotation.
This made them a bit sceptical at the onset of the intervention. For example, respondent 2
said: “At the start of the intervention, for around four sessions, I felt a bit confused. I
thought to myself: ‘what is this for Buddha thing they’re doing here?’ I did not know
where they were heading.” Respondent 8 explained that he experienced this ‘woolliness’
because the intervention stayed somewhat vague; it was sometimes difficult for him to
concretize the content of the sessions. This finding raises the question whether the
respondents were properly informed before the intervention. Respondent 8 did suggest
being more clear about the intervention’s content when recruiting respondents: “I received
an information pamphlet through e-mail but maybe the intake could be more extensive.
You could for example show the book to the interested person.”

Added value after regular addiction care

Two respondents stated that the added value of ‘Living to the Full’ as an after-care
intervention was that it focused more on the whole person, rather than on the addiction
problem itself. Respondent 1: “The focus was all about way of life. It did not have
anything to do with substance use.” Respondent 2 thought that this focus made it a better
intervention for people struggling with addiction than regular treatment: “The regular
treatment is only prevention of substance use. But this intervention is meant to work on
you, which is an even better prevention.” Another two respondents felt that ‘Living to the

I.K. Jongejan –University of Twente – September 2017 16

Full’ was a good after-care intervention because it focused not only on how to deal with
substance use, but also on the underlying causes and the consequences.

Mindfulness
Four respondents mentioned that mindfulness helped them retain some peace of mind,
mainly due to observation, acceptance and reflection on thoughts. For example,
respondent 1 explained that mindfulness helped her structure her chaotic thoughts:
“Taking 20 minutes of mindfulness helped me categorising my thoughts and find solutions.
Just because you step out of your thoughts for a moment, stop running and stand still for a
bit.” Similarly, respondent 5 explained: “I learned that it is OK to allow thoughts into
your mind. The thoughts pass and then I have the chance to control them, to change
them.” Further, respondent 6 shared that he felt as though he was now able to control his
thoughts by paying attention to them. It helps him worry less: “I learned that I should only
worry about things that you can do something about.”
Three respondents mentioned that mindfulness was helpful in relation to substance
dependence. For instance, respondent 2 shared: “I used to be really scared for relapsing,
but now I feel I have more control over that because of mindfulness thinking. I have this
voice in my head saying that I don’t want to drink and am not allowed to.” According to
respondent 5, becoming more aware also helps with reducing substance use: “Becoming
more aware of small things has helped me drinking moderately. Now, I only drink when I
really want to enjoy the taste.”
Many respondents also talked about accepting themselves and their mistakes.
Respondent 1 shared that she had learned to accept herself: “I accept myself with my up-
and downsides. I stopped telling myself I am doing it wrong all the time.” Respondents felt
that acceptance of self could help them reduce substance use. For instance, respondent 1
shared that feelings of guilt had often made her use more substances. Similarly,
respondent 5 explained that accepting one’s flaws is essential in continuing after relapse:
“If you drink too much one day, you will have to start over the next day, and think: ‘well, I
drank too much yesterday, and that was not what I promised myself’, accept it and just
keep going.”

Group and trainer

All respondents found it helpful to go through the intervention in a group setting, mostly
because of support, sharing experiences and to have some reference to relate to. For

I.K. Jongejan –University of Twente – September 2017 17

example, respondent 4 explains: “Going through this intervention in a group provides
energy, dynamics and acknowledgement. If one person shares something, someone else
might grow from it, too.” As for the group size, three respondents mentioned that a group
of around six people would be ideal. For instance, respondent 4, who was in the group of
four in Zwolle said: “The group should not be too large, considering that people have to
really open up about their lives, which is not easy considering their intense addiction.”
Further, respondent 4 shared that she valued starting and finishing the intervention with
the same group. Respondent 5 valued homogeneity of ages and problem substances in the
group: “Mostly because they will be going through lots of similar things, which makes it
easier to talk to each other.”
Five respondents mentioned that they were satisfied with the trainers. This was
mostly because of good advice and a warm and empathic way of counselling. Two
respondents noticed that their trainer was good at leading them back to the topic if
someone was wandering off to make sure that all participants were involved. Respondent
4: “This is especially useful, as some people tend to keep quiet if the rest talks so much.
Now everybody had a chance to share their stories.”

Treatment content

Besides the mindfulness exercises, two specific parts of the intervention were described as
important by the respondents: exploration of one’s own values and engaging in reflection.
For instance, respondent 4 now keeps her personal values in mind to remind her of what
makes her happy in case she is going through a tough time. About engaging in reflection,
respondent 6 said: “At the start of the intervention, we did an analysis of where you are
now, and what you want to achieve in the coming weeks. That is when I discovered the
reasons for my drinking habit.” Specific exercises or metaphors that respondents
mentioned included: the backpack exercise, which focuses on accepting your mental
baggage; the mountain meditation, which focuses on self-confidence; the waterfall
metaphor, which is about observing thoughts; the different layers of thoughts; the bus role-
play, which is about objection to change; and some visualisation exercises. For example,
respondent 1 said: “The mountain meditation made me feel powerful. I still I think back
sometimes to that meditation and try to relive that feeling of strength.” Respondent 2
explained: “The metaphor of the waterfall helped me to control my thoughts. Just seeing
your thoughts stream like a waterfall helps you focus on other things.”

I.K. Jongejan –University of Twente – September 2017 18

Homework
Generally, respondents thought that the amount of homework was fine, although some
found it difficult to keep up with. Two respondents noticed that the homework was not
always being discussed. For instance, respondent 1 said that a reminder of the homework
might have been useful for her. Additionally, three respondents stated that the book
‘Living to the Full’ was rather difficult to understand, although the trainers did include
some explanation of concepts in the sessions. For instance, respondent 2 explained: “The
text in the book includes concepts that you are unfamiliar with if you’re not working in the
field. More explanation of these concepts would have been useful. Sometimes, I looked
them up on the internet to understand what they meant.”

Time investment
Three respondents thought that the intervention could have been somewhat longer. For
respondent 5, the end of the intervention was a bit sudden: “It would have been nice if
there was another session after 14 days, just to check everything is going well. It allows
for some closing time. I was afraid that I would relapse immediately.” Three respondents
thought that the length of the intervention was fine.
Thus, the intervention was well accepted by the respondents as a proper after-care
for SUD. Mindfulness was experienced as calming as well as helpful in relation to
substance use. The support and guidance from group and trainers were experienced
positively, as well as several exercises and reflection on values. Points of improvement
were on the group size, the discussion of homework, the length of the intervention and the
explanation of difficult terminology. The next section considers the question whether the
intervention has had a possible extended impact on the wellbeing, depression symptoms
and substance use of respondents after their regular treatment.

Possible impact of the intervention on substance use, wellbeing and depression

symptoms

Possible impact on wellbeing

Group change in wellbeing

The mean scores for overall-, emotional-, social- and psychological wellbeing in the total
sample, in Kampen and in Zwolle increased after the intervention. Two-tailed paired-

I.K. Jongejan –University of Twente – September 2017 19

sample T-tests showed that this increase was statistically significant in the case of overall-,
social and psychological wellbeing in the total sample, and of social wellbeing in the
group in Zwolle (see table 2a).

Table 2a: Two-tailed paired-sample T-tests comparing mean pre- and post-intervention scores on wellbeing
in the total sample, Kampen and Zwolle.

Total sample

Wellbeing n M Min Max SD t df p

Overall Pre-intervention 7 28.76 6.00 61.36 22.74 -2.341 6 .058

Post-intervention 7 40.57 30.36 57.36 10.46

Emotional Pre-intervention 7 4.76 1.00 11.33 4.38 -1.582 6 .165

Post-intervention 7 7.24 5.33 9.33 1.46

Social Pre-intervention 7 7.66 0.00 19.80 7.23 -2.509 6 .046

Post-intervention 7 11.23 4.60 17.00 4.07

Psychological Pre-intervention 7 13.86 3.00 25.83 9.38 2.022 6 .090

Post-intervention 7 17.95 11.83 24.83 5.47

Kampen

Wellbeing n M Min Max SD t df p

Overall Pre-intervention 3 34.19 6.00 61.36 27.69 -.977 2 .431

Post-intervention 3 43.64 34.21 57.36 12.15

Emotional Pre-intervention 3 6.44 1.00 11.33 5.19 -.397 2 .729

Post-intervention 3 7.44 6.00 9.33 1.71

Social Pre-intervention 3 9.93 2.00 19.80 9.06 -.828 2 .495

Post-intervention 3 12.20 8.60 17.00 4.33

Psychological Pre-intervention 3 15.44 3.00 24.83 11.23 1.314 2 .319

Post-intervention 3 20.06 14.50 24.83 5.21

Zwolle

I.K. Jongejan –University of Twente – September 2017 20

 Wellbeing n M Min Maxi SD t df p

Overall Pre-intervention 4 24.68 7.00 56.36 21.71 -2.149 3 .121

Post-intervention 4 38.27 30.36 52.36 10.19

Emotional Pre-intervention 4 3.50 1.00 9.33 3.93 Z = -1.461 - .144

Post-intervention 4 7.08 5.33 9.00 1.50

Social Pre-intervention 4 5.95 0.00 15.00 6.38 -2.824 3 .067

Post-intervention 4 10.50 4.60 15.00 4.35

Psychological Pre-intervention 4 12.67 4.00 25.83 9.36 1.304 3 .283

Post-intervention 4 16.38 11.83 24.83 5.84

Individual change in wellbeing

Table 2b shows the wellbeing scores of individual respondents. Even though for
respondents 2 and 4, overall wellbeing scores somewhat decreased, they did not mention
noticing that in their daily life. Respondent 4 said that she learned to be milder for herself
and her mistakes and that the intervention had made her calmer: “Going through life in a
relaxed way makes you much happier.” Respondent 2 shared that his feelings of happiness
and had increased during the intervention, that he became more active in the community
and that his view on the future and on other people had broadened: “Before the
intervention, I was very busy with myself, and now I can see others again.” Similarly,
respondent 5 said that he had improved in his social contacts and that he became more
cheerful and rested. Respondent 1 had learned to be milder to herself: “I learned to accept
myself with my up- and downsides. I used to feel really guilty for using cannabis. Now I
have accepted that I sometimes need to use it. It feels good to value yourself as a good
person.” Respondent 6 said that he had regained hope for the future and worries less.

I.K. Jongejan –University of Twente – September 2017 21

Table 2b. Respondents’ overall-, emotional-, social-, and psychological wellbeing scores pre- and post-
intervention

Wellbeing

psychological-
emotional-
Respondent

overall -

social-
Overall increase

1 Pre-intervention scores 38 9 8 21
Post-intervention scores 44 8 11 25
3 Pre-intervention scores 6 1 2 3
Post-intervention scores 37 9 11 17
5 Pre-intervention scores 7 3 0 4
Post-intervention scores 34 9 7 18
6 Pre-intervention scores 18 2 7 9
Post-intervention scores 41 11 15 15
7 Pre-intervention scores 22 1 5 16
Post-intervention scores 35 6 13 16

Overall decrease

2 Pre-intervention scores 66 14 23 29
Post-intervention scores 62 12 21 29
4 Pre-intervention scores 61 12 19 30
Post-intervention scores 58 10 19 29

Possible impact on depression symptoms

Group change in depression

The mean scores for depression in the total sample, in Kampen and in Zwolle decreased.
Two-tailed paired-sample T-tests showed that this decrease was statistically insignificant (see
table 3a). However, it needs to be noted that the decrease of mean depression score in the
whole sample approached significance.

I.K. Jongejan –University of Twente – September 2017 22

Table 3a: Two-tailed paired-sample T-tests comparing mean pre- and post-intervention depression scores in the
total sample, Kampen and Zwolle.

Total sample

Depression N M Min Max SD t df p

Pre-intervention 7 23.86 3 47 16.61 1.874 6 .110

Post-intervention 7 16.43 1 29 12.03

Kampen

Depression N M Min Max SD t df p

Pre-intervention 3 22.33 5 47 21.94 .895 2 .465

Post-intervention 3 14.67 1 23 11.93

Zwolle

Depression N M Min Max SD T df p

Pre-intervention 4 25.00 3 37 15.06 1.698 3 .188

Post-intervention 4 17.75 1 29 13.75

Individual change in respondents

Table 3b shows the individual change in depression scores. Respondent 5 shared that he
became calmer and more cheerful through the intervention, and that he sleeps better.
Although respondent 1’s depression scores increased, she explained that the intervention
had not changed her depression symptoms: “Those symptoms come and go; sometimes I
wake up with this dark cloud in my head, feeling sad, tired and not able to do anything.
Now, I just accept that this dark cloud is sometimes there. This might explain my higher
scores on depression, but it does not feel like that.” Further, even though respondent 2’s
score before the intervention was quite low, he explained that he did feel depressed. The
intervention had helped him falling and staying asleep at night, as well as feel less
depressed in general: “Struggle with addiction often goes hand in hand with depression.
The intervention helped coping with that.”

I.K. Jongejan –University of Twente – September 2017 23

Table 3b. Respondents’ depression scores pre- and post-intervention

DASS pre- DASS post-

Respondent score score

Increase

1 15 20

Decrease

2 5 1

3 47 23

5 31 12

4 3 1

7 37 29

Remained the same

6 29 29

Possible impact of the intervention on relapse into substance use

Table 4 shows the main problem substance use scores of individual respondents showing
that six out of seven respondents did not relapse into substance use during the
intervention. Respondent 6 increased in alcohol use a few times (2) to alcohol use once or
twice a week (3). He shared that during the intervention, he started drinking again, though
he does not feel that the intervention had anything to do with that: “Rather, it was the hot
weather, which is hard for me to bear. The intervention was a moment on which it was not
possible to drink, so in that sense, it even helped.” Respondents 2 and 4 were abstinent
from alcohol already before the intervention and were still abstinent after the intervention.
They stated that the intervention helped them fight craving better. For instance, respondent
4 explained: “When I feel craving, I just accept the shitty feeling and let it come over me.”
Respondent 5 still uses alcohol every now and then and explained how he gained more
control over his drinking through the intervention: “I still like to have my beer in the
weekend, but only if I feel like I’m in control of the situation. I manage to control my
thoughts now, thinking: why do I want to stop drinking, will it be worth it to drink a
beer?” Respondent 1 used cannabis 5 to 6 times a week before and after the intervention,
but her view on using cannabis has changed: “I learned to accept it. I still use cannabis

I.K. Jongejan –University of Twente – September 2017 24

sometimes, but it bothers me less. The main issue with substance use is not the substance
use itself, but the way you feel about that. I used to feel really guilty about using. So that
absolutely improved.”

Table 4. Respondents’ scores on main problem substance use pre- and post-intervention

Pre-intervention substance Post-intervention substance

Respondent use score use score

Increase
Alcohol a few times Alcohol once or twice a week
6
2 3

Decrease
Gambling once No gambling
7
1 0

Remained the same

Cannabis 5-6 times a week Cannabis 5-6 times a week
1
5 5
No alcohol No alcohol
2
0 0
No alcohol No alcohol
3
0 0
No alcohol No alcohol
4
0 0
Alcohol a few times Alcohol a few times
5
2 2

Thus, it appeared that overall-, psychological and social wellbeing had statistically
significantly improved in respondents. Indeed, respondents shared that they felt happier,
less worried, more sociable, hopeful, calm and milder towards themselves. No statistically
significant change was observed in emotional wellbeing. The decrease in depression
scores showed a clear trend towards statistical significance. Respondents did share that
they generally felt less depressed. Finally, relapse was prevented in six out of seven
participants.

I.K. Jongejan –University of Twente – September 2017 25

 Discussion

The goal of this pilot-study was to describe the experience of previously treated SUD-
patients with an ACT-based after-care intervention and its possible extended impact on
their wellbeing, depression symptoms and relapse into substance use. It appeared that the
intervention was well accepted by the respondents and considered proper after-care for
SUD. Relapse was prevented in six out of seven respondents during the intervention.
Overall- social and psychological wellbeing significantly improved and the reduction in
depression symptoms showed a clear trend towards significance. Respondents’ experience
supported these results.

Acceptability of the intervention

As expected, the respondents accepted the intervention well and experienced it as useful.
This finding might be explained by the desire for after-care in SUD patients, illustrated by
the research of Tuten, Jones, Lertch and Stitzer (2007) who reported that 98% of SUD-
patients enrolled in a residential detoxification program wished to have some form of
after-care. This apparent need for after-care was also confirmed in the interviews, in which
respondents shared that they would have preferred that the intervention was somewhat
longer and did not have a sudden ending to it. The high acceptability found in this study is
consistent with the study of Amaro and colleagues (2014) who reported high acceptability
of a mindfulness-based relapse-prevention program by SUD-patients. Further, principles
of ACT were accepted well by other patient groups in regular treatments (Johns et al.,
2016; Fledderus et al., 2012) and SUD-patients accepted other forms of after-care well
(Haug et al., 2015; Burleson & Kaminer, 2007).
Respondents found the intervention suitable as after-care because it focused on the
individual as a whole rather than solely focusing on the SUD. This finding fits the
theoretical goal of ACT to not solely focus on the disease but rather on the development of
general skills that allow for personal development (Fledderus et al., 2012). This extended
focus provided respondents the support they needed in their current post-treatment phase
of sustaining behaviour change and integrating it into daily life. Further, this finding
indicated that the intervention was complementary to the regular treatment, rather than a
repetition of (parts of) the treatment. The mindfulness exercises were eventually
experienced as beneficial to all respondents that were interviewed. This finding is
consistent with the study of Brewer and colleagues (2009) who reported that mindfulness

I.K. Jongejan –University of Twente – September 2017 26

treatment was rated as highly satisfactory by SUD-patients, as well as the finding that a
mindfulness-based relapse-prevention program was highly accepted by SUD-patients
(Amaro et al., 2014). In the current study, mindfulness helped respondents relax, being
milder and more accepting towards the self and fight craving-related thoughts. This
finding is consistent to ACT-theory, in which acceptance and cognitive defusion are two
core-processes (Hayes et al., 2006). The finding that mindfulness helped SUD-patients to
cope with craving-related thoughts was also found by Skanavi and colleagues (2011) who
reported significant decrease in avoidance thoughts in SUD-patients after mindfulness-
based treatment.
An interesting finding was that SUD-patients seemed to appreciate social support
and guidance: the guiding, warm and empathic role of the trainers and being in an
intimate, stable group setting was experienced positively. This finding raises the question
whether the intervention would have been as well accepted if it were provided
individually. The apparent need and appreciation for social support and guidance might be
explained by reduced self-efficacy in SUD-patients, which means that they have reduced
belief in their ability to reach a desired goal (Taylor & Williams-Salisbury, 2015). As
studies have found that enhanced self-efficacy improves treatment outcomes in SUD-
patients (Kadden & Litt, 2011) and reduces the risk of relapse (Tate et al., 2008; Ilgen &
McKellar, 2005), SUD-patients might especially benefit from the support and guidance of
this ACT-based after-care. One could wonder however, whether an after-care intervention
without ACT-components, focusing on social support alone would be sufficient to gain
similar results.
Respondents emphasized that reading the book and keeping up with homework
was sometimes challenging, which indicates that they could have used more guidance on
that matter. For example, homework could be discussed extensively as well as difficult
concepts and metaphors. Also, respondents eventually thought that the intervention came
across somewhat ‘woolly’, which they had not expected. This indicates the need for a
clear introduction before the start of the intervention, in which, for example, the
respondents are told that, although mindfulness is associated to Buddhism, it does not
necessarily carry any religious connotations.

I.K. Jongejan –University of Twente – September 2017 27

Possible impact on wellbeing and depression symptoms

It was also expected that the intervention would improve wellbeing and reduce depression
in SUD-patients. Indeed, overall-, social- and psychological wellbeing changed
statistically significantly, which is an interesting and promising finding considering the
small n of this study. Respondents shared that they got milder towards their flaws, felt
calmer, worried less, were motivated to participate in the community, improved in their
relationships and felt hopeful about the future. This finding is consistent with studies that
reported improved wellbeing after participating in an ACT-intervention in people with
depression symptoms (Bohlmeijer et al., 2011; Fledderus et al., 2012; Pots et al., 2015;
Lappalainen et al., 2014; 2015). The importance of enhanced wellbeing in SUD-patients is
illustrated by studies that have shown that increased wellbeing is associated with
decreased (risk of) substance use (Poudel, Sharma, Gautam & Poudel, 2016; Stevens,
Jasons, Ram & Light, 2015; Pidd, Roche & Fisher, 2015).
Additionally, social wellbeing improved statistically significantly, which again is
an interesting finding considering the small n of this study. It was measured by questions
on whether respondents felt part of the community and had a positive attitude towards
society and other people. As such, this finding is consistent with Vanderplasschen and
colleagues (2010), who found that SUD-patients who participated in after-care increased
in number of contacts with family members. The importance of increased social wellbeing
is illustrated by a study of Stevens and colleagues (2015), who showed that social support
is linked to abstinence-specific self-efficacy. Apparently, feeling socially capable and
supported helps people with SUD to believe in their capabilities to stay abstinent. The
importance of social wellbeing for SUD-patients is further illustrated by studies that have
linked low social support to substance use (Tsai & Thompson, 2013; Dorard, Bungener &
Berthoz, 2013) and to lower quality of life of SUD-patients (Brown, Jun, Min & Tracy,
2013). Other studies have linked higher social support to reduced likelihood of relapse
(Ellis, Bernichon, Yu, Roberts & Herrell, 2004) and longer abstinence (Laudet, Cleland,
Magura, Vogel & Knight, 2004). Even though social support is not similar to social
wellbeing, SUD-patients who increase in social wellbeing might be better able to maintain
and mobilize social support and benefit from it.
Further, the reduction in depression symptoms showed a trend towards statistical
significance. Most respondents experienced this change in their daily life. They noticed
that depression symptoms such as feeling down, having troubles sleeping, worrying and

I.K. Jongejan –University of Twente – September 2017 28

feeling anxious decreased, partly because they could accept these feelings more. The
increased capability of accepting aversive feelings fits one of the core-processes of ACT:
acceptance (Hayes et al., 2006). The importance of reduced depression symptoms in SUD-
patients is illustrated by studies that have reported a relationship between negative affect
and substance use (Kelly, Stout, Magill, Tonigan & Pagano, 2011; Abayomi, Onifade,
Adelufosi & Akinhanmi, 2013). For instance, Lo and colleagues (2015) researched
whether the diagnosis of depression lead to substance use in a longitudinal study, reporting
that depression and substance use often co-occurred.

Possible impact on relapse into substance use

It was expected that the after-care intervention would prevent relapse into substance use.
Indeed, relapse was prevented in six out of seven respondents. This finding is consistent
with previous studies that reported reduced probability of relapse in SUD-patients
attending after-care (Jason et al., 2007; Frydrych et al., 2009; Burleson et al., 2012).
Respondents noticed that the intervention was helpful in relation to substance use. Firstly,
because becoming more self-accepting could help continuing abstinence after relapse and
secondly, because observing and controlling thoughts was found to be helpful in dealing
with craving-related thoughts.

Strengths and limitations

To date, to our best knowledge no research on this topic has been conducted on SUD-
patients in The Netherlands, which is the case in this study. Also, the experience of SUD-
patients with this ACT-based after-care intervention is assessed well by this study, as the
extensive semi-structured interviews have allowed for a deep understanding of this.
However, the results of this study are not very generalizable, considering the small
n. Additionally, only eight out of eleven patients that participated in the intervention were
included in the study. Three out of four patients that dropped out were not interviewed,
which might have led to possible bias in the results. Further, no follow-up measurement
had been conducted, while it could have been useful to assess the possible longer-term
impact of the after-care intervention on wellbeing, depression symptoms and relapse into
substance use. Finally, considering the small n of this study, the Shapiro-Wilk tests that
were used to check for normality of the data were not reliable. This means that the choice
of statistical test used on the data might have been incorrect.

I.K. Jongejan –University of Twente – September 2017 29

Recommendations
As ‘Living to the Full’ seems to be a promising after-care intervention for SUD-patients
according to this pilot-study, further research should be considered. This research could
assess the acceptability and the impact of the intervention more clearly by using a larger n
or using follow-up data to assess the longer-term impact. If positive results are found here,
a larger-scale Randomized Controlled Trial (RCT) could be conducted, in which the
effects of this intervention are to be assessed more reliably. As ‘Living to the Full’ was
shown to be accepted well and to have benefited this specific sample, the intervention
could be implemented on a small scale within Tactus. In the case of implementation or
further research, one should improve the information given to participants before the start
of the intervention so that participants know what to expect from it. Also, trainers are
recommended to emphasize homework and explanation of terminology during the
sessions. The group is recommended to consist of around six people, who start and finish
the intervention together. Finally, more generalizable results from larger-n-studies are
recommended before the intervention is implemented on a broader scale.

I.K. Jongejan –University of Twente – September 2017 30

 Conclusion

The ACT-based after-care intervention ‘Living to the Full’ seems to be a suitable after-
care intervention for SUD-patients. Not only was it accepted well by the respondents, it
constituted significant change in their wellbeing. Considering the small n of this study,
this finding indicates the possibly large impact of this intervention on the wellbeing of
SUD-patients. Relapse into substance use was prevented in six out of seven respondents,
which is a promising finding considering the high risk of relapse in SUD. Depression
symptoms changed nearly significantly and respondents reported to feel less depressed. As
wellbeing and depression are linked to substance use by previous research, improvement
on these constructs in SUD-patients are of utter importance. Future research is needed to
further confirm the findings of this pilot study.

I.K. Jongejan –University of Twente – September 2017 31

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 Appendices

Appendix A – Evaluation form in Dutch

Evaluatie pilot Voluit Leven
Wij zijn benieuwd naar jouw ervaringen over de pilot Voluit Leven die je hebt gevolgd. Hieronder vind je een
aantal vragen die gaan over de tevredenheid en de opzet van behandeling.

Zou je deze vragen willen beantwoorden? De resultaten worden gebruikt om de behandeling te verbeteren.

Jouw medewerking wordt zeer gewaardeerd. Je kunt de ingevulde vragenlijst terugsturen via de e-mail vóór het
interview.

Deel 1: Algemene evaluatie over de verslavingsbehandeling

Hieronder staan vragen over de algemene indruk van de behandeling. Zou je het voor jou best passende
antwoord willen aankruisen?

1. Wat vind je van de kwaliteit van de behandeling die je hebt ontvangen?

o Uitstekend
o Goed
o Redelijk
o Slecht

2. Heb je het soort behandeling ontvangen dat je hoopte te krijgen?

o Nee, beslist niet
o Nee, nauwelijks
o Ja, in het algemeen wel
o Ja, zeker

3. In hoeverre heeft de behandeling aan jouw wensen voldaan?

o Aan al mijn wensen is voldaan
o Aan de meeste van mijn wensen is voldaan
o Aan slechts enkele van mijn wensen is voldaan
o Aan geen van mijn wensen is voldaan

4. Stel dat een vriend(in) dezelfde hulp nodig zou hebben, zou je dan de behandeling aanbevelen?
o Nee, beslist niet
o Nee, ik denk van niet
o Ja, ik denk van wel
o Ja, zeker

5. Hoe tevreden ben je over de hoeveelheid hulp die je hebt ontvangen?

o Zeer tevreden
o Tamelijk tevreden
o Tamelijk ontevreden
o Zeer ontevreden

6. Heeft de behandeling je geholpen beter om te gaan met jouw klachten?

o Ja, het heeft aanzienlijk geholpen
o Ja, het heeft wel wat geholpen
o Nee, het heeft eigenlijk niet geholpen
o Nee, het heeft de zaak alleen maar verergerd

7. Hoe tevreden ben je over het geheel genomen met de behandeling die je hebt ontvangen?
o Zeer tevreden
o Tamelijk tevreden
o Tamelijk ontevreden
o Zeer ontevreden

I.K. Jongejan –University of Twente – September 2017 38

8. Zou je de behandeling nog een keer doen, als je dat nodig zou hebben?
o Beslist niet
o Nee, ik denk van niet
o Ja, ik denk van wel
o Ja, zeker

Deel 2: Evaluatie van onderdelen van de verslavingsbehandeling

1. Hieronder staat een lijst met onderdelen van de behandeling. Zou je per onderdeel willen aankruisen wat je
vond van de hoeveelheid?
Hoeveelheid Veel te Te weinig Precies Te veel Veel te veel
weinig goed
Het aantal sessies

Hoeveelheid teksten

Hoeveelheid huiswerk

Hoeveelheid opdrachten
tijdens de sessies

2. Hieronder staat een lijst met onderdelen van de behandeling. Zou je willen aankruisen hoe zinvol je de
onderdelen vond?
Zinvolheid Helemaal Niet zinvol Een beetje Zinvol Heel zinvol
niet zinvol zinvol
Mindfulness-oefeningen

Bijhouden van pijnlijke

momenten en gedachten
Acceptatie van onprettige
gevoelens
Gedachten waarnemen
(cognitieve defusie)
Leven naar waarden

Huiswerk maken

Deel 3: Evaluatie van de deelname aan de verslavingsbehandeling

1. Wat vond je van de samenhang tussen de verschillende onderdelen (zoals tussen de mindfulness oefeningen,
gedachten waarnemen en leven naar waarden)?

2. Kun je beschrijven aan welke bijeenkomsten je het meeste hebt gehad? Waarom heb je het meeste aan deze
bijeenkomsten gehad?

3. Kun je beschrijven aan welke bijeenkomsten je het minste hebt gehad? Waarom heb je het minste aan deze
bijeenkomsten gehad?

I.K. Jongejan –University of Twente – September 2017 39

4. Welke aanbevelingen heb je voor verbetering van de behandeling?

5. Welke rapportcijfer geef in je zijn algemeenheid voor de behandeling? Omcirkel het cijfer.

1 2 3 4 5 6 7 8 9 10

Heel slecht Heel goed

Hartelijk dank voor je medewerking!

I.K. Jongejan –University of Twente – September 2017 40

Appendix B – Semi-structured interview guide in English
Part A: Questions on the experiences with the intervention

1. In general, what were your experiences with the intervention?

- What did you learn from it?
- Was it different than usual treatment?
- Was that good or bad?

2. Did you have experience with ACT interventions before?

3. Did the intervention meet your expectations?

4. If we take a look at the different parts of the intervention, what stayed with you the most?
Can you describe why?

5. How have you experienced the mindfulness exercises? Did these benefit you?

6. How have you experienced the part in which you had to think about your values and live
according to those? Did this benefit you?

7. Which session was specifically helpful to you? Why?

- Which one was less helpful? Why?
- Was there a specific assignment that was helpful? Why?
- Was there a specific assignment that was less helpful? Why?
- Did you think the sessions fit together? Why?

8. How have you experienced the workload?

- What did you think of the amount of sessions?
- What did you think of the amount of homework?

9. How have you experienced working in a group setting?

- How was the support from group members?
- How was the support from trainers?

10. How did the treatment help you to better deal with your complaints?

11. What do you think of the fact that the intervention was offered as after-care?
- Did add value to the intervention? Why?
- Did it have added value when it comes to addiction care?

12. What is a strong point and weak point of the treatment? Why?

13. Do you have any suggestions for improving the treatment?

I.K. Jongejan –University of Twente – September 2017 41

Part B: The impact of the intervention on wellbeing, depression symptoms and substance use

1. Has the treatment reduced your complaints?

- Which complaints changed?
- In what way did they change?
- What part of the intervention was helpful in this?

2. How has the intervention changed your substance use?

- Which parts of the intervention contributed to that?

3. How has the intervention changed your depression symptoms?

- Ability to relax
- Mood
- Physical complaints
- Emotional reactions
- Worrying
- View on the future
- Self-worth
- Life-goal
- Anxiousness

4. How has the intervention changed your wellbeing?

- Feeling of happiness
- Feeling of community

I.K. Jongejan –University of Twente – September 2017 42

Appendix C – Semi-structured interview guide in Dutch

Deel A: Vragen over de ervaringen met de interventie

1. Wat is uw algemene ervaring met de interventie?

- Wat heeft u ervan geleerd?
- Was dit anders dan de algemene verslavingsbehandeling?
- Was dat goed of slecht?

2. Had u al eerder ervaring opgedaan met een ACT-interventie?

3. Voldeed de interventie aan uw verwachtingen?

4. Als we kijken naar de verschillende onderdelen van de interventie, welke is u dan het
meeste bijgebleven?

5. Hoe vond u de mindfulness-oefeningen? Denkt u dat die u hebben geholpen?

6. Hoe vond u het gedeelte waarin u nadacht over de waarden die belangrijk zijn in uw
leven? Heeft dit u geholpen?

7. Welke sessie was vooral nuttig voor u? Waarom?

- Welke was minder nuttig voor u? Waarom?
- Was er een specifieke opdracht die u heel nuttig vond, en waarom?
- Was er een specifieke opdracht die u minder nuttig vond, en waarom?
- Vind u dat de sessies allemaal bij elkaar passen? Waarom?

8. Wat vond u van de hoeveelheid werk en tijd die u in de interventie moest steken?
- Wat vond u van het aantal sessies?
- Wat vond u van de hoeveelheid huiswerk?

9. Hoe heeft u het ervaren om de interventie in een groep te doorlopen?

- Hoe was de steun van groepsgenoten?
- Hoe was de steun van trainers?

10. Hoe heeft de interventie geholpen om met uw klachten om te gaan?

11. Wat vond u ervan dat de interventie als nazorg werd aangeboden?
- Had dat een toegevoegde waarde? Waarom?
- Wat was de toegevoegde waarde op het gebied van verslaving?

12. Wat is een sterk en een zwak punt van deze interventie? Waarom?

13. Heeft u suggesties om de interventie te verbeteren?

I.K. Jongejan –University of Twente – September 2017 43

Part B: De impact van de interventie op welbevinden, depressiesymptomen en
middelengebruik.

1. In hoeverre heeft deze interventie ervoor gezorgd dat uw klachten zijn veranderd?
- Welke klachten zijn veranderd?
- Hoe zijn ze veranderd?
- Welk deel van de interventie heeft hier vooral in meegewerkt?

2. In hoeverre heeft de interventie uw middelengebruik veranderd?

- Welk deel van de interventie heeft hier vooral in meegewerkt?

3. In hoeverre heeft de interventie uw depressieklachten veranderd?

- Kunnen relaxen
- Stemming
- Lichamelijke klachten
- Emotionele reacties
- Piekeren
- Toekomstperspectief
- Eigenwaarde
- Levensdoel
- Angstigheid

4. In hoeverre heeft de interventie uw welbevinden veranderd?

- Gevoelens van geluk
- Verbondenheid met mensen

I.K. Jongejan –University of Twente – September 2017 44

Appendix D – coding scheme

General impression Added value Mindfulness

- Positive/negative - individual as a whole - Focus on body
- Recommend to others - mindfulness - Control breathing
- ‘Woolly’ - underlying motivations - Awareness
- Tool - Reflection
- Skeptical - Observing thoughts
Acceptance Group and trainer Separate parts and assignments
- Control thoughts - Support group - Mountain meditation
- Broader view - Support trainer - Waterfall metaphor
- Milder towards self - Group size - Backpack
- Saying no - Similar substances - Values
- Increased acceptance - Change in group -Reflection
- Role-plays
Homework Time investment Wellbeing
- Discussion of homework - Intervention length - Feelings of happiness
- Decent amount - Sessions length - Calmness
- Difficult text - Time investment - Connectedness
- Homework - Wellbeing
Depression Substance use Craving
- Depression symptoms - Substance use - Craving
- Sleep - Fight craving
- Craving-related thoughts

I.K. Jongejan –University of Twente – September 2017 45