My Dissertation, Research & Scientific Thesis:

The point of this page is to make the data accessible, for: primarily the Acu-Stim Practitioners, professional and ley. For use to inform and support their practice, with a sound empirical data base. And for the many volunteers, clients and staff who enjoyed the 100% positive outcomes.

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Below is the dissertation, my thesis, submitted to the

Department of Psychology and Speech Pathology

Manchester Metropolitan University 

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This spanned 7 years of working in the field as an ethnographic community psychologist. Gathering experimental data. With a base at the Peer Intervention Project for Education in Stretford South Manchester.

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BSc(HONS) PSYCHOLOGY

Supervised by: Dr Darren Chadwick PhD March. 2007.

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Table of Contents

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Title Page. 1.

Acknowledgements Page. 3.

Abstract Page. 4.

Foreword Page .5.

1. Introduction Page. 6.

1.1. Background Page. 6.

1.2. Treatment Interventions Page. 12.

1.3. Treatment Directions Page. 13.

2.0. Method Page. 24.

2.1. Design Page. 24.

2.2. Participants Page. 25.

2.3. Materials/Apparatus Page. 26.

2.4. Procedure Page. 28.

2.5. Ethical Issues Page. 34.

3.0. Results Page. 36.

3.1. Data Analysis Page. 40.

3.2. Post hoc tests Page. 41.

4.0. Discussion Page. 42.

5.0. References Page. 55.

6.0. Appendices Page. 65.

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Acknowledgements

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I would like to thank, and acknowledge:

Tim Bottomley, The Piper Project, Staff, Volunteers and Service Users GMMH NHS

Dr John Brooke. Greater Manchester Drugs (Ian Smith) Library.

Dr Darren Chadwick. Manchester Metropolitan University, School of Health, Psychology & Social Care, Psychology & Social Change Division, Elizabeth Gaskell Campus.

Dr Tony Quinell (G.P). Bolton Salford & Trafford NHS Mental Health Trust.

Craig Smith Operations Director & Roy Huddart. Technical Manager Nidd Valley Medical Ltd.

And all the participants who kindly enabled this dissertation to be produced.

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ABSTRACT

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The study set out to measure the effects of Acu-Point Electrical Stimulation Treatment in the form of ‘Acu-Stim’, on eight withdrawal symptoms from substances of misuse, e.g. Drugs and Alcohol.

A repeated measures design was used with six participants. Their withdrawal levels were assessed three times; pre, during and post treatment over a nine day period.

A scale based assessment questionnaire using Likert scales numbered 0 to 10 were used to measure Anxiety, Stress, Panic Attack, Hyperactivity, Sleep quality, Lethargy, Depression and Craving levels in three conditions (pre, during and post treatment).

It was expected that overall withdrawal symptom levels would be reduced pre, during and post treatment. There was a significant main effect for stress, anxiety, hyperactivity, sleep quality, lethargy, depression and craving. There was no significant difference for panic attack.

A Freidman (chi square) one way analysis of variance by ranks was used on the data taken from the Likert scale scores.

The results showed a significant statistical difference.

Therefore, the null hypothesis was rejected at the p<0.01 level of significance.

Post hoc analyses revealed that Stress, Hyperactivity, Depression, Craving, Lethargy and Sleep Quality also significantly differed between conditions (p<0.05) but Anxiety and Panic attack didn’t significantly differ in this instance.

The findings conclude that ‘Acu-Stim’ treatment reduces substance withdrawal symptoms.

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If the results are valid they could be interpreted as providing support for a complimentary therapy based treatment direction for a non chemical treatment for substance misuse, chemical dependency and withdrawal symptoms.

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Foreword

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‘It is time for behavioural scientists to acknowledge the complexity of alcohol and drug abuse disorders and to increase methodological sophistication accordingly’ (Foy, Cline and Laasi, 1987).

Naturally, validity will also be maximised when multiple measures, such as self report, urinalysis and collateral reports all converge to give similar results. (Waldron 1997).

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1.0. Introduction.

1.1. Background.

The introduction contains a review on the subject of drug treatment interventions; additionally it contains data outlining the concepts and definitions of a Bio-Psycho & Social, Person Centred Treatment Intervention, for Drug or Alcohol Withdrawal, and Emotional Well Being, embodied in the techniques and practice of ‘Acu-Stim’, a specialised form of; Acu-Point, Electrical Stimulation Treatment.

The term, ‘Bio-Psycho & Social’ is used here to highlight, conceptualise and bring together the multifaceted influences that can affect all individuals from time to time. (similar to, but not the same as, or fragmented like mainstream health psychology’s ‘Biopsychosocial’ model proposed by Engle (1977,1980).

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In this context ‘Drug or Alcohol’ will equate to any psychoactive or mind altering substance, namely the eleven categories referred to in the DSM –IV-TR (American Psychiatric Association 2000).

‘Withdrawal’ refers to substance withdrawal from drugs or alcohol, i.e. a collection of symptoms that develop ‘when a person who has

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frequently used a substance, discontinues or markedly reduces the amount used’. (Morrison, 1995).

During withdrawal, thoughts and feelings become amplified effecting ‘Emotional wellbeing’ , ‘Mental health’, or a persons ‘psychological’ state, related to or affected by non physical entities such as: Sounds, Thoughts, Feelings, and Emotions. Also moods, which include: Euphoria, Mania, Paranoia, Depression, Panic, Stress and Anxiety.

For example, the thought or expectation of pain (non physical) has the same effect on corresponding brain areas and neural pathways as the actual physical pain. (Koyama, McHaffie , Laurienti and Coghill. 2005). What is more, their work is supported by empirical evidence in the form of, f.M.R.I. (functional magnetic resonance imaging) brain scans.

‘Emotional wellbeing underpins good physical health and reduces the likelihood that children and young people will take inappropriate risks’. (DOH 2004a). Risks such as alcohol and drug abuse.

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Where it says ‘children and young people’ in the above quote, this can equally apply to all vulnerable or at risk individuals or groups. This includes adults with drug or alcohol misuse and dependency problems, affecting their vulnerability and concomitant likelihood of inappropriate risk taking. The broad definition of a ‘vulnerable adult’ (Lord Chancellor’s Department 1997). is a person;

‘who is or may be in need of community care services by reason of mental or other disability, age or illness; and who is or may be unable to take care of him or herself, or unable to protect him or herself against significant harm or exploitation’. (D.O.H. & Home Office 2000). This could also be the case when influenced by the sub culture in and around the use of drugs or alcohol.

With reference to drugs and alcohol; they usually act on receptors on nerve cells affecting brain function which in turn alters chemical transmission through neurotransmitters. (Erickson 2005).

Furthermore, chemical transmission is through neurotransmitters, which according to Beck (1986). include three ranges of neurotransmitter frequency; enkephalins, catecholamines, and beta-endorphins.

Summing up, ‘The language of the brain is frequency’. (Stubbs 1976).

From an ecological perspective, the language of the brain could be influenced by environmental and social stressors.

Bronfenbrenner, (1979) and Gitterman & Germain, (1976) explain that the aetiology, (cause) and treatment of human behaviour (which can be drug or alcohol linked) is interrelated with the multiple social systems in which individuals interact. (Springer, McNeece & Arnold 2003a).

‘Offending and problematic drug and alcohol use are strongly associated with poor educational achievement, low literacy levels, mental health problems, dual diagnosis, poverty, deprivation, discrimination and unemployment. Tackling these factors can lead to improved health outcomes’. (D.O.H. 2004b).

One way of tackling these factors (or ‘multiple social systems’) in terms of a treatment intervention, would be with one that hopefully addresses, attempts to address or at least takes into consideration all of the presenting individual’s bio-psycho-social needs, expressed through behavioural symptoms.

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Therefore, behaviour would be the function of the Personality, interacting with the Environment, giving a holistic or gestalt view of the individual, inseparable from their environment.

As in the formula: B= f (P, E) (Lewin 1946, 1951).

Or, if you influence or effect change in one part, it will also have an effect on all the other parts. (Bradshaw 1992).

Therefore, a positive treatment system could influence the social outcomes of human behaviour. In much the same way as a ‘Person Centred’ or, Client-Centred treatment approach, used in person centred counselling. (Rogers 1969). In effect, the treatment provider would be aiming to give unconditional positive regard, while remaining congruent.

Although, a Gestalt description maybe more apt, i.e. addressing the needs of the whole person in context. The whole being greater than the sum of all its parts. (Wertheimer 1972).

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The context being, that particular person’s life context, or ‘Bio-Psycho-Social’, life situation. For that reason, putting the needs of the person who presents them self for treatment, would be paramount.

An example of putting the clients needs first is demonstrated by ‘Client Treatment Matching’ ( Dodgen & Shea 2000a) which has been found to be both ‘clinically effective’, and ‘cost effective’, when implementing an intervention for drug and or alcohol misuser’s.

(Del Boca, & Mattson 1994).

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The intervention in this instance being a method of treatment employed by ‘drug workers’ to interrupt the cycle of addiction, (drug, alcohol misuse, or chemical dependency). delivered within the cycle of change or care continuum. (Prochaska & DiClemente 1992).

The care continuum has 6 stages that are cyclic and not linear, as people in recovery tend to ‘relapse’ a number of times before stabilising at the maintenance stage. (Prochaska & Norcross 1999). (see appendix 1)

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This model is used today whereby; the drug worker or treatment intervention service provider can be seen as the corner stone to treatment provision, acting as a liaison specialist at the centre of any shared care treatment arrangement. (N.T.A. 2002a). (National Treatment Agency).

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The arrangement should make explicit which clinician is responsible for different aspects of the patients /client’s treatment and care. These may include prescribing substitute drugs in appropriate circumstances. (D.O.H. 1999).

Previously, the D.O.H (Department Of Health) in its ‘Guidelines of Good Clinical Practice, in the Treatment of Drug Misuse’. D.O.H. (1984) indicated that general practitioners have a responsibility for the specific drug treatment needs of their patients, as well as their general healthcare needs.

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Moreover, in light of the White Paper, ‘The New NHS. Modern – Dependable’, D.O.H. (1997) not only the role of the general practitioner, but other primary care and community settings as a whole, have become increasingly important in managing and caring for drug users.

In 1999 the long-awaited new edition of clinical guidelines (or orange book) was published. (D.O.H. 1999).

These guidelines firmly established the harm minimisation approach, based on methadone maintenance treatment for opiod dependence, but introduced new recommendations such as dose titration and witnessed dispensing that were more controversial interventions at the time. (Gabbay & Carnwath 2004).

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Further details about other drug treatment interventions provided by drug and alcohol services can also be found in Davidson, Rollnick & MacEwan (1991) Ghodse, (1995) and Jarvis, Tebutt & Mattick (1995).

Drug and alcohol services nationally, have been advised by the Government, through the Home Office, the National Health Service and the N.T.A. (National Treatment Agency for substance misuse) to implement treatment interventions, taking guidance from ‘Models of care for treatment of adult drug misusers: Update 2006’. NTA (2006a). which basically reiterates the same four tiers of treatment intervention, found in ‘models of care’, with an emphasis on ‘treatment effectiveness and improving clients journeys from assessment through to care planning and integrated care pathways’. (NTA 2002b).

1.2. Treatment interventions.

The four tiers of intervention are:

Tier 1. Non Drug Specific Services.

Tier 2. Open Access Services.

Tier 3. Community Services.

Tier 4a. Specialist Services.

Tier 4b. Non Drug Specific Specialist Services.

The above four tiers of intervention have been adapted from the National Treatment Agencies models of care. (N.T.A. 2006b).

(see appendix 2).

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Within the above 4 tiers, specific treatment directions can be implemented to match a presenting clients bio-psycho-social needs.

Therefore, meeting their needs will in turn prevent or reduce harm to individuals and society at large.

‘Treatment benefits not only the individual drug user but, through reducing drug related crime and the spread of blood borne diseases, the wider community’

(Royal College of Psychiatrists & Physicians, 2000a).

1.3. Treatment Directions

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The treatment interventions below are usually delivered within Tier’s 2, 3 and 4a, with the treatments broadly divided into three specific directions. Pharmacological, Psychosocial and Complimentary.

Pharmacological Directions.

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One example of a pharmacological direction is methadone prescribing.

Methadone is a synthetic opiod produced by German scientists during the Second World War for pain relief when the supply of morphine was low. (Dogden and Shea 2000b)

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Daily Methadone consumption is recommended on the grounds that certain clients need careful monitoring, and are very vulnerable to relapse and or overdose. Hence the Substance Misuse Management in General Practice, SMMGP (2000) recommendation that, most new patients should be required to take their daily dose under direct supervision.

With the ‘proper’ dosage of methadone for most client’s being 60 to 80mg. (Goldstein. 2001a).

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Methadone is a long acting, synthetic opioid that inhibits the effects of heroin and other opioids, by blocking the opioid receptors of the brain that bind opiates, such as heroin. (White house policy document, 2000). Whereby, methadone behaves like an agonist and antagonist affecting neurotransmission in the brain.

‘Agonist drugs are substances that stimulate receptor sites, mimicking the action of neurotransmitters and ‘fooling’ the receptor into accepting it. Antagonist drugs inhibit the action of a receptor site and can counteract the effect of an agonist drug by occupying receptor sites without stimulating neurotransmitter activity. Thus agonist and antagonist drugs can be used in treatment’

(Springer, Mc Neece, & Arnold, 2003b).

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Because these chemical receptors can remain blocked by methadone for up to 24 hours,( Goldstein 2001b) The rationale is, even if a person addicted to heroin, takes heroin after the administration of methadone, this person is not likely to feel the same effects of the heroin, as he or she previously felt.

Furthermore, the long half life of methadone enables treatment to be administered on a daily basis keeping the client stable, or in other words; whether it ‘held them’ or not. (Goldstein 2001a).

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Some of the advantages of methadone maintenance are the reduction in and or cessation of illicit drug use, reduced risk of contracting blood borne viruses, such as hepatitis and HIV. (if previously injecting) Also, the reduction in and or cessation of illegal activities to fund the procurement of drugs.

(NTA. 2006a). (Rassool 1998). (Bertschy 1995).

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Conversely, some of the disadvantages are in delivering the appropriate dosage. Aylette (1982) concluded that; there is no unique amount of methadone needed to suit each individual. As far as methadone maintenance is concerned, the U.K differed fundamentally from the rest of the world whereby, only one third of clients were on supervised daily consumption; (R.C.P.& R.C.P. 2000b). leaving the gate open for overdose and the selling of methadone on the black market. Furthermore, it is a well known activity within the drug treatment community that ‘clinic patients’ or clients, sell on their prescribed drugs, known as ‘leakage’. (Parker & Kirby 2004).

Additionally, most pharmacological drug treatments have the added risk of ‘side-effects’, (Holmes 1998). addiction/dependency, using on top and overdosing. ‘Patients on methadone maintenance commonly use cocaine, alcohol and benzodiazepines’

(Milhorn 1990).

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Pharmacological treatment directions for drug/chemical dependency, in this case methadone maintenance, still remain the most widely used treatment intervention for addiction to, or dependency on opiates such as heroin. This is mainly due to the evidence base available, that also supports the latest government’s strategies and policies in; ‘tackling drugs changing lives’ (NTA. 2006b).

Consequently, ‘The best evidence for pharmacological treatments in the drugs field is for oral methadone which has been shown to provide major harm minimisation outcomes in a variety of different settings over a number of years’ (Keen 2003). Also ( Bertschy 1995) and (Farrell, Ward, Mattick, Hall, Stimson & Des Jarlais 1994).

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Furthermore, when methadone maintenance treatment has been delivered in conjunction with a psychosocial drug treatment direction, such as basic counselling, it is much more likely to be effective. And in some cases (methadone maintenance) may only work for a minority of eligible clients. (McLellan, Arndt, Metzger, Woody, & O'Brien 1993).

Therefore, methadone maintenance although one of the best pharmacological treatments for opiate dependency, should not be a ‘stand alone’ treatment intervention

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Psychosocial Directions.

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One example of a psychosocial direction is C.B.T (Cognitive Behavioural Therapy) or C.T. (Cognitive Therapy)

Cognitive therapy ‘is a system of psychotherapy that attempts to reduce excessive emotional reactions and self-defeating behaviour by modifying the faulty or erroneous thinking and maladaptive beliefs that underlie these reactions’ (Beck, Wright, Newman and Liese 1991). C.B.T’s broad approach encompasses several important common tasks of successful substance misuse treatment.

Furthermore, C.B.T has been extensively evaluated in rigorous clinical trials and has solid empirical support as to its efficacy. (Carroll 2003).

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Moreover, C.B.T. should only be carried out by professionally trained and qualified personnel as per the instructions for delivering all psycho-social treatment interventions. (NTA 2006a).

Complimentary Directions

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A few examples of complimentary directions within the field of acupuncture are: Electro Acupuncture, Acu-point electrical stimulation, which is very similar to AL TENS, (Acupuncture Like Transcutaneous Electrical Nerve Stimulation) and ‘Auricular’ or Ear acupuncture.

Auricular acupuncture for the treatment of substance misuse and chemical dependency has been used with success through out the U.K. Europe, North America and China. Also known as ‘Acudetox’.

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‘Acudetox alleviates withdrawal symptoms so mental and physical

stability are quickly achieved’. (Andrews 2003a).

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‘Acudetox’ (inserting 5 acupuncture needles in each ear) is a service employed by West Kent National Health Service and Social Care in the U.K. where approximately 2,500 treatments are carried out each year. (Andrews 2003b)

In the past, Electro acupuncture (inserting acupuncture needles and passing electrical current through them) has also been found to be an effective method in the treatment of substance misuse and chemical dependency, it was shown to reduce morphine and or heroin withdrawal significantly, in experimental animal studies by Yang and Kwok (1986) Where the release of opiod peptides (endorphin, enkephalin and dynorphin) produced a marked sedative effect.

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Moreover, ‘The findings obtained in experimental animals have since been confirmed in humans in clinical practice’

(Han 2003).

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It is also possible to achieve the same effect without the use of needles. Becker (1985) wrote about the very intricate and involved scientific investigations that led to the use in the 1980's of peripheral electrical stimulation to stimulate healing in broken bones.

Additionally, in an experiment by, Han, Chen, and Sun (1991) where they used serial samples of cerebral spinal fluid taken from human volunteers, they found that different kinds of neuropeptides (brain chemicals) can be released into the central nervous system.

This effect was produced by simply changing the pulsed frequency or speed of electrical stimulation, which was not dependent on needle insertion. Support for this also comes from much earlier studies by Wang, Mao and Han (1922) using TENS needle-less acupuncture at all frequencies to produce an ‘Acupuncture effect’ after a specific time.

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Additional corroboration, by means of f.M.R.I. brain scan experiments, using high 100Hz frequencies and low 2Hz electrical pulsed frequencies for heroin addiction has been demonstrated by; Zang, Jin, Cui, Zang, K.L, Zang, L, Zeng, Fei Luo, Andrews, Chen & Han (2003) and (Wu et al 1999) and (Wu et al 2000).

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Consequently, providing further support for the use of needle-less, but acupuncture like, electrical stimulation in the field of substance misuse.

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Other forms of needle-less acupuncture have also been applied to the field of addiction, for instance the randomized double-blind study, by Gariti, Auriacombe, Incmikoski, McLellan, & Patterson, et al (1992) using N.E.T, (Neuro-Electric Therapy) in opiate and cocaine detoxification.

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Whereby, a comfortable detoxification was reported, with relief from physiological and psychological withdrawal symptoms.

This was also without the need to use other substitute drugs and or medications; when abstaining fully, from the use of illicit and licit drugs.

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Earlier, clinical reports published in the 1970’s and 1980’s on electro acupuncture by Wen and Cheung (1973), Wen (1977) and Wen et al (1980) also offer support for this form of complimentary treatment for drug addictions and chemical dependency, even though, Wen’s (1977) study used an opiate blocker, in combination with electro acupuncture to ‘provide a faster de-tox’.

Similar results to Wen (1977 & 1980) were found by Gomez & Mikhail (1978) with electro therapy on methadone withdrawal. Their research was also more experimental in its design, by providing a control group.

Where as conversely, an experiment with no control group by; Gossop, Bradley, Strang and Connell (1984) looking at ‘The Clinical Effectiveness of Electro stimulation vs Oral Methadone in Managing Opiate Withdrawal’, found Electro Stimulation following Patterson’s (1976) N.E.T protocols to be ineffective against opiate withdrawal syndrome.

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Contrarily, important research, also in the 1970’s and 1980’s, by Patterson (1974, 1979 and 1980) and (Patterson, Frith and Gardiner 1984). in addition to numerous other studies, provide evidence to support the efficacy of electrical stimulation treatments for addictions, which then, as now became known affectionately as ‘Black Box’.

(Townsend 1983).

The ‘Black Box’ back then, was scientifically, known as N.E.T. (Neuro-Electric Therapy) and was the brain child of Dr Meg Patterson. (1974, 1979, 1980, & 1984) Whereby, ‘NET became popular with pop stars such as Eric Clapton, Pete Townsend, Keith Richards, and Boy George’. (BMJ, 2002).

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Moreover, it was the work by Patterson et al, (1974, 1979, 1980, 1984, & 1993). that contributed to the instigation of this study, by adapting and changing her protocols of electrical stimulation, via electrodes placed on the skin behind the ears, at various frequencies between 0.5Hz and 3000Hz; for drug and alcohol detoxification and withdrawal, and the work from Han (2003). and Zang et al (2003). who used specific frequencies of 100Hz and 2Hz to trigger the release of endorphins, enkephalin and dynorphin; via adhesive electrodes placed on acupuncture points, such as on the hand i.e. hegu or Li4.

(see appendix 3).

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One of the aims of this study is to demonstrate the hypothesis to be valid, by measuring the perceived physiological and psychological levels of withdrawal, associated with substance misuse and chemical dependency in three conditions; pre, during, and post treatment.

With an overall aim to use a combination of the above research data and treatment techniques, in conjunction with pilot work that took place in Manchester (U.K.) based substance misuse services, since 2000 (see abstract in appendix 4) to produce a revised and revived version of ‘Black Box’, (Dicicco 2006). now known as ‘Acu-Stim’ treatments and training, within drug and alcohol services through out the North West of England. (see appendix 5).

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A further aim of this dissertation is to bridge a gap in the literature coming mainly from the 70’s and 80’s pertaining to this form of treatment. Kornor and Waal (2005). also found, that addiction treatment research literature had barely been updated in the last 20 to 30 years.

Hypotheses.

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H.0. There will be no significant difference between pre, during and post treatment withdrawal symptom levels.

H.1. There will be a significant difference between the pre treatment stress levels and the post treatment stress levels, with the post treatment levels being lower.

H.2. There will be a significant difference between the pre treatment levels of drug craving and the post treatment levels of drug craving, with the post treatment levels being lower.

H.3.There will be a significant difference between the pre treatment depression levels and the post treatment depression levels, with the post treatment levels being lower.

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2.0 Method

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2.1 Design

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In this quasi experiment of ‘Acu-Stim’s’ effect on drug withdrawal symptoms, a repeated measures design was used on one group of six participants, recruited through purposive sampling from an initial opportunistic sample of 30. The selected participants were treated on six occasions with a standard treatment protocol, (see appendix 6) used to manipulate the independent variable (I.V.1.) over a nine day period. Questionnaire, scale based assessments, (see appendix 7) were carried out in three conditions, to measure the dependent variables of withdrawal symptoms (D.V.1) on ten levels. The first condition was pre treatment, (used as a control or base line measurement) the second condition was just before the fourth treatment (during) and the third condition was post. (taking place after the sixth, ‘Acu-Stim’ treatment). The levels of the D.V. were the perceived levels of: 1. Stress, 2. Anxiety, 3. Panic attacks, 4. Hyperactivity, 5. Sleep disturbance, 6. Depression, 7. Low energy, 8.Cravings, 9. Sleep, and 10. Feeling’s.

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The D.V. levels 1 to 10 were measured by scores given on a 10 point scale, pre, during and post treatment. It was predicted that participant’s scores in the pre treatment condition would be higher than in the post treatment condition.

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2.2 Participants

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Six participants took part in this quasi-experiment, three female and three male. The participants varied in age from 24 to 39 with a mean age of 34.1. All participants were voluntarily attending a community drop in centre, to watch a presentation on a complimentary treatment direction for drug and alcohol withdrawal symptoms. (see slide handouts in appendix 8)

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The initial sample was opportunistic and comprised 30 participants who were given a questionnaire to complete. (appendix 7) 19 returned the questionnaire, with 13 leaving the study and being debriefed at this point. The remaining six who were recruited through purposive sampling, qualified for this study by:

1. Meeting the pre arranged quota of 3 male and 3 female, and furthermore,

2.Having used substances such as drugs or alcohol in the past or present.

3. Not having any contraindications for the treatment,

4.Not being on any prescribed medication.

5. Not having any serious, significant or major illnesses or operations.

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2.3 Apparatus and Materials

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An explanation sheet (see appendix 9) was used in the beginning to inform the participants of the treatment being tested in the study, along with a briefing sheet and consent form. (see appendix 10) The questionnaire/scale (appendix 7) was also used initially to produce classification variables for those who would qualify for the study, with the same questionnaire/scale used to measure the D.V. in conditions one, two and three, and to generate the dependent variable levels through scores on likert scales numbered 0 to 10. This is a revised version of the assessment tool that has been used to assess the risk and fitness of a client to receive electrical stimulation in the form of Acu-Stim within NHS drug services since 2000.

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A separate craving scale sheet question was used to generate dependent variable level 8 scored on a scale between 0 and 10. (see appendix 11)This was based on the work by Coombs, Manley and Rosenberg’s (2001) ‘Cue Therapy’.

A reflexive diary sheet (see appendix 12) was used comprising two questions, one with a lie scale for the question on sleep (D.V. level 9) with the scale scored in reverse to D.V. level 5. (sleep quality) on the questionnaire/scale assessment form (appendix 7) The second question on the sheet was open ended and qualitative asking how the participant felt after treatment. (D.V. level 10. This is dealt with at the end of the results and discussion section). A treatment consent form (see appendix 13) was used to re affirm anonymity and make sure the participant fully understood what the treatment entailed. An Acu-Stim Treatment Record Sheet (see appendix 14) was used to record the dates of treatment, what acupuncture points were used and at what electrical pulsed frequency. All the sheets were completed by the researcher for standardization and to take the pressure off participants with writing difficulties. Pictures of acupuncture points on the ear and body were used to show participants where the stimulation and pads would be placed. (see appendix 3, 15,16,17 & 18)

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The treatment room was 10 feet by 15 feet, warm and comfortable with low lighting and in a quiet confidential setting. In the room was a desk, lockable confidential filing cabinet, with anonymised manila folders for each participant. A comfortable chair was provided for the participant to sit on during the interview/ questionnaire stage and an adjustable swivel chair for the researcher to enable the correct delivery of treatment. Across from the desk and interview area was a therapy table, black plastic covered, so could be cleaned easily, with 4 inch padding for comfort which met current British safety standards.

The ‘Acu-Stim’ equipment used to stimulate acupuncture points at specific frequencies; comprised two pro tens electrical stimulators, self adhesive electrode pads, auricular clips and lead wires. This equipment has been supplied by and approved for the use of this treatment by Nidd Valley Medical LTD (see appendix 19 & 20) and approved by Bolton Salford and Trafford Mental Health NHS Trust, Complimentary Therapies Sub Committee. (see appendix 21) Antiseptic wipes were used to clean ‘Acu-Stim’ probe and clips and a bottle of water for use during auricular treatment. A watch was used to time the treatments for 30 minutes.

2.4 Procedure

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After gaining consent from the project chair (see letter Appendix 22) to deliver a presentation on, and speak to the clients about ‘Acu-Stim’ on the 12th July 2006.

The first step was to explain what the treatment is, reading aloud from the explanation sheet (appendix 9) to the group of thirty clients attending the community project and answering any questions.

The briefing sheet/consent form was then read out (appendix 10)

It was explained that only three males and three females would be able to take part in the study, but everyone who qualified for a treatment would be able to have one at a pre arranged appointment.

All thirty were then given a questionnaire sheet to fill in, (appendix 7) they were asked to fill it in as best they could, (taking into account some of the sample may have learning difficulties) put their initials and date of birth on the sheet, fold the sheet in half and place it in the box marked confidential. The box was a sealed brown cardboard box with a letter box type hole cut in the side and placed on the table in the corner of the room.

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It was explained that they could place their completed questionnaire in the box any time between 11am and 4pm that day. That all replies would remain anonymous, and would be looked at by the researcher who would return with the questionnaires, the beginning of next week on Tuesday to answer any questions and inform those who could take part in the study.

It was explained that the researcher would be at the project next week between 10am and 4pm, in the room marked confidential. It was explained once more, that only six people out of all those who had completed a questionnaire and met the requirements for treatment would be eligible to sign up for the study, with treatment times to be arranged over the next two weeks. (to make sure there were no misunderstandings) All the questionnaires were then taken for analysis, which involved purposive sampling.

Out of the initial 30 questionnaires handed out (appendix 7) 19 completed sheets were collected from the box marked confidential.

From the 19 completed questionnaires 6 participants qualified and were chosen for the study.

The six participants met the study criteria by circling N for no in question 1. a, b, and c.

In question 2, each of the 7 likert scales a, b, c, d, e, f, and g, had been circled between 0 and 10. Question 3. the answer was N, no. to are you on any prescribed medication? Question 4 a. the answer was Y, yes to Have you used any substances, such as drugs or alcohol? In the past or present? And 4.b. either: Heroin, Alcohol, Cocaine, Crack, Amphetamine sulphate, Cannabis, or street names for drugs and alcohol were entered.

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The researcher waited in the room marked confidential between 10am and 4pm as previously arranged. Participants came in individually giving their initials and date of birth, which was matched with the corresponding code on each questionnaire. Those who could not take part in the study were debriefed and asked if they would like to talk to a drugs counsellor, with those who met the requirements for the treatment and not the study, and wanted to have a similar treatment, were referred to specialised drug and alcohol services.

The six who qualified for the study were asked again if they would like to take part. After this was confirmed, three female participants were allocated (p numbers) participant numbers 1, 3 and 5 with the males being given even numbers 2, 4 and 6. They were asked to remember these numbers for reasons of anonymity.

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The six selected participants who qualified for the study were then interviewed individually, in a private and confidential room. The explanation sheet (appendix 9) was read to each participant individually by the researcher, and asked if they understood how it worked, all participants said yes. They were then asked to read and sign the briefing sheet/consent form. (appendix 10) followed by signing the consent for Acu-Stim treatment form (appendix 13)

After these had also been read out by the researcher.

All participants were asked if they would have any difficulty attending at any of the times, between 9am and 3.30pm. Wednesday, Thursday, and Friday of the current week and at the same times Tuesday, Wednesday and Thursday of the following week. Participants were then randomly allocated their treatment times and dates on an appointment sheet (see appendix 23). according to their ‘p’ number, p.1.being allocated the earliest appointment at 9am and p.6. the last appointment at 2.30pm. For ease of remembering, each participant kept the same time to attend for treatment through out the study.

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Between 09:00 hrs on Wednesday the 19th of July 2006 and 15:30hrs Thursday the 27th of July 2006. Six individual ‘Acu–Stim’ sessions were delivered to six individual participants. 36 sessions in total were carried out over the nine day evaluation period, which included Saturday, Sunday and Monday as rest days, where no treatments were delivered.

It was explained that this was now the study ‘proper’, and that the researcher would aim not to use any unscripted vocal contact, so may seem rather artificial or strange at times when asking the questions.

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All participants were treated individually and informed that there would be a debriefing session at the end where any questions would be answered, and if they wanted to leave the study at any time they were free to do so without any obligation. They were all warmly thanked for their help so far.

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Condition. 1.

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Condition 1 was the period just prior to beginning the first session.

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‘Pre treatment’, used as a control or base line measurement.

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Step 1.The assessment form (appendix 7) was read out and completed Step 2.The Cravings question (appendix 11) was read out and completed and Step 3. The Reflexive diary scale question 1. How did you sleep last night? (appendix 12) was read out and scored on the scales by the researcher for standardisation. This took place in the confidential treatment room at the desk. The treatment was then delivered following the standardised treatment protocol (appendix 6) on the treatment couch. After 30 minutes at the end of the pulsed treatment; question 2 on the reflexive diary sheet (appendix 12) was then asked. ‘How do you feel after your treatment’? The researcher recorded what was said by the participant on the sheet in block letters showing each participant what had been written and asked ‘Are you ok with that’. Indicating to what had been written. All participants indicated they were happy with what was being recorded.

The treatment only, was then repeated for the second session on day two for each participant individually, where the researcher only asked ‘how are you feeling today’, and ‘would you like to carry on with this study and the treatment session’? The treatment was then given as per the standard procedure, but steps 1. to 3. above were omitted and no written notes were taken.

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Condition. 2.

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After the third session, condition 2. ‘During treatment’, at the mid point. Steps 1 to 3 were taken again. Both questions 1 and 2 on the reflexive diary about ‘Sleep’ and ‘Feelings’ were asked. The researcher asked, ‘How did you sleep last night? Before the session and ‘How did you feel after your treatment’? at the end of the session. All scores and answers were recorded on the scales and sheets by the researcher.

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Following a three day break, sessions four and five followed the same standard procedure as session two above, with the standardised treatment protocol being delivered with no recording of data, other than the record of treatment given which was the same on all occasions.

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Condition. 3.

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On the sixth day of treatment, after the sixth session, condition 3. ‘post treatment’, the standardised procedure implementing steps 1 to 3 were carried out as in condition1 and 2 above, followed by the standard treatment protocol.(appendix 6)

On completion of the study, all the participants were debriefed individually at the end of the sixth session, being informed that the researcher would also be available to talk to them during the next day and should they have any further questions or queries please do not hesitate to ask.

2.5 Ethics.

In order to dispel any misconceptions as to who the researcher was, where from, and why there. Ethical considerations around informed consent and carrying out research with human participants were adhered to. This was following the British Psychological Society Professional Code of Conduct, Ethical Principles and Guidelines. BPS (2000). that includes: Competence, recognising and working within limits as a treatment provider and psychology undergraduate.

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Consent, obtaining valid and informed consent of all participants. Confidentiality, maintaining adequate records without breaching confidentiality and keeping anonymity. Personal Conduct, behaving professionally, not damaging clients or undermining public confidence. Recognizing responsibilities to participants, the host organization, the researcher, colleagues and the university.

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In line with BPS (2000). at the end of the study, participants were fully debriefed and asked if they were happy with the whole procedure. They were thanked for taking part and it was explained again that their details would remain anonymous. Particular account was taken of local cultural values and of the possibility of intruding upon the privacy of individuals. (BPS 2000). Owing to the sensitive nature of this study, extra special care was taken, due to the privileged access granted to the researcher, within this sub culture of a drug and alcohol misusing population.

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3.0. Results

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The Friedman Chi Square test was used to test for differences between the means on the data. (please see appendix 27 for the SPSS V.12 for windows, statistical outputs). It is the recommended non parametric test for 3 or more conditions, (Coolican 1999). a repeated measures design, with data at the ordinal level of measurement. In this case the data was originally at the ‘plastic interval scale’ (Wright 1976). level, using a 10 point likert scale.

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‘The Friedman two way analysis of variance by ranks tests the null hypothesis that the k repeated measures or matched groups come from the same population with the same median’ (Siegel & Castellan 1988a).

The test was performed on the data using the SPSS.v12 statistical computer program.

The results from the three conditions pre, during and post-treatment were collected and organised into the table of raw data shown in appendix 24. The averages and standard deviations were calculated for 8 levels of the Dependent Variables for withdrawal: Stress, Anxiety, Panic Attack, Hyperactivity, Sleep Quality, Depression, Low energy and Craving.

Level 9. scores on sleep have not been used in the calculations. Level 10. Feelings are dealt with in a supplement at the end of the results section. (please see appendix 24 for a complete set of data).

Table 1: Dependent Variables; Mean and Standard Deviation Pre, During and Post Treatment Friedman test results

Treatment.   (All the data is here, it just needs editing when I have more time. . , sorry about that)

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Pre    During        Post  Treatment results

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D.V.

M

s.d

M

s.d.

M

s.d

Fx

df

p

Sig.

stress

7.83

1.72

5.33

1.03

2.33

1.21

12.00

2

0.002

**

anxiety

6.33

2.16

4.33

1.50

2.33

1.36

7.91

2

0.019

*

panic

0.17

0.40

0.00

0.00

0.00

0.00

2.00

2

0.368

n.s

hyper

6.00

1.09

4.16

1.16

2.33

0.81

11.56

2

0.003

**

sleep

7.50

1.64

3.83

2.48

2.83

1.47

9.33

2

0.009

**

depress

5.33

2.42

3.17

2.13

1.50

1.37

11.56

2

0.009

**

lethargy

5.50

1.76

3.67

1.86

1.67

1.21

9.36

2

0.009

**

craving

6.50

1.64

3.50

2.16

1.50

0.58

11.56

2

0.009

**

** = p<0.01 * = p<0.05 n.s = Not significant.

M = Mean. s.d = Standard deviation. Fx = Friedmans chi square

The above table shows Friedman Chi squares for each level of the dependent variable with 2 degrees of freedom.

For further clarity please see tables 2, 3 & 4 in appendix 25 showing the means and standard deviations for 3 major withdrawal symptoms: Stress, Depression and Craving.

The line graph in figure 1. p.40. shows the eight withdrawal symptoms over three conditions.

Figure 1. Withdrawal symptom levels, Condition 1 pre treatment, condition 2 during and condition 3 post treatment mean scores.

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The above figure shows the eight withdrawal symptoms mean scores in condition1 pre treatment, condition2 during treatment, and condition 3 post treatment. An overall reduction in symptoms can be seen, with panic attack showing virtually no difference running along the bottom axis.

The line graph in figure 2 below depicts the mean stress, depression and craving levels; pre and post treatment.

Figure 2. Withdrawal Levels for stress, depression & craving. Pre and Post Treatment

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UPLOAD IMAGE

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For a full set of descriptive statistics please see appendix 26.

3.1. Analysis

There was a significant main effect for: Stress (F=12.00, df=2, p<0.01). Hyperactivity, Depression and Craving (F=11.56, df=2, p<0.01). Lethargy (F=9.36, df=2, P<0.01). Sleep Quality (F=9.33, df=2, p<0.01).

Anxiety (F=7.91, df=2, p=<0.05).

There was no significant main effect for Panic Attack (F=2.00, df=2,)

The Freidman test performed on this data is one tailed with 2 degrees of freedom.

The probability associated with F > 9.00 (equal to or greater than) when N = 6 and k = 3 is p< 0.01. (N = number of participants. k = number of conditions. F = critical value)

Thus, for the data items 1, 4, 5, 6, 7 and 8 we may reject the null hypothesis H.0. at the 0.01 level of significance since the calculated values of Fx 9.33, 9.36, 11.56 and 12.00 are larger than the tabled critical value of 9.00.

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Therefore, the difference between pre, during and post treatment withdrawal symptoms of Stress, Hyperactivity,  Sleep Quality, Depression, Low Energy/Lethargy and Craving are highly statistically significant.

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The probability associated with F > 7.00 when N = 6 and k = 3 is p< 0.05

Thus, for item 2 we may reject the null hypothesis H.0. at the 0.05 level of significance since the calculated value of Fx 7.91 is larger than the critical value of 7.00.

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Therefore, the difference between pre, during and post treatment anxiety levels are statistically significant.

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The probability associated with F > 5.33 when N = 6 and k = 3 is p<0.10

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Thus, for item 3 we may retain the null hypothesis H.0. at the 0.10 level of significance since the calculated value of Fx 2.00 is smaller than the critical value of 5.33. Therefore the difference between pre, during and post treatment levels of panic attack are not statistically significant.

3.2 Post hoc tests

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Because the value of F is calculated to be significant on 7 of the 8 levels of the dependent variable, it points towards (at least) one

condition being different from another. (Siegel and Castellan, 1988b) Therefore, to determine which conditions differ from each other a post hoc test for differences between (condition 1 and 2) pre and during and (condition 2 and 3) during and post, for each level of the dependent variable was performed. (e.g. between two related sets of data).

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Post hoc analyses (appendix 28) revealed that Stress, Hyperactivity, Depression, Craving, Lethargy/Low Energy and Sleep Quality significantly differed (p<0.05) between pre and during and between during and post treatment but Anxiety did not significantly differ between post and during and during and post treatment so was rejected at the (p<0.05) level of significance Panic attack didn’t significantly differ between any of the conditions so was also rejected at the (p<0.05) level of significance.

Results Supplement

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The qualitative data in the form of comments during and after treatment conditions from the participants have not been formally analysed in this report. Please see appendix 24. D.V. Level 10. for abbreviated comments.

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4.0 Discussion

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Interpretation of the results:

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As can be seen by the above results the hypotheses:

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H1, H2 and H3 have been supported with the Freidman tests showing significant statistical differences between 7 of the 8 pre and post treatment withdrawal symptoms, Stress, Anxiety, Hyperactivity, Sleep, Depression, Low energy and Craving.

Although, item 3 panic attack showed no significant difference, with the scores for 5 of the participants on this level of the dependent variable ‘panic attacks’ being 0 in all conditions pre, during and post treatment, with one participant (I.D. number 2) scoring 1 in the pre treatment condition 1.

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This would account for no difference being recorded on this level. The other anomaly in the results was highlighted by the post hoc test results, where no significant difference between anxiety levels pre and during and during and post treatment were recorded.

Overall, a statistically significant difference was found pre, during and post treatment. With post treatment withdrawal levels being statistically and clinically lower.

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Thus, flagging up the possibility that the specific Electrical Acu-point Stimulation treatment, (‘Acu-Stim’) used in this study has a positive and dramatic effect on withdrawal symptoms.

Alternatively, it could be that there was no real significant difference between any conditions, but the design has failed to show this.

Or, there really is a significant difference in the reduction of withdrawal symptoms from the use of licit and illicit substances after only six sessions of ‘Acu-Stim’.

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This may be surprising to Gossop, Bradley, Strang and Connell (1984) as it contradicts the findings of their study carried out 23 years ago, on ‘The Clinical Effectiveness of Electro stimulation vs Oral Methadone in Managing Opiate Withdrawal’. This could be because the form of ‘Electro stimulation’ used in their study differs substantially by a number of different points, compared to the Acu Point Electrical Stimulation Treatment (Acu-Stim) used in this study. e.g. treatment protocols, procedures, delivery, frequency parameters, electrode placement and equipment used. (appendix 6).

Assessment Instruments:

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Additionally, the measurement instrument used in Gossop et al, (1984) study was designed solely to measure opiate withdrawal symptoms, where as the measurement instrument used in this study was purposefully designed to measure poly drug withdrawal symptoms to be treated by ‘Acu-Stim’. (appendix 7).

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Furthermore, the (C.O.W.S) Clinical Opiate Withdrawal Scale (Wesson, Donald, Ling and Walter, 2003) in combination with the (M.A.P) Maudsley Addiction Profile (Marsden, Gossop, Stewart, Best, Farrell and Strang 1998) and the (B.D.I). Beck’s Depression Inventory

(Beck, Ward, Mendelson, Mock and Erbaugh 1961) were scrutinized and recognized as valid and reliable measurement instruments that could be adapted to measure poly drug withdrawal symptoms. (appendix 29)

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However, a hybrid and very much shortened version of these assessment instruments had been adapted to measure symptoms that could be treated by ‘Acu-Stim’.

Symptoms such as hyperactivity a classic opiate withdrawal symptom the opposite of the drugs effect on the central nervous system (sedation) (Krivanek, 1988).

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Therefore, a slow 2Hz pulsed electrical stimulation would be delivered to stimulate the production of endorphins which act like a sedative, whereas, lethargy and or depression are classic stimulant withdrawal symptoms, (Uslaner, Kalechstein, Richter, Ling and Newton, 1999). Therefore, a fast 100Hz pulsed electrical stimulation would be delivered to help stimulate the production of natural anti depressants such as Serotonin, Nor epinephrine and Dopamine.

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Moreover, support for these findings comes from Zang et al (2003) using Fmri bran scans to record brain network activations that were positively correlated with 2Hz and 100Hz electrical stimulation via acupuncture points to produce an analgesic effect similar to that caused by central nervous system depressants such as opiates.

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Therefore, because the same frequency parameters as Zang et al (2003) and Han et al (2003) were used in this study, the results could imply that the feelings of emotional well being and the reduction of withdrawal symptoms (to practically zero) are due to the release of endorphins and other neurotransmitters through the ‘Acu-Stim’ pulsed electrical frequencies.

Furthermore, anecdotal (qualitative) evidence in the form of comments made by the participants in this study supports the efficacy of this specific form of treatment.

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This can be seen by the abbreviated comments to the question, ‘How did you feel after your treatment today’? (appendix 12). Some comments were: ‘OK’,’ Calm’, ‘Better’, ‘Very good’ and Stoned.

However, as Kornor and Waal (2005) pointed out there does seem to be a large gap in the addictions literature.

Therefore, service users and the general public should be made aware of this when being offered treatment options concerning specifically This, ‘Acu-Stim’ treatment and where it could fit in with government guidelines on treatment interventions within the ‘models of care’. (N.T.A. 2006).

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Therefore, the clinical, although not experimental outcomes from treatment sessions which comprise; positive anecdotal evidence supporting the delivery of ‘Acu-Stim’ as a viable treatment intervention, from the vast amount of chemically dependent clients, who have received this treatment and over 100 therapists to date, delivering this treatment throughout the North West of England, could be taken into consideration. (Dicicco 2006).

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Furthermore, because the findings from this study are interpreted as a safe and effective way to reduce withdrawal symptoms, methadone treatment prescribing regimes could incorporate the ‘Acu-Stim’ treatment regimen as part of a reduction or maintenance program.

Thus, reducing the amount of possible overdoses and ‘leakage’ on to the black market (Parker & Kirby 2004).

Assessment of the design

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However, in light of the possibility of a type 1 error, rejecting the null hypothesis wrongly, the design of the study will now be looked at for flaws.

In hindsight, with more time and resources a double blind, R.C.T. (randomized controlled trial with a no treatment control group) that was longitudinal could have been implemented. This would increase validity, reliability and credibility to the outcomes, with a greater chance of being replicated and published in the future.

Hence, there is a possibility that this form of treatment could be taken more seriously in the drug and alcohol treatment community.

Moreover, this study has faced similar challenges to those of Patterson, when carrying out her research in the 1970’s and 1980’s. e.g. the stigma attached to complimentary therapies as a whole, (causing prejudice and misconceptions) not being recognized as a valid treatment by Government legislators, accumulated evidence has been classed as anecdotal and not experimental, possibly due to a lack of funding and using small selective samples.

The sample in this study was also relatively small and may not have reflected the mean trend for scores in the general population, but on comparison with scores on a similar study six years ago with chemically dependent clients, coming from the substance using and service attending population in Manchester. (appendix 4)

The mean score differences pre and post treatment were similar, showing the same trend as in this study with lower scores for craving post treatment.

However, stricter controls could have been implemented had there been more resources such as a no treatment control group and or a residential setting with trained staff. Participants could then be monitored by medical staff throughout the study with interventions such as urinalysis before treatments to prevent undisclosed drug or alcohol use contaminating the results.

To reiterate, the assessment tools used in this study have all been based on recognized instruments such as the M.A.P, ( Marsden et al, 1998). B.D.I (Beck et al, 1961) and the C.O.W.S (Wesson et al 2003) mentioned previously.

However, the participants in this study had given up their time voluntarily and the time allotted at the experimental venue was also limited.

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Hence, time was a contributing factor that led to the use of a short modified form of assessment instrument with the scales overarching model based on those used in ‘Cue therapy’ by Coombs , Manley and Rosenberg (2001).

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Furthermore, had it been possible to take blood pressure, E.E.G. (Electro Encephalogram) and cardio-vascular measurements pre, during and post treatment. There would have been true interval level data collected, where a parametric test could have been performed on the data to produce more robust experimental results.

However, it is always possible that the positive results found through this quasi experiment could have also been confounded through experimenter bias in the form of non verbal communication and social interaction, also known as ‘demand characteristics’ (Orne 1962) where perhaps, both the researcher’s expectations of the hypothesis to be valid and the possibility of some participants having a high need for approval, resulting in wanting to please the researcher, nevertheless could have confounded the result with errors.

This includes all random errors, unsystematic extraneous variables such as, the way participants and or the researcher felt on the treatment days and throughout the study, including:

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When, how, if used drugs, alcohol, tobacco, caffeine. Bio, psycho, social influences, age, sex, expectations, researcher, location, or just lying down for half an hour in a quiet room, all of which could have had an effect on the dependent variable, as well as the possibility that the result was a ‘placebo effect’, and not the effect of the treatment (I.V.) on the withdrawal symptoms (D.V).

Consequently, there is a great need for replication of this study following the same procedure verbatim, which would help with the generalization of the results and offer further support to external validity.

Conclusions:

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The expectations of this study that Acu-Point Electrical Stimulation (‘Acu-Stim’). would reduce the effects of withdrawal symptoms have been supported by the findings in the results.

Moreover, this form of treatment fits in with a Bio-Psycho, Social and Person Centred model of addressing a presenting client’s needs.

Coincidently, fitting in with the latest government guidelines on drug and alcohol treatment (NTA 2006).

Moreover, the assumption is; that by physically treating the biological and psychological symptoms of withdrawal with the ‘Acu-Stim’ treatment protocol, it is likely to result in at least a less chaotic way of living for the individual client, eventually filtering down to effect deeper levels of social interaction on a societal level. (Springer, McNeece & Arnold 2003a).

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The person centred part of the treatment is woven in to the Acu-Stim practitioners training, where the overall philosophy is of the ‘client knows best’ what His or Her needs are. (a form of solution focused treatment)

Thus, by tailoring and delivering a treatment to match the biological and psychological symptoms of a client in the personal context of a unique and individual social environment, the chances of positive outcomes from treatment should likely be increased. (Dodgen & Shea 2000a).

Whether the outcomes of the statistically significant results are purely down to the independent variable of the treatment’s effects, on the dependent variable of the perceived psychological and physical symptoms of withdrawal. Or the result of demand characteristics remains to be determined.

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