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The current study examined the trajectory of distress tolerance among substance users receiving residential treatment over a series of five assessment waves occurring intermittently from pre-treatment to 12-months post-treatment and investigated the relationship between DT change over time and both abstinence duration and severity of substance use post-treatment. As predicted, both behavioral and perceived DT improved over time, such that substance users evidenced increased persistence time on a distressing behavioral task, and rated self-reported ability to tolerate distress as generally increasing, from pre-treatment to 12-months post- treatment. In addition, abstinence duration post-treatment was positively associated with both perceived and behavioral DT such that individuals who were able to maintain longer periods of abstinence post-treatment evidenced greater improvements in perceived and behavioral DT. Moreover, greater frequency of use between post-treatment assessment waves was associated with attenuated improvement in post-treatment behavioral DT. Contrary to expectation, this association was not observed for perceived DT change.

This study is the first to provide evidence for naturally occurring DT change over time. Though initial evidence supports the efficacy of DT-targeted treatment in improving DT among varying substance using populations (e.g., Bornovalova et al., 2012; Brown et al., 2014), this study suggests that DT may improve organically over time specifically within this population, as the participants in this trial did not receive treatment targeting distress tolerance (Daughters et al., 2017). The rate of DT change was best characterized as non-linear, suggesting that the rate of

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DT change itself changes over time. One explanation may be the influence of environmental factors on an individual’s perceived and actual ability to improve DT over time. For example, as demonstrated in this study more than half of the total increase in both perceived and behavioral DT occurred while participants were in the restricted environment of residential treatment, between T1 (treatment entry) and T2 (residential treatment discharge). We observe fluctuations in

the rate of DT improvement among substance users after treatment discharge, between T2 and T5,

when environmental factors between participants were no longer held constant. In particular, housing and financial stability, employment, social networks, and acute stressors, that are known to influence the course of recovery for substance users (Davies, Elison, Ward, & Laudet, 2015; Sinha, 2007; Walton, Blow, Bingham, & Chermack, 2003; Worley, Witkiewitz, Brown,

Kivlahan, & Longabaugh, 2015) may also have influenced DT trajectories.

Relatedly, we found significant variance in the behavioral DT slope factor specifically, suggesting that not only does the rate of change in DT vary over time, but that differences in overall behavioral DT trajectories exist among substance users. Individual differences in both perceived and behavioral DT at pre-treatment have been investigated in previous studies,

revealing relationships between DT and gender (Ali, Seitz-Brown, & Daughters, 2015; Burjarski, Norberg, & Copeland, 2012; Daughters et al., 2009; Tull et al., 2013), and co-occurring

psychopathology (Ali, Seitz-Brown, & Daughters, 2015; Gorka, Ali, & Daughters, 2012; Tull et al., 2013). These associations have also been linked to treatment efficacy and outcome among substance users specifically (e.g., Daughters et al., 2009; Gorka, Ali, & Daughters, 2012). However, no study has investigated individual difference factors in relation to behavioral or perceived DT change over time in this population. Though such work is outside the scope of the current study, the association of pre-treatment DT with sample characteristics such as gender and

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specific substance dependence diagnoses reported here (Table 1) provide additional evidence supporting the importance of future studies identifying additional predictors of DT trajectories to further elucidate nuanced variation in DT change.

In the current study, we were specifically interested in examining the influence of

substance-related predictors of DT change, namely abstinence and severity of use post-treatment. As predicted, sustained abstinence was associated with greater improvements in both perceived and behavioral DT. This is consistent with findings showing that sustained abstinence allows for recovery of cognitive and affective processes as well as changes in underlying neurobiological structure and function related to DT (Fox, Hong, & Sinha, 2008; Fox et al., 2007; Garavan, Brennan, Hester, & Whelan, 2013; Schmidt, Pennington, Cardoos, Durazzo, & Meyerhoff, 2017; Tull, Schulzinger, Schmidt, Zvolensky, & Lejuez, 2007; Wang et al., 2012). In addition, we found that greater post-treatment frequency of use was associated with attenuated behavioral DT such that participants who used more frequently between assessment waves were unable to persist on a distressing task for as long as those who used less frequently, if at all, during the study period. Research indicates that impairment in cognitive function is associated with acute and chronic substance use (Broyd, van Hell, Beale, Yucel, & Solowij, 2016; Everitt & Robbins, 2016; Volkow et al., 2016), and may be exacerbated by increased rates of use (Grant &

Chamberlain, 2014; Vonmoos et al., 2014). In addition, evidence suggests that prior heavy use predicts future avoidance behavior and decreased problem solving (Weiss, Bold, Sullivan, Armeli, & Tennen, 2016). Contrary to hypotheses, we did not find a relationship between frequency of substance use and perceived DT change. Theoretical perspectives posit that substance users in particular not only evidence impaired cognitive and behavioral functioning, but additionally lack insight and self-awareness as a by-product of substance use (Goldstein et

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al., 2009). Thus it may be that individuals who used substances post-treatment were unable to realize the impact of use on current functioning, particularly when evaluating DT. Additional research is needed to understand discrepancies between perceived and behavioral DT within this population more specifically and the implications of this disconnect on future functioning. Nonetheless, findings from the current study lend support to this work and suggest that abstinence allows for recovery of DT while substance use has acute and temporally-specific effects on behavioral DT in particular, providing preliminary evidence for the malleability and sensitivity of DT to proximal psychological and biological events.

Though findings from this study are both novel and important, there are several

limitations to consider. First, sample size limits our ability to test for the effects of predictors of DT change over time using a LCM approach. For example, simulation studies conducted by Muthen and Muthen (2002) indicate that the addition of a covariate in a latent growth model significantly increases the sample size necessary to detect effects. As such, we selectively included only two covariates—substance use frequency and abstinence duration—as predictors of DT change in the present study due to their theoretical relevance, and did not evaluate additional potential covariates in relation to current study aims. Additionally, though we examined the relationship between substance use variables and DT change, we were unable to establish definite temporal precedence of abstinence duration and frequency of use in the current study. First, abstinence duration was included in the LCM as a time-invariant covariate, and as such, we were limited to interpreting the association between abstinence and DT change, but could not evaluate the predictive utility of abstinence on such change. Additionally, frequency of use was associated with behavioral DT measured at concurrent, but not subsequent, assessment occasions. For example, we found that substance use occurring between treatment discharge and

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three months post-treatment was associated with attenuated behavioral DT at three-months post- treatment but was not related to DT at six months post-treatment. One explanation for the null findings of lagged effects may be the large and variable temporal spacing between assessment waves. It may be that substance use behavior has a more immediate effect on DT than could be determined in the current study. Thus, future studies assessing DT and substance use behavior at more frequent intervals post-treatment may be needed to disentangle temporal relationships between substance use and DT change. Finally, the results of the current study reflect the impact of substance use on DT change among a primarily African American sample of residential treatment seeking substance users, limiting the generalizability of study findings. One future direction may be to replicate the current study in other populations, including those from varying racial and ethnic backgrounds, and even non-treatment-seeking substance users or individuals in alternative treatment settings.

Nevertheless, findings from the current study provide important information currently lacking in the DT literature. First, we demonstrated that both perceived and behavioral DT exhibit organic, temporal fluctuations even in the absence of targeted treatment. In general, the temporal stability of the DT construct has been discussed extensively among DT researchers (Leyro, Zvolensky, & Bernstein, 2010) and this study is the first to provide evidence for natural change in both perceived and behavioral conceptualizations of DT among substance users. In addition, by identifying important predictors of this change, we demonstrated both perceived and behavioral DT are sensitive to proximal biological and psychological events. Such situational factors are important to consider in the context of substance use treatment. For example, as higher DT serves as a protective factor against poor treatment outcomes among substance users (Brown, Lejuez, Kahler, & Strong, 2002; Cameron, Reed, & Ninnemann, 2013; Daughters,

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Lejuez, Kahler, Strong, & Brown, 2005; Strong et al., 2012), prioritizing abstinence duration in current treatment models may allow for natural improvements in DT to occur, and thus improve rates of substance use recovery. Finally, study findings, which support the conceptualization of DT as a malleable treatment target, lend support for continued investigation into the efficacy and implementation of DT-targeted treatment, and emphasize the potential utility of DT-focused treatment among substance users. In conclusion, this study provides the foundation for future research to evaluate DT change as a protective factor among treatment seeking substance users, which may lead to improved outcomes among those suffering from a substance use disorder.

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