Extended Abstract
Introduction
Substance and stimulant use and dependence lead to structural changes in society across economic, social, political, and cultural domains, representing a challenging global issue. Available statistics indicate that substance use disorder affect more than 7% of the world’s population and 5% of the active population in Iran. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), considers the essential feature of substance use disorder to be the presence of cognitive, behavioral, and physiological symptoms, such as impaired control over substance use, social dysfunction, risky use, and physiological dependence occurring within a 12-month period. One of the complications associated with substance use is aggressive behavior. Aggression can be categorized into overt and indirect forms. Overt aggression may manifest physically (e.g., physical assault) or verbally (e.g., verbal threats). Indirect aggression occurs through behaviors such as backbiting and rumor-spreading, which can culminate in an individual’s isolation from society. In both categories, the mental health of the individual and the community is adversely affected by these behaviors.
Alongside pharmacological treatments and preventative programs for substance use disorder, various therapies and interventions employing physical, psychological, and spiritual approaches have been utilized as well. These approaches include psychoanalysis, behavior therapy, pharmacotherapy, cognitive and interpersonal psychotherapies, individual and group therapies, and supportive group therapy, which the efficacy of some of them has been confirmed by empirical evidence. Nevertheless, these therapies, such as catharsis in psychoanalysis or behavior modification in behavior therapy through the provision of novel reinforcement for appropriate behavior, reduce the speed and success of treatment due to their efficacy being limited to a single context and their neglect of other relevant contexts.
One of the novel therapies for addressing the problems of substance-dependent individuals is schema therapy. This treatment is an integration of cognitive, experiential, and behavioral pattern-breaking intervention strategies. Schema therapy is a structured and organized approach that overlaps with other therapeutic models, such as cognitive, Gestalt, object relations, psychoanalytic, and constructivist approaches, while not fully aligning with any single therapeutic approach.
By combining four modalities, i.e., cognitive, experiential, behavioral, and relational approaches, schema therapy in individuals not only challenges maladaptive schemas, which are the primary cause of ineffective and irrational thoughts, but also emotionally reduces and depletes negative emotions, such as anger stemming from unmet needs for spontaneity and secure attachment.
Schema therapy is an effective treatment in the field of substance use disorder, influencing individuals’ coping styles and emotion regulation, and can also be effective in reducing avoidance behaviors and substance cravings. This study was conducted to determine the effect of group schema therapy on aggressive behaviors in individuals with substance use disorder.
Methods
This quasi-experimental study was conducted on 42 male individuals with substance use disorder. The participants were allocated into two groups of 21: A control group and an experimental group. For the experimental group, an integrated schema therapy protocol consisting of eight 2-hour sessions was implemented, while the control group received the clinic’s routine treatment approach.
The inclusion criteria included provision of informed consent to participate in the study; a minimum of 20 days having elapsed since admission to a rehabilitation center and physical detoxification; physical health (based on the patient’s medical record); and an age range of 20 to 75 years. It is noteworthy that the patients had a history of stimulant use.
The exclusion criteria included incurable physical illness; absence from more than one class session; lack of necessary mental health and, occasionally, severe psychosis (based on the patient’s medical record) requiring solely pharmacotherapy; dishonesty; lack of cooperation in completing questionnaires; and physical or psychological inability to participate in the course after informed and personal consent.
Aggression was assessed using the revised version of the Buss-Perry Aggression Questionnaire (1992). This questionnaire is a self-report instrument comprising 29 items to evaluate four types of aggressive behavior (physical aggression, verbal aggression, anger, and hostility). The reliability of the Buss-Perry Aggression Questionnaire was examined using the test-retest method and Pearson’s correlation coefficient. The reliability coefficients were determined to be 0.74, 0.78, 0.68, and 0.68 for the factors of anger, aggression, resentment, and suspicion, respectively.
Results
The mean and standard deviation of the aggression score in the schema therapy group (79.619±12.212) were better in the post-test compared to the control group (107.476±7.890) (P<0.001). According to the results of the post-hoc analysis of covariance (ANCOVA) on aggression scores, after adjusting for the pre-test, schema therapy had a significant effect on aggressive behaviors in substance-dependent individuals (F = 124/359).
Conclusion
Based on the findings of this study, schema therapy was effective in reducing aggressive behaviors in individuals with substance use disorder.
Early maladaptive schemas can be activated in situations involving exposure to substances and anger-provoking stimuli. Thus, by directly addressing these early schemas in challenging situations, schema therapy can be effective in increasing individuals’ tolerance for conditions that generate aggression and substance craving, ultimately giving rise to an improvement in substance use disorder.
The limitations of this study include the inability to fully control variables, such as cultural, economic, and social status, as well as the focus on a male population. Additionally, due to time constraints and the anticipated attrition of participants, the follow-up of treatment effects were not conducted. It is recommended that future studies consider the follow-up of treatment effects, which necessitates greater collaboration between addiction treatment centers and the protocol implementation site. Given the favorable effectiveness of schema therapy on substance use disorder and aggressive behavior, it is proposed that this therapy be utilized as an efficacious psychotherapy alongside pharmacotherapy to improve the symptoms of substance use disorder and its consequences on a broader scale. It is also recommended that future studies be conducted on a female population.
Ethical Statement
The current study was approved by the Research Ethics Committee of Islamic Azad University, Chalus Branch (IR.IAU.CHALUS.REC.1401.072).
Funding
This article has been extracted from Mahboubeh Zahedi’s Ph.D dissertation in General Psychology at Islamic Azad University, Gorgan Branch.
Conflicts of Interest
No conflicts of interest.