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Background: A history of complex trauma alters basic self-structure, attachment system and core areas of interpersonal functioning and relationships. There is increasing recognition of the high proportions of complex trauma histories within substance misusers and limited research into the sequelae of complex trauma, particularly in relation to comorbid complex trauma and substance misuse. There is a distinct lack of adequate theory and guidelines for treatment. Research Aim: to explore psychologist’s experiences of and perspectives about their work with substance misusers with a history of complex trauma. Complex trauma is a term used to describe experience’s which arise from severe, prolonged and repeated trauma which is often interpersonal in nature. Courtois & Ford (2009) have defined complex trauma as “involving stressors that: are repetitive or prolonged, involve direct harm and/or neglect and abandonment by ostensibly responsible adults, occur at developmentally vulnerable times in the victim’s life, such as early childhood, have great potential to compromise severely a child’s development.” (p1). The prototype trauma that was first described under the term complex trauma was child abuse and neglect. Method: Semi-structured interviews were conducted with eleven clinical and counselling substance misuse psychologists working across four health boards in Central Scotland. The data was analysed using Interpretative Phenomenological Analysis (IPA). Results: Six main superordinate themes emerged from the data: 1. Challenges in negotiating therapeutic relationship; 2. Balancing relational forces; 3. Walking the tightrope of comorbidity; 4. Conceptual dearth (surrounding complex trauma); 5. Emotional impact of Work, and, 6. Core role of therapeutic relationship (in treatment and recovery). Discussion: Participants accounts suggest there are many risks to balance as well as paradoxes inherent in this type of work. The nature of a history of complex trauma means that often clients have difficulties with attachment and relational aspects in their lives, which in turn affect their engagement in the therapeutic relationship. The findings of this study suggest that it is precisely because relationships seem so threatening and challenging for these clients, that the therapeutic relationship appears to form such a vital role in the therapeutic treatment and recovery process for these client.

This thesis portfolio includes two studies, a qualitative grounded theory of treatment adherence in people who inject drugs (PWID) and a systematic review of staff turnover in substance misuse services. The empirical paper is presented first, the findings of which led to the systematic review. The qualitative interview study arose from observations made within a clinical trial for the treatment of chronic Hepatitis C (HCV). The Chief Investigator of the ERADICATE trial team initially approached the Adult Psychological Therapies Service to investigate what seemed to be an anomaly – patient engagement with HCV treatment had far exceeded expectations. Indeed, positive treatment adherence is not common among PWID. What is more remarkable is participants continued the trial while experiencing the highly aversive side-effects of interferon, a medication known to mimic opioid withdrawal. It is important, if not crucial, to acknowledge the wider socio-cultural context in which this thesis portfolio was produced; the political landscape changed significantly over the course of writing. Divisive judgements about what characteristics make a person worthy and deserving of resources, became more dominant in public discourse and heightened the author’s awareness to these aspects in the data. PWID are among the most marginalised, and stigmatised groups in society. Several of the participants interviewed were homeless and all were at various points on a relapsing trajectory of injecting drug use. Perhaps positive treatment adherence in this population is counter-intuitive because intuition is often based on assumptions derived from implicit biases. Indeed, until 2008, Scottish policy systematically denied HCV treatment to PWID. Due to the assumption that re-infection was inevitable, treatment was seen to be wasteful. Epidemiological studies now show is that public health is significantly improved when PWID are treated, as population prevalence goes down. Completing this thesis led to an examination of fundamental assumptions, not just relating to the participants or the data, but also relating to the question of what Clinical Psychology is. What can we contribute to the science of human behaviour? How does a self-aware mind arise and become autonomous? What leads adults to mentalize and enact their intentionality through particular behaviours, like taking medication? In grappling with these questions, the reader will detect the influence of developmental theorists, Vygotsky, Erikson and Bowlby. Seminal experiments, such as Tronick’s still face (Tronick, 1989)1 and Harlow’s monkeys (Harlow and Zimmerman, 1958)2, alongside newer fields of interpersonal neurobiology and developmental trauma have supplied the soil in which to ground the data gathered in this study. From our earliest days we are designed to absorb stimuli and integrate our perception into a gestalt. When PWID are characterised as “chaotic”, there is a failure to appreciate what this may really reflect: difficulty making sense of internal experience resulting in the absence of order, coherence and meaning. Therefore, the ontological presupposition underlying both the empirical paper and systematic review, is that humans are resilient, relational beings. When the correct conditions and contingencies are in place, our innate propensity to learn and grow can manifest in positive, adaptive behaviour. Narratives are not only ways of seeing the world, but ways of constructing it; we live through and are created by the stories told by others and ourselves (Murray, 2003)3. The public narrative of scepticism that has emerged around scientific endeavour, makes it all the more incumbent upon researchers to carry out their work with personal conviction, integrity and transparency (Rea, 2017, February 22)4. This qualitative analysis was completed with a high level of scientific rigour. Indicators of quality were employed throughout, for example, particular attention was paid to preserving the colloquial expression of participants in transcription and substantiates the authentic representation of their voice. The resultant grounded theory shows that the interpersonal context is a key part of adherence behaviour among PWID. This finding precipitated another question, if good quality relationships are important for patient engagement, how do staff stay engaged in the task of providing consistent, sensitive care on a sustained basis? The current evidence base on supporting and preserving compassion did not substantiate a systematic review, however, the opposite phenomenon, people leaving their jobs has been explored. As Clinical Psychologists we are able to connect with and influence different audiences by skilfully adapting our language. In order to appeal to managers and team leaders, the most pragmatic way of framing staff disengagement, was to examine actual staff turnover as a ‘hard’, concrete outcome. The methodological quality of studies included for review was reasonable in the context of methodological limitations. Findings point to the importance of collective support, good quality relationships and job satisfaction in mitigating against turnover in substance misuse services. This thesis portfolio is a sensitive and pragmatic understanding of engagement in both PWID and staff with the respective systems within which they are embedded. The results are contextualised and oriented toward medical colleagues working in HCV treatment, service leaders and fellow applied psychologists.

Background: When a family encounters the problem of adolescent substance misuse, the burden of managing it often falls primarily on the mother. Objective and methods: This research was conducted in two phases to explore the experiences of mothers of adolescents who misuse substances. Phase one was a systematic qualitative evidence synthesis of qualitative studies on the experiences of mothers of adolescents who misused substances. In this phase, conventional content analysis was used to create a narrative synthesis of themes and categories. Phase two was a qualitative study using thematic analysis to describe mothers’ experiences of parenting an adolescent who misused drugs. Findings: Eleven qualitative studies were included in the literature review. New categories regarding mothers’ experiences emerged from the review and synthesis: 1) I love you and we can talk no matter what; 2) So this is really happening . . . My kid’s on drugs; 3) What have I done?; 4) My family is shattered: a) I can’t believe what you’re doing, b) I can’t face this, c) I’ve lost my baby; and 5) It’s not my addiction. Four mothers were interviewed for the qualitative study. Mothers described their realities and the challenges they faced parenting an adolescent who misused drugs. Their experiences were represented in the following categories:1) recognition, 2) punishment/surveillance, 3) negative emotions, 4) relationships, 5) escalating effects, 6) strategies, and 7) home–a safe place. Conclusions: The findings from this research contribute to our understanding of the everyday lives and struggles that mothers face with their adolescents’ substances misuse. Nurses, by implementing early targeted interventions, will meet the needs of these mothers and assist themselves and ultimately their adolescents to attain optimal wellbeing.

Title: Drug Related Crimes and Overdoses during the COVID-19 Pandemic Format: Poster Authors: Janaya Colbert, Kristin Mahan, MA, Jill D. Stinson, PhD Department of Psychology, College of Arts & Sciences, East Tennessee State University, Johnson City, TN The COVID-19 pandemic affected many aspects of life, including restricting many people to their homes. During the lockdown, more people were isolated inside, which may have resulted in varying levels of drug and substance-related crimes, as well as overdose deaths. Increases in substance misuse may be associated with stress regarding COVID-19, but these events may be less often officially reported during the lockdown. An increase in substance use may also be associated with an increase in overdose deaths. In the present study, we will compare trends of drug and substance related outcomes before and during the pandemic in Tennessee, and differentiate effects between rural and urban counties. Data for this project were obtained from the Tennessee Bureau of Investigation’s (TBI) online incident-based reporting system and the County Health Rankings and Roadmaps online database. Variables of interest include all 95 Tennessee counties, number of driving under the influence (DUI) cases, number of drug/narcotic violation cases, and number of overdose deaths. In 2019, there were 19,556 reported DUI cases and in 2020, there were 17,578 reported DUI cases in Tennessee. In 2019, there were 50,618 reported drug/narcotic violations and in 2020, there were 49,875 reported drug/narcotic violations. In 2019 there were 4,776 reported overdose deaths and 5,097 reported overdose deaths in 2020. Utilizing 2x2 factorial ANOVAs, we will analyze the relationships between county type (i.e., urban vs. rural) and report year (i.e., 2019 vs. 2020) for each outcome of interest. Our hypotheses include: (a) there will be differences between urban and rural counties on the rates of drug and substance related outcomes (i.e., DUI cases, drug/narcotic violation cases, overdose deaths) pre- and mid-pandemic; (b) drug-related crimes and DUI cases decreased during the pandemic when compared to the previous year due to lockdown procedures and decreased ability to access substances; and (c) overdose deaths increased from pre- to mid- pandemic. Anticipated results will help examine how the COVID-19 pandemic has affected rates of drug and substance related crimes, which can help inform prevention and treatment strategies in the future. Additionally, potential discrepancies between rural and urban counties may highlight prevention and treatment disparities for those struggling with substance misuse, which can inform resource allocation within Tennessee.

No / This study aimed to enable a cohort of women to describe their personal experiences of motherhood in the context of problematic substance use and street-based prostitution. The study also aimed to describe the impact upon women of separation from their children. Findings that emerged from focus group data were organised into four over-arching themes: children and motherhood, personal accounts of drug use and street-based prostitution, risks to women and their children and supportive/unsupportive factors in the women’s lives. Each theme consisted of many categories that illustrated the impact of dependent drug use and involvement in prostitution on the lives of the women and their children. This article describes the theme of children and motherhood. Involvement in street-based prostitution is extremely risky, frequently characterised by calculated risk taking, with consequences for both the woman and her children. Parental responsibilities and lifestyle contribute to stress, which is typically compounded by problematic substance use. Risks are increased for both the woman and her children when timely and appropriate support is unavailable. Emphasis should be placed upon the proactive identification and implementation of positive supportive strategies. Ethical approval was obtained via the Local Research Ethics Committee to undertake this research study.

While there is evidence to support the efficacy of mindfulness-based treatment for substance use, the mechanisms through which they lead to therapeutic outcomes have received less attention. A growing body of literature suggests that the ways in which people respond to cravings may be an important mediator of change. Individuals with substance use problems may use them to cope with or avoid negative experiences, which could include the experience of craving itself. Thought suppression in particular has been investigated as a specific form of experiential avoidance, and findings suggest that thought suppression strategies may interfere with attempts to quit using substances. While mindfulness training should be expected to reduce the tendency to suppress or avoid cravings, evidence to support this expectation is limited, largely because no measures yet exist that assess the suppression of craving. Therefore, the purpose of the present study was to develop a self-report measure of the suppression of craving. Existing measures of other types of thought suppression and experiential avoidance were examined to identify items that could be adapted for use in the Craving Suppression Scale (CSS). To assist with the item development process, a focus group was also conducted at a local residential treatment facility. Participants were asked to discuss what they do when they are experiencing cravings and what thoughts go through their minds when cravings come up. Their responses were used to guide content development for the CSS items. Items were developed for two sub-scales: suppression of craving and beliefs about craving. Items were administered to a sample of inpatients in substance use treatment and an online sample of individuals reporting current or previous substance use problems (total N = 208). Factor analysis of the remaining items supported a two-factor structure for the CSS as hypothesized. Relationships were examined between the CSS and other measures of other forms of experiential avoidance/suppression, craving, and emotional distress. The CSS scales correlated well with other measures of suppression but had mixed relationships with other constructs of interest. Evidence for the validity and potential utility of the CSS are discussed along with theoretical and treatment implications.

Adolescence is a time of experimentation and exploration. For many young people, a feature of this developmental period is the initiation of substance use. Whilst the majority of young people do not go on to develop substance use problems, any substance use has potential for danger. The current body of literature on the prevention of substance use problems suggests that in order to advance understanding, researchers must adopt a risk-focused approach. There is a wide range of indices that have been cited as risk factors for the development of substance use disorders. Chapter 2 explores some of the aetiological models and literature on risk factors with specific reference to psychological wellbeing, studies highlighting comorbid relationships between adolescent mental health and substance use problems, and the functional value of substances in relation to well-being. Although attention to psychological risk factors has received increased press in the literature, the number of controlled, longitudinal studies is relatively small. A review of recent studies (Chapter 3) indicates that the presence of anxiety, depression, low self-esteem or behavioural problems such as delinquency represent psychological risk factors for the development of later substance use problems, however findings are inconsistent and many studies do not examine differential predictive utility by substance or gender. Thus, Study 1 of this research aimed to add to this body of work by exploring the prediction of alcohol, cannabis and other illicit substance use at age fifteen from key indicators of psychological well-being taken at age thirteen. The data from a normative sample of high school students indicated subtle differences in trajectory for young males and females and effects specific to different drug categories. Delinquency emerged as the most consistent predictor in both males and females. Low self-esteem was also an important indicator for future female marijuana use and marijuana intoxication and both male and female other illicit substance use. The findings highlighted the need for a greater contextual understanding of the relationship between delinquency, self-esteem and substance use. The second study sought to provide a deeper understanding of these issues by examining the perceived functional value of substances in relation to psychological wellbeing, by means of a qualitative study of a group of young people who had experienced problems with their substance use. Chapter 4 explores the limited phenomenological research in this area, with a focus on studies which have used methods of measurement that highlight the perspective of young people. Using a Consensual Qualitative Research approach, Study 2 builds on the drug type and gender contrasts noted in Study 1, and explores the interface between substance use and psychological well-being in depth using a clinical population. A number of key functions are identified by young people, with evidence of both convergence and divergence across drug categories (alcohol, cannabis, other illicit substances). Interviewees reported six functions common to all substances; social connectedness, improve affect, positive self-transformation, better coping with problems, fun and laughter, and feeling intoxicated. Nine additional functions were identified in relation to cannabis and other illicit substances. Several gender differences were also noted, with males tending to report more positive reinforcement from alcohol and cannabis, and young females more frequently describing benefits related to use of other illicit substances. The concluding chapter (Chapter 5) reviews the main findings across both studies and their implications for theory, practice, and future research. Overall, the findings of the research provide support for both problem behaviour and adaptive models of adolescent substance use, and indicate that young people are capable of reflecting on their substance use experiences. Incorporating the wisdom of young people into risk frameworks may enhance prevention, education and intervention efforts.

Adolescence is a time of experimentation and exploration. For many young people, a feature of this developmental period is the initiation of substance use. Whilst the majority of young people do not go on to develop substance use problems, any substance use has potential for danger. The current body of literature on the prevention of substance use problems suggests that in order to advance understanding, researchers must adopt a risk-focused approach. There is a wide range of indices that have been cited as risk factors for the development of substance use disorders. Chapter 2 explores some of the aetiological models and literature on risk factors with specific reference to psychological wellbeing, studies highlighting comorbid relationships between adolescent mental health and substance use problems, and the functional value of substances in relation to well-being. Although attention to psychological risk factors has received increased press in the literature, the number of controlled, longitudinal studies is relatively small. A review of recent studies (Chapter 3) indicates that the presence of anxiety, depression, low self-esteem or behavioural problems such as delinquency represent psychological risk factors for the development of later substance use problems, however findings are inconsistent and many studies do not examine differential predictive utility by substance or gender. Thus, Study 1 of this research aimed to add to this body of work by exploring the prediction of alcohol, cannabis and other illicit substance use at age fifteen from key indicators of psychological well-being taken at age thirteen. The data from a normative sample of high school students indicated subtle differences in trajectory for young males and females and effects specific to different drug categories. Delinquency emerged as the most consistent predictor in both males and females. Low self-esteem was also an important indicator for future female marijuana use and marijuana intoxication and both male and female other illicit substance use. The findings highlighted the need for a greater contextual understanding of the relationship between delinquency, self-esteem and substance use. The second study sought to provide a deeper understanding of these issues by examining the perceived functional value of substances in relation to psychological wellbeing, by means of a qualitative study of a group of young people who had experienced problems with their substance use. Chapter 4 explores the limited phenomenological research in this area, with a focus on studies which have used methods of measurement that highlight the perspective of young people. Using a Consensual Qualitative Research approach, Study 2 builds on the drug type and gender contrasts noted in Study 1, and explores the interface between substance use and psychological well-being in depth using a clinical population. A number of key functions are identified by young people, with evidence of both convergence and divergence across drug categories (alcohol, cannabis, other illicit substances). Interviewees reported six functions common to all substances; social connectedness, improve affect, positive self-transformation, better coping with problems, fun and laughter, and feeling intoxicated. Nine additional functions were identified in relation to cannabis and other illicit substances. Several gender differences were also noted, with males tending to report more positive reinforcement from alcohol and cannabis, and young females more frequently describing benefits related to use of other illicit substances. The concluding chapter (Chapter 5) reviews the main findings across both studies and their implications for theory, practice, and future research. Overall, the findings of the research provide support for both problem behaviour and adaptive models of adolescent substance use, and indicate that young people are capable of reflecting on their substance use experiences. Incorporating the wisdom of young people into risk frameworks may enhance prevention, education and intervention efforts.

Adolescence is a time of experimentation and exploration. For many young people, a feature of this developmental period is the initiation of substance use. Whilst the majority of young people do not go on to develop substance use problems, any substance use has potential for danger. The current body of literature on the prevention of substance use problems suggests that in order to advance understanding, researchers must adopt a risk-focused approach. There is a wide range of indices that have been cited as risk factors for the development of substance use disorders. Chapter 2 explores some of the aetiological models and literature on risk factors with specific reference to psychological wellbeing, studies highlighting comorbid relationships between adolescent mental health and substance use problems, and the functional value of substances in relation to well-being. Although attention to psychological risk factors has received increased press in the literature, the number of controlled, longitudinal studies is relatively small. A review of recent studies (Chapter 3) indicates that the presence of anxiety, depression, low self-esteem or behavioural problems such as delinquency represent psychological risk factors for the development of later substance use problems, however findings are inconsistent and many studies do not examine differential predictive utility by substance or gender. Thus, Study 1 of this research aimed to add to this body of work by exploring the prediction of alcohol, cannabis and other illicit substance use at age fifteen from key indicators of psychological well-being taken at age thirteen. The data from a normative sample of high school students indicated subtle differences in trajectory for young males and females and effects specific to different drug categories. Delinquency emerged as the most consistent predictor in both males and females. Low self-esteem was also an important indicator for future female marijuana use and marijuana intoxication and both male and female other illicit substance use. The findings highlighted the need for a greater contextual understanding of the relationship between delinquency, self-esteem and substance use. The second study sought to provide a deeper understanding of these issues by examining the perceived functional value of substances in relation to psychological wellbeing, by means of a qualitative study of a group of young people who had experienced problems with their substance use. Chapter 4 explores the limited phenomenological research in this area, with a focus on studies which have used methods of measurement that highlight the perspective of young people. Using a Consensual Qualitative Research approach, Study 2 builds on the drug type and gender contrasts noted in Study 1, and explores the interface between substance use and psychological well-being in depth using a clinical population. A number of key functions are identified by young people, with evidence of both convergence and divergence across drug categories (alcohol, cannabis, other illicit substances). Interviewees reported six functions common to all substances; social connectedness, improve affect, positive self-transformation, better coping with problems, fun and laughter, and feeling intoxicated. Nine additional functions were identified in relation to cannabis and other illicit substances. Several gender differences were also noted, with males tending to report more positive reinforcement from alcohol and cannabis, and young females more frequently describing benefits related to use of other illicit substances. The concluding chapter (Chapter 5) reviews the main findings across both studies and their implications for theory, practice, and future research. Overall, the findings of the research provide support for both problem behaviour and adaptive models of adolescent substance use, and indicate that young people are capable of reflecting on their substance use experiences. Incorporating the wisdom of young people into risk frameworks may enhance prevention, education and intervention efforts.