DO PSYCHOLOGICAL CHARACTERISTICS OF ADDICTION TREATMENT PROFESSIONALS PREDICT ACCEPTANCE OF HARM REDUCTION INTERVENTIONS? Kirstin J. Lauritsen A Dissertation Submitted to the Graduate College of Bowling Green State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY August 2017 Committee: Harold Rosenberg, Advisor Marc V. Simon Graduate Faculty Representative William O'Brien Steve Jex © 2017 Kirstin J. Lauritsen All Rights Reserved iii ABSTRACT Harold Rosenberg, Advisor I designed this study to assess the acceptability of 12 harm reduction interventions by American addiction treatment professionals, the availability of each intervention, and the association between professionals’ reported acceptance and their stigmatizing attitudes (i.e., authoritarianism and benevolence), psychological flexibility, and burnout (i.e., emotional exhaustion, depersonalization, and personal accomplishment). I recruited a sample of 257 members of NAADAC, the Association for Addiction Professionals, to complete web-based questionnaires. Depending on the intervention and the severity of the client’s substance use disorder diagnosis (mild-moderate or severe using DSM-5 criteria), 63% to 90% of participants rated five behavioral and three pharmaceutical interventions as acceptable. Smaller proportions (27% to 52%) rated limited or moderate use of cannabis, opioids, cocaine/crack cocaine, and amphetamines as acceptable. Whatever their acceptability, interventions were not available from most providers or their agencies. Exploratory factor analyses suggested two subscales of harm reduction interventions: 1) behavioral and pharmaceutical interventions and 2) limited or moderate use goals. Regression analyses revealed that higher benevolence and lower depersonalization significantly predicted greater acceptance of behavioral and pharmaceutical interventions for individuals diagnosed with a mild-moderate substance use disorder. Higher benevolence, higher emotional exhaustion, and lower depersonalization significantly predicted greater acceptance of behavioral and pharmaceutical interventions for individuals with a severe substance use disorder. Subsequent exploratory regression analyses revealed that these characteristics were associated with acceptance of the behavioral interventions but not of the iv pharmaceutical interventions. There was no association between participants’ psychological characteristics and their acceptance of limited or moderate use goals. Acceptance of harm reduction was also unrelated to providers’ political orientation, personal history of diagnosed substance use disorder, years providing addiction treatment, or legal status of marijuana in the provider’s state. Several limitations could restrict the generalizability of this study. Specifically, I recruited a sample of older, more experienced counselors from a single professional organization and I had a low rate of usable responses. Additionally, participants may have provided what they felt were socially desirable responses. Consistent with this possibility, participants’ mean scores on the psychological measures reflected high benevolence, low authoritarianism, low psychological flexibility, and low burnout, all with little variability. Keywords: Harm Reduction; Acceptability; Stigma; Psychological Flexibility; Burnout v For my grandmother, Jeanne Haselton Rich, who showed me what it means to live a life filled with love, passion, and adventure. Oceans of love from your favorite granddaughter. vi ACKNOWLEDGMENTS To borrow the words of Sir Isaac Newton, I truly believe that my successes are the result of “standing on the shoulders of giants.” As such, I am profoundly thankful to my research advisor, Dr. Harold Rosenberg, for his support and mentorship over the course of my doctoral training. I have had the privilege of spending time in the company of both Harold and his wife, Lonnie, enjoying good company, great food, and abundant laughter. I am also grateful for the love and unparalleled support of TWO amazing families, the Chomas and the Lauritsens. Their confidence in me has never wavered and their encouragement has carried me through those moments when I felt overwhelmed and unsure of myself. Finally, words cannot express how thankful I am for my husband, Adam. It was because of his encouragement that I set out to achieve my dream of earning a Ph.D. in psychology, and it was through his support that my dream was realized. He is my rock. Without him, this adventure would not have been possible. To all of my giants, thank you. vii TABLE OF CONTENTS Page INTRODUCTION………………………………………………………………………...... 1 Definition and Principles of Harm Reduction……………………………………… 1 History of Harm Reduction………………………………………………………… 2 Harm Reduction Interventions…………………………………………………… ... 4 Needle and syringe programs……………………………………………… . 5 Methadone maintenance……………………………………………………. 6 Naloxone take-home kits…………………………………………………… 8 Suboxone maintenance……………………………………………………... 9 Education and information…………………………………………………. 10 Pre/post loading and pill testing……………………………………………. 11 Non-abstinence goals………………………………………………………. 11 Acceptance of Harm Reduction and Psychological Characteristics of Addiction Professionals………………………………………………………………………... 15 Stigmatizing attitudes……………………………………………………… . 16 Burnout……………………………………………………………………... 18 Psychological flexibility……………………………………………………. 20 Current Study……………………………………………………………………….. 21 METHOD…………………………………………………………………………………… 24 Participants………………………………………………………………………... .. 24 Procedure…………………………………………………………………………… 24 viii Measures…………………………………………………………………………. ... 24 Demographics Questionnaire………………………………………………. 24 Harm Reduction Attitudes Questionnaire-II……………………………… .. 25 Community Attitudes Toward Substance Users……………………………. 26 Acceptance and Action Questionnaire-II………………………………… ... 27 Maslach Burnout Inventory………………………………………………… 27 RESULTS………………………………………………………………………………… .. 29 Eligible Participants………………………………………………………………… 29 Sample Characteristics……………………………………………………………… 29 Acceptability of Harm Reduction Interventions……………………………………. 30 Availability of Harm Reduction Interventions …………………………………….. 32 Exploratory Factor Analysis of Harm Reduction Interventions……………………. 33 Association of Psychological Characteristics with Acceptance of Behavioral and Pharmaceutical Interventions and Limited or Moderate Use………………………. 35 Exploratory Analysis I: Association of Demographic Characteristics with Acceptance of Harm Reduction Interventions……………………………………………………… 37 Exploratory Analysis II: Association of Psychological Characteristics with Acceptance of Behavioral Interventions, Pharmaceutical Interventions, and Limited or Moderate Use………………………………………………………………………………….. 39 DISCUSSION………………………………………………………………………………. 42 REFERENCES……………………………………………………………………………… 54 APPENDIX A. APPROVAL LETTER FROM HUMAN SUBJECTS REVIEW BOARD…………………………………………………………………………………… .. 66 ix APPENDIX B. CONSENT DOCUMENT………………………………………………… 67 APPENDIX C. DEMOGRAPHIC QUESTIONNAIRE…………………………………… 68 APPENDIX D. HARM REDUCTION ATTITUDES QUESTIONNAIRE – II ………….. 70 APPENDIX E. COMMUNITY ATTITUDES TOWARD SUBSTANCE USERS ………. 77 APPENDIX F. ACCEPTANCE AND ACTION QUESTIONNAIRE – II ……………….. 79 APPENDIX G. MASLACH BURNOUT INVENTORY – HUMAN SERVICES SURVEY…………………………………………………………………………………… 80 APPENDIX H. PERMISSION FOR COPYRIGHTED MATERIAL ……………………. 81 x LIST OF TABLES Table Page 1 Background Characteristics of the Sample ................................................................ 82 2 Means (SDs) and Percentages Endorsing Each Harm Reduction Intervention as Somewhat or Completely Unacceptable or Somewhat or Completely Acceptable for Individuals Diagnosed with Mild-Moderate or Severe Substance Use Disorders ..... 84 3 Correlations Among Ratings of Acceptance of Harm Reduction Interventions for Clients Diagnosed With a Mild-Moderate Substance Use Disorder ...................................... 86 4 Correlations Among Ratings of Acceptance of Harm Reduction Interventions for Clients Diagnosed With a Severe Substance Use Disorder ................................................... 87 5 Pattern Matrix of Acceptability of Harm Reduction Interventions for Individuals Diagnosed With Mild-Moderate and Severe Substance Use Disorders .................... 88 6 Correlations Among Measures of Psychological Characteristics .............................. 89