A pilot randomized controlled trial of dialectical behavior therapy (DBT) for reducing craving and achieving cessation in patients with marijuana use disorder: feasibility, acceptability, and appropriateness

Davoudi, Mohammadreza; Allame, Zahra; Foroughi, Aliakbar; Taheri, Amir Abbas

doi:10.47626/2237-6089-2020-0123

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Original Article • Trends Psychiatry Psychother. 43 (4) • Oct-Dec 2021 • https://doi.org/10.47626/2237-6089-2020-0123 copy

A pilot randomized controlled trial of dialectical behavior therapy (DBT) for reducing craving and achieving cessation in patients with marijuana use disorder: feasibility, acceptability, and appropriateness

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

To conduct a pilot RCT investigating the feasibility, acceptability, and preliminary efficacy of dialectical behavioral therapy (DBT) for marijuana cessation and craving reduction.

Methods

Sixty-one patients with marijuana use disorder diagnoses were randomly assigned to a DBT group or a control group (psycho-education). Patients completed measures at pre-intervention, post-intervention, and at two-month follow-up. The Marijuana Craving Questionnaire (MCQ) and marijuana urine test kits were used to assess craving and abstinence respectively.

Results

The feasibility of DBT was significantly higher than control group feasibility. In the DBT 29/30 participants completed all sessions (96% retention) and 24/31 control group participants completed all sessions (77% retention) (χ2 = 4.95, p = 0.02). Moreover, 29/30 (96%) participants in the DBT group completed the two-month follow-up and 20/31 (64.5%) control group members completed the two-month follow-up (χ2 = 9.97, p = 0.002). The results showed that patients in the DBT group had significantly higher intervention acceptability rates (16.57 vs. 9.6) than those in the control group. This pattern was repeated for appropriateness rates (p < 0.05). The overall results for craving showed that there was no significant difference between the groups (F = 3.52, p > 0.05), although DBT showed a significant reduction in the “emotionality” subscale compared to the control group (F = 19.94, p < 0.05). To analyze cessation rates, DBT was compared to the control group at the posttest (46% vs. 16%) and follow-up (40% vs. 9.5%) and the results confirmed higher effectiveness in the DBT group for cessation (p < 0.05). Furthermore, among those who had lapsed, participants in the DBT group had fewer consumption days than those in the control group (p < 0.05).

Conclusions

DBT showed feasibility, acceptability, and promising efficacy in terms of the marijuana cessation rate.

Clinical trial registration

Thailand Registry of Clinical Trials, TCTR20200319007.

Dialectical behavior therapy; marijuana use; feasibility studies; craving; lapse

Cessation	Content
Pre-session	Explanation of dialectical behavioral therapy, principles, and goals. Brief introduction to the content of each session. Familiarity with participants. Participants are given an intervention booklet to read at home.
1st session (mindfulness 1)	Introduce the concept of mindfulness and three mental states (wise, reasonable, emotional) and their relations with substance use.
2nd session (mindfulness 2)	Teach two clusters of mindfulness skills. The first includes viewing, participation, and description. The second includes a non-judgmental stance and inclusive self-consciousness.
3rd session	Summarize the mindfulness sessions – definition of addiction, standard therapies of addiction, introduction to and teaching of dialectical avoidance technique. Review the positive and negative aspects of abstinence. Explanation and investigation of relapse and its causes. Explaining the skill of the pure mind, the addicted mind, the types of behaviors related to the pure mentality and the addicted mentality, and preparing a list of supporters.
4th-5th sessions (Distress tolerance)	Teaching distraction strategies with five skills include activities, comparisons, emotions, thoughts, and enjoyment. Through enjoyable activities, focusing on work or other topics, counting, leaving the situation, paying attention to daily tasks, distracting from thoughts, and self-harm behaviors – teaching and training self-soothing with five senses.
6th-7th sessions (Emotion regulation)	Definition of emotion, how emotions work, familiarity with emotion regulation skills. Emotion Identification Exercise, Emotion Registration Exercise. Identifying barriers to experiencing emotion in a healthy way and ways to overcome these barriers. Teaching creating short-term positive emotional experiences for experiencing positive emotional states.
8th-10th sessions (Emotion regulation and distress tolerance in an MUD context)	Explain craving and its connection to the experience of emotions. Introducing methods for identifying values. Importance of committed action based on a list of essential values in life. Develop new coping strategies in response to unpleasant emotions, sensations, and cognitions, especially craving as a multidimensional problem and teaching problem solving and behavior analysis.
11th session	Basic acceptance technique training. Introduce living in the present moment techniques.
12th-13th sessions	Interpersonal effectiveness training. Participants learn assertiveness skills about substance users. Other skills include non-verbal communication, verbal communication, and problem-solving, decision-making, and listening skills.
14th-16th sessions	Review of sessions. Elimination of ambiguities. Exercising skills in the presence of other people.

Variable	Intervention group	Control group	p-value
Educational level*			0.2
No higher education, n (%)	2 (6)	6 (19)
Diploma, n (%)	14 (46)	15 (48)
University student or graduate, n (%)	14 (46)	10 (33)
Age ^†	25.6 (5.67)	27.19 (7.48)	0.3
Months of marijuana use	19.53 (5.9)	17.48 (6.03)	0.1
Craving (total) ^†
Pre-test	45.2 (8.3)	47.9 (10.2)	0.2
Post-test	42.13 (7.7)	44.48 (8.1)	0.1
Follow-up	42.66 (9.25)	45.8 (8.4)	0.1

Variable/source	Type III sum of squares	df	Mean square	F	Sig	Partial eta squared	Observed power
Craving
Tests of within-subjects effects
Factor1	347.696	2	173.84	2.6	0.07*	0.04	0.512
Factor1 × group	4.76	2	2.38	0.036	0.11	0.001	0.055
Error (factor1)	7845.154	118	66.48
Tests of between-subjects effects
Group	341.084	1	341.08	3.52	0.06 ^†	0.056	0.455
Error	5708.79	59	96.75
Emotionality
Tests of within-subjects effects
Factor1	257.33	2	128.65	11.69	0.00 ^†	0.165	0.9
Factor1 × group	74.70	2	37.35	0.37	0.03*	0.05	0.63
Error (factor1)	1297.81	118	10.99
Tests of between-subjects effects
Group	283.89	1	283.89	19.94	0.00 ^†	0.25	0.9
Error	839.906	59	14.23

	DBT	Control	p-value
Cessation*
Post-test	14 (46%)	5 (16%)	0.01 ^‡
Follow-up	12 (40%)	3 (9.5%)	0.006 ^‡
Number of days use ^†
Post-test	2.43±1.8	7.5±5.03	0.00 ^‡
Follow-up	3.44±1.91	8.75±3.27	0.00 ^‡

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[1] Correspondence: Amir Abbas Taheri Department of Clinical Psychology Kermanshah University of Medical Sciences Shahid Beheshti Boulevard 6715847141 - Kermanshah, Iran Tel.: +989109683454 E-mail: amir.taheri27@yahoo.com