Jason B. Luoma, Ph.D.
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Data on outcomes for ACT targeting substance
misuse have started to emerge
Outcome data are not enough
We need to know how an intervention results in
change, not simply that it does
To do this, we need to measure mediating variables
Definition: the ability to contact the present moment
more fully as a conscious human being, and to
change or persist in behavior when doing so serves
valued ends” (Hayes, Luoma, Bond, Masuda, &
Lillis, 2006, p. 6)
Most commonly measured by the Acceptance and
Action Questionnaire (AAQ)
Has adequate internal consistency in most samples, but
not in substance misusing samples.
α = (Bissett, 2002;)
 α = (Luoma, Kohlenberg, Hayes, Bunting, & Rye, 2008)
 α = .40 (this study)

Mediates outcome in some non addicted samples (e.g.,
Bond & Bunce, 2000), but not addicted samples
Not in RCT with ACT for polysubstance abusing clients (Bissett,
2002)
 Not in ACT-based self-stigma intervention in substance abusing
sample (Luoma, Kohlenberg, Hayes, & Fletcher, 2010)

Step 1: Item Generation – adapted the original 49-item pool
used for the development of the AAQ-II to include items specific
to substance misuse
AAQ Item
AAQ-SA Item
My thoughts and feelings get in the
way of my success.
My urges and cravings to use get in
the way of my success
I can do things that are important to
me even when I’m feeling unhappy.
I can do things that are important to
me even when I'm feeling urges to
use substances.
I work towards things I value, even
though at times I feel uncomfortable
or uncertain.
I work toward things I value, even
though at times I feel cravings to use
substances.
I’m afraid of my feelings.
I'm afraid of my positive feelings
about a substance I've abused.
All items rated across two dimensions by 8 ACT experts
1) Face validity
2) Overall quality
On a 1-4 scale from 1 (poor) to 4 (excellent)
 Dropped eight items because of scores below 2.5
(the mid-point of the rating scales) for one or both
scales.
 Remaining 41 items had an average fit rating of
3.16 (SD = .32) and an average quality rating of 3.24
(SD = .37)
352 patients receiving residential (n = 29) or outpatient (n = 323)
substance abuse treatment
 Gender: 210 men, 141 women, 1 unidentified
 Age: Averaged 31.1 years (SD = 10.2, range 18 – 63)
 Race: .6% identified as Alaskan Native, 3.4% American Indian,
.9% Asian/Pacific Islander, 4.3% Black/African American, 80.4%
White, 6.5 % other, and 4% providing no response.
 Hispanic/Latino(a): 7.4% identified as Mexican, 4.6% other
Hispanic, 41.8% not of Hispanic origin, and 46.3% no response.
 30% (n=97) of the sample had less than a high school
education, 52.9% (n=171) had completed high school or
obtained a GED, and 17% (n=55) had at least some college.
 Prior treatment averaged 1.2 episodes (n = 342, SD = 1.7).
Factor Loading
Item
1
2
3
4
5
6
7
8
9
I can do things that are important to me even
when I'm feeling urges to use substances. (r)
My urges and cravings to use get in the way of my
success.
If I have urges to use substances, then I am a
substance abuser.
I try to achieve my sobriety goals, even if I am
uncertain that I can. (r)
I work toward things I value, even though at
times I feel cravings to use substances. (r)
I am not very aware of what occurs around me
when I am thinking of using substances.
I can set a course in my life and stick to it, even if I
have doubts about my sobriety. (r)
Memories of my substance abuse history make it
difficult for me to live a life that I would value.
If I get bored working toward my recovery, I can
still take the steps necessary to succeed. (r)
values defused
commit accepta
ment
nce
.670
.233
.286
.666
.043
.522
.637
.042
.744
.064
.234
.623
.697
.168
.205
.570
.668
.257
Series of analyses
led to an 18item twofactor solution,
using oblimin
rotation
Factor Loading
Item
values
defused
commitment acceptance
10.
If I feel uncertain about my recovery, I can still make a choice and
take action. (r)
.636
.214
11.
If I promised to do something, I'll do it, even if I later don't feel like
it. (r)
.702
.154
12
Having some worries about substance use will not prevent me from
living a fulfilling life. (r)
.608
.087
13
I would rather achieve my goals than avoid thoughts and feelings
about substances. (r)
.508
.251
14
Urges and cravings cause problems in my life.
.220
.687
15
I'm afraid of my positive feelings about a substance I've abused.
.108
.676
16
When I think of substance use my mind is often on "automatic
pilot", not fully involved in what I am doing in the moment.
.079
.713
17
I worry about not being able to control my urges and cravings.
.187
.726
18
Feeling sad or anxious makes me want to use substances.
.110
.623
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Values commitment: α =.82
Defused acceptance: α =.84
Overall scale: α = .85
Two subscales correlate with each other at a low
level, r (288) = .26, p < .001.
Compared participants reporting zero days of usage in
the last 30 days to those reporting any days of
usage.
Summary: AAQ-SA scores were significantly lower in
group reporting usage, while AAQ scores were not
In a combined factor analysis, AAQ items sorted on a
different factors from AAQ-SA items
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General Psychological Flexibility. The Acceptance and Action
Questionnaire (AAQ;Hayes, Strosahl et al., 2004
Depression. The Beck Depression Inventory
Internalized Shame. The Internalized Shame Scale (ISS;Cook, 1996)
Social Support. The Multidimensional Scale of Perceived Social Support
(MSPSS;Zimet, Dahlem, Ziment, & Farley, 1988
Self-Esteem. The Rosenberg Self-Esteem Scale (RSES;Rosenberg, 1965)
Self Concealment. The Self Concealment Scale (SCS;Larson & Chastain,
1990)
Stigma-Related Rejection. The Stigma-Related Rejection Scale
(SRS;Luoma, Twohig et al., 2007)
Active Coping with Stigma. We created a seven-item scale based on two
subscales from previous research on stigma toward mental illness (Link,
Struening, Neese-Todd, Asmussen, & Phelan, 2002).
values commitment defused acceptance
full scale
values commitment
1.000 (300)
0.259** (290) 0.779** (290)
defused acceptance
1.000 (293) 0.807** (290)
full scale
1.000 (290)
AAQ
0.192** (289)
0.508** (283) 0.464** (280)
depression (BDI)
-0.149 (119)
-0.333** (115) -0.312** (114)
internalized shame (ISS)
-0.100 (125)
-0.536** (124) -0.424** (122)
social support (MSPSS)
-0.085 (158)
-0.223* (153)
-0.185 (153)
self-esteem (RSES)
0.481** (153)
0.538** (150) 0.613** (149)
self concealment (SCS)
0.015 (135)
-0.416** (134) -0.270* (132)
active coping with stigma
0.364** (282)
0.135 (276) 0.298** (273)
Note: Numbers represent the correlation with sample size in parentheses.
*p < .01, **p < .001
values commitment defused acceptance
full scale
values commitment
1.000 (300)
0.259** (290) 0.779** (290)
defused acceptance
1.000 (293) 0.807** (290)
full scale
1.000 (290)
AAQ
0.192** (289)
0.508** (283) 0.464** (280)
depression (BDI)
-0.149 (119)
-0.333** (115) -0.312** (114)
internalized shame (ISS)
-0.100 (125)
-0.536** (124) -0.424** (122)
social support (MSPSS)
-0.085 (158)
-0.223* (153)
-0.185 (153)
self-esteem (RSES)
0.481** (153)
0.538** (150) 0.613** (149)
self concealment (SCS)
0.015 (135)
-0.416** (134) -0.270* (132)
active coping with stigma
0.364** (282)
0.135 (276) 0.298** (273)
Note: Numbers represent the correlation with sample size in parentheses.
*p < .01, **p < .001

More convergent and discriminant validity for
values commitment subscale
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Differentiate from self-efficacy scales
Examine possible method variance through
confirmatory factor analysis
The Substance Abuse Self-Stigma Scale (SASSS)
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Only one validated measure of stigma in substance
abuse
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Perceived stigma (Luoma et al., 2010)
We have developed a self-stigma intervention but
no validated, self-stigma measures exist
1) Shame and self devaluation and
2) Fear of enacted stigma,
3) Psychologically inflexible ways of responding to 1 &
2
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Many people apply the common stereotypes of
addiction to themselves
They devalue themselves, experience shame, and
see themselves as deeply flawed, discredited, or
broken
People fear being judged or rejected.
Fear of enacted stigma is associated with
 avoidance of treatment (Cunningham, Sobell, Sobell,
Agrawal, & Toneatto, 1993; Hingson, Mangione, Meyers, & Scotch,
1982; Klingeman, 1991; Tuchfeld, 1981).
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diminished self-esteem/self-efficacy (Corrigan & Watson,
2002a; Link, Struening, Neese-Todd, Asmussen, & Phelan, 2001;
Wright et al., 2000);
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lower quality of life (Rosenfield, 1997);
early dropout from treatment (Sirey et al., 2001);
poorer social functioning over time (Perlick et al., 2001a).
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Much of the harm of self-stigma does not come
merely from the presence of self-devaluing
thoughts, shame, and fear, but also from the
manner in which people respond to these
experiences.
A common response is experiential avoidance – the
attempt to control, reduce, or eliminate negatively
evaluated private experiences (e.g., thoughts,
feelings, memories), even when doing so causes
harm.
Stereotype threat
 When people who identify with a stigmatized group
enter situations where they perceive the potential
for devaluation based on this identity (Steele, Spencer, &
Aronson, 2002), they often expend energy searching for
and defending against this perceived threat.
 The effort is taxing and distracts the individual in
ways that can hinder social or intellectual
performance (e.g., Quinn, Kahng, & Crocker, 2004).
Disengagement from valued domains
 People withdrawing their efforts from domains of
living that relate to relevant stereotypes where
they fear judgment, rejection, or that they might
“confirm” a stereotype (Major & O'Brien, 2005).
Withdrawal and Secrecy
 Typically predicts negative psychosocial outcomes
(Ahern et al., 2007; Link, Mirotznik, & Cullen, 1991; Luoma et
al., 2007; Rüsch et al., 2006).
Followed the guidelines of Clark and Watson (1995)
1. Conducted a thorough literature review on stigma
and related measures and developed a definition
of stigma
2. Focus groups:
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3 groups of clients in treatment, 2 groups of addictions
professionals
Tried to identify common domains of stigma toward
substance users.
Difference / Alienation - Substance abusers (SAs) are different, separated, set apart,
strange, difficult to understand, or alien.
Devaluation – SAs are losers, failures in life, disappointments, or generally inadequate as
human beings.
Moral Weakness – SAs are indecent, lack virtue, and morally weak, sinners, immoral,
dishonorable, have poor character, or are disreputable
Lack of Willpower or Work Ethic – SAs are weak-willed, lack self control, lazy.
Hopelessness/ Helplessness – SAs are unlikely to recover and their future is bleak.
Incompetence – SAs are incompetent, inept, and generally ineffective in their lives.
Blameworthy – SAs are to blame for their difficulties and worthy of contempt.
Violent/Unreliable – SAs are easy to anger, often violent, erratic in their behavior and
generally untrustworthy.
Shame – SAs should be ashamed of themselves and feel guilty about their behavior.
Concealment – SAs are secretive and work hard to conceal their problem behavior.
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Based on existing measures of stigma, our content
domains, and measures of psychological flexibility,
we generated a large pool of items (500+).
We refined these through an extensive rating
process to arrive at 128 items which were given to a
sample of 17 individuals
Further refinement resulted in a 74 item scale that
was given to a validation sample.
3 scales
 Self devaluation
 Fear of enacted stigma
 Experiential avoidance of self-devaluation and fear
of enacted stigma
Essentially the same sample as the last study (n=323)
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Used principal components factor analysis with
varimax rotation
Resulted in four factor solution based on scree plot:
1.
2.
3.
4.
Self devaluation
Fear of enacted stigma
Experiential avoidance of stigma
Stigma as a barrier to valuing
1.
I have the thought that a major reason for my problems with substances is
my own poor character.
2.
I have the thought that I should be ashamed of myself.
3.
I have the thought that I deserve the bad things that have happened to me.
4.
I have the thought that I can’t be trusted.
5.
I feel inferior to people who have never had a problem with substances.
6.
I feel out of place in the world because of my problems with substances.
7.
I have the thought that I’ve permanently screwed up my life by using drugs.
8.
I feel ashamed of myself.
1.
People think I’m worthless if they know about my substance use history.
2.
People around me will always suspect I have returned to using substances.
3.
People without a substance use history could never really understand me.
4.
A job interviewer wouldn’t hire me if I mentioned my substance history in a job
interview.
5.
If someone were to find out about my history of substance use, they would
expect me to be weak-willed.
6.
People would be scared of me if they knew about my substance abuse history.
7.
If someone were to find out about my history of substance use, they would
doubt my character.
8.
People will think I have little talent or skill if they know about my substance
history.
9.
People think the bad things that have happened to me are my fault.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
I would choose to avoid someone who seemed interested in my friendship if I knew they had never
used substances.
When I feel incompetent at something I want to do, I stop trying.
I put a lot of effort into hiding my substance use history.
I avoid doing things where I would be blamed if it didn’t work out.
I wouldn’t try to fill roles that required a person of character.
Shame gets in the way of how I want to live my life.
I withdraw from other people because I’m afraid I will scare them.
I would lie to people in my life about my substance use if I were sure they would never find out.
I avoid situations where another person might have to depend on me.
I avoid situations that make me feel different.
I can’t stand feeling like the bad things that happen to me are my fault.
I would willingly sacrifice important things in my life to feel like I fit in.
I need to control my angry thoughts and feelings.
Blaming myself for my substance abuse history gets in the way of my success.
I would willingly sacrifice important life goals if that meant I could feel better about myself.
1.
I do things that are good for me, even if I feel like I don’t deserve it. (r)
2.
If something is important to me, I keep doing it, even if I feel incompetent. (r)
3.
I’m willing to be in situations where I might feel different from others. (r)
4.
I am getting on with the business of living, no matter how guilty I feel. (r)
5.
I am open about my substance use history with most people. (r)
6.
I pursue important goals in life, even when I fear I might not follow through. (r)
7.
I can set a direction for my life even if I feel hopeless. (r)
8.
Even if I knew the employer didn’t like to hire people in recovery, I would still
apply for a job if it interested me. (r)
9.
I can set a course in my life and stick to it, even when I feel like I’m a bad person.
(r)
10.
If I didn’t have a job, I would still look for one, even if it felt hopeless. (r)
Scale 1: selfdevaluation
Scale 1
Scale 2: Fear
of sitgma
Scale 3:
Avoidance
Scale 4:
Values
.49
.62
.23
.55
.17
Scale 2
.49
Scale 3
.62
.55
Scale 4
.23
.17
.42
Total score
.77
.75
.89
.42
.60
Total
number of
years of
drug use
Scale 1: selfdevaluation
Scale 2:
Fear of
stigma
Scale 3:
Avoidance
Scale 4:
Values
Total score
.16**
.26**
.15*
.05
.22**
AAQ-9 item
version
.431**
BDI-II
.343**
Internalized
shame scale .588**
Internalized
Stigma
.591**
.286**
.519**
.295**
.525**
.312**
.430**
.253**
.454**
.431**
.687**
.363**
.688**
.481**
.725**
.420**
.747**
Scale 1: selfdevaluation
Scale 2:
Fear of
stigma
Scale 3:
Avoidance
Scale 4:
Values
Total score
Perceived
social
support
0.137
.234**
.196*
0.022
.186*
Perceived
stigma
.255**
.426**
.375**
.217**
.444**
Self esteem
-.522**
-.329**
-.634**
-.546**
-.682**
.394**
.460**
.549**
.246**
.571**
Stigmarelated
rejection
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Psychometrics look good
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Good internal consistency (alpha)
Good correlations with other measures
Strong factor structure
Not as sure what to make of scale 4 (values
interference)
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Correlates less with other scales
Additional research could indicate whether this is really 3
factors versus 4
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Next steps
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
Sensitivity to change
Separate validation sample and confirmatory factor
analysis