Running head: EVALUATING THE REDISCOVERY PROCESS 1 Evaluating The Rediscovery Process as a Treatment Programme for a Range of Substance Use Disorders. Phil Parker Id: php0059 A Thesis Submitted in Partial Fulfilment of the Requirements for the Degree, Doctor of Philosophy in the Psychology of Health London Metropolitan University Sept 2019 EVALUATING THE REDISCOVERY PROCESS 2 Abstract Poor outcomes for many of those in treatment for substance use disorders (SUD) has raised interest in recovery-based approaches, positive psychology and the importance of flourishing, a quality defined as functioning positively in all realms of life. However, there is little research into approaches that focus on flourishing in SUD. This study evaluates The Rediscovery Process (TRP), a brief, recovery focussed approach for SUD. It teaches self-coaching techniques designed to increase flourishing and recovery capital (psychological health, physical health, quality of life, days at work, college, volunteering and housing status) and to reduce impulsivity. A mixed-methods approach was used, comprising of three studies. First, to evaluate the effect of the TRP on substance use, flourishing, impulsivity and recovery capital, a preliminary pilot study using a randomised wait-list controlled structure was conducted. 72 participants who had been formally diagnosed with single and poly-drug use issues, including, alcohol, opiate, cocaine, crack, cannabis and amphetamine were assigned to either immediately receive the intervention or to wait for the treatment, providing a wait-list control arm. Validated measures of substance use, flourishing, impulsivity and recovery capital were assessed pre- and 1 month post- intervention. The results of the study showed that, compared to the wait-list control group, the TRP provided a significant decrease in alcohol use (the most commonly used substance in the study) and impulsivity, and an increase in flourishing and recovery capital. Due to the low numbers of those using other substances in the study, no other significant changes in use were identified. Associations between flourishing, impulsivity and alcohol usage were also evaluated and a significant moderate negative association between impulsivity and flourishing was found, an association which has not been EVALUATING THE REDISCOVERY PROCESS 3 previously reported. Second, once the intervention and wait-list groups had both received the intervention, a cohort study (n = 69) evaluated the sustainability of this combined group’s changes. Validated measures of substance use, flourishing, impulsivity and recovery capital were assessed pre-, 1 and 3 months post-intervention. Impulsivity and alcohol use decreased significantly at 1 and 3 months post-intervention, compared to pre- intervention measurements. Flourishing and psychological health increased significantly at 1 and 3 months post-intervention, compared to pre-intervention measurements. No effect on outcomes was seen in the different referral routes for all analysed measures, at all time points, with the exception of impulsivity at 1month and QOL at 3month. Associations between flourishing, impulsivity and alcohol usage were also evaluated and a highly significant strong association between a decrease in impulsivity and an increase in flourishing was found, however, no other significant associations were found. Third, a thematic analysis evaluation of participants’ experience of the TRP identified two main themes (1) control and (2) flourishing. These themes reflected the value participants found in applying the approach to controlling substance use, emotional regulation, personal growth, empowerment and their sense of self. Many participants noted differences between this approach and those previously tried and the majority found the intervention effective. However, some did not find it of use and there was evidence of issues of a conflict between the concepts of this and other previously used models, which made adopting the new ideas difficult for some. These studies show that, compared to TAU, the TRP approach significantly reduced alcohol use and impulsivity and increased flourishing and elements of recovery capital and this was maintained over the 3 month period. This supports its place as an approach for those with SUD and opens the possibility of its inclusion within the range of positive psychology interventions for SUD. These results help bridge the gap between the EVALUATING THE REDISCOVERY PROCESS 4 more traditional focus of addressing the psycho-pathology in SUD and the newer interest in increasing flourishing. It is hoped that this study will encourage further research and a wider adoption of the flourishing concept and this new approach, in SUD. Keywords: Positive psychology, flourishing, addiction, recovery capital, substance use, alcohol, impulsivity, self-coaching, Lightning Process, training programme EVALUATING THE REDISCOVERY PROCESS 5 ACKNOWLEDGEMENTS This thesis was accomplished with the assistance and support of many people. I would like to thank my initial primary supervisor Dr. Esther Murray, who provided much support and guidance during the first years of this project and to Dr. Sam Banbury who kindly agreed to take on the project on Dr. Murray’s departure, helpfully supporting and supervising the project to its conclusion. My thanks also go to Dr. Chris Chandler (secondary supervisor) for his thoughtful guidance and support provided throughout the duration of the project. I would like to thank the TRP practitioners and charities involved who donated considerable amounts of their time and experience to the project. It simply would not have been possible to have undertaken the study without their generosity. I would also like to thank all the participants who, whilst facing considerable challenges in their lives, took the time to attend an unfamiliar intervention and complete the all-important collection data forms and survey. Finally, I would like to thank my long suffering wife, family, management team and dog for tolerating my absence and ruminations about the project over the last 5 years, again without your support and forbearance it would not have been possible. EVALUATING THE REDISCOVERY PROCESS 6 Table of Contents List of Tables 16 List of Figures 25 List of Abbreviations 26 Chapter 1: Introduction 28 Defining the Problem 28 The Aim and Hypotheses of the Studies 30 Objectives of the Studies 31 Conflict Issues and Reflexivity 32 Dual Role of Designer and Researcher 33 Ameliorating Conflict of Interest Issues - Reflexivity Procedures 35 Personal Reflexivity 38 Epistemological Reflexivity 41 Methodological Reflexivity 43 Reflexivity Summary 46 Chapter 2: Current Issues, Concepts and Approaches Within SUD, and the Need for Novel Approaches 48 Key terms: SUD, Addiction and Recovery 48 The TRP approach 50 Views of Substance Use 50 Pathology or Dysfunction - the Disease Model 51 AA, 12 Step Programs (TS), Mutual Aid and 12 Step Facilitation (TSF) 52 Psycho-Social, Cognitive, behavioural, Motivational Models 54 Choice Theory: Conscious and Less Conscious Choice 55 EVALUATING THE REDISCOVERY PROCESS 7 Stress Model, the Self-Medication Model and Dual Diagnosis 57 Decision-Making Theories 58 Trans Theoretical Model (TTM)/Cycle of Change 61 The Abstinence Violation Effect, Motivational Interviewing (MI) 62 Cognitive Behavioural Therapy (CBT) 64 Summary of Choice Theory 67 Impulsivity 68 Impulsivity and SUD 68 Free Will and Free Won’t 69 Summary of Impulsivity 70 Instrumental Learning and Neuroplasticity 70 Self-Cure 72 Integrative Models 72 Neuro Linguistic Programming (NLP) 73 Research, Criticism and Debate 74 Positive Psychology 76 Positive Psychology and Links to Other Approaches 78 Broaden and Build 80 Positive Psychology and SUD Research 81 Flourishing and SUD Research 83 Chapter 3: The Utility of Measuring Flourishing in Substance and Alcohol Use Disorders Research; a Systematic Review 86 Specific Use of the Term ‘flourishing’ 86 Materials and Methods 87 Identification 89 Eligibility 89 Included 89 EVALUATING THE REDISCOVERY PROCESS 8 Screening 89 Literature Search Results 90 Review of the Studies 91 Study Design 91 The Value of Measuring Flourishing in Those with SUD 92 Database Studies 92 Novel Studies 94 College Studies 95 Salvation Army Study 96 Service Staff’s Perspective on the Value of Flourishing 97 Discussion 99 Chapter 4: The Rediscovery Process 102 Origin of TRP 102 The TRP Intervention 102 Themes in LP/TRP Model for Change 103 Language 104 Somatic Learning 104 Encouraging Flourishing 105 Awareness 105 Interrupt, redirecting focus and self-coaching 106 Additional Steps in TRP and Post Seminar Support 108 LP and TRP Research and Critiques 109 TRP and Mindfulness 116 Similarities and Difference between MI, CbT and TRP 117 TRP and AA/TSF 119 Conclusion 121 Chapter 5: Quantitative Studies - Research Methodology 122 EVALUATING THE REDISCOVERY PROCESS 9 Background and Nomenclature of Preliminary Controlled and Cohort Studies 122 Participants 124 Clarity of Diagnosis 124 Recruitment, Attrition and Conflict of Interest Issues 126 Materials 129 Treatment Outcomes Profile Form 129 Flourishing Scale 130 Impulsivity Measures 131 Procedure 132 Ethical Considerations 135 Chapter 6: QuanTitative Study: Data And Analysis 136 Power 136 Participant numbers and missing data analysis 137 Reliability of the Measures 139 Chapter 7: Analysis of the Primary Outcome – Changes in Substance Use 141 Drug Categories Recorded 141 Sample Characteristics and Analysis of Changes in Alcohol Use During