Keywords

Substance use disorders (SUD), or substance-related disorders, are one of the biggest problems in public health around the world (UNODC, 2014). In 2014, the United Nations Office on Drugs and Crime (UNODC) estimated that between 10 and 13 % of the world’s entire population, approximately 16 to 39 million individuals, suffers from SUD (UNODC, 2014). The UNODC also established that the cost of addictions ranges from $200 to $250 million dollars annually and only one out of five people suffering from SUD receives adequate treatment for recovery (UNODC, 2014).

Several authors have proposed that SUD, or addictions, not only affects individuals’ physical and psychological functioning, but also a spiritual dimension related to meaning in life (Becoña, 2002; Calafat, Gómez, Juan, & Becoña, 2007; Lyons, Deane, Caputi, & Kelly, 2011; Lyons, Frank, & Kelly, 2010; Marsh, Smith, Piek, & Saunders, 2003; Piedmont, 2004; Thompson, 2012; Wiklund, 2008a, 2008b). Viktor Frankl (1994), the founder of logotherapy, posited that individuals abuse substances to deal with existential vacuum , or feelings of meaninglessness. He defined meaning as the degree to which individuals perceive life as coherent and significant, and whether they behave consistently with established valuable life goals (Frankl, 1959/1984). According to Frankl, the main causative factors associated with the development of an addiction are proneness to boredom, a meaningless life, and the use of maladaptive coping strategies associated with distress (Frankl, 1959/1984; Thompson, 2012).

Even though it is well known that addictions are caused by an interaction of biological, environmental, and psychological variables (Sloboda, Glantz, & Tarter, 2012), several research findings have validated the assumption that substance abuse is associated with perceived lack of meaning (Hart & Carey, 2014; Marsh et al., 2003; Noblejas de la Flor, 1997; Roos, Kirouac, Pearson, Fink, & Witkiewitz, 2015). There is a strong relationship between meaninglessness and drug use and abuse, and severity of SUD symptoms across the lifespan (Addad & Himi, 2008; Newcomb & Harlow, 1986; Noblejas de la Flor, 1997; Rahman, 2001; Schnetzer, Schulenberg, & Buchanan, 2013).

Specifically, perceived lack of meaning in life has been suggested to be a risk factor in youth substance use (Hart & Carey, 2014; Konkoly, Bachner, Martos, & Kushnir, 2009; Palfai, Ralston, & Wright, 2011; Schnetzer et al., 2013). In adolescents, the establishment of meaningful goals is associated with decreased frequency of alcohol use (Lecci, MacLean, & Croteau, 2002), fewer reports of alcohol abuse symptoms, and fewer negative consequences due to alcohol use (Palfai et al., 2011; Palfai & Weafer, 2006). Moreover, in teenagers that use alcohol as a coping strategy, drinking is a predictor of alcohol-related problems (Lecci et al., 2002).

In college samples, correlational studies have indicated that higher scores on measures of perceived meaning are associated with decreases in the use of alcohol, tobacco, marijuana, and cocaine (Hart & Carey, 2014; Konkoly et al., 2009; Martin, MacKinnon, Johnson, & Rohsenow, 2011; Minehan, Newcomb, & Galaif, 2000; Schnetzer et al., 2013). Meaning in life also mediates the relationship between drug use and depression, stress, boredom, and perceived control and power (Harlow, Newcomb, & Bentler, 1986; Minehan et al., 2000; Newcomb & Harlow, 1986). These findings suggest that in the presence of other risk variables, such as depression and stress , the absence of meaning in life increases the likelihood of experiencing drug abuse. Interestingly, Newcomb and Harlow (1986) also found that the presence or absence of meaning has a stronger impact on the relationship between stress and alcohol use in early adolescence when compared to late adolescence. Therefore, it appears that in early adolescence there is a greater vulnerability associated with the use of alcohol to cope with feelings of meaninglessness, and thus, meaning-centered intervention s to prevent substance use should be implemented before this stage.

Similarly, in a study comparing a sample of adolescents in high schools with a group of adolescents that were hospitalized for mental health issues, the authors found that adolescents receiving inpatient treatment reported significantly lower levels of self-esteem and meaning in life (Kinnier et al., 1994). Moreover, in the two groups of adolescents, meaning in life was again a significant mediator variable between depression and substance use (Kinnier et al., 1994). The results suggested that higher levels of depression predicted lower levels of meaning in life, which in turn had a direct effect on higher levels of substance use. In this study, the presence or absence of meaning accounted for 33 % in the variance of drug use for the group of hospitalized adolescents (Kinnier et al., 1994).

Overall, these findings suggest that meaning in life is a protective factor for substance abuse among adolescents and college students. On the contrary, the absence of meaning is associated with an increased likelihood of developing a substance use disorder (Frankl, 1959/1984; Thompson, 2012). Despite the supporting evidence, a review of the literature did not uncover any published experimental studies exploring the effectiveness of meaning-centered interventions in reducing substance use problems in adolescent or college student samples. This research gap hinders any causal assumption about the role of meaning in the prevention of youth substance use and SUD. Moreover, it highlights the importance of setting a research agenda to examine logotherapeutic preventive interventions in children and young adolescents.

In terms of gender differences , some studies have evidenced particularities in the association between meaning in life and drug use in males and females. For instance, Schnetzer et al. (2013) found that in males, meaning was a significant mediator between depression and alcohol use. However, this finding was not replicated in females. Additionally, Harlow et al. (1986) found that in the absence of meaning women seem to use drugs more often as a coping mechanism, whereas men appear to engage in suicidal ideation more frequently. Similarly, Schlesinger, Susman, and Koenigsberg (1990) determined that when comparing males and females suffering from alcoholism, women reported significantly lower meaning in life scores than men did. These studies suggest potential gender differences in the relationship between meaning and substance abuse that are important to consider when planning interventions.

Findings are less clear when it comes to the role of meaning over the development of an addiction (Hart & Carey, 2014; Roos et al., 2015). Even though there is strong evidence showing lower levels of perceived meaning in individuals diagnosed with SUD, some empirical findings have failed to validate this association under certain conditions (Hart & Carey, 2014; Kinnier et al., 1994; Nicholson et al., 1994; Noblejas de la Flor, 1997; Rahman, 2001; Schnetzer et al., 2013). Specifically, in individuals initiating treatment, some studies have not found a significant correlation between levels of meaning and current alcohol consumption, daily alcohol consumption, total alcohol use over the last 3 months, alcohol blood levels, and the total number of abstinence days since the initiation of treatment (Brown, Ashcroft, & Miller 1998; Osaka, Morita, Nakatani, & Fujisawa, 2008; Waisberg & Porter, 1994). Along the same lines, Martin et al. (2011) did not find any significant correlation between perceived meaning in life and reported cocaine and alcohol use before entering treatment.

Considering that most of the studies showing mixed findings were conducted with clients initiating treatment, it can be argued that these individuals could boost their levels of meaning to reduce cognitive dissonance produced by drug use. In fact, the absence of meaning becomes more salient as individuals with an SUD problem stop using drugs and begin treatment (Hart & Carey, 2014; Martínez, 2002). To validate this hypothesis, in future studies it will be important to measure changes in the perception of meaning throughout the course of addiction. It is also important to assess how individuals define and conceptualize sources of meaning before and after treatment (Hart & Carey, 2014).

Regarding the potential benefit of meaning in the treatment of addiction, perceived meaning in life is a significant predictor of treatment outcome and motivation to change in recovery (Carroll, 1993; Krentzman, Farkas, & Townsend, 2010; Noblejas de la Flor, 1997). Empirical findings have evidenced that levels of perceived meaning in life increase significantly over the course of treatment (Roos et al., 2015). This is true even in treatment programs that do not directly address meaning in their interventions (Flora & Stalikas, 2012; Noblejas de la Flor, 1997; Waisberg & Porter, 1994).

In a longitudinal study, Robinson, Cranford, Webb, and Brower (2007) found that levels of meaning in life increased significantly after 6 months of treatment. The study was conducted with 123 individuals with alcoholism receiving outpatient treatment based on Alcoholics Anonymous (A.A.) principles. Results also indicated that when there was a one-unit increment in scores of presence of meaning, there was a 3 % decrease in the likelihood of re-engaging in a substance abuse pattern. In this sample, enhanced meaning was associated with an average of a 12 % decreased likelihood of re-engaging in compulsive alcohol use. After 6 months of treatment, meaninglessness was a significant predictor of alcohol abuse.

Additionally, in members of A.A. and individuals receiving inpatient treatment, longer abstinence periods have been related to greater meaning in life (Carroll, 1993; Krentzman et al., 2010). Krentzman et al. (2010) found that for every one-point increment in meaning scores, there was a 2 % higher likelihood that individuals would remain sober after 12 months of treatment. When increments of meaning scores were above the group mean, the likelihood of individuals remaining abstinent increased to 3.9 %. The authors also found that higher levels of meaning had a stronger effect in Black individuals when compared to White individuals. In Black individuals there was a 4.4 % increment for every unit change in meaning scores. These findings are suggestive of potential differences in the way meaning interacts with distinct cultural and vulnerability factors (Brown et al., 1998).

Similarly, Miller (1998) found that meaning in life, or the lack thereof, significantly predicted cocaine and alcohol relapse after treatment. Meaning also significantly predicted the number of days in which cocaine and alcohol were used following 6 months of treatment. Moreover, in individuals with cocaine addiction, higher perceived meaning in life reported at the beginning of treatment was associated with better treatment outcomes, lower relapse rates, and decreased frequency of alcohol and cocaine use. Meaning significantly predicted these variables even after controlling for depression, substance use severity, and age (Krentzman et al., 2010).

More importantly, in a recent publication of a longitudinal analysis of secondary data using latent growth curve models, Roos et al. (2015) found that meaning in life and temptation to drink were significantly and negatively related across time. Participants were recruited from the Matching Alcohol Treatments to Client Heterogeneity Project (Project MATCH Research Group, 1997). Analyses were conducted with 1729 individuals receiving treatment for alcohol use disorder (AUD ). Participants were allocated to one of three different treatment approaches: motivational enhancement therapy, cognitive-behavioral therapy, or 12-step facilitation therapy. Data on meaning and temptation to drink were collected at the beginning of treatment, at the end of treatment (3 months after baseline), and at 9 and 15 months following the beginning of treatment.

Results indicated that regardless of the treatment condition, over the course of treatment higher levels of meaning in life were significantly related to decreased reported temptation to drink. At the 15-month follow-up, decreases in meaning in life and increases in temptation to drink were significantly related to greater intensity and frequency of drinking (Roos et al., 2015). Moreover, individuals reporting lower levels of meaning and greater temptation to drink were more likely to report increased negative consequences due to alcohol use. This study suggested that meaning in life is a relevant target for treatment and recovery. The findings of this study further form a strong argument for increased research efforts to validate meaning-based interventions in the treatment of SUD (Roos et al., 2015).

Along the same lines, subsequent to treatment addiction, meaning has also been found to be related to better functioning and quality of life (Hart, 2009; Robinson, Krentzman, Webb, & Brower, 2011). In Hart’s (2009) study, after 2 years of treatment participants were asked about their perceived improvement in functioning (interpersonal, personal, and community functioning) since completion of treatment. They were also asked to report as to their current perception of meaning, quality of life, and spirituality. Hart found that individuals’ quality of life was positively and significantly related to perceived meaning. Moreover, perceived improvement in functioning was associated with higher levels of meaning in life 2 years after treatment. In addition, Robinson et al. (2011) found that over the course of 6 months positive changes in meaning in life in individuals diagnosed with SUD predicted improvement of drinking outcomes and a greater percentage of days abstinent at 9 months after baseline.

Overall, these findings support the potential role of meaning in life in decreasing abstinence rates, promoting better recovery, and decreasing vulnerability to relapse when coping with stress and cravings (Laudet, Morgen, & White, 2006; Piderman, Schneekloth, & Pankratz, 2008; Robinson et al., 2011). Thus, increased meaning in life during the course of treatment may account for successful outcomes and improvement of symptoms (Amodeo, Kurtz, & Cutter, 1992; Carroll, 1993; Chen, 2006; Krentzman et al., 2010; Noblejas de la Flor, 1997; Waisberg & Porter, 1994).

In fact, most treatment approaches to SUD, implicitly or explicitly, intervene with an individual’s perceived levels of meaning in life at different stages of therapy. For instance, programs such as motivational interviewing (McCambridge & Strang, 2005), self-support groups of A.A. and N.A. (Narcotics Anonymous; Laudet et al., 2006; Majer, 1992), and some forms of cognitive-behavioral therapy address aspects related to finding meaning and purpose in life (Grosse & Castonguay, 2005). These models of treatment focus on meaning-related aspects by establishing or enhancing an individual’s sense of personal coherence, meaningful goals in therapy, values clarification to facilitate motivation to change, and self-transcendent behaviors that go beyond the desire to use substances (Hayes et al., 2004; Hettema, Steele, & Miller, 2005; Laudet et al., 2006).

Of specific relevance for this chapter are the treatment models that incorporate meaning in life as a fundamental component of intervention (Martínez, 1999, 2002, 2004, 2009a, 2009b; Somov, 2007; Thompson, 2012). In the next section, we highlight the contribution of meaning-centered psychotherapy, or logotherapeutic approaches, in the treatment of SUD.

Logotherapy in the Treatment of SUD

Since Frankl first suggested the importance of addressing meaning in the treatment of addictions (Frankl, 1994), a number of logotherapeutic interventions for the treatment of addictions have been developed (Hart, 2009; Martínez, 2013; Somov, 2007; Thompson, 2012; Wiklund, 2008a). In the context of SUD , some logotherapeutic developments include individual and group protocols to enhance meaning in life, as well as meaning-based groups to promote skill building and relapse prevention (Martínez, 2004, 2005, 2009b; Somov, 2007; Thompson, 2012).

According to Wiklund (2008b), an individual suffering from an addiction experiences difficulties discovering meaning in life. These problems are associated with feelings of guilt and shame that hinder the perception that life can be meaningful and that the individual is worthy of good things (Addad & Himi, 2008). Thus, Wiklund (2008b) asserted that attempts to discover meaning in the beginning stages of treatment are often limited by feelings of worthlessness and negative perceptions of the self. He further proposed that the first step in treating clients is to facilitate a positive and hopeful self-reference framework to interpret the world, which is later used as a building block to discover meaning (Thompson, 2012). In logotherapy, meaning is presented as a question that clients need to answer (Wiklund, 2008a). Clients are constantly challenged to discover meaning in their lives and actualize values (Thompson, 2012). Furthermore, purposeful goals and consistency with values become the fundamental factors to promote treatment adherence and maintenance of positive outcomes (Flora & Stalikas, 2012; Lyons et al., 2011; Martínez, 2013; Noblejas de la Flor, 1997; Wiklund, 2008a).

In addition, during treatment the therapist addresses the client’s existential vacuum , which becomes more salient when he or she stops consuming substances, using the drive for meaning to motivate change and the establishment of new goals (Martínez, 2002; Thompson, 2012). Then, the therapist helps the client to also find the meaning of suffering caused by addiction, discover new sources of meaning and values, and develop new projects based on what is personally meaningful (Ford, 1996; Thompson, 2012). In regards to relapse prevention, an individual’s perception of the presence of meaning, and the possibility of actualizing meaning and values in daily activities, have the potential of reducing vulnerability to relapse (Martínez, 2009b; Roos et al., 2015). From a theory of meaning, when individuals are aware of their need for meaning, drug use is no longer a priority as it becomes a threat to engaging in a life worth living (Ford, 1996; Thompson, 2012).

In spite of compelling evidence suggesting the important role of meaning in the prevention and treatment of SUD, there do not appear to be any validated meaning-based treatment programs established. Without empirically valid protocols and manuals, the diffusion of such important interventions is limited as researchers and practitioners often overlook advances in logotherapy (Martínez & Flórez, 2015). Thus, there is a growing need for empirically-based logotherapeutic clinical protocols focusing on substance-related disorders (Martínez & Flórez, 2015). The next step is for meaning-centered clinicians to evaluate their interventions, engage in on-going research efforts to evaluate treatment, and diffuse findings through publications and presentations (Schulenberg & Flórez, 2013).

With this in mind, a logotherapeutic model for the treatment of SUD is introduced. This model of treatment was developed by the El Colectivo Aquí y Ahora Foundation (CAYA ), located in Bogotá, Colombia. Following this introduction, preliminary findings are reported as to levels of perceived meaning in life in individuals that completed CAYA’s logotherapeutic treatment model for addiction versus individuals that received another form of treatment .

CAYA’s Logotherapeutic Treatment Model

CAYA is a foundation that specializes in the treatment of substance abuse disorders in adolescents and adults. The organization has been providing inpatient and outpatient therapeutic services for addictions for more than two decades (Martínez, 2005; Martínez et al., 2015). The therapeutic model was designed based on literature reviews about addiction as well as empirical findings that indicate best practices for the treatment of SUD (Martínez, 2005; Martínez et al., 2015). To implement the program, mental health providers receive clinical training in logotherapy. The treatment program is a multi-component model that focuses on four major axes of intervention: meaning in life, motivation to change, personality traits, and relapse prevention. These four axes of intervention constantly interact to strengthen treatment goals and skill building in clients.

The first axis of intervention constitutes the philosophical core of the program. It highlights the importance of meaning in life and existential analyses in the treatment of SUD (Galanter, 2006; Roos et al., 2015). The existence of this focus of intervention is based on research findings that confirm a significant association between absence of meaning and substance use (Galanter, 2006; Roos et al., 2015). Moreover, the theoretical framework of the program is based on Frankl’s logotherapy theory, which sustains that the development of SUD is related to existential vacuum (Frankl, 1959/1984). Within this axis, the logotherapeutic theoretical and practical advancements developed by Martínez (2002, 2009c) are integrated. Specifically, during treatment the therapist conducts an existential analysis of the client’s addictions (Martínez, 2002), assesses his or her current use of personal resources (namely self-distancing self-projection, and self-transcendence; see Martínez & Flórez, 2015), and forms a strong therapeutic relationship from a logotherapeutic perspective (Martínez & Flórez, 2015).

The second axis of intervention of the CAYA model focuses on the motivation to change (Martínez, 2013). The client’s motivation to stop using substances and receive treatment is a vital component for treatment adherence and maintenance of change (McCambridge & Strang, 2005). CAYA integrates Miller and Rollnick’s (2004) principles of motivational interviewing (see also Hettema et al., 2005) with Frankl’s theory of logotherapy, in which a will to meaning becomes a motivational force in the process of recovery (1994). Depending on the developmental stage of the client (e.g., teenagers vs. adults), CAYA’s treatment model focuses on specific motivational sources associated with each client (Martínez et al., 2015). In therapy, the emotional and social expectations of drug use and abstinence are explored to attribute new significance to reasons that underlie substance use (Martínez, 2002). For instance, the belief that using drugs helps people be more social is replaced with more realistic information on how people behave inadequately in social situations while under the influence of alcohol and drugs.

The third axis of intervention addresses comorbid mental health problems that augment vulnerability for relapse, particularly those related to personality. In the CAYA model, personality problems that manifest in rigidity of behavior are considered to contribute to the progression of addictions, and thus they are important to include in the treatment of SUD (Martínez, 2002). CAYA’s theoretical model further suggests that in a number of individuals diagnosed with SUD, the presence of a Personality Disorder (PD) precedes and underlies substance abuse problems (Martínez, 2011). This assumption has been supported by a growing body of research confirming a significant relationship between PD and SUD (Pettinati, Pierce, Belden, & Meyers, 1999; Trull, Jahng, Tomko, Wood, & Sher, 2010; Van Den Bosch & Verheul, 2007). There is a greater prevalence of PD in individuals suffering from substance abuse disorders (Bosch, Verheul, & Brink, 2001; Trull et al., 2010; Van Den Bosch & Verheul, 2007). Approximately 44 % of individuals diagnosed with alcohol dependency also have a PD. Moreover, 79 % of individuals diagnosed with opioid addiction also meet criteria for a PD diagnosis (Van Den Bosch & Verheul, 2007). In addition, in a study conducted by Pettinati et al. (1999) it was found that individuals diagnosed with PD had a higher likelihood of relapse regardless of positive outcomes obtained in treatment. From a logotherapy perspective, it is also assumed that an inauthentic personality leads to the use of maladaptive coping strategies such as drug use (Martínez, 2011; Martínez & Flórez, 2015). Based on this view, CAYA’s logotherapeutic model aims to promote an authentic personality by replacing rigid patterns of behaviors with flexible and adaptive responses (Martínez, 2005; Martínez et al., 2015). This process of change is conducted through the mobilization of self-distancing and self-regulation as well as individualized exposure exercises in which clients are asked to implement a new coping strategy to replace a rigid behavior of escape and avoidance of distress.

The fourth and final axis of intervention focuses entirely on relapse prevention (Martínez, 2009a). In the treatment of SUD, relapse is often common following treatment (Marlatt, Parks, & Witkiewitz, 2002; McKay, 2001; Miller, Walters, & Bennett, 2001). For instance, 50–58 % of young adults relapse during the first 6 months following treatment (Chassin, Flora, & King, 2004; Cornelius et al., 2003; Maisto, Pollock, Cornelius, & Martin, 2003). Moreover, treatment models of SUD that do not incorporate relapse prevention programs report lower long-term abstinence rates and more intense relapse episodes (Rawson et al., 2002; Witkiewitz & Marlatt, 2004). Thus, treatment targets individual risk factors in order to decrease the likelihood of relapse, identifies protective factors in order to facilitate relapse prevention, and teaches specific strategies to cope with high-risk situations (Godley, Dennis, Godley, & Funk, 2004; Martínez, 2004). Relapse prevention is anchored to meaning, values, and the promotion of self-transcendent behavior to decrease the saliency of cravings and motivation to drink (Martínez, 2004).

Implementation of the CAYA Model of Treatment

CAYA’s logotherapeutic model for the treatment of addictions is implemented over the course of 3 months of inpatient treatment. The program includes individual, family, and group therapy, in which each treatment modality interacts to target each of the four axes noted previously. The program delivers 10 family psychotherapy sessions and 36 multifamily sessions (with several families of individuals suffering from SUD). In the multifamily sessions, the mental health providers offer psychoeducation and address specific common treatment needs (Martínez, 2005; Martínez et al., 2015). The client also receives approximately 16 individual sessions of meaning-centered psychotherapy (at least one individual session weekly) and 320 group therapy sessions over a 3-month period of inpatient treatment (Martínez et al., 2015). After treatment is completed, there is a 1-year period of individual, group, and family follow-up for relapse prevention (Martínez, 2005; Martínez et al., 2015).

The program is implemented in three consecutive phases. The initial phase starts during the first week of treatment and lasts from 4 to 6 weeks. The main objectives of this phase are to develop a clear case formulation of the phenomenology of the client, consolidate the therapeutic relationship, and augment motivation to change. Through assessment and continuous observation the mental health provider focuses on a case formulation that identifies (1) the client’s perceived meaning in life, (2) the level of spiritual resources being displayed, (3) the client’s maladaptive coping strategies that lead to an inauthentic personality, and (4) the client’s history of substance abuse as well as other symptoms of psychopathology. Additionally, in individual and group therapy, the processes of self-distancing and motivation to change are mobilized through activities in which clients establish reasons for sobriety, understand the freedom and responsibility of finding meaning, identify inadequate coping strategies, and take perspective of their symptoms. The CAYA model uses two manuals that are given to clients for them to reflect on their substance abuse history as it relates to meaning and to train them to identify values and meaningful activities.

In these manuals, clients are asked to respond to a series of questions about their substance use that prompt them to think about the reasons to change and the consequences of their use (e.g., “What concerns you about your substance use?, What situations in your life indicate that changing might be a good idea?, How would you like your life to be if you change?, What is likely to happen if you do not change?, What is the best thing that can happen to you if you change?,” etc.). The manuals also contain exercises in which clients are asked to reflect on the steps that are necessary for change. For instance, clients are asked to write and address three letters to themselves with respect to how they are doing 1, 5, and 10 years (a different time corresponding to each of the three letters) after having recovered from addiction. In these letters, clients detail how their current self is doing with respect to maintaining sobriety. Letters also prompt clients to write about their feelings, their fears, their relationships with loved ones, and what they have accomplished since they recovered.

Once the therapist has a clear case formulation, the second phase of treatment begins, lasting from week 4 to week 10. In the second phase, the therapist continues to address the client’s motivation to change and strengthens the therapeutic relationship. However, in this phase there is a greater emphasis on helping the client change inadequate maladaptive coping strategies for more adequate coping strategies through processes of self-distancing (self-comprehension, self-regulation, and self-projection; see Martínez & Flórez, 2015). To this end, the therapist develops a treatment plan that includes in vivo exposure to activities that evoke old maladaptive coping strategies (i.e., activities that create feelings of distress in clients). Through these activities, the client attributes new meanings to situations associated with subjective threats, and practices the implementation of new, increasingly effective strategies in the presence of undesired feelings (e.g., a client with fear of evaluation is asked to give several speeches in public). In this phase, the client learns to use self-comprehension (the ability to objectively see oneself and assume a healthy stance upon such observation), self-regulation (the ability to monitor and regulate cognitive and emotional processes), and self-projection (the ability to perceive oneself differently in the future) to cope with difficult situations and move forward toward a more authentic personality (see Martínez & Flórez, 2015).

In the third and final stage, which lasts approximately from the 11th to the 16th week of treatment, the therapist focuses specifically on strengthening commitment to change, preventing relapse, and augmenting processes of self-transcendence for a meaningful life. The therapist praises and validates the client’s progress, and encourages the client to establish a plan to maintain change after completion of treatment. For relapse prevention, the therapist implements a six-session manual (Martínez, 2005) in which the client anticipates obstacles to maintaining sobriety; signs of relapse; and high-risk situations, places, and behaviors for relapse, as well as develops plans to adequately cope with these situations in order to prevent possible setbacks that could trigger previous maladaptive patterns of living. An example of an activity useful for relapse prevention is known as humoristic cognitive reframing. In humoristic cognitive reframing, the client generates an alternative funny thought to a thought associated with using drugs (humoristic cognitive reframing: “I want to get high, maybe I should go and climb.”). This is similar to Frankl’s paradoxical intention technique, in which a client’s sense of humor is used to facilitate self-distancing and as a means to alleviate the emotional burden of thoughts associated with substances. Lastly, during this phase there is a great emphasis on mobilizing self-transcendence resources (affectation and commitment) oriented to meaning. Through affectation the client gets in touch with his or her ability to be moved by the presence of values and meaning. Through commitment, the client is directed toward giving himself or herself to a cause or a higher power that brings a sense of meaning. Using the meaning in life manual given to them during treatment, clients learn to identify creative, experiential and attitudinal values and establish actions consistent with these values. Moreover, to facilitate values clarification, they are asked to monitor and register the meaning of the moment of different past, present, and future instances of their lives.

Over the course of treatment, group therapy is the main intervention modality in the CAYA model of rehabilitation. Every day (except for weekends) there are seven group interventions in which the following groups rotate each week:

  • The existential group: This group consists of a 16-session protocol that focuses on the meaning of life and the meaning of suffering.

  • The meaning in life group: This group consists of an 8-session protocol that focuses on the topics of freedom, responsibility, will to meaning (inner drive to discover meaning), values, optimism, and ultimate meaning.

  • The dereflection group: This group consists of an 8-session protocol directed to augment the perception of meaning and redirect attention away from symptoms and toward valuable and positive activities.

  • The existential growth group: This group consists of a 90-session protocol that teaches clients a logotherapy perspective of relapse prevention, motivation to change, meaning in life, and an authentic personality.

  • The relapse prevention group: This group consists of a 16-session protocol that focuses on relapse prevention .

  • The experiential group: This group is a daily group in which clients are exposed to personalized therapeutic activities that are shared with the group and target each client’s specific maladaptive strategies (e.g., a client that fears evaluation gives a presentation to the group, a client that engages in aggression discusses assertiveness and strategies to be appropriately assertive).

  • The gathering group: A daily morning group that promotes self-distancing and responsibility.

The objective of these groups is to build within the client a model of logotherapy that constitutes the overall framework of recovery and facilitates the objectives of the three phases of treatment.

The CAYA foundation understands the importance of directing research efforts to validate treatment and identify mechanisms of change. As a result, CAYA is invested in conducting research to evaluate treatment objectives and outcomes. Currently, CAYA is conducting an ongoing investigation to evaluate treatment effectiveness over 2 years of follow-up. Moreover, CAYA is initiating a study about the influence that each of the four axes of treatment has on treatment outcome. In the next section of the chapter, preliminary findings are presented of an investigation that evaluated the effects that the CAYA logotherapeutic model had in augmenting perceived meaning in life in a group of individuals with SUD.

Meaning in Life Following Treatment for SUD

This study had a quasi-experimental nonequivalent group design (Shadish, Cook, & Campbell, 2002). In the study, changes of meaning in life pre- and post-treatment were compared in individuals that participated in the CAYA treatment program (Group 1, or G1) versus individuals that received a 12-step inpatient treatment program with medication management (Group 2, or G2). It was expected that following both treatments individuals were going to experience significant changes in meaning. Furthermore, it was hypothesized that participants receiving logotherapeutic treatment were going to show greater changes in meaning scores after treatment .

Participants

The study sample consisted of 81 participants seeking treatment for SUD. The inclusion criteria consisted of individuals who voluntarily participated in either of the two treatment programs during the first 6 months of 2014. In the two treatment programs, the CAYA program and the 12-step inpatient program, all of the individuals that were receiving treatment consented to participate. There were no incentives for participation. Moreover, the study followed the ethical guidelines stipulated by the Colombian psychological legislation.

Participants’ ages ranged from 14 to 57 years old, with a mean age of 25.68 years (SD = 10.74) and a median age of 22. With respect to gender, 70.4 % of participants identified as males and 29.6 % identified as females. Group 1 was composed of 31 participants (38 % of the total sample, 64.5 % males and 35.5 % females). Group 2 was composed of 50 participants (61 % of the total sample, 74 % males and 26 % females).

Measures

The Meaning in Life Dimensional Scale (MLDS ; Martínez, Trujillo, Díaz del Castillo, & Osma, 2011) was used to measure meaning in life. The MLDS is an 18-item self-report scale presented in Spanish. In this scale, meaning is defined as a subjective sense of coherence and vital purpose. The aim of the questionnaire is to identify an individual’s current perception and experience of meaning. It employs a 4-point Likert-type response format ranging from 0 (completely disagree) to 3 (completely agree). Total MLDS scores range from 0 to 54. Higher total scores are indicative of greater perceived meaning in life. As an example, one of the items is: “I have discovered clear goals in my life.”

For interpretation of the measure, total MLDS scores are classified via four levels of perceived meaning in life: search for meaning, medium level of meaning, high level of meaning, and plenitude. The search for meaning level refers to those individuals that are having difficulties discovering meaning and setting valuable life goals. The medium level corresponds to people that report perceiving meaning in life, but that also indicate moments of confusion with life goals and lack of perceived coherence. The high level of meaning is associated with individuals that experience a purposeful life most of the time and perceive their lives as coherent and significant. Finally, the plenitude level of meaning includes individuals that perceive they are pursuing meaningful and clear goals and their lives are full of purpose, personal coherence, and significance .

To calculate the classification score, each participant’s mean score is computed. A mean total score ranging from 0 to 2 is classified as being within the search for meaning level, a mean total score from 2 to 2.34 falls within the medium level, a score from 2.35 to 2.64 is classified at the high level of meaning, and a score from 2.65 to 3 corresponds to the plenitude level of meaning. The measure was designed to be used for both research and clinical proposes. The validation of the scale was conducted with 820 individuals from Colombia, with an age range of 20 to 70 years old (Martínez et al., 2011). Exploratory factor analysis suggested a two-dimensional structure: existential coherence and purpose in life. Moreover, the internal consistency coefficient reported for the MLDS was 0.94 (Martínez et al., 2011).

Procedures

Participants were contacted through each treatment program. Both treatment models have a duration of 90 days and include individual, group, and family therapy. After obtaining informed consent, participants received the standard treatment program for each of the group conditions. Participants receiving the CAYA model of treatment participated in all therapeutic modalities and activities described previously. Participants receiving the 12-step model of treatment were educated according to standard A.A./N.A. philosophy (Galanter, 2007). The mental health providers that implemented the treatments also administered the self-report measures. Data were collected at the beginning and at the end of treatment.

Results

After data collection, statistical analyses were performed using SPSS statistical software (Meyers, Gamst, & Guarino, 2013). All of the responses were included. Pre- and post-descriptive statistics for the MLDS were obtained for the overall sample and each treatment group. Results are presented in terms of participants’ changes in levels of meaning. To compare significance of changes in levels of meaning for individual cases the McNemar test was used. Then, to compare mean group differences, t-test statistics were calculated.

At the beginning of treatment, in the overall sample, 58 % of the participants’ scores fell in the search for meaning level, whereas only 4.9 % of the participants’ scores fell in the plenitude level of meaning. As for changes in levels of meaning for each group, Fig. 1 shows the classification of individual levels of meaning for G1 and G2 at pre-test and post-test in terms of percentages. As indicated in the graph, for G1 there was an increase of 19.4 % of participants in the plenitude level of meaning after treatment. Moreover, following treatment there was a decrease of 32.3 % of participants in the search for meaning level. In the G2 treatment condition there was an increase of 4 % of participants in the plenitude level of meaning and a decrease of 33 % of participants in the search for meaning level after treatment.

Fig. 1
figure 1

Classification of individuals’ levels of meaning by percentage. G1 = logotherapeutic intervention, G2 = 12-step treatment program

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The McNemar test for matched-paired samples was used to test for statistically significant differences in individual changes in levels of meaning. A significant difference was found for changes in levels of meaning following treatment in individuals in the G1 treatment condition (p < 0.001). However, for individuals in the G2 treatment condition, changes in levels of meaning after treatment were not statistically significant (p = 0.092). In terms of the overall MLDS scores for each treatment group, the G1 condition started with a median score of 1.88 and the G2 condition started with a median score of 1.86 (Fig. 2). There were no statistically significant group differences between G1 and G2’s pre-test scores. At post-test, G1’s median score was 2.5, whereas G2’s median score was 2.1.

Fig. 2
figure 2

MLDS pre- and post-test median scores for G1 and G2. G1 = logotherapeutic intervention, G2 = 12-step treatment program

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A paired-samples t-test was conducted to compare mean differences on MLDS pre-test and post-test scores for each group. The mean comparison is different than the changes in levels of meaning comparison presented above in which the McNemar test was used. Using a paired-samples t-test , the overall mean differences were analyzed without consideration for individuals’ classification of meaning levels. Changes in median scores from pre-test to post-test using the overall mean and not individual changes in levels of meaning were statistically significant for both groups (G1 pre M = 1.88, SD = 0.55, post M = 2.5, SD = 0.33, t(30) = 5.8, p < 0.001; G2 pre M = 1.86, SD = 0.53, post M = 2.1, SD = 0.52, t(49) = 4.1, p < 0.001). Thus, in both treatment groups, there was significant improvement in meaning scores after treatment. Finally, an independent samples t-test was conducted to compare MLDS post-test scores between groups. There was a statistically significant difference between G1 and G2 scores; t(79) = 2.58, p < 0.01. These results suggest that the G1 treatment condition was superior to the G2 treatment condition with respect to improving participants’ perceived meaning in life.

Discussion

This study compared changes in levels of meaning in individuals receiving two different treatment modalities for SUD, the CAYA model and a 12-step therapeutic model that follows A.A./N.A. guidelines and which incorporates medication management. The hypothesis of the study was that for both groups statistically significant changes in meaning were going to be observed following treatment. Additionally, it was anticipated that individuals receiving the CAYA treatment model were going to report significantly greater changes in meaning when compared to individuals receiving a standard 12-step model of treatment.

Results indicated that in both treatment conditions participants reported greater levels of meaning when compared to their baseline scores. Findings indicate that regardless of differences in these models of intervention, efforts to treat SUD are associated with improvements in perceived meaning in life. This hypothesis has also been supported in previous studies, in which changes in meaning were associated with improvements in SUD symptoms across distinct treatment approaches (Roos et al., 2015). Findings provide validation for Frankl’s initial suggestion that meaning in life plays an important role in the recovery of substance use disorders. These results also suggest that interventions targeting symptoms of SUD are tapping, directly or indirectly, meaning-related issues (Roos et al., 2015).

As anticipated, results also confirmed that the logotherapeutic model was superior to the 12-step inpatient treatment program with medication management in enhancing perception of meaning. These findings suggest that a treatment model for SUD that incorporates a theory of meaning and meaning-centered intervention s is more effective in increasing perception of meaning than a standard 12-step model of treatment. In the CAYA model, over the course of treatment, meaning-related issues and existential concerns are explicitly addressed. In addition, inpatient clients learn about Frankl’s theory of meaning and participate in weekly meaning in life groups throughout treatment. Findings also support the effectiveness of CAYA’s model with respect to enhancing participants’ levels of meaning in life.

Overall, these preliminary findings strengthen the argument for implementing meaning-based intervention s in the treatment of addictions. Potentially, the benefits of incorporating meaning-centered interventions go beyond increasing meaning perception and reducing SUD symptoms as meaning is associated with protective factors for mental health problems such as depression, anxiety, and posttraumatic stress disorder, as well as with positive functioning across several life domains (Ortíz, Schulenberg, & Pacciola, 2013). With this in mind, meaning-based interventions may boost other significant mediators of change to protect against relapse and promote better functioning and adjustment following treatment (DeWitz, Woolsey, & Walsh, 2009; Drescher et al., 2012; Halama, 2003; Schulenberg, Hutzell, Nassif, & Rogina, 2008; Steger, Kashdan, & Oishi, 2008).

In terms of the limitations of the study, causality cannot be inferred because there was not a random allocation of participants for each treatment condition. Moreover, individual differences between groups were not accounted for, and thus, results can be confounded by pre-existing variables interacting with treatment effects. In addition, due to the multi-component nature of the CAYA treatment model, it cannot be concluded that the active component associated with changes in meaning is the meaning-based intervention . Rather, treatment effectiveness in enhancing perceived meaning could be attributed to the interactive effect of the four axes of intervention.

Therefore, for future studies it is important to conduct increasingly rigorous research designed to disentangle the effects of treatment components. In addition, to decrease confounds, it is important to control for variables such as therapeutic relationship and therapist training, as well as other important variables such as an individual’s social support. Finally, in this study there were no data examined as to SUD severity or with regard to changes in symptom presentation over the course of treatment. In the future, the relationship between meaning in life and changes in SUD symptoms during the course of the CAYA inpatient treatment program needs to be systematically explored.

Final Comments

There seems to be compelling evidence advocating for the incorporation of meaning-centered intervention s in the treatment and prevention of SUD. However, more rigorous research is needed as empirical findings are still not definitive (Hart & Carey, 2014; Roos et al., 2015). Amongst the biggest limitations of the current body of knowledge about the role of meaning in SUD is that the majority of studies are correlational. Thus, they do not validate that the absence of meaning is a casual factor in the onset of SUD (Hart & Carey, 2014). Furthermore, the lack of randomized controlled trials validating meaning-centered interventions limits empirical support for the applicability and efficacy of these interventions in the treatment of addiction (Hart & Carey, 2014).

Other limitations found in the literature are the ambiguity and lack of consensus as to the definition of meaning. In some studies, meaning is interpreted as spirituality or a search for a higher power. Although some research has supported a strong relationship between meaning and spiritual values, meaning is not synonymous with spirituality, and meaning-based intervention s are independent from spiritual or religious models. This confusion of terms has misguided research and practice. Moreover, it has hindered clarification of the specific role of meaning in SUD recovery.

Additionally, longitudinal studies that use advanced statistical analyses are needed to explore changes in meaning over the course of the addiction process (Hart & Carey, 2014). All of the reported studies have been conducted either in a “normal” population of adolescents and college students, people who are less likely to present with SUD, or in populations that are already seeking treatment. Therefore, there is a gap in the dynamics of meaning and substance use disorder at different stages of its progression.

There is also scarce research that explores how distinct components of meaning in life relate to SUD treatment and prevention. For instance, conceptually meaning has cognitive, affective, and behavioral components that encompass different aspects of a meaningful life. The study of how such components relate to substance use would yield important findings to inform meaning-centered interventions. For instance, future studies should focus on the mediational role of values, goal setting, sense of purpose, sense of coherence, positive affect, positive thinking, and other adaptive meaning-based coping strategies.

To conclude, although there are still several limitations in the research on meaning in life in addictions, the current body of knowledge evidences the importance of meaning-centered intervention s in the treatment and prevention of addictions. The preliminary empirical results of recent investigations constitute a solid foundation to direct efforts to experimental designs and the validation of interventions.

Key Takeaways

  • Based on the literature review demonstrating that meaning is a protector factor for substance use disorders across the lifespan, it is important to recognize the role of meaning in life in both preventive and treatment interventions for adolescents and adults. For instance, in regards to the prevention of SUD, given that the absence of meaning is a risk factor for the development of substance use, assessment of levels of meaning in adolescents can help identify vulnerable individuals who would benefit from more specific interventions to prevent future alcohol and drug use. Thus, it is important to incorporate formal evaluation of perceived meaning, values, and sense of purpose in preventive and health promotion programs.

  • Similarly, during preventive efforts related to substance abuse it is important to incorporate psychoeducation on values, meaning, and goal-congruent behavior adapted to different developmental stages. For instance, programs can include activities oriented toward identifying individuals’ sources of meaning, their valued goals and ideals, and further emphasize the dissonance between such values and substance use.

  • In the treatment of SUD, ongoing formal monitoring of levels of meaning in life and symptoms is recommended. This can be done through valid self-report measures and the documentation of qualitative reports obtained from observations and perceived changes in clients. Assessment is vital to tracking progress, identifying specific needs for intervention, and evaluating the interaction of meaning in life and symptoms.

  • For mental health providers implementing logotherapeutic interventions, it is recommended that they incorporate a program evaluation of treatment outcomes, have clear documentation of treatment procedures, and establish a routine follow-up with clients after treatment for validation and further diffusion of meaning-centered approaches. Initially, findings from program evaluation can be compared to research data on treatment outcomes and abstinence rates following other SUD treatments. Ideally, these models of treatment should be tested against other treatments and evidence-based practices.

  • In treatment, meaning-based interventions can be included at every stage, through individual, as well as group therapy. Brief psychoeducation on meaning, using Frankl’s theory of logotherapy, can be beneficial. Moreover, group therapy can be oriented to enhance the perception of meaning in recovery and to help clients make sense of their addictions by putting their suffering in the service of something or someone meaningful to them.

  • At the beginning of treatment, clients may be reluctant to think about meaning and values because doing so might confront them with past failures at actualizing their values and goals due to drug use. Moreover, at the beginning of treatment the clients’ symptoms and resistance to change may keep them from discovering what is meaningful. Thus, it is important for the mental health provider to recognize the best way in which to introduce the topic of meaning to clients, and be aware of any resistance. At the beginning, therapists may find it useful to focus on restoring a sense of dignity and worth in clients before establishing goals oriented to meaning.

  • In treatment, clients should be provided with opportunities to actualize their values (e.g., with their families/loved ones, by serving others, through accomplishing tasks, etc.) and to develop clear, concrete, and realistic meaningful goals during and following treatment. In therapy, clients should identify and delineate the specific steps needed to attain such goals.

  • Lastly, mental health providers should be careful not to impose their own meaning and values onto clients. Thus, past, present, and future sources of meaning should be explored using Socratic questioning and clients’ narratives on what is important to them (see Martínez & Flórez, 2015).