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Substance use disorders are often accompanied by irrational beliefs and unfavorable attitudes that contribute to their development and persistence. Metaphor therapy, utilizing stories and imagery, has emerged as a potential intervention to reshape thoughts. This study aimed to investigate the impact of metaphor therapy on irrational beliefs and attitudes among individuals with substance use disorders. A quasi-experimental study was conducted at Assiut University Hospital’s substance use inpatient unit from April to December 2023. A non-probability purposive sample of 115 individuals with substance use disorders was selected but only 100 were recruited and randomly assigned to study and control groups. The study group (n = 50) received six 90-min group metaphor therapy sessions over 6 months, while the control group (n = 50) received no intervention. Irrational beliefs and attitudes toward substance use were assessed using the Irrational Beliefs Scale and Attitude Toward Substance Abuse Questionnaire at pre-treatment, post-treatment, and follow-up.
Results
The metaphor therapy group demonstrated significant decreases in mean irrational belief subscale and total scores at post-treatment and follow-up compared to pre-treatment. Additionally, this group exhibited higher mean attitude scores, indicating more negative attitudes (rejection of substance use) during post-treatment and follow-up assessments. No significant changes were observed in the control group.
Conclusions
Metaphor therapy was effective in reducing irrational beliefs and fostering more favorable attitudes toward substance use among individuals with substance use disorders. The finding suggests metaphor therapy could be a valuable intervention for addressing cognitive and attitudinal factors contributing to substance use.
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SCID-5-CV
The Structured Clinical Interview for DSM-5 Disorders—Clinician Version
DSM-5
The Diagnostic and Statistical Manual of Mental Disorders-5th Edition
ATSAQ
Attitude Toward Substance Abuse Questionnaire
IBS
Irrational Beliefs Scale
Background
Substance use is a progressive, chronic, and potentially fatal illness that not only results in loss of life, but also has detrimental effects on families and society [1]. Around 6 million Egyptians, comprising approximately 8.5% of the population, suffer from substance use disorders, with the majority aged 15–25 [2]. Moreover, 33% of Cairo residents and 22.4% in Upper Egypt struggle with substance use [3]. Similar to many mental illnesses, substance use disorders often involve gaps in knowledge, coping abilities, insight, mentalization, self-observation, and awareness [4].
Understanding the brain regions and circuits affected by addiction, such as the prefrontal cortex, amygdala, and nucleus accumbens, can offer a more comprehensive view of how metaphor therapy might influence cognitive and emotional processes at a neurobiological level. These key brain structures are involved in decision-making, emotional regulation, and reward processing, which are all implicated in the development and maintenance of substance use disorders [5‐8]. Moreover, an individual's tendencies toward substance use or abstention are believed to strongly correlate with their irrational beliefs, attitudes toward substances, and cognitive distortions [9].
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Various psychological hypotheses propose numerous causes for substance use disorders. Cognitive theories place greater emphasis on irrational beliefs than behavioral or psychodynamic theories. Irrational beliefs are frequently spontaneous, instinctive, and persistent, playing a significant role in substance use development and persistence. People’s knowledge and beliefs significantly influence this condition’s occurrence, progression, symptoms, causes, and behavioral changes. Irrational beliefs include expectations of validation from others, high self-expectations, blame readiness, exaggerated responses to failure, emotional irresponsibility, high fear/anxiety, problem avoidance, dependency, inability to change, and perfectionism [10].
Many psychologists have written about how changing attitudes and upholding a negative view of substance use is one of the most crucial strategies for treating and preventing substance use disorders [11].
In addition, understanding attitudes and their components has prompted researchers to recognize the importance of studying attitudes toward social issues, particularly pathological ones. Identifying attitudes toward substance use can offer insight into the factors influencing behaviors, such as the intention to act if given the opportunity to use substances and perceptions about this phenomenon [12]. Understanding tendencies toward a substance use phenomenon enables the prediction of the likelihood of behavior expansion or contraction. These attitudes are acquired through reinforcement, imitation, social learning, and personal experiences from sources like media, social environment, and parents. To understand why individuals, hold certain attitudes, examining the interaction between cognition, behavior, and emotions is crucial. Awareness influences the attitude–behavior link [13]. Logical thinking and awareness of substance use's negative consequences may lead to unfavorable attitudes, avoidance of substance use environments/situations, and vice versa [14].
One of the most crucial strategies in treating and preventing substance use involves modifying the system of irrational beliefs, which in turn alters attitudes of individuals with substance use toward maintaining favorable or negative views of substance use [11]. In line with this, several methods for preventing and treating substance use disorders have been proposed, including metaphor therapy, which aims to alter irrational beliefs and unfavorable attitudes about substance use while reinforcing favorable ones [15].
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Metaphors utilize stories, storytelling, images, or visual metaphors to offer alternative perspectives on certain matters. Across cultures and religions, these types of narratives, analogies, and parables are employed to enhance understanding, make points more memorable, and facilitate positive changes [16].
Metaphor therapy is a less commonly studied method. Stories, myths, and allegories are recognized as influential factors in reshaping irrational beliefs and correcting attitudes, playing a significant role in resolving human internal conflicts. Proverbs and metaphors prevalent in conversational literature are ingrained in the beliefs of every nation, serving as guiding principles in daily life and a consistent source of sociability and exchange of idea [17]. Adults often resonate well with stories and are more receptive to allegorical approaches, which they may not readily accept directly [18].
Lakoff and Johnson’s Conceptual Metaphor Theory (1980) suggests that the meaning individuals assign to abstract concepts is influenced by the structure of their thoughts [19]. This has significant therapeutic implications, as metaphors aid in restructuring our perceptions of the world and ourselves, acting as filters that alter attitudes toward certain phenomena [16]. Therefore, it is hoped that this study may assist individuals with substance use undergoing metaphor therapy in addressing their irrational beliefs and developing positive attitudes toward substance use. The creative pause induced by metaphor is the primary source of the psychological processes underlying therapeutic metaphor, which exhibits superior psychological intervention effects compared to non-metaphor interventions [20]. Hence, given the prevalence of substance use in Egypt and the ongoing struggle to find effective ways to address substance use-related issues, the present study aims to investigate the impact of metaphor therapy on irrational beliefs and attitudes toward substance use among individuals with substance use. So, we aimed to examine the impact of metaphor therapy on irrational beliefs and attitudes toward substance use among individuals with substance use.
Methods
A quasi-experimental study was conducted at Assiut University Hospital’s substance use inpatient management unit from April 2023 to December 2023. Inclusion criteria encompassed participants with substance use disorders who agreed to join the study, lacked a history of psychiatric or organic brain disorders, had no chronic illnesses, exhibited irrational beliefs, and scored 155 or lower on the attitude toward substance use questionnaire. The Diagnostic and Statistical Manual of Mental Disorders-5th Edition (DSM-5) [21] was used to diagnose psychiatric disorders, and the Structured Clinical Interview for DSM-5 Disorders—Clinician Version (SCID-5-CV) during the psychiatric interview [22] was used to confirm the diagnosis and exclude comorbidities.
A non-probability purposive sample of 115 individuals with substance use disorders was selected, with nine excluded due to psychotic diagnostic evidence and six due to refusal to participate. The remaining 100 individuals with substance use were randomly assigned to study and control groups using the randomization blind technique involving opaque envelopes, ensuring impartiality, and reducing bias.
Sample size: Using G*Power and power analysis indicated that for a large effect size (d = 0.8), a minimum total sample size of 52 participants (26 per group) would be sufficient to achieve a statistical power of 80% at an alpha level of 0.05. With 100 participants, this study is adequately powered to detect significant differences between the groups, allowing for robust conclusions about the efficacy of metaphor therapy.
The primary intervention, metaphor therapy, comprised six 90-min group sessions held at 2-day intervals for the study group. The control group did not receive any intervention. Prior to the intervention, both groups underwent pre-testing using the attitude toward substance use questionnaire and irrational beliefs scale. The program, conducted at the substance use management unit, extended over 6 months, with post-tests administered to both groups 1 week after the final session.
Measures: each patient was evaluated through the following tools
Personal data sheet. Developed by the researchers; it includes (patient code, age, residence, level of education, marital status, and occupation).
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Clinical variables of substance use: It includes information on diagnosis (poly or mono substance use), method of administration (oral, inhalation, injection), types of substance use, age of onset, and motivations for use.
Irrational Beliefs Scale (IBS): This scale, devised for the Arab context by Al-Rihani [23], comprises 52 items divided into thirteen subscales of irrational beliefs. These include 11 irrational beliefs outlined by Albert Ellis [24] along with two beliefs tailored for Arab societies. Each subscale, featuring four items, addresses distinct concepts. Subscales are designated as follows: seeking approval, high self-expectation, blame-proneness, frustration reactivity, emotional irresponsibility, anxious overconcern, problem avoidance, dependency, hopelessness regarding change, upset for other people’s problems, perfectionism, seriousness, and masculinity. Respondents select either “yes” or “no” to the scale items. A “yes” indicates agreement with the irrational belief and is assigned two points, while a “no” indicates disagreement and receives one point. This scoring is reversed for negative items. Scores range from 52 to 104, with higher scores suggesting greater irrational thinking and lower scores indicating rational thinking. Al-Rihani identifies a score below 65 as indicative of high rationality, while a score of 65–78 represents the borderline. A score exceeding 78 is considered irrational. The reliability coefficient for IBS in this study was 0.80.
Attitude Toward Substance Abuse Questionnaire (ATSAQ): This questionnaire, developed by Kador [25], comprises 40 items categorized into three dimensions. Firstly, the cognitive dimension consists of 14 items pertaining to an individual's beliefs, ideas, perceptions, and information regarding substance use. Secondly, the emotional dimension comprises 14 items reflecting the individual’s feelings and emotions toward substance use. Thirdly, the behavioral dimension includes 12 items representing the individual’s willingness to perform actions and responses concerning substance use. Responses are recorded using a 5-point Likert-type scale, with options including “totally agree”, “somewhat agree”, “no idea”, “somewhat disagree”, and “totally disagree”, scored as 1, 2, 3, 4, and 5, respectively. Final scores range from 40 to 200. A score above 155 indicates negative attitudes towards substance use, indicating a rejection of the idea and viewing substance use as a problem, while a score equal to or below 155 suggests positive attitudes towards substance use, indicating a tendency towards substance use. The Cronbach’s alpha coefficients for the ATSAQ subscales were 0.75, 0.79, and 0.83, respectively.
Pilot study: Before commencing data collection, a pilot study was conducted involving five patients to assess the clarity, intelligibility, and feasibility of applying study instruments, as well as to estimate the duration of data collection. These patients, comprising 10% of the sample, were included in the study as no adjustments were made to the instruments based on their feedback.
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Therapy’ Description: Metaphor therapy comprised six sessions lasting 90 min each. In each session, two metaphoric stories addressing irrational beliefs and attitudes towards substance use were presented to the patient. The patient was then prompted to connect the metaphor with their emotions, thoughts, and behaviors, especially those related to substance use. They were encouraged to reflect on the metaphors daily and were provided with behavioral assignment forms at the end of each session. Sessions commenced with a review of the previous session's assignments. The therapy took place in the unit where the participants received their regular medication. The program’s content was developed and refined through consultation with two professors of psychology to ensure content validity and relevance. Each metaphor or story followed six steps when employed with subjects:
Stage 1: Hearing a metaphor, listening to the metaphor’s underlying meanings rather than its literal words, allowing participants to hear beyond the surface.
Stage 2: Metaphor validation, marking the metaphor as significant for exploration and deeper understanding.
Stage 3: Expanding a metaphor, encouraging participants to share their associations, feelings, and images evoked by the metaphor.
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Stage 4: Play with possibilities, exploring various interpretations of the metaphor based on established associations.
Stage 5: Marking and selection, selecting the interpretation that best aligns with treatment goals.
Stage 6: Connection with the future, using the metaphor to discuss future perspectives with the client.
Procedure
Firstly, assessment phase: it started with welcoming the treatment group and introduction among members of the therapeutic group. Followed by establishing a positive attitude towards the treatment program and creating an atmosphere of trust and familiarity. Also, clarifying the goals and content of the treatment program and urging them to cooperate, participate positively, and spend on the number and dates of sessions. Then assess the subjects by clinical variable of substance use, irrational beliefs scale and attitude toward substance use questionnaire.
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Secondly, implementation phase: The focus of this phase was on exploring the relationship between cognition, emotion, and behavior.
Session One: Subjects received two metaphorical stories illustrating high self-expectations and approval-seeking tendencies, followed by discussions connecting these stories to their beliefs, emotions, and behaviors related to substance use. Behavioral assignment forms were provided, along with instructions to reflect on the metaphors daily and list any changes in beliefs and behaviors resulting from the stories (e.g., “Deidre of the Sorrows”).
Session Two: The session began with a review of the previous assignment. Subjects then discussed topics such as self-blame, the onset of substance use, and the factors contributing to withdrawal and relapse. Metaphorical stories depicting blame-proneness and frustration reactivity were shared, highlighting irrational thoughts. The session concluded with the distribution of behavioral assignment forms (e.g., “The Monster who Grew Small”).
Session Three: Homework from the previous session was reviewed, with subjects sharing their feelings and thoughts related to substance use. Metaphorical scenarios portraying emotional irresponsibility and anxiety over concern were presented (e.g., “The Handless Maiden”). Homework forms were then distributed to the subjects.
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Session Four: Researchers presented two metaphoric stories (e.g., “Unanana and the Elephant”) discussing dysfunctional dependency and problem avoidance. Subjects were then prompted to relate these concepts to their own thoughts, feelings, and behaviors, especially those associated with substance use and corresponding to irrational beliefs.
Session Five: After reviewing homework from the previous session, the therapist addressed subjects’ irrational beliefs and shared metaphorical analogies about helplessness for change and perfectionism (e.g., Ice King story).
Session Six: Subjects received metaphorical stories illustrating masculinity and seriousness (e.g., “Mind Monsters”—bad wolf, good wolf), and the therapist challenged irrational beliefs. Metaphors discussed in earlier sessions were revisited. At the conclusion of the therapy period, subjects were encouraged to commit the metaphors to memory to maximize their benefits.
At the session’s end, the researcher expressed gratitude to the therapeutic group members for their cooperation throughout the program, wishing them a fulfilling life enriched with meaning and quality experiences. Individuals were invited to reach out for communication if needed, with a follow-up session scheduled for 1 month later.
Thirdly, evaluation phase: During this phase, the following updates were noted: (1) both groups were assessed immediately after program implementation 1 week post-test using IBS and ATSAQ. (2) A month after subjects were discharged, they were contacted via telephone to evaluate the program's impact using IBS and ATSAQ for follow-up.
Statistical analysis
Data entry and statistical analysis were conducted using the SPSS 26 Statistical Software Package. Qualitative data were presented as numbers and percentages. The χ2 test or Fisher’s exact test was utilized to compare categorical variables as appropriate. Quantitative data were described using mean and standard deviation. The independent t-test was employed for comparison between two groups, and repeated measures ANOVA was utilized for comparison between means of three related groups (pre, post, and follow-up). Pearson correlation coefficient was used to measure the correlation between Change pre–post and change pre–follow-up of total attitude and total irrational beliefs, as well as other parameters. To quantify the magnitude of changes within and between groups, Cohen's d effect sizes were calculated. In Tables 1 and 2, Cohen's d was used to compare between the study and control groups. For Tables 3 and 4, effect sizes were computed for three comparisons within each group: pre vs. post, pre vs. follow-up, and pre vs. post vs. follow-up, for both the study and control groups separately. A P-value < 0.05 was considered statistically significant.
Chi-square test, t: independent t-test, effect size = Cohen’s d coefficient, #More than answer
Table 3
Changes of total score of irrational beliefs and its dimensions over time among study and control groups
Variables
Study group n = 50
Control group n = 50
p-value***
Pre
Post
Follow-up
p-value* (effect size)
p-value** (pairwise comparison)
Pre
Post
Follow-up
p-value* (effect size)
p-value** (pairwise comparison)
Mean ± SD
Mean ± SD
Mean ± SD
P1(effect size)
P2(effect size)
Mean ± SD
Mean ± SD
Mean ± SD
P1 (effect size)
P2 (effect size)
Seeking approval
6.94 ± 0.91
4.76 ± 0.69
5.02 ± 0.74
< 0.001*, (1.46)
< 0.001*, (2.70)
< 0.001*, (2.31)
6.66 ± 0.96
6.82 ± 0.85
6.80 ± 0.95
0.302, (0.16)
0.176, (− 0.18)
0.762, (− 0.15)
< 0.001*
High self-expectation = perfection
6.94 ± 0.74
4.98 ± 0.65
4.76 ± 0.94
< 0.001*, (1.68)
< 0.001*, (2.82)
< 0.001*, (2.48)
6.46 ± 0.76
6.64 ± 0.85
6.56 ± 0.73
0.124, (0.217)
0.113, (− 0.22)
0.399, (− 0.13)
< 0.001*
Blame proneness
7.12 ± 0.69
4.70 ± 0.65
4.48 ± 0.71
< 0.001*, (2.48)
< 0.001*, (3.61)
< 0.001*, (3.87)
7.22 ± 0.79
7.02 ± 0.82
6.96 ± 0.95
0.117, (0.24)
0.288, (0.25)
0.272, (0.30)
< 0.001*
Frustration reactivity = anticipate
6.20 ± 0.83
4.94 ± 0.59
5.56 ± 0.64
< 0.001*, (0.59)
< 0.001*, (1.75)
< 0.001*, (0.86)
6.14 ± 0.76
6.30 ± 0.61
6.36 ± 0.75
0.166, (0.291)
0.627, (− 0.23)
0.141, (− 0.29)
< 0.001*
Emotional irresponsibility = impulsive
7.08 ± 0.78
4.34 ± 0.59
5.16 ± 0.47
< 0.001*, (1.96)
< 0.001*, (3.96)
< 0.001*, (2.98)
7.06 ± 0.79
6.86 ± 0.81
7.30 ± 0.86
0.054, (0.199)
0.644, (0.25)
0.513, (− 0.29)
< 0.001*
Anxious overconcern
7.30 ± 0.74
4.82 ± 0.56
5.22 ± 0.51
< 0.001*, (2.38)
< 0.001*, (3.78)
< 0.001*, (3.28)
6.76 ± 0.98
6.38 ± 0.67
6.52 ± 0.65
0.055, (0.241)
0.068, (0.45)
0.289, (0.28)
< 0.001*
Problem avoidance
6.78 ± 1.13
5.42 ± 0.81
5.78 ± 0.65
< 0.001*, (0.80)
< 0.001*, (1.38)
< 0.001*, (1.09)
6.82 ± 0.77
6.58 ± 0.61
6.60 ± 0.78
0.154, (0.209)
0.190, (0.35)
0.441, (0.28)
< 0.001*
Dependency
7.00 ± 0.97
5.20 ± 0.61
5.44 ± 0.64
< 0.001*, (1.60)
< 0.001*, (2.22)
< 0.001*, (1.90)
6.36 ± 1.06
6.58 ± 1.09
6.56 ± 1.01
0.197, (0.204)
0.351, (− 0.20)
0.478, (− 0.19)
< 0.001*
Hopelessness regarding change
7.14 ± 0.64
4.24 ± 0.43
5.42 ± 0.84
< 0.001*, (1.69)
< 0.001*, (5.32)
< 0.001*, (2.28)
5.88 ± 0.77
5.74 ± 0.72
6.08 ± 0.90
0.039*, (0.204)
0.438, (0.19)
0.478, (− 0.24)
< 0.001*
Upset for other people's problems
6.84 ± 1.11
4.70 ± 0.79
5.12 ± 0.90
< 0.001*, (1.22)
< 0.001*, (2.22)
< 0.001*, (1.70)
6.66 ± 0.92
6.92 ± 1.08
6.98 ± 0.80
0.242, (0.248)
0.610, (− 0.26)
0.264, (− 0.37)
< 0.001*
Perfectionism = solution
7.52 ± 0.58
4.28 ± 0.50
5.14 ± 0.76
< 0.001*, (2.29)
< 0.001*, (5.99)
< 0.001*, (3.52)
7.02 ± 0.62
7.16 ± 0.82
7.24 ± 0.82
0.132, (0.250)
0.762, (− 0.19)
0.257, (− 0.30)
< 0.001*
Seriousness
7.12 ± 0.80
4.58 ± 0.61
6.02 ± 0.71
< 0.001*, (1.02)
< 0.001*, (3.57)
< 0.001*, (1.45)
6.76 ± 0.66
6.86 ± 0.57
6.60 ± 0.64
0.072, (0.193)
0.766, (− 0.16)
0.555, (0.25)
< 0.001*
Masculinity
6.82 ± 0.75
4.56 ± 0.64
5.20 ± 0.73
< 0.001*, (1.69)
< 0.001*, (3.24)
< 0.001*, (2.19)
6.76 ± 0.72
6.64 ± 0.66
6.50 ± 0.81
0.057, (0.308)
0.547, (0.17)
0.108, (0.34)
< 0.001*
Total of irrational beliefs
90.80 ± 5.50
61.52 ± 2.82
68.32 ± 4.18
< 0.001*, (3.39)
< 0.001*, (6.70)
< 0.001*, (4.59)
86.56 ± 5.44
86.50 ± 5.35
87.06 ± 4.67
0.537, (0.115)
0.905, (0.01)
0.431, (− 0.10)
< 0.001*
*Repeated measure ANOVA test, **Bonferroni post hoc test, P1 = pre Vs. post in each group, P2 = pre Vs. follow-up in each group, effect size = Cohen’s d coefficient,***p-value = comparing between study and control group groups pre, post and follow-up, *statistically significant difference (p < 0.05)
Table 4
Changes of total score of attitude and its dimensions over time among study and control groups
Variables
Study group n = 50
Control group n = 50
p-value***
Pre
Post
Follow-up
p-value* (effect size)
p-value** (pairwise comparison)
Pre
Post
Follow-up
p-value* (effect size)
p-value** (pairwise comparison)
Mean ± SD
Mean ± SD
Mean ± SD
P1 (effect size)
P2 (effect size)
Mean ± SD
Mean ± SD
Mean ± SD
P1 (effect size)
P2 (effect size)
Cognitive dimension
21.86 ± 2.34
62.94 ± 2.55
59.52 ± 5.65
< 0.001*, (5.68)
< 0.001*, (− 16.74)
< 0.001*, (− 8.71)
22.28 ± 2.55
23.04 ± 3.08
23.02 ± 3.57
0.387, (0.173)
0.490, (− 0.26)
0.693, (− 0.23)
< 0.001*
Emotional dimension
23.20 ± 3.46
62.48 ± 3.48
60.48 ± 5.67
< 0.001*, (5.68)
< 0.001*, (− 11.36)
< 0.001*, (− 7.94)
24.60 ± 6.46
25.34 ± 3.47
26.18 ± 4.27
0.108, (0.263)
0.937, (− 0.15)
0.212, (− 0.29)
< 0.001*
Behavioral dimension
20.92 ± 4.96
52.92 ± 2.67
51.64 ± 5.56
< 0.001*, (3.96)
< 0.001*, (− 8.03)
< 0.001*, (− 5.83)
19.54 ± 3.91
20.42 ± 2.94
20.26 ± 3.29
0.194, (0.167)
0.067, (− 0.25)
0.761, (− 0.20)
< 0.001*
Total of attitude
65.98 ± 8.60
178.34 ± 7.03
171.64 ± 16.11
< 0.001*, (5.68)
< 0.001*, (− 14.34)
< 0.001*, (− 8.20)
66.42 ± 9.84
68.80 ± 6.55
69.46 ± 8.95
0.065, (1.68)
0.129, (− 0.28)
0.158, (− 0.32)
< 0.001*
*Repeated measure ANOVA test, **Bonferroni post hoc test, P1 = pre Vs. post in each group, P2 = pre Vs. follow-up in each group, effect size = Cohen’s d coefficient, ***p-value = comparing between study and control group groups pre, post and follow-up, * statistically significant difference (p < 0.05)
Results
No significant statistical differences were observed between the study and control groups concerning sociodemographic and clinical variables. The majority of participants were under 30 years old, had attained a secondary level of education, were married, and were employed (refer to Table 1).
Furthermore, most participants reported using opioids, administering substances through inhalation, and citing peer pressure as their initial reason for trying substances (refer to Table 2).
Table 3 and Fig. 1 demonstrate significant decrease in the mean scores of the subscales and total irrational beliefs in the study group at post-measure and follow-up compared to pre-assessment.
Fig. 1
Changes of total score of irrational beliefs over time among study and control groups
Similarly, Table 4 and Fig. 2 indicate significant differences were observed between pre–post assessment and pre–follow-up assessment in the study group regarding total score of attitude. Furthermore, participants in the study group demonstrated higher mean scores on total attitude during post-treatment and follow-up assessments compared to pre-assessment. In contrast, there was no significant change in the control group regarding pre–post–follow-up assessment in subscales and total score of irrational beliefs and attitude scales.
Fig. 2
Changes of total score of attitudes over time among study and control groups
Moreover, Tables 3 and 4 show large to extremely large effect sizes for almost all variables in the study group when comparing pre vs. post, pre vs. follow-up, and pre vs. post vs. follow-up. In contrast, the control group exhibits mostly negligible to small effect sizes across all comparisons.
Table 5 presents correlations between the change in pre–post and pre–follow-up total attitude and total irrational beliefs scores with other parameters. Participation in the metaphor program was linked to an increase in negative attitudes toward substance use and a decrease in irrational belief scores from pre to post and pre to follow-up. Additionally, the use of cannabinoids was more vulnerable to improve negative attitudes toward substance use (r = 0.200, p = 0.046) and a decrease irrational beliefs (r = − 0.204, p = 0.042) in the pre–post measure scores. Moreover, the belief that substances enhance sexual ability exhibited a significant negative correlation with total irrational beliefs (r = − 0.220, p = 0.028) in the pre–post measure scores.
Table 5
Correlation between change pre–post and change pre–follow-up of total of attitude and total of irrational beliefs and other parameters
Variables
Change pre–post
Change pre–follow-up
Attitude
Irrational
Attitude
Irrational
Age
r
− 0.141
0.135
− 0.162
0.158
p value
0.162
0.181
0.108
0.116
Study group
r
0.984**
− 0.942**
0.961**
− 0.903**
p value
0.0001*
0.0001*
0.0001*
0.0001*
Education years
r
0.001
0.008
− 0.007
− 0.002
p value
0.992
0.940
0.946
0.984
Diagnosis: mono drug addict
r
0.085
− 0.051
0.126
− 0.050
p value
0.399
0.612
0.211
0.623
Age of starting abuse (in years)
r
− 0.149
0.149
− 0.176
0.118
p value
0.140
0.140
0.079
0.241
Duration of abuse
r
− 0.071
0.071
− 0.111
0.070
p value
0.485
0.486
0.271
0.491
#Types of drug use
Cannabinoids
r
0.200
− 0.204
0.178
− 0.164
p value
0.046*
0.042*
0.076
0.103
Opioids
r
0.030
− 0.011
0.014
− 0.006
p value
0.767
0.913
0.892
0.955
Tramadol
r
0.081
− 0.088
0.076
− 0.140
p value
0.425
0.383
0.452
0.164
Amphetamines
r
0.145
− 0.144
0.149
− 0.139
p value
0.149
0.152
0.140
0.167
#Methods of drug use
Oral
r
0.065
− 0.080
0.068
− 0.128
p value
0.524
0.430
0.504
0.204
Inhalation
r
0.101
− 0.045
0.077
− 0.037
p value
0.317
0.658
0.449
0.718
Injection
r
− 0.101
0.038
− 0.111
0.030
p value
0.319
0.708
0.271
0.767
#Motivation for use
Peer pressure
r
− 0.068
0.004
− 0.063
− 0.019
p value
0.500
0.970
0.536
0.854
Trial
r
0.133
− 0.100
0.125
− 0.089
p value
0.187
0.323
0.217
0.379
Increase strength and activity
r
0.001
0.013
0.016
0.017
p value
0.996
0.898
0.878
0.869
Escape from social financial problems
r
0.132
− 0.116
0.076
− 0.057
p value
0.192
0.252
0.451
0.574
Weakness sexual ability
r
0.176
− 0.220
0.169
− 0.166
p value
0.079
0.028*
0.093
0.099
#More than answer
* Statistically significant difference (p<0.05)
Discussion
In general, most people involved in substance use typically do not recognize their get in substance use disorders for a long time and may even deny it for years. Overwhelming challenges have been caused by the rapid global expansion of substance use disorders. The effects of substance use disorders on a person's family, the community, and the users themselves last for a very long time. People having irrational beliefs typically started to begin taking substance use to deal with their thoughts. However, substance use might be the cause of, or contribute to change of attitudes, behavior and feelings [26]. Hence metaphor therapy is used worldwide to change the attitudes of patients. Stories, myths, and allegories are all thought to be important tools for treating, reshaping, and correcting dysfunctional thoughts and negative attitudes toward many issues. Proverbs and metaphors that are frequently and widely utilized in conversational literature are part of every nation's belief and are applied as guiding principles in daily life. Additionally, they serve as the original and consistent source for conversation and sociability [27]. Thus, the current study was conducted to investigate the impact of metaphor therapy on irrational beliefs and attitude toward people with substance use.
It is intriguing that, in the current study, significant differences were observed between pre–post assessment and pre–follow-up assessment in the study group regarding all irrational beliefs' subscales. Furthermore, participants in the study group demonstrated lower mean scores on all subscales of irrational beliefs during post-treatment and follow-up assessments compared to pre-assessment. In contrast, there was no significant change in the control group regarding pre–post–follow-up assessment.
This finding aligns with previous research emphasizing the role of metaphor and cognitive therapy in reducing approval seeking among individuals with substance use disorders [16]. Substance users often experience high levels of shame due to long-term substance abuse and its associated mental consequences, along with undesirable behaviors such as aggression, depression, low self-esteem, and weak self-concept. Helping them understand the rationale behind their behaviors and managing their emotions effectively can alleviate the burden of shame. Metaphor intervention aids in personal development, fostering gratitude for life and promoting self-acceptance, thereby cultivating a positive self-concept. Metaphors offer a conceptual link between faulty interpretations and new perspectives, providing a novel viewpoint on experiences.
Metaphors are more than just pictures of words; they have the power to actively influence our thoughts, emotions, and actions because they enable the client and therapist to express vivid imagery that go beyond the literal, they can also create images that are more responsible and comprehensible [28]. As, challenging maladaptive thoughts and replacing them with sound, adaptive thoughts [29].
Furthermore, a study by Zhang and colleagues [30] demonstrated that greater activation in the left inferior frontal gyrus (IFG) correlated with guided metaphor restructuring. The metaphor group reported more insightful experiences, a greater increase in positive affect, a significant decrease in irrational thoughts, and a greater decrease in psychological distress [30].
On the contrary, Rechsteiner and colleagues [31] found no significant difference in the effects of individual metaphor therapy on reducing beliefs related to blame-proneness, emotional irresponsibility, problem avoidance, dependency, and hopelessness regarding change [31]. This lack of significant difference could be attributed to challenges in effectively conveying messages through metaphors and stories. Additionally, the capacity and willingness of individuals with substance use disorders to utilize their own imagination and visualization skills play a significant role in the effectiveness of metaphors. Thus, there may be other factors contributing to the ineffectiveness of metaphor therapy beyond the individuals themselves. This raises questions about how individuals, despite experiencing periods of relapse and facing barriers to their physical, cognitive, and behavioral aspects due to dysfunctional beliefs and catastrophic interpretations of their symptoms, are able to visualize the messages conveyed in metaphors. It is possible that some patients have limitations in their use of imagination, resulting in certain metaphors failing to deeply resonate with them.
In the current study, there was significant differences were observed between pre–post assessment and pre–follow-up assessment in the study group regarding total score of attitude. Furthermore, participants in the study group demonstrated higher mean scores on total attitude during post-treatment and follow-up assessments compared to pre-assessment. In contrast, there was no significant change in the control group regarding pre–post–follow-up assessment in total score of attitude scale.
In line with this, the study by Syed and Jacob [32], which concluded that metaphoric language holds significant therapeutic value and has a high potential impact in balancing the subjective perspectives of mental health clients [32]. Another study found that metaphors are constructed by both the therapist and the client and can offer a rich foundation for reprocessing attitude and beliefs [4]. This suggests that metaphor therapy plays a role in influencing and reframing attitudes toward substance use. Metaphors, combining images and concepts, are powerful tools in psychological therapies that can expand thinking, deepen understanding, explore issues in new ways, and select new coping strategies.
In the correlation study, it was found that receiving the metaphor program was associated with an increase in negative attitudes toward substance use and a decrease in irrational belief scores from pre to post and pre to follow-up assessments.
This may be attributed to the impact of metaphor therapy, which potentially reduced the occurrence of irrational beliefs among individuals with substance use disorders while fostering more favorable attitudes toward substance use. In essence, metaphor therapy appears to have effectively transformed the cognitive framework of substance users, leading to improvements in attitudes. This observation is in line with findings from studies conducted by Fazel (2023), Jafarizadeh and colleagues (2020), and Basharpoor and colleagues (2019) [33‐35]. These studies suggest that irrational ideas play a specific role in shaping human behavior within the psychological structure. When individuals lack accurate knowledge and harbor illogical beliefs about daily activities, they may struggle to navigate life effectively. In such cases, individuals may resort to deviant behaviors as a means of coping with life's challenges, particularly if they are unable to recognize healthy coping strategies. Consequently, irrational ideas may act as mediators, influencing attitudes toward substance use and laying the foundation for related behaviors.
Furthermore, individuals who reported using cannabinoids were more likely to respond to an increase in negative attitudes toward substance use and a decrease in total irrational beliefs in the pre–post measure scores. Also, there was a significant negative correlation between the belief that substances increase sexual ability and total irrational beliefs in the pre–post measure scores. This correlation may be explained by the cultural perspective that cannabinoids are not typically considered as substance use. In some cultures, such as the Egyptian culture, cannabinoids may even be perceived to enhance sexual desire. Therefore, improving attitudes and decreasing irrational beliefs among cannabinoid users could potentially aid in their management. By addressing these cultural beliefs and misconceptions, interventions and treatment strategies can be tailored more effectively to meet the needs of individuals struggling with cannabinoid use disorder.
The study was limited to a relatively small sample size from a single treatment facility. Based on the findings, it is recommended that future studies take into consideration the following points. Firstly, to larger sample size and multi-center studies in future research endeavors. By expanding the pool of participants, researchers can improve the reliability and generalizability of their findings concerning attitudes toward substance use and behavior addition [36‐38] and the effectiveness of metaphor therapy in addressing irrational beliefs. The majority of individuals with substance use disorders also experience co-occurring mental illnesses, which may precede the addiction, result from it, or occur coincidentally due to organic or other factors at any age [39‐44]. A comprehensive and integrated treatment approach is essential to achieve meaningful outcomes. Future research should aim to develop methods for identifying clients' primary metaphoric conceptualizations, allowing for more personalized therapy and improved outcomes. Exploring the cultural context of therapy delivery is also important, with a focus on understanding how cultural differences impact the effectiveness of interventions across various settings. Additionally, studies should compare psychotherapies like cognitive behavioral therapy to establish evidence-based treatments for substance use and behavioral addictions.
Conclusion
Metaphor therapy was effective in reducing irrational beliefs and fostering more favorable attitudes toward substance use. The findings suggest metaphor therapy could be a valuable intervention for addressing cognitive and attitudinal factors contributing to substance use.
Acknowledgements
None.
Declarations
Ethics approval and consent to participate
This research received approval from The Institutional Review Board (IRB) of the Faculty of Nursing, Assiut University with NB (1120240584). All participants signed a written informed consent form before participating in the study. They were informed that their data would be anonymized and protected. They were advised that the study is optional, and they might withdraw at any moment. This research was conducted in accordance with the most recent version of the Helsinki Declaration.
Consent for publication
The participant has consented to publishing their data result.
Competing interests
The authors have no competing interests to declare that are relevant to the content of this article.
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Ebrahem SM, Alam FH, El Berry K. The effectiveness of rational emotive therapy on stress and irrational thoughts among drug addicts. Int J Novel Res Healthcare Nurs. 2020;7(1):965–77.
2.
El-Genady EMI, Wahab M. Effect of perceived social support and resilience on life satisfaction and stress tolerance among patients with substance use disorders. Int J Novel Res Healthcare Nurs. 2020;7(1):651–63.
3.
Rabie M, Shaker NM, Gaber E, El-Habiby M, Ismail D, El-Gaafary M, et al. Prevalence updates of substance use among Egyptian adolescents. Middle East Curr Psychiatry. 2020;27:1–8.CrossRef
4.
Marcovitz DE, Maruti S, Kast KA, Suzuki J. The use of therapeutic metaphor on an addiction consult service. J Acad Consult Liaison Psychiatry. 2021;62(1):102–8.PubMedCrossRef
5.
Tanaka M, Vécsei L. A decade of dedication: pioneering perspectives on neurological diseases and mental illnesses. Biomedicines. 2024;12(5):1083.PubMedPubMedCentralCrossRef
6.
Battaglia S, Nazzi C, Fullana MA, di Pellegrino G, Borgomaneri S. ‘Nip it in the bud’: low-frequency rTMS of the prefrontal cortex disrupts threat memory consolidation in humans. Behav Res Ther. 2024;178:104548.PubMedCrossRef
7.
Battaglia S, Avenanti A, Vécsei L, Tanaka M. Neurodegeneration in cognitive impairment and mood disorders for experimental, clinical and translational neuropsychiatry. Biomedicines. 2024;12(3):574.PubMedPubMedCentralCrossRef
8.
Battaglia S, Nazzi C, Di Fazio C, Borgomaneri S. The role of pre-supplementary motor cortex in action control with emotional stimuli: a repetitive transcranial magnetic stimulation study. Ann N Y Acad Sci. 2024;1536(1):151–66.PubMedCrossRef
9.
Gallegos MI, Zaring-Hinkle B, Wang N, Bray JH. Detachment, peer pressure, and age of first substance use as gateways to later substance use. Drug Alcohol Depend. 2021;218:108352.PubMedCrossRef
10.
Alsubaie S. Psychosocial life aspects among substance misuse clients who are at rehabilitation phase: a narrative review. Health Psychol Res. 2023;11:66174.PubMedPubMedCentralCrossRef
11.
Kazemi A. Prediction of the attitude towards drug use based on assertiveness and psychological hardiness. Spain: Barcelona University; 2020.
12.
Şencan F, Canatan K. Göç ve kentleşme sürecinde ergenleri madde kullanımına yönelten sosyal bağlamın analizi. Sosyal Çalışma Dergisi. 2020;4(2):115–25.
13.
Rathinam B, Ezhumalai S. Perceived social support among abstinent individuals with substance use disorder. J Psychosoc Rehabil Ment Health. 2022;9(1):81–7.PubMedCrossRef
14.
Hamzaoglu N, Karatas S. Evaluation of young people’s attitudes towards people who use addictive substances. J Subst Use. 2020;25(5):495–500.CrossRef
15.
Coll-Florit M, Climent S, Sanfilippo M, Hernández-Encuentra E. Metaphors of depression. Studying first person accounts of life with depression published in blogs. Metaphor Symbol. 2021;36(1):1–19.CrossRef
16.
Malkomsen A, Røssberg JI, Dammen T, Wilberg T, Løvgren A, Ulberg R, et al. How therapists in cognitive behavioral and psychodynamic therapy reflect upon the use of metaphors in therapy: a qualitative study. BMC Psychiatry. 2022;22(1):433.PubMedPubMedCentralCrossRef
17.
Marchin É, Marty F, Gaudriault P. The experience of addiction as a metaphor for an extraordinary way of functioning. Adolescence. 2020;38(1):39–50.CrossRef
18.
Jason LA, Guerrero M, Salomon-Amend M, Stevens E, Light JM, Stoolmiller M. Context matters: home-level but not individual-level recovery social capital predicts residents’ relapse. Am J Community Psychol. 2021;67(3–4):392–404.PubMedCrossRef
19.
Violi P. Metaphors we live by: George Lakoff and Mark Johnson, Chicago: the University of Chicago Press, 1980. 242 pp. $13.95 (hardcover). J Pragmat. 1982;6(2):189–95.CrossRef
20.
Yu G, Liu R, Zhang W. Therapeutic metaphors: theories, empirical efficacy and underlying mechanisms. Adv Psychol Sci. 2022;30(7):1546.CrossRef
21.
American Psychiatric Association D, Association AP. Diagnostic and statistical manual of mental disorders: DSM-5, vol. 5. Washington, DC: American psychiatric association; 2013.CrossRef
22.
First MB. Structured clinical interview for the DSM (SCID). In: The encyclopedia of clinical psychology. Hoboken: Wiley; 2015. p. 1–6.
23.
Al-Rihani S. Developing the test of irrational thoughts among Jordanians and Americans: a cultural study of ellis’ theory of rational emotional therapy. Amman: J. University of Jordan Studies; 1985.
24.
Ellis A. An introduction to the principles of scientific psychoanalysis. Genet Psychol Monogr. 1950;41:147.PubMed
25.
Kador N. Attitude of the Young Unemployed to Wards Drugs published MSC thesis in psychology. Kasdi Merbah University. 2006. 1–161.
26.
Saad A, Awaad M, Mohsen N, Khalil SA, Aly M-a. Prevalence and clinical characteristics of dual diagnosis (Substance Abuse and Mental Illness) among egyptian psychiatric patients. Addict Disord Their Treat. 2020;19(3):136–41.CrossRef
27.
Johnson DD. The effectiveness of cognitive behavioral therapy for the treatment of substance abuse in comparison to other major treatments in the field. Culver City: Antioch University; 2021.
28.
Shkëmbi F, Treska V. Metaphor as a technique in therapy. Eur J Soc Sci Educ Res. 2023;10(1s):39–48.
29.
Yu F, Zhang J, Luo J, Zhang W. Enhanced insightfulness and neural activation induced by metaphorical solutions to appropriate mental distress problems. Psychophysiology. 2021;58(10): e13886.PubMedCrossRef
30.
Zhang X, Zhang L, Yu F, Zhang W. Can brain activities of guided metaphorical restructuring predict therapeutic changes? Neuroscience. 2023;531:39–49.PubMedCrossRef
31.
Rechsteiner K, Maercker A, Heim E, Meili I. Metaphors for trauma: a cross-cultural qualitative comparison in Brazil, India, Poland, and Switzerland. J Trauma Stress. 2020;33(5):643–53.PubMedCrossRef
32.
Syed A, Jacob MS. Languaging psychopathology: neurobiology and metaphor. Front Psychiatry. 2024;15:1320771.PubMedPubMedCentralCrossRef
33.
Fazel M. A replication study of the factor structure of the attitudes and beliefs scale-2: a measure of irrational and rational beliefs. New York: St. John’s University; 2023.
34.
Jafarizadeh R, Aghaie B, Azarbarzin M, Sadeghi N. Relationship between dysfunctional attitudes and mental health in psychiatric nurses. 2020
35.
Basharpoor S, Hoseinikiasari ST, Soleymani E, Massah O. The role of irrational beliefs and attitudes to death in quality of life of the older people. Salmand Iran J Ageing. 2019;14(3):260–71.
36.
Ahmed GK, Abdalla AA, Mohamed AM, Mohamed LA, Shamaa HA. Relation between internet gaming addiction and comorbid psychiatric disorders and emotion avoidance among adolescents: a cross-sectional study. Psychiatry Res. 2022;312:114584.PubMedCrossRef
37.
Ahmed GK, Abdalla AA, Mohamed AM, Mohamed LA, Shamaa HA. Relationship between time spent playing internet gaming apps and behavioral problems, sleep problems, alexithymia, and emotion dysregulations in children: a multicentre study. Child Adolesc Psychiatry Ment Health. 2022;16(1):67.PubMedPubMedCentralCrossRef
38.
Ibrahim AK, Fouad I, Kelly SJ, El Fawal B, Ahmed GK. Prevalence and determinants of Internet Addiction among medical students and its association with depression. J Affect Disord. 2022;314:94–102.PubMedCrossRef
39.
Ahmed GK, Elbeh K, Gomaa HM, Soliman S. Does COVID-19 infection have an impact on children’s psychological problems? Middle East Curr Psychiatry. 2021;28(1):77.CrossRef
40.
Ahmed GK, Mostafa S, Elbeh K, Gomaa HM, Soliman S. Effect of COVID-19 infection on psychological aspects of pre-schooler children: a cross-sectional study. Middle East Curr Psychiatry. 2022;29(1):42.CrossRef
41.
Hassaan SH, Darwish AM, Khalifa H, Ramadan HKA, Hassany SM, Ahmed GK, et al. Assessment of cognitive functions and psychiatric symptoms in hepatitis C patients receiving pegylated interferon alpha and ribavirin: a prospective cohort study. Int J Psychiatry Med. 2019;54(6):424–40.PubMedCrossRef
42.
Ahmed GK, Ramadan HK-A, Elbeh K, Haridy NA. The role of infections and inflammation in schizophrenia: review of the evidence. Middle East Curr Psychiatry. 2024;31(1):9.CrossRef
43.
El-Morshedy RM, El-kholy MM, Khedr EM, Ahmed GK, Yassin E, Mohamed MN. A prospective study of the effect of COVID-19 on psychiatric symptoms and sleep problems from infection to 9-month follow-up. Eur Arch Psychiatry Clin Neurosci. 2024. https://doi.org/10.1007/s00406-023-01755-y.CrossRefPubMed
44.
Ahmed GK, Elbeh K, Karim AA, Khedr EM. Case report: catatonia associated with post-traumatic stress disorder. Front Psychiatry. 2021;12:740436.PubMedPubMedCentralCrossRef
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